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Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Acute Visual Loss Secondary to Sneezing

Engin Özakin, MD; Davut Kaplan, MD; Özcan Özdemir, MD; Nurdan Acar, MD; Arif Alper Cevik, MD; Ahmet Özer, MD; Serkan Dogan, MD

Abstract

A case is presented of a 24-year-old woman with acute, painless visual loss that occurred after sneezing. The patient had no previous ocular disease history. Ophthalmic work-up revealed a cilioretinal artery occlusion in the right eye. Transesophageal echocardiography showed a secundum atrial septal defect with right-to-left shunt. Sudden visual loss requires thorough investigation to determine the cause. In this case, examination revealed a retinal artery occlusion, whose risk factors include older age, systemic hypertension, diabetes mellitus, atherosclerosis, and giant cell arteritis (temporal) in more than 75% of patients. Especially in patients younger than 40 years, an embolus of cardiac origin (atrial septal defect, patent foramen ovale, or valvular) should be suspected as a cause of retinal artery occlusion.

[Ophthalmic Surg Lasers Imaging Retina. 2014;45:e30–e31.]

From the departments of Emergency Medicine (EO, AAC, NA, SD, DK), Neurology (OO), and Ophthalmology (AO), Eskisehir Osmangazi University Medical Center, Eskisehir, Turkey; and Medical College and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates (AAC).

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Engin Özakin, MD, Eskisehir Osmangazi University Medical Center, Department of Emergency Medicine, Meselik, 26480, Eskisehir, Turkey; +90 222 2256129; fax: +90-222-2393774; email: enginozakin@hotmail.com.

Received: December 22, 2013
Accepted: February 11, 2014
Posted Online: July 24, 2014

Abstract

A case is presented of a 24-year-old woman with acute, painless visual loss that occurred after sneezing. The patient had no previous ocular disease history. Ophthalmic work-up revealed a cilioretinal artery occlusion in the right eye. Transesophageal echocardiography showed a secundum atrial septal defect with right-to-left shunt. Sudden visual loss requires thorough investigation to determine the cause. In this case, examination revealed a retinal artery occlusion, whose risk factors include older age, systemic hypertension, diabetes mellitus, atherosclerosis, and giant cell arteritis (temporal) in more than 75% of patients. Especially in patients younger than 40 years, an embolus of cardiac origin (atrial septal defect, patent foramen ovale, or valvular) should be suspected as a cause of retinal artery occlusion.

[Ophthalmic Surg Lasers Imaging Retina. 2014;45:e30–e31.]

From the departments of Emergency Medicine (EO, AAC, NA, SD, DK), Neurology (OO), and Ophthalmology (AO), Eskisehir Osmangazi University Medical Center, Eskisehir, Turkey; and Medical College and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates (AAC).

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Engin Özakin, MD, Eskisehir Osmangazi University Medical Center, Department of Emergency Medicine, Meselik, 26480, Eskisehir, Turkey; +90 222 2256129; fax: +90-222-2393774; email: enginozakin@hotmail.com.

Received: December 22, 2013
Accepted: February 11, 2014
Posted Online: July 24, 2014

Case Report

A 24-year-old woman presented to the emergency department with acute visual loss in the right eye that began after sneezing. She had no previous ocular disease history. A bedside funduscopic examination demonstrated peripapillary atrophy and a pale macula with a cherry-red spot in the right eye (Figure 1). The patient was referred to the ophthalmology and neurology departments. On ophthalmologic examination, visual acuity was counting fingers in the right eye and 20/20 in the left eye. Biomicroscopic anterior segment examination findings were within normal limits. Fundus fluorescein angiography showed a cilioretinal artery occlusion in the right eye (Figure 2). Echocardiography and carotid Doppler ultra-sonography were performed. Transesophageal echocardiography showed a secundum atrial septal defect with right-to-left shunt.

Fundus photograph showing a cherry-red spot at the macula due to cilioretinal artery occlusion.

Figure 1.

Fundus photograph showing a cherry-red spot at the macula due to cilioretinal artery occlusion.

Early fundus fluorescein angiography image showing extensive choroidal fill defect at the cilioretinal artery region.

Figure 2.

Early fundus fluorescein angiography image showing extensive choroidal fill defect at the cilioretinal artery region.

Discussion

Retinal Artery Occlusion Due to a Patent Foramen Ovale

In the current case, the leading presenting symptom was acute, painless visual loss following sneezing. Causes of retinal artery occlusion vary depending on patient age. Some of the common risk factors for retinal artery occlusion are older age, systemic hypertension, diabetes mellitus, atherosclerosis1 and giant cell arteritis (temporal)2 in more than 75% of patients. An embolus originating from the cardiac system (atrial septal defect, patent foramen ovale, or valvular) should be suspected as a cause of retinal artery occlusion, especially in patients younger than 40 years. Therefore, meticulous cardiovascular examination, especially for murmurs, should be performed. A Valsalva maneuver such as sneezing contributes to an increase in intrathoracic, central venous, and right atrial pressure, above that of the left atrium, leading to right-to-left shunting through the patent foramen ovale or atrial septal defect. Thus, a Valsalva maneuver (eg, weight lifting, straining, vomiting, or sneezing) preceding the onset of focal neurological or retinal symptoms should raise suspicion for paradoxical embolism, including peripheral, cerebral, and retinal embolism.3

Emergency physicians should be aware of atrial septal defect or patent foramen ovale in the presence of unexplained peripheral embolism, particularly in young patients. Early recognition of this disease may prevent further peripheral embolic events.

References

  1. Ffytche TJ. A rationalization of treatment of central retinal artery occlusion. Trans Ophthalmol Soc UK. 1974;94(2):468–479.
  2. Fineman MS, Savino PJ, Federman JL, Eagle RC Jr, . Branch retinal artery occlusion as the initial sign of giant cell arteritis. Am J Ophthalmol. 1996;122(3):428–430.
  3. Ozdemir O, Tamayo A, et al. Cryptogenic stroke and patent foramen ovale: Clinical clues to paradoxical embolism. J Neurol Sci. 2008;275(1–2):121–127. doi:10.1016/j.jns.2008.08.018 [CrossRef]

10.3928/23258160-20140717-01

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