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75-year-old man was seen in the office on February 24, 2011. He had laryngeal cancer treated in 1993 with radiation. He was told at the time there might be an affect on his carotid circulation and then about eight to ten years ago he was told that he had very narrow carotids, which were so stenosed that he wasn’t a surgical candidate and more recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future. There are some issues with him because of technicalities with the surgery associated with his laryngectomy. He had cataract surgery done in the right eye just in February and you noticed that the vision in the right eye is a little bit hazy since the cataract surgery. The left eye has had a macular pucker for sometime and has poor vision for several years. The cataract was removed from the left eye December of 2010. He is on Pred Forte and Bromday. VISUAL ACUITY: OD 20/60, OS 20/200. IOP: OD 15, OS 13. SLIT EXAMINATION: The posterior chamber intraocular lens is in good position in both eyes. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.0. There is posterior vitreous separation. There is retinal hemorrhage in the temporal periphery anterior to the equator between 8 and 10 o’clock. OS: Vertical C/D ratio is 0.0. There is posterior vitreous separation and 1+ epiretinal membrane with a pseudo macular hole and there is retinal hemorrhage in the periphery, again temporally at this time from 2 o’clock to 4 o’clock. OCT SCAN: The OCT scan shows a near normal central foveal thickness in both eyes. The average thickness in the right eye is 195 microns with a volume of 6.8 mm3. The left eye has 268 microns with a volume of 8.09 mm3, but the left point thickness is reasonable at about 200 microns. Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography shows enlargement of the foveal avascular zone in each eye and also a temporal capillary drop in each eye. IMPRESSION: 1. OCULAR ISCHEMIC SYNDROME – BOTH EYES 2. MACULAR PUCKER – LEFT EYE DISCUSSION: I explained to the patient he has developed ocular ischemic syndrome associated with his carotid stenosis. I explained to him the way the circulation to the eye works is normally the branch to the eye is the first branch off the carotid vessels and when the carotids are closed like his are, then that makes them the last branch to receive circulation in patients who have cerebral perfusions slowly from their vertebral arteries and in that situation the retinal circulation, nutrition and oxygenation is all compromised. He may have some sort of mitral valve procedure done in the future, which might help his retinal circulation and improve his visual function. At this moment though, I think there has probably been some permanent damage. There is nothing I think that would be reasonable to help his eyes. We talked about macular pucker surgery. The macular pucker surgery is minimal and I don’t think it is significantly contributing to his visual loss.

ocularischemiacarotids_chbl01.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion188 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl02.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion112 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl03.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion94 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl04.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion111 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl05.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion91 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl06.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion76 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl07.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion94 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl08.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion99 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl09.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion92 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl10.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion80 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl11.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion70 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl12.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion100 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl13.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion69 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl14.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion96 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
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ocularischemiacarotids_chbl15.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion62 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl16.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion48 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl17.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion44 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl18.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion80 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl19.png
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion74 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl21.jpg
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion105 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl22.jpg
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion104 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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ocularischemiacarotids_chbl23.jpg
Ocular Ishemic Syndrome - Bilateral Carotid Occlusions - OD 20/60 OS 20/200 Enlarged Foveal Avascular Zone and Temporal Non-perfusion155 views75-year-old man had laryngeal cancer treated in 15 year ago with radiation. He recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future.
VISUAL ACUITY: OD 20/60, OS 20/200
00000
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75-year-old man was seen in the office on February 24, 2011. He had laryngeal cancer treated in 1993 with radiation. He was told at the time there might be an affect on his carotid circulation and then about eight to ten years ago he was told that he had very narrow carotids, which were so stenosed that he wasn’t a surgical candidate and more recently was told that the carotid circulation is closed off on both sides. He does have a patent vertebral artery, which is supplying him pretty well and in addition to that his cardiac output is compromised by poor mitral valves. His consideration is to what can be done about that in the future. There are some issues with him because of technicalities with the surgery associated with his laryngectomy. He had cataract surgery done in the right eye just in February and you noticed that the vision in the right eye is a little bit hazy since the cataract surgery. The left eye has had a macular pucker for sometime and has poor vision for several years. The cataract was removed from the left eye December of 2010. He is on Pred Forte and Bromday. VISUAL ACUITY: OD 20/60, OS 20/200. IOP: OD 15, OS 13. SLIT EXAMINATION: The posterior chamber intraocular lens is in good position in both eyes. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.0. There is posterior vitreous separation. There is retinal hemorrhage in the temporal periphery anterior to the equator between 8 and 10 o’clock. OS: Vertical C/D ratio is 0.0. There is posterior vitreous separation and 1+ epiretinal membrane with a pseudo macular hole and there is retinal hemorrhage in the periphery, again temporally at this time from 2 o’clock to 4 o’clock. OCT SCAN: The OCT scan shows a near normal central foveal thickness in both eyes. The average thickness in the right eye is 195 microns with a volume of 6.8 mm3. The left eye has 268 microns with a volume of 8.09 mm3, but the left point thickness is reasonable at about 200 microns. Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography shows enlargement of the foveal avascular zone in each eye and also a temporal capillary drop in each eye. IMPRESSION: 1. OCULAR ISCHEMIC SYNDROME – BOTH EYES 2. MACULAR PUCKER – LEFT EYE DISCUSSION: I explained to the patient he has developed ocular ischemic syndrome associated with his carotid stenosis. I explained to him the way the circulation to the eye works is normally the branch to the eye is the first branch off the carotid vessels and when the carotids are closed like his are, then that makes them the last branch to receive circulation in patients who have cerebral perfusions slowly from their vertebral arteries and in that situation the retinal circulation, nutrition and oxygenation is all compromised. He may have some sort of mitral valve procedure done in the future, which might help his retinal circulation and improve his visual function. At this moment though, I think there has probably been some permanent damage. There is nothing I think that would be reasonable to help his eyes. We talked about macular pucker surgery. The macular pucker surgery is minimal and I don’t think it is significantly contributing to his visual loss.