Patient case: “life-saving” eye exam uncovers underlying health issue

Bradley Sutton, OD, of the Indiana University School of Optometry, presents an interesting patient case that shows the life-saving importance of regular eye exams.

Bradley Sutton, OD:

I’m Dr. Brad Sutton. I’m a clinical professor at the Indiana University School of Optometry and the associate dean there for clinical and patient care services. I’m here today to share an interesting case that really highlights how we are not just eye care providers, but also really key components, often, in a patient’s systemic health. A long-time patient of mine came in to see me here recently. She’s a 74-year-old African American female just coming in for her yearly diabetic eye exam and she really only complained of needing more light to read. That was really her only entering complaint. She was a type 1 diabetic for about 50 years, so a very long period of diabetes, but really good current control. Her most recent hemoglobin A1C was 5.4. She also has hypertension, asthma, a hand tremor, diagnosis of multiple sclerosis, and pancreatitis. She’s on several medications, including lisinopril, Plavix, aspirin, amantadine, atorvastatin, Breo for her asthma as needed, and an insulin pump.

History of retinopexy in her right eye temporarily due to a retinal horseshoe tear. She had had a procedure done to fix a barricade, a horseshoe tear in her right eye. Most importantly for this case is she said no history of diabetic retinopathy. Even though she’s a 50-year-plus diabetic, she has had no history of diabetic retinopathy. Entering acuity was excellent. 20/20 in the right eye, 20/25 in the left eye with a small astigmatic correction in both eyes. All entrance testing was normal, so no issues with pupils, visual fields, et cetera, EOMs. Good IOP 18 by Goldman in each eye. The anterior segment findings are basically non-contributory of the case, all normal for her age, so a little bit of blepharitis, a little bit of dry eye, but just normal stuff for her age. She had mild cataracts, so 2-plus nuclear sclerotic and one plus cortical cataracts in both eyes.

She had normal optic nerves in both eyes and the fundus in the right eye was significant only for the retinopexy scar temporarily. The only thing of note was the retinopexy scar, no diabetic retinopathy. In the left eye, the posterior pole was essentially clear, but when you got to the level of the arcades and the mid-periphery, from the arcade area out, there were multiple dot blot hemorrhages in all four quadrants. The mid-periphery, arcade area and beyond had multiple dot blot hemorrhages in every quadrant.

Here are a couple of photographs. You can see on this Optos image the edge of a retinopexy in the right eye, and in the left eye, I know it’s a little dark here, but there are several hemorrhages starting about the level of the arcades going further out into the periphery, from there, basically sparing the area inside the arcades.

At this point, we had some differential diagnoses to consider. One option in the left eye would be venous stasis retinopathy, which is an impending central retinal vein occlusion. Those eyes will often get hemorrhaging in all 4 quadrants prior to having a full-fledged or full-blown CRBO, but it doesn’t necessarily typically spare the central posterior pole. Another significant possibility was diabetic retinopathy, but she’s a 50-year diabetic as we’ve talked about, but she’s never had retinopathy before and has no retinopathy in the other eye. She also has sparing of that posterior pole area. Could also be hypertensive retinopathy, which is unlikely for the same reason, the fact that she has no changes in her fellow eye and the central area is spared. Could also potentially be due to sickle cell retinopathy, although she has no history of sickle cell and at 74 years old, she’d be very unlikely to not know that she has sickle cell. Also, it would be unlikely for it to be unilateral.

I was very suspicious of ocular hypoperfusion syndrome, which is basically impaired ocular blood flow due to carotid blockage or blockage somewhere else in the system of vascular supply to the given eye. I contacted her PCP with concern about potential carotid blockage and they ordered some testing. Doppler ultrasound testing of the carotids revealed nearly 100% blockage of the left internal carotid and 50% blockage of the right. Interestingly, the left subclavian artery was also significantly blocked. Because she wasn’t 100% blocked in that carotid, they usually won’t operate on 100% blockage. She was just short of that. They did do emergency surgery to clear the blockages in her carotid artery on the left side and the subclavian artery. She was actually hospitalized for one month. So this was a very, very significant systemic situation for her.

Follow-up 3 months later revealed some retinal hemorrhaging in the left eye still, but it was very much improved, so much less hemorrhaging than the previous visit, and there were no other changes and her vision was stable. She states that the previous eye exam basically saved my life. So she came in telling us that her physician and her surgeons said that the eye exam that she had gone through actually saved her life because no one knew about the blockages that she had and it was a very serious situation. Following up 1 year later, she had almost no retinal hemorrhaging left. It was basically, essentially entirely resolved and with a stable vision and no other changes. Here are some images 3 months after and you can see that the hemorrhaging is significantly less in this image. Then 1 year later, there’s really no hemorrhaging left to find, maybe just a couple small little dot hemorrhages here and there.

The bottom line with this case is we never know what we’re going to encounter when it comes to the eye exam. While these findings were not critically important for her vision at this stage, now if you get into ocular ischemic syndrome where the blockage is so longstanding that the blood flow issues are so significant that they develop neovascularization in the eye, et cetera, that can affect the vision and the eye itself. But when it’s just hypoperfusion state, the eye itself is really not the problem. The problem is what the eye is telling us about the systemic situation.

In this particular patient’s case, it allowed us to investigate what ended up being a very significant problem that she was completely unaware that she had. The take-home message is we are definitely way more than just eye care providers as we often have a window when looking at the eye into dealing with what the patient may be having, undergoing systemically.