Ischemic condition affecting the eye. The ischemia can occur secondary to systemically problem [or] particulary the eye. Many retinal vascular disorders {like CRAO,CRVO,Diabetic retinopathy,Hypertensive Retinopathy} shows ischemic signs.

1. OCCULAR ISCHEMIC SYNDROME
By-
Harsh Jain
Sudhanshu
B.V.P –Optometry {Pune}

3. Important Points
 Ischemia is the decrease of blood supply to a tissue. It can be
local, caused locally by a thrombus or embolus, or global due to
a low perfusion pressure.
 Hypoxia is lack of oxygen to a tissue from any cause.
 Syndrome is a group of symptoms which consistently occur
together.
 Stenosis means abnormal narrowing of blood vessels.
 Perfusion pressure, refers to the pressure gradient that drives
coronary blood pressure, meaning the difference between the
diastolic aortic pressure and the right atrial end diastolic
pressure.

4. Aetiology
 Ocular ischaemic syndrome refers to a Rare condition
resulting from Chronic ocular hypoperfusion secondary to
carotid artery stenosis.
 It is mainly unilateral {80%}
 This is chronic insufficiency of the ophthalmic artery
leading to reduced perfusion of the entire eye. The most
common cause is Carotid Stenosis.{Pocket atlas of Ophthalmology}

5. Pathogenesis
• The chronic ocular Hypoperfusion is secondary to Ipsilateral
atherosclerotic carotid stenosis of more than 90 % resulting in
50% reduction of Ipsilateral perfusion pressure.
• It typically affects patients during the 7th decade and may be
associated with Diabetes,Hypertension,Ischemic heart diseases
and Cerebro-vascular diseases.
Clinical Ophthalmology –Jack J Kanski

6. Carotid Stenosis
• It refers to atherosclerotic occlusive carotid artery disease
often associated with ulceration at the bifurcation of
common carotid artery.
• Risk factors include Male gender, old age (60-90 years),
smoking, for carotid hypertension, diabetes mellitus and
Hyperlipidaemia.

7. Manifestations
• Amaurosis fugax (transient retinal ischaemic attack)
• Retinal artery occlusion (due to embolus)
• Transient cerebral ischaemic attacks (TIA) Stroke
• Asymetrical diabetic retinopathy
Comprehensive Ophthalmology –A.K Khurana

8. Symptoms
• Loss of vision, which usually progresses gradually over
several weeks or months.
• Transient black outs (amaurosis fugax) may be noted by
some patients.
• Pain-ocular or periorbital— may be complained by some
patients.
• Delayed dark adaptation may be noted by a few patients.
Comprehensive Ophthalmology –A.K Khurana

9. Signs
• Cornea may show oedema and striae.
• Anterior chamber my reveal faint aqueous flare with few, if any,
cell (ischaemic pseudoiritis).
• Pupil may be mid dilated and poorly reacting. Iris shows
rubeosis iridis (in 66% cases) and atrophic patches.
• Cataract may occur as a complication in advanced cases.
• Neovascular glaucoma is a frequent sequelae to anterior
segment neovascularization.
Comprehensive Ophthalmology –A.K Khurana

11. Anterior Segment
Examination
• Diffuse episcleral injection and corneal oedema.
• Aqueous flare with a few cells {Ischemic pseudo-iritis}
• Iris atrophy and a mild dilated and poorly reacting pupil.
• Rubeosis Iridis is common.
• Cataract in very advanced cases.

12. Fundus Examination
o Venous dilatation with irregular caliber but no or only mild
tortuosity.
o Retinal arterial narrowing is present.
o Retina show midperipheral dot and blot haemorrhages,
microaneurysms and cotton wool spots.
o Retinal neovascularization is noted in 37% cases, which may be
in the form of NVD and occasionally NVE.
o Macular oedema is a common complication.

13. FFA
• Early phase shows delayed choroidal filling and prolonged
artero-venous transit time.{Fig –a & b}
• Late phase shows disc and perivascular hyper fluorescence,and
leakage at the posterior pole.{Fig –c}

15. Carotid Imaging
• It may involve color Doppler ultra-sonography, digital
subtraction angiography and MR angiography.

16. Management
 Anterior segment Manifestation :- are treated with topical
steroids and mydriatics.
 Neovascular Glaucoma may be treated medically or
surgerically.
 Proliferative Retinopathy can be treated with PRP although
the outcome is considerably less certain than in PDR.
 Macular Oedema may respond to intra-vitreal steroid or
anti-VEGF agents or carotid surgery.

18. Clinical Ophthalmology –Jack.J.Kanski

19. Reference
• Clinical Ophthalmology –Jack.J.Kanski
• Comprehensive Ophthalmology –A.K Khurana
• Pocket Atlas of Ophthalmology –T.Schlote.J. Rohrbach