Visual loss

A 49-year-old man complains of sudden onset, painless unilateral visual loss lasting about a minute. He describes ‘a black curtain coming down’. His blood pressure is 158/90, heart rate 73 bpm. There is an audible bruit on auscultation of his neck. His past medical history is insignificant other than deep vein thrombosis of his right leg ten years ago. The most likely diagnosis is:

A. Retinal vein thrombosis

B. Retinal artery occlusion

C. Amaurosis fugax

D. Optic neuritis

E. Acute angle glaucoma

Ans : Visual loss

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(C ) This man gives a classical description of amaurosis fugax (C), painless, unilateral visual loss of short duration described as ‘a black curtain descending’, caused by retinal artery emboli, with a likely cardiac source as a consequence of atrial fibrillation. Retinal artery (B) and vein (A) occlusion are also painless and of sudden onset, but they typically occur in older patients and result in prolonged visual loss. Amaurosis fugax may herald retinal artery occlusion which is confirmed on ophthalmoscopy showing oedema and a cherry red macula. It is also a complication of giant cell (temporal) arteritis. Retinal haemorrhages and cotton wool spots are typically seen in retinal vein occlusion. Optic neuritis (D) is associated with MS and patients complain of painful, blurred vision. Acute angle glaucoma (E), again seen in older patients, presents with painful, blurred vision. Patients describe ‘seeing haloes around things’.

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