A 57-year-old Hispanic female was referred to our clinic with decreased vision in the left eye of two months duration. Past medical history included hypothyroidism. Additionally, eight years prior, she experienced a branch retinal artery occlusion (BRAO) in the right eye. At that time an extensive work-up was performed, including a hematologic evaluation, which was found to be normal for lupus anticoagulant, factor VIII, factor II, and anti-thrombin III antigen. However, the patient was found be homozygous (4G/4G) for a mutation in PAI-1. The decision was made to not immediately start a blood thinning agent but to observe the patient. With the current episode of decreased vision, the patient initially reported three days of grey, cloudy vision in the left eye. She presented to an outside clinic with a best-corrected visual acuity (BCVA) was 20/20 and 20/60 in the right and left eyes, respectively. Dilated fundus examination revealed the right eye to have an area of whitening and a sclerotic arteriole superior to the fovea in the right eye while the left eye had 2+ vitritis and two white fluffy focal retinal lesions (Images 1). The clinical features were thought to be consistent with toxoplasmosis so the patient was initially started on oral trimethoprim-sulfamethoxazole 800mg twice a day and oral prednisone 40mg daily. A broad infectious and inflammatory work up, including toxoplasmosis IgG and IgM, syphilis, quanitiferon gold, bartonella, ANA, ANCA, ACE, HLA-B51, and a chest X-ray, were all found to be negative and the patient was referred to our institution. When the patient first presented to our clinic (two months after initial decreased vision), her BCVA was stable and fundus examination of the right eye was relatively normal while the left eye showed mild 1+ vitritis and a small white retinal lesion off the inferior arcade (Image 2). Fluorescein angiography (Image 3) and OCT angiography (OCT-A) (Image 4) revealed multiple areas of arterial occlusion in the left eye while the area where the white lesion had previously been seen showed mild capillary drop out. Oral antibiotics were stopped and an oral prednisone taper was tapered. One month later, the patient’s symptoms and the vitritis had resolved and visual acuity in the left eye improved to 20/30. The patient was referred to a hematologist for management of the thrombotic disease but was then lost to follow-up.
Images 1. Fundus photos on first presentation showing a white lesion in the right eye while the left eye showed moderate vitritis with white lesions off the superior and inferior arcades.
Image 2. Fundus photos two months after first presentation showing resolution of the white lesion in the right eye and improvement of the vitritis in the left eye.
Image 3. Fluorescein angiography two months after first presentation showing mild capillary drop out in the right eye (arrow) and several arterial occlusions in the left eye (arrows).
Image 4. OCT angiography non-segmented images two months after first presentation showing mild loss of inner retinal perfusion of the right and severe loss of perfusion in the left eye (arrows).