After a Stroke, Decreased Vision for a 73-Year-Old Patient

Rod Foroozan, MD


March 30, 2017

Clinical Presentation

A 73-year-old woman presented with decreased vision after a stroke, which occurred 3 months earlier and involved the left middle cerebral artery. She experienced blurring and shadows in her left eye after the stroke, but was not sure of the exact date of the onset of these symptoms. She said her vision had been stable since the problem began.

She has a history of hypertension and hyperlipidemia, but no history of headache, pain in the jaw with chewing, or scalp tenderness. She does not drink alcohol or smoke tobacco. There is no family history of visual loss. She is currently taking aspirin, simvastatin, and lisinopril.

On examination, visual acuity in both eyes was 20/20. Color vision in both eyes, measured with Ishihara pseudoisochromatic plates, was 10/10. Pupils were brisk in each eye with a trace (0.3 log unit) left relative afferent pupillary defect (RAPD). Automated perimetry was full in the right eye but showed an inferior arcuate defect in the left eye. Intraocular pressure was 16 mm Hg in each eye. Slit-lamp examination of the anterior segment showed nuclear sclerosis in each eye. Funduscopic examination showed a tilted optic disc with parapapillary atrophy in each eye. The neuroretinal rim of the right optic disc was normal, but the left optic disc was pale superiorly, with vascular attenuation of the arterioles superiorly. The optic discs had a cup-to-disc ratio of 0.4 in the right eye and 0.5 in the left eye.

Optical coherence tomography (OCT) measures of the retinal nerve fiber layer (RNFL) were lower in the left eye than in the right eye (Figure 1). OCT of the macula in the right eye (Figure 2) showed symmetric thickness of the superior and inferior retina. The superior retina in the left eye (Figure 2) was markedly thinner than the inferior retina.

Figure 1. OCT of the retinal nerve fiber layer.

Figure 2. OCT of the macula in the right eye and of the superior retina in the left eye.


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