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Amalric Triangular Sign in a Case of Central Retinal Artery Occlusion Combined With Posterior Ciliary Artery Occlusion - Case Report

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Case Reports

Amalric Triangular Sign in a Case of Central Retinal Artery Occlusion Combined With Posterior Ciliary Artery Occlusion - Case Report

Soojin Lim et al. Am J Ophthalmol Case Rep.

Abstract

Purpose: Amalric triangular sign is a rare phenomenon indicating choroidal ischemia. In this study, we reported a typical Amalric triangular sign in a case of central retinal artery occlusion (CRAO) combined with posterior ciliary artery (PCA) occlusion.

Observations: A 49-year-old women developed sudden visual loss in her left eye for one day. Ocular examination revealed rubeosis iridis, macular retinal edema followed by multiple whitish triangular patches in the peripheral four days later. Fluorescein angiography (FAG) revealed delayed choroidal filling time, delayed arteriovenous transit time, choroidal non-perfusion areas and triangular lesions of hyperfluorescent corresponding to the hypopigmented patches on the fundus. Carotid Doppler and magnetic resonance angiography (MRA) then disclosed 90% stenosis of left internal carotid artery (ICA), causing ischemia of the central retinal artery and posterior ciliary artery.

Conclusions and importance: The Amalric triangular sign indicates the occlusion on the main truck of PCA. The sign might combine with CRAO or branch retinal artery occlusion (BRAO) as presented in our case and therefore is a strong indication of possible systemic vascular risk.

Keywords: Almaric triangular sign; Central retinal artery occlusion; Choroid perfusion.

Figures

Fig. 1
Fig. 1
Left color fundus photographs and optical coherence tomography scanning of the patient at the initial visit. (A) Obvious retinal edema with an indistinct cherry-red spot in the posterior pole. (B) (C) (D) (E) showed the peripheral retina; (F) (G) Optical coherence tomography from line 1 and line 2 showed increased reflectivity and thickness of the inner retina. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
Fig. 2
Fig. 2
Left color fundus photograph, fluorescein angiography and optical coherence tomography scanning four days after the initial visit. (A)∼(D) Color fundus photograph revealed the triangular hypopigmented subretinal lesions (the green lines highlight the contour). Fluorescein angiography revealed (E) choroidal nonperfusion area in the early phase and (F) (G) (H) triangular hyperfluorescent lesions in the late phase (the red dashed lines highlight the contour). (I) Optical coherence tomography corresponding to the area from white dash line in (A) still showed inner retinal edema. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
Fig. 3
Fig. 3
Carotid magnetic resonance angiography. (A)The carotid magnetic resonance angiography showed severe stenosis of left internal carotid artery (B)The red box: amplification of stenosis area. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
Fig. 4
Fig. 4
Left color fundus photograph, fluorescein angiography and optical coherence tomography scanning two months after the initial visit. (A)–(D) The whitening triangular lesions on the fundus were evolved to as atrophic patches. Fluorescein angiography revealed (E) delayed choroidal perfusion in early phase and (F) (G) (H) late staining. (I) Optical coherence tomography revealed retinal pigment epithelium proliferation (red circle) in the area of atrophic patches corresponding to the area of hypofluorescence in fluorescein angiography (Figure F, red arrow). (The multiple small round pigment spots in mid-peripheral and peripheral retina with late staining in fluorescein angiography were panretinal photocoagulation scars). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

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