Intraretinal gray lesions as a sign of reversible visual loss following prolonged ophthalmic artery hypoperfusion.

A 49-year-old woman developed severe unilateral visual loss following carotid artery ligation for a carotid-cavernous fistula. The pathophysiology was presumed to be an ophthalmic artery steal caused by the fistula. This was confirmed when visual acuity was restored by a subsequent ligation of the ophthalmic artery, despite 2 weeks of profound visual loss and ocular ischemia. Superficial cotton-wool spots and deep gray intraretinal lesions developed in the retina during the period of ocular ischemia. We postulate that the deep intraretinal lesions are clinical manifestations of a zone of retinal microvascular watershed ischemia, and that their presence may be an important diagnostic guide to the presence of reversible ocular ischemia.