A woman with sudden unilateral vision loss

A 60-year-old female with a history of breast cancer in remission presented to the emergency department with 1 day of acute onset left eye visual changes, which she described as “shadows” and “tunnel-like.” She reported mild pain and “stinging” with extraocular movements of the left eye. Physical exam demonstrated relative afferent pupillary defect in the left eye, with visual field defects in the infranasal and supratemporal regions. The patient had normal intraocular pressure (IOP) and 20/20 corrected central vision. Ocular point-of-care ultrasound of the left eye was performed, demonstrating “spot sign” (Figure 1, Video 1). The presumptive diagnosis was corroborated by a comprehensive ocular examination by ophthalmology. She was ultimately discharged to outpatient follow up on dual-antiplatelet therapy.

Central retinal artery occlusion (CRAO) typically presents with painless loss of vision,¹ resulting from sudden blockage of the central retinal artery. This is an ocular emergency and a stroke equivalent, with retinal hypoperfusion causing rapidly progressive retinal damage and vision loss.²

“Spot sign” is a hyperechoic focus sometimes seen posterior to the globe within the optic nerve sheath, indicative of a calcified embolus from atherosclerotic plaques. Transbulbar ultrasound is valuable for the initial diagnosis and workup of CRAO because it helps to elucidate whether occlusion is secondary to thrombus or calcified embolus, with positive spot sign associated with decreased effectiveness of thrombolysis. The absence of spot sign may help to identify patients more likely to benefit from thrombolytic treatment.³

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