Central retinal artery occlusion: Difference between revisions

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== Background  ==
== Background  ==
 
The first branch of internal carotid artery is the ophthalmic artery.  Visual loss from CRAO is usually painless and is more common in the elderly with carotid artery disease
*Internal carotid -> ophthalmic -> central retinal artery  
*Cherry red spot (fundoscopy)  
*Cherry red spot (fundoscopy)  
**Macula is thinnest portion of retina  
**Macula is thinnest portion of retina  
**Intact underlying choroidal circulation remains visible through this section  
**Intact underlying choroidal circulation remains visible through this section  
***Macular area maintains normal color (red) versus surrounding ischemic, pale retina  
***Macular area maintains normal color (red) versus surrounding ischemic, pale retina due to differing blood supplies
*Restoration of blood flow within 100min may lead to complete recovery  
*Restoration of blood flow within 100min may lead to complete recovery  
**Occlusion >240min leads to irreversible damage
**Occlusion >240min leads to irreversible damage


=== Etiology ===
==Etiology==
 
#Embolism  
#Embolism  
#Thrombosis  
#Thrombosis  
#[[Temporal Arteritis]]  
#[[Temporal Arteritis]]  
#Vasculitis  
#Vasculitis  
#Sickle cell
#[[Sickle Cell Disease]]
#Trauma  
#Trauma  
#Vasospasm (migraine)  
#Vasospasm (migraine)  
#Glaucoma  
#[[Acute_Angle-Closure_Glaucoma|Glaucoma]]
#Low retinal blood flow (carotid stenosis or hypotension)
#Low retinal blood flow (carotid stenosis or hypotension)


== Clinical Features  ==
== Clinical Features  ==
#Sudden, painless, monocular vision loss  
#Sudden, painless, monocular vision loss  
##Often preceded by episodes of amaurosis fugax
##Often preceded by episodes of amaurosis fugax


== Diagnosis  ==
== Diagnosis  ==
#APD  
#APD  
#Fundoscopy  
#Fundoscopy  
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== DDx  ==
== DDx  ==
#Amaurosis fugax  
#Amaurosis fugax  
#CRVO  
#CRVO  
#[[Temporal Arteritis]]  
#[[Temporal Arteritis]]  
#Acute glaucoma
#[[Acute_Angle-Closure_Glaucoma|Acute glaucoma]]


== Treatment  ==
== Treatment  ==
;Consult ophtho with goals for reducing itraocular pressure, dislodging  the embolus or increasing arterial flow


#Consult ophtho
No evidence supporting or refuting the following treatments: <ref>Rudkin A et al. Clinical characteristics and outcome of current standard management of central retinal artery occlusion. Clin Experiment Ophthalmol 2010; 38:496-501</ref>
#No evidence supporting or refuting the following treatments:  
#Ocular massage  
##Ocular massage  
#*Intermittent direct digital pressure applied through closed eyelid x 10-15 sec w/ rapid release to create pressure gradient to dislodge embolism  
###Intermittent direct digital pressure applied through closed eyelid x 10-15 sec w/ rapid release to create pressure gradient to dislodge embolism  
#Timolol ophthalmic 0.5% to decrease IOP
##Timolol ophthalmic 0.5%&nbsp; to decrease IOP<br>
#Increase PCO2 leading to retinal artery vasodilation/increased retinal blood flow  
##Increase PCO2 leading to retinal artery vasodilation/increased retinal blood flow <br>
#*Rebreathe into paper bag x10 min q hr  
###Rebreathe into paper bag x10 min q hr  
#*Inhale 95% O2 and 5% CO2 (Carbogen)<ref>Atebara N. Efficacy of anterior chamber paracentesis and carbogen in treating nonarteritic central retinal artery occlusion. Ophthalmology 1995; 102:2029-2038</ref>
###Inhale 95% O2 and 5% CO2 (Carbogen)<br>  
#Anterior chamber paracentesis  
##Anterior chamber paracentesis  
#*Causes acute drop in IOP to dislodge embolism  
###Causes acute drop in IOP to dislodge embolism  
#Intraarterial fibrinolysis or low dose systemic thrombolytics<ref>Schumacher M, et al: Central retinal artery occlusion: Local intraarterial fibrinolysis versus conservative treatment, a multicenter
##Intraarterial fibrinolysis  
randomized trial. Ophthalmology 2010; 117:1367-1375</ref><ref><ref>Chen C et al: Efficacy of intravenous tissue-type plasminogen activator in central retinal artery occlusion: Report from a randomized, controlled trial. Stroke 2011; 42:2229-2234.</ref>
##Acetazolamide, 500 mg IV or PO  
#Acetazolamide, 500 mg IV or PO  
##Mannitol
#Mannitol


== Dispo  ==
== Disposition ==


*D/c w/ ophtho f/u in 1-4wk
*D/c w/ ophtho f/u in 1-4wk

Revision as of 00:00, 10 May 2014

Background

The first branch of internal carotid artery is the ophthalmic artery. Visual loss from CRAO is usually painless and is more common in the elderly with carotid artery disease

  • Cherry red spot (fundoscopy)
    • Macula is thinnest portion of retina
    • Intact underlying choroidal circulation remains visible through this section
      • Macular area maintains normal color (red) versus surrounding ischemic, pale retina due to differing blood supplies
  • Restoration of blood flow within 100min may lead to complete recovery
    • Occlusion >240min leads to irreversible damage

Etiology

  1. Embolism
  2. Thrombosis
  3. Temporal Arteritis
  4. Vasculitis
  5. Sickle Cell Disease
  6. Trauma
  7. Vasospasm (migraine)
  8. Glaucoma
  9. Low retinal blood flow (carotid stenosis or hypotension)

Clinical Features

  1. Sudden, painless, monocular vision loss
    1. Often preceded by episodes of amaurosis fugax

Diagnosis

  1. APD
  2. Fundoscopy
    1. Pale retina, cherry red macula
    2. Boxcar segmentation of blood column

DDx

  1. Amaurosis fugax
  2. CRVO
  3. Temporal Arteritis
  4. Acute glaucoma

Treatment

Consult ophtho with goals for reducing itraocular pressure, dislodging the embolus or increasing arterial flow

No evidence supporting or refuting the following treatments: [1]

  1. Ocular massage
    • Intermittent direct digital pressure applied through closed eyelid x 10-15 sec w/ rapid release to create pressure gradient to dislodge embolism
  2. Timolol ophthalmic 0.5% to decrease IOP
  3. Increase PCO2 leading to retinal artery vasodilation/increased retinal blood flow
    • Rebreathe into paper bag x10 min q hr
    • Inhale 95% O2 and 5% CO2 (Carbogen)[2]
  4. Anterior chamber paracentesis
    • Causes acute drop in IOP to dislodge embolism
  5. Intraarterial fibrinolysis or low dose systemic thrombolytics[3]Cite error: Closing </ref> missing for <ref> tag
  6. Acetazolamide, 500 mg IV or PO
  7. Mannitol

Disposition

  • D/c w/ ophtho f/u in 1-4wk

See Also

Source

  • Tintinalli
  • UpToDate
  • Rosen's


  1. ↑ Rudkin A et al. Clinical characteristics and outcome of current standard management of central retinal artery occlusion. Clin Experiment Ophthalmol 2010; 38:496-501
  2. ↑ Atebara N. Efficacy of anterior chamber paracentesis and carbogen in treating nonarteritic central retinal artery occlusion. Ophthalmology 1995; 102:2029-2038
  3. ↑ Schumacher M, et al: Central retinal artery occlusion: Local intraarterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 2010; 117:1367-1375
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