Figure 1. Photo of left eye of patient
A 27-year-old male patient presented to the office, having woken up 3 hours earlier, and reported seeing a shadow on the left side of his vision. Although his medical history was unremarkable and he was taking no medications, he did report that he had been exercising vigorously for the previous 2 weeks, perhaps in an attempt to stick to a New Year’s resolution. His visual acuity was -8.50 OU, but he was correctable to 20/20 OD and 20/25 OS. Pupil reactions and confrontation fields were normal. Intraocular pressures were 15 mm Hg OD, 14 mm Hg OS. With dilated indirect ophthalmoscopy, the right eye revealed mild venous enlargement but no other abnormalities. An examination of the left eye did not reveal a posterior vitreous detachment, pigmented cells, red blood cells or any retinal breaks. The veins in the left eye were dilated and tortuous with a few small hemorrhages and cotton wool spots. In the central macula area, some pale areas of edema were seen, with no obvious foveal reflex. The superior nasal disc area was slightly swollen with a hemorrhage at the nasal margin of the disc (Figure 1).
Submit your diagnosis to see full explanation.
Central retinal vein occlusion (CRVO) is an unlikely event in a young, healthy patient. It has been considered as a distinct entity in young individuals.1-3 CRVO presents as 1 of 2 types; ischemic or nonischemic. The latter is less severe, and can be caused by dehydration. It can play a role by causing both a blood hyperviscosity, and an associated hypercoagulable state.4,5 In the 2 weeks before the event, the patient had been working out very vigorously. The result of the associated dehydration contributed to the venous dilation and the other retinal and disc findings. The vigorous exercise and high myopia also caused the shadow. The sudden shadow on the left side of the vision was vitreous syneresis rather than a posterior vitreous detachment (PVD), which is unlikely at his age.
The pale areas of edema in the central area is called paracental acute middle maculopathy (PAMM) which is caused by hypoperfusion of the deep vascular complex, and a manifestation of the ischemic cascade. Younger patients had a higher prevalence of PAMM, a milder clinical course, and non traditional risk factors.3 These areas of edema may resolve on their own or result in atrophy and cause persistent scotomas in some patients during long term follow-up. PAMM may be present alone or as a complication of other retinal vascular diseases.
The retinal consultants diagnosed the patients with a benign form of CRVO, likely caused by dehydration. They suggested that the patient drink more fluids when exercising. Complete resolution of his early CRVO occurred within the next 2 months as the result of following this advice.
- Fong AC, Schatz H. Central retinal vein occlusion in young adults. Surv Ophthalmol. 1993;37(6):393-417. doi:10.1016/0039-6257(93)90138-w
- Gutman FA. Evaluation of a patient with central retinal vein occlusion. Ophthalmology 1983;90: 481-3. doi:10.1016/s0161-6420(83)34528-0
- Eah K, Kim Y, Park Y, et al. Central retinal vein occlusion in young patients clinical characteristics and prognostic factors. Retina. 2021;41(3):630-637. doi:10.1097/IAE.0000000000002872
- Khan K, Thomas A, Rothman A, Fekrat S. Central retinal vein occlusion in younger patients: causes, presentation and outcomes. Invest Ophthal Vis Sci. 2017;58(8):3652.
- Lahey al, Tunç M, Kearney J, et al. Laboratory evaluation of hypercoagulable states in patients with central vein occlusion who were less than 56 years of age. Ophthalmol. 2002;109:126-131. doi:10.1016/s0161-6420(01)00842-9