A 71-year-old woman arrives to clinic with sudden vision loss. She was in her usual state of health until waking up this morning unable to see out of her right eye. She denies pain, but reports her right eye “feels funny.” The patient’s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis. Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate. Her temperature is 98°F (36.7°C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air. The patient's pupils are symmetric in size and equally reactive to light with accommodation. A fundoscopic exam of the right eye is shown in Figure A. The left optic fundus is unremarkable. Which of the following is the most likely diagnosis?
Papilledema
Retinal vein occlusion
Retinal detachment
Closed angle glaucoma
Retinal vein occlusion
This patient is presenting with sudden, painless, unilateral vision loss with a fundoscopic exam positive for venous dilation and retinal hemorrhage. These findings are consistent with the diagnosis of retinal vein occlusion.

Retinal vein occlusion can occur in either central or branch retinal veins and is often caused by compression from nearby arterial atherosclerosis. It presents as acute onset, painless vision loss, normally in one eye. On fundoscopic exam, classic findings of this disease include venous engorgement, retinal hemorrhage, cotton wool exudates, and edema/swelling of the optic disk can be seen. There is no definitive treatment for this disorder but symptomatic treatment includes intravitreal glucocorticoid injections and retinal laser photocoagulation. Retinal vein occlusion may resolve spontaneously or progress to permanent vision loss.

Robinson and Halpern present evidence regarding the treatment of retinal vein occlusion. They discuss how the treatments for the acute phase of this disease have been disappointing. They recommend managing long-term complications such as neovascularization with phototherapy.

Figure/Illustration A is a fundoscopic exam showing engorged retinal veins, optic disk swelling, and widespread retinal hemorrhages (red circle). These findings are characteristic of central retinal vein occlusion.

Incorrect Answers:
Answer A: Central retinal artery occlusion can present as sudden onset, unilateral vision loss. Fundoscopic exam will show a “cherry-red” spot at the fovea and a “fuzzy” retina with attenuated vessels. Embolic sources may include carotid artery atherosclerosis or cardiac vegetation. Treatment is with risk factor control.

Answer B: Closed-angle glaucoma presents as sudden, painful, vision loss caused by increased intraocular pressure. The eye will appear red and often feel “hard.” The optic disc will show characteristic cupping. Intraocular pressure will be levated and treatment is with acetazolamide, steroids, timolol, bromidine, and pilocarpine. Irodotomy is reserved for refractory cases.

Answer C: Papilledema may present as an enlargement in the blind spot and is usually bilateral, as it is caused by increased intracranial pressure. On fundoscopic exam, there will be bilateral optic disk swelling, seen as an elevated optic disk and blurred margins. Patients should undergo a neurologic evaluation to determine the etiology of the papilledema.

Answer D: Retinal detachment presents as monocular loss of vision, often described as a “curtain pulled down,” and preceded by “flashers” and “floaters.” On fundoscopic exam, crinkling of the retinal tissue and abrupt changes in vessel direction can be seen. Surgical reattachment of the retina is required to prevent loss of vision.

Bullet Summary:
Retinal vein occlusion presents with a sudden, monocular, painless loss of vision with optic disk swelling, dilated veins, cotton wool spots, and retinal hemorrhages.