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A 26-year-old man with renal failure and vision loss
Digital Journal of Ophthalmology 2008
Volume 14, Number 13
July 12, 2008
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Tarek Alasil | University of Southern California
Mario Meallet | University of Southern California
Differential Diagnosis
1. Central retinal vein occlusion (CRVO).

2. Ocular ischemic syndrome (carotid occlusion disease):
In ocular ischemic syndrome, the veins are usually dilated and irregular (but not tortuous). Although revascularization of the disc is present in one third of the cases, disc edema and hemorrhages are not characteristic. Retinal hemorrhages tend to be in the mid periphery. Patients may have a history of amaurosis fugax, transient ischemic attacks, or orbital pain. The intra-ocular pressure is often low as is the central retinal artery perfusion pressure.

3. Diabetic retinopathy:
For diabetic retinopathy, hemorrhages and microaneurysms are usually concentrated in the posterior pole, exudates are more prominent, and the condition is typically bilateral. Intravenous flourescein angiography may be required to distinguish this condition from central retinal vein occlusion.

4. Papilledema:
This is characterized by bilateral disc swelling with flame-shaped hemorrhages surrounding the disc but not extending to the peripheral retina. It results from increased intracranial pressure.

5. Radiation retinopathy:
A history of irradiation is critical for this diagnosis. Disc swelling with radiation papillopathy, and retinal neovascularization may be present. Generally, cotton-wool spots are a more prominent feature than hemorrhages.

6. Acute hypertensive retinopathy:
The blood pressure at presentation is critical for the diagnosis. It is characterized by focal or generalized vasoconstriction and breakdown of the blood-retinal barrier, with subsequent hemorrhages and exudates. Findings include:
• Retinopathy: This is characterized by arteriovenous nicking, copper or silver wire arterial changes, hemorrhages, exudates, and cotton wool spots.
• Choroidopathy: This is characterized by fibrinoid necrosis of choroidal arterioles. There may be Elschnig’s spots (zones of nonperfusion of the choriocapillaris with pale white or red patches of the retinal pigment epithelium) and exudative retinal detachment. This is often due to an acute hypertensive episode (preeclampsia, eclampsia, or pheochromocytoma). FA shows early hypoperfusion and late staining.
• Optic neuropathy: This is characterized by florid disc edema with macular exudates.
The pathology is characterized by thickening of arteriolar walls, which leads to nicking of venules and endothelial hyperplasia. Complications of hypertensive retinopathy include retinal vein occlusion, retinal macroaneurysm, nonarteritic anterior ischemic optic neuropathy, ocular motor nerve palsies, and worsening of diabetic retinopathy.