Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS) is reduced or lack of blood (hypo-perfusion) supply to organ such as eye. Ischemia will result in severe pain (eyeball pain) and symptoms of vision deficiency. Ocular ischemic syndrome is predominantly present with severe pain and may be a warning sign of possible stroke, if ignored. Vision loss or lack of vision also is recognized as amaurosis fugax that may be at times a predominant symptom with mild to moderate symptoms. Further investigation to rule out carotid artery blockade is extremely urgent to prevent stroke.
Epidemiology of Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Twice more common in males than females.
- Age- 50 to 80 years.
- Five percent of patients with internal carotid artery stenosis develop Ocular Ischemic Syndrome – OIS.
Types of Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
Unilateral or Bilateral:
- Carotid artery occlusion – most common.
- Common carotid terminology/artery.
- Internal carotid artery.
- Anterior segment ischemic syndrome.
- Retinal arterial occlusion.
- Ophthalmic artery occlusion.
- Takayasu’s arteritis.
- Giant cell arteritis.
Pathophysiology of Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
Ninety percent of ischemic diseases of eyes is associated with vision loss. Most common cause of ischemia is hypoperfusion secondary to occlusion of carotid artery. Most often occlusion is observed in common carotid artery, which may result in stroke, if not treated. Hypoperfusion can occur secondary to blockade of arteries or rupture of small branches. Ocular and retinal arterial bleeding is often observed with history of hypertension and diabetes. Hemorrhage and hypoperfusion results in injury of fibers and retinal cells, damage could be permanent.
Thromboembolism of ocular vessels often results in ocular ischemic syndrome. Thromboembolism is observed with history of carotid artery occlusion secondary to thrombosis of common carotid artery. Thromboses of ocular vessels are rare and often observed with a history of atherosclerosis. Embolism is secondary to dislodged thrombus from distant organs such as deep venous thrombosis, pulmonary thromboembolism, or arterial fibrillation. Thrombosis of retinal or ophthalmic artery is observed in diseases such as Giant Cell arteritis and Takayasu’s arteritis.
Ophthalmic artery occlusion secondary to carotid artery stenosis or embolism results in proliferation of blood vessels or neovascularization. Physiological changes in ischemic retinal tissue results in necrosis and partial blindness. Eye pressure on examination is found increased secondary to neovascularization resulting in glaucoma.
Eye surgery for strabismus may result in anterior segment ischemic syndrome.
The reduced arterial pressure is manifested as spontaneous pulsation of CRA (Central Retinal Artery). The findings are variable and can include any or all of the findings listed above. More than eighty percent of patients with OIS-Ocular Ischemic Syndrome who develop neovascularization of the anterior segment manifest best corrected vision of finger counting within 12 months of diagnosis.
OIS-Ocular Ischemic Syndrome symptoms are observed in ocular arterial stenosis over 50%. Carotid arterial stenosis over 90% causes symptoms of OIS-Ocular Ischemic Syndrome.
Symptoms of Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Moderate to severe pain – over eye and eyeballs.
- Vision loss.
- Patients with known hypertension and coronary artery disease.
- History of stroke.
- Renal insufficiency.
Signs Observed During Eye Examination:
- Retina: Retinal hemorrhage.
- Retinal veins: Dilated and varicose.
- Retinal arterial pulsation are observed.
- Cornea: Edematous.
- Macula: Cherry red spot and cotton wool spots are observed on fundoscopy.
- Glaucoma: Eye pressure is increased.
Treatment for Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Early diagnosis is extremely important to prevent rapid increased of intraocular pressure.
- Topical – Corticosteroid and cycloplegic ointment or drops are use to prevent increase of intraocular pressure.
Systemic Treatment for Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Steroid such as methylprednisolone is advised, when giant cell arteritis is suspected.
- Diuretics- Acetazolamide I.V. 500 mg.
- Antiplatelet Therapy.
- Thrombolytic Therapy.
- Treatment of Diabetes and Hypertension.
- Hyperbaric Oxygen Therapy.
Surgery for Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Paracentesis of aqueous humor to reduce intraocular pressure.
- Pain-retinal photocoagulation with an argon laser is effective in reducing the neovascular components, mostly in later stage.
- Carotid endarterectomy to prevent stroke. Following surgery, close to one-third of these cases improve, close to one-third remain stable and about one-third worsen.
- Ciliary body ablation-cyclocryotherapy cyclophotocoagulation.
Treatment to Lower Intraocular Pressure to Prevent Acute Glaucoma and Blindness Secondary to Nerve Damage:
- Incisional surgery.
- Ablation of the ciliary body: Ciliary body produces aqueous humor. Aim of the procedure is ciliary body ablation to prevent secretion of aqueous humor. Endoscopic cryoablation or freezing cryoprobe ablation of ciliary body is more precise treatment to damage ciliary body with minimum invasion.
Watch 3D Video of Ischemic Eye Pain
Tests to Diagnose Ischemic Eyeball Pain or Ocular Ischemic Syndrome (OIS)
- Increase White Blood Cell Count: Infection.
- Sedimentary Rate: Temporal Arteritis.
- Ultrasound: Diagnosed carotid artery thrombosis and stenosis.
- Visual Field Testing and Visual Acuity: Changes in retina and fundus of eyeball.
- Blood Sugar: Diagnoses level of sugar in diabetic patients.
- EKG and Echocardiography: Diagnosed cardiac diseases.
- EEG, Ct Scan and MRI: Diagnose stroke.
- American Academy of Ophthalmology. (2021). Ocular Ischemic Syndrome. https://www.aao.org/eye-health/diseases/ocular-ischemic-syndrome
- National Eye Institute. (2020). Ocular Ischemic Syndrome. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/ocular-ischemic-syndrome
- American Society of Retina Specialists. (n.d.). Ocular Ischemic Syndrome (OIS). https://www.asrs.org/patients/retinal-diseases/17/ocular-ischemic-syndrome-ois