Evolution of a Retinal Hemorrhage

PRESENTATION

We present a 57-year-old man with no past medical history who experienced the sudden onset of an inferonasal visual field deficit in the right eye shortly after a long-distance run. One week prior, he had ascended to approximately 10,000 feet while traveling in Hawaii, and on the descent noted a headache that lasted several hours. On the day of visual loss, the patient was a neurologist and he self-administered low molecular weight heparin (1 mg/kg) IM and aspirin 162 mg orally. He was examined in the eye clinic the following day. He had no prior vasculopathic, cardiac, or rheumatologic conditions, and no systemic symptoms.

Visual acuity was 20/15 in the right and 20/20 in the left eye. Confrontation visual fields and color vision were normal in both eyes. Amsler grid testing showed a blurred area inferiorly on the right and was normal on the left. Automated perimetry revealed decreased sensitivity inferonasally in the right eye and was full in the left eye. Funduscopy revealed a cotton wool spot about one disc diameter in size superiorly away from the right optic disc but was normal in the left eye. At that time, no retinal hemorrhage was present [Figure 1]. Also noted was arteriorlar narrowing, which is associated with an increased risk of vaso-occlusive events and may be present without a history of systemic hypertension.

Figure 1.

Fundus photograph of the right eye revealed a cotton wool spot superior to the right optic disc.

The patient was sent for intravenous fluorescein angiography [IVFA, Figure 2] and photographs were taken within one hour of the initial funduscopy. Remarkably, a new retinal hemorrhage [Figure 3] was noted around the cotton wool spot. A literature review revealed no reports of observed hyperacute retinal hemorrhage associated with a cotton wool spot.[1] No evidence of arteriolar occlusion, emboli, or vasculitis was noted. The patient's symptoms remained unchanged at the time of the hemorrhage. MRI of brain and orbits, magnetic resonance angiography (MRA) of head and neck, carotid ultrasonography, and transthoracic echocardiography disclosed no pathologic findings. Blood tests for erythrocyte sedimentation rate, syphilis, antinuclear antibody, complete blood count, and antinuclear cytoplasmic antibody were all normal. A transthoracic echocardiogram was done and no signs were found to suggest a cardioembolic source. A non-contrast MRA of the head and neck did not reveal significant atherosclerosis or other vessel pathology.

Figure 2.

Intravenous fluorescein angiogram without evidence of arteriolar occlusion.

Figure 3.

Fundus photographs about one hour after the photograph in Figure 1, with new hemorrhage around the cotton wool spot.

Given that the patient had no clinical history of hypertension, diabetes, trauma, symptoms of a systemic collagen vascular disease, symptoms or laboratory testing suggestive of an auto-immune disorder or vasculopathy, radiation exposure, severe anemia or hypoxia and that laboratory testing and imaging studies did not indicate the presence of pathologic processes to explain his symptoms, the most likely cause of the retinopathy was high-altitude retinopathy. However, the typical vascular dilation that is seen with high-altitude retinopathy was not present in this patient and the actual cause(s) of the patient's cotton wool spot remains undetermined. He returned to clinic 5 weeks later and the cotton wool spot had resolved and no new ocular problems and systemic conditions developed over the ensuing 5 years. The other typical causes of a cotton wool spot and retinal haemorrhage were excluded by the laboratory testing and long duration of follow up without new retinopathy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.