A case report of embolic retinal artery occlusion: the lost measurement of healthcare quality.

In this case, we report a 43-year-old African-American woman who presented with acute vision loss of the left eye. The patient was found to have central retinal artery occlusion (CRAO). Clinical examination showed characteristic physical findings of severe mitral stenosis. Echoardiographic findings confirmed the diagnosis. Laboratory testing was negative for hypercoagulability diseases. The patient suffered permanent vision loss in her left eye due to thromboembolic phenomenon secondary to mitral stenosis. Few case reports in literature, most of which date back to more than half a century ago, have reported CRAO secondary to embolic phenomenon due to mitral stenosis. The patient was born and had lived all of her life in the United States; she was admitted to hospitals on several occasions for delivery, cesarean section, and routine preventive healthcare. However, the distinctive physical examination findings were detected in none of her healthcare encounters, which would have prevented such a devastating complication of mitral stenosis. Rheumatic heart disease still exists in such a developed nation, and attentive and skilful physical examination during routine healthcare visits is important for optimum medical care.