Chewa Raja Joanne Shalini, Redzuan Muhammad Adib, Rafique Ali Abdullah Ashraf
Department of Ophthalmology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, MYS.
Department of Ophthalmology, Hospital Al-Sultan Abdullah, Universiti Teknologi MARA, Puncak Alam, MYS.
Cureus. 2024 Nov 22;16(11):e74198. doi: 10.7759/cureus.74198. eCollection 2024 Nov.
A 40-year-old gravida 7 para 4+2 lady who was 14 weeks pregnant presented with a three-day history of sudden-onset flashes of light associated with a superonasal visual field defect on her right eye. She had two prior miscarriages that occurred in the second and third trimesters. Previous serological tests for antiphospholipid syndrome (APS) were normal. No other comorbidities were reported. On examination, visual acuity for both eyes was 6/6 with normal intra-ocular pressure. There was an embolus lodged at the inferotemporal peripheral retinal artery of the right eye with adjacent pale and oedematous distal retina. This corresponded with a superonasal scotoma on the Humphrey 30-2 visual field test. Other examinations were unremarkable. The patient was referred to obstetrics, rheumatology, and neuro-medical teams for co-management. Full blood count, coagulation profile, auto-immune panel, and antiphospholipid serological screening test were normal. No abnormalities were seen on her electrocardiogram and echocardiogram. A magnetic resonance angiogram of the brain revealed significant bilateral internal carotid stenosis at C2 and C6 levels. However carotid artery assessment showed normal flow below the jawline. The patient was diagnosed with seronegative APS with right-eye inferotemporal branch retinal artery occlusion (BRAO). A multidisciplinary team monitored her pregnancy, and she was started on subcutaneous enoxaparin 40 mg twice a day and oral aspirin/glycine 100 mg/45 mg once daily. At 20 weeks of pregnancy, the Hollenhorst plaque disappeared, and the visual field defect started to improve. She went on to deliver a healthy child at 36+6 weeks. Post-partum, she has continued on oral aspirin 100 mg once daily. A carotid angiogram performed post-delivery showed no evidence of internal carotid artery stenosis or thrombosis. This case highlights the importance of recognizing BRAO as it can be the presentation of a previously unrecognized seronegative antiphospholipid syndrome. Early recognition of the correct diagnosis is vital to allow effective multidisciplinary management, especially when dealing with a patient in pregnancy.
一名40岁、孕7产4⁺²的女性，怀孕14周，出现了为期三天的突发闪光症状，并伴有右眼鼻上象限视野缺损。她曾有两次流产，分别发生在孕中期和孕晚期。之前抗磷脂综合征（APS）的血清学检查结果正常。未报告其他合并症。检查时，双眼视力均为6/6，眼压正常。右眼颞下周边视网膜动脉有一个栓子，相邻的远端视网膜苍白且水肿。这与Humphrey 30 - 2视野检查中的鼻上象限暗点相符。其他检查无异常。患者被转诊至产科、风湿病科和神经科团队进行联合管理。血常规、凝血指标、自身免疫指标及抗磷脂血清学筛查检查均正常。心电图和超声心动图未见异常。脑部磁共振血管造影显示双侧颈内动脉在C2和C6水平有明显狭窄。然而，颈动脉评估显示下颌线以下血流正常。患者被诊断为血清阴性APS伴右眼颞下分支视网膜动脉阻塞（BRAO）。多学科团队对她的孕期进行监测，并开始让她每天皮下注射两次40毫克依诺肝素，每天口服一次100毫克阿司匹林/45毫克甘氨酸。怀孕20周时，Hollenhorst斑消失，视野缺损开始改善。她在孕36⁺6周时顺利产下一名健康婴儿。产后，她继续每天口服100毫克阿司匹林。产后进行的颈动脉血管造影显示没有颈内动脉狭窄或血栓形成的迹象。该病例强调了认识BRAO的重要性，因为它可能是先前未被识别的血清阴性抗磷脂综合征的表现。早期识别正确诊断对于进行有效的多学科管理至关重要，尤其是在处理孕期患者时。
