CENTRAL RETINAL ARTERY OCCLUSION(CRAO)Final ophthalmology

Case 1BCase 1BABELLO, ANTHONYABELLO, ANTHONY

ACERO, RIAACERO, RIAACOSTA, ANDREACOSTA, ANDRE

AGCAOILI, NIKKIAGCAOILI, NIKKIAGCAOILI, ROMARICOAGCAOILI, ROMARICO

HISTORYHISTORY

62 year old, female62 year old, female

Sudden loss of vision in her right eye an Sudden loss of vision in her right eye an hour agohour ago

HISTORYHISTORY

Vision was hand movement right eyeVision was hand movement right eye

20/20 left eye20/20 left eye

Right pupil – does not respond to light Right pupil – does not respond to light directly; reacts consensuallydirectly; reacts consensually

Left pupil – responds to light directly; Left pupil – responds to light directly; does not react consensuallydoes not react consensually

Pale retina with a reddish spot on macular Pale retina with a reddish spot on macular areaarea

DIAGNOSISDIAGNOSIS

Central Retinal Artery Central Retinal Artery OcclusionOcclusion


Painless catastrophic visual loss Painless catastrophic visual loss occurring over a period of few secondsoccurring over a period of few seconds

Antecedent Transient Visual Loss Antecedent Transient Visual Loss (amaurosis fugax)(amaurosis fugax)

Visual acuity ranges between counting Visual acuity ranges between counting fingers and light perception in 90% of fingers and light perception in 90% of eyes at initial examinationeyes at initial examination


Afferent pupillary defect can appear Afferent pupillary defect can appear within seconds, preceding the fundus within seconds, preceding the fundus abnormalities by an hourabnormalities by an hour

25% of eyes with CRAO have cilioretinal 25% of eyes with CRAO have cilioretinal arteries that spare macular retinaarteries that spare macular retina potentially preserving central visionpotentially preserving central vision

Pathophysiology of signs Pathophysiology of signs and symptomsand symptoms

PathophysiologyPathophysiologyObstruction of the central

retinal artery

Loss of blood supply to the inner layer of the retina

Inner layer edema and pyknosis of the ganglion cell nuclei

Ischemic Necrosis Visual Loss

PathophysiologyPathophysiology

CausesCauses Systemic hypertension seen in two thirds of Systemic hypertension seen in two thirds of

patientspatients Diabetes mellitusDiabetes mellitus Cardiac valvular disease seen in one fourth Cardiac valvular disease seen in one fourth

of patientsof patients


CausesCauses EmbolismEmbolism

This is most commonly cholesterol but can be This is most commonly cholesterol but can be calcific, bacterial, or talc from intravenous calcific, bacterial, or talc from intravenous drug abuse.drug abuse.

This is associated with poorer visual acuity This is associated with poorer visual acuity and higher morbidity and mortality.and higher morbidity and mortality.

Emboli from the heart are the most common Emboli from the heart are the most common cause of CRAO in patients younger than 40 cause of CRAO in patients younger than 40 years.years.


CausesCauses Atherosclerotic changesAtherosclerotic changes

Carotid atherosclerosis is seen in 45% of Carotid atherosclerosis is seen in 45% of cases of CRAO, with 60% or greater stenosis cases of CRAO, with 60% or greater stenosis in 20% of cases.in 20% of cases.

Atherosclerotic disease is the leading cause Atherosclerotic disease is the leading cause of CRAO in patients aged 40-60 years.of CRAO in patients aged 40-60 years.

OtherOther

PathophysiologyPathophysiology• Retina becomes Retina becomes opacified and opacified and yellow-white in yellow-white in appearanceappearance– takes as little as takes as little as

15 minutes to 15 minutes to several hours before several hours before becoming evident becoming evident

– resolves in 4-6 resolves in 4-6 weeksweeks

• Foveal cherry red Foveal cherry red spotspot– Visualization of the Visualization of the

choroidal pigment choroidal pigment and retinal pigment and retinal pigment epitheliumepithelium

Diagnostic ProceduresDiagnostic Procedures


• Laboratory StudiesLaboratory Studies– helpful in determining the etiology of central retinal helpful in determining the etiology of central retinal

artery occlusion (CRAO)artery occlusion (CRAO)

• CBC countCBC count– to evaluate anemia, polycythemia, and platelet disordersto evaluate anemia, polycythemia, and platelet disorders

• Erythrocyte Sedimentation Rate (ESR)Erythrocyte Sedimentation Rate (ESR)– evaluation for giant cell arteritisevaluation for giant cell arteritis

• Fibrinogen, antiphospholipid antibodies, prothrombin Fibrinogen, antiphospholipid antibodies, prothrombin time/activated partial thromboplastin time (PT/aPTT), time/activated partial thromboplastin time (PT/aPTT), and serum protein electrophoresisand serum protein electrophoresis– to evaluate for coagulopathiesto evaluate for coagulopathies


Fasting blood sugar, cholesterol, Fasting blood sugar, cholesterol, triglycerides, and lipid panel triglycerides, and lipid panel to evaluate for atherosclerotic diseaseto evaluate for atherosclerotic disease

Blood culturesBlood cultures to evaluate for bacterial endocarditis and to evaluate for bacterial endocarditis and

septic emboliseptic emboli


• Imaging studiesImaging studies– helpful in determining the etiology of CRAOhelpful in determining the etiology of CRAO

• Carotid ultrasound imagingCarotid ultrasound imaging– to evaluate atherosclerotic disease. This to evaluate atherosclerotic disease. This

appears to be more sensitive than carotid appears to be more sensitive than carotid Doppler, which only determines the flow.Doppler, which only determines the flow.

• Magnetic resonance angiogramMagnetic resonance angiogram– may be more accurate in detecting may be more accurate in detecting

obstruction.obstruction.


• Fluorescein angiogramFluorescein angiogram– Delay in arteriovenous transit time (<11 seconds is Delay in arteriovenous transit time (<11 seconds is

in the reference range)in the reference range)– Delay in retinal arterial fillingDelay in retinal arterial filling– Normal choroidal filling (begins 1-2 seconds before Normal choroidal filling (begins 1-2 seconds before

retinal filling and completely filled within 5 retinal filling and completely filled within 5 seconds of dye appearance in healthy eyes). A delay seconds of dye appearance in healthy eyes). A delay of 5 seconds or greater is seen in 10% of patients. of 5 seconds or greater is seen in 10% of patients. Consider ophthalmic artery occlusion or carotid Consider ophthalmic artery occlusion or carotid artery obstruction if there is a significant delay artery obstruction if there is a significant delay in choroidal filling.in choroidal filling.

– Arterial narrowing with normal fluorescein transit Arterial narrowing with normal fluorescein transit after recanalizationafter recanalization

Other Diagnostic Other Diagnostic ProceduresProcedures

• ECGECG– to evaluate for possible atrial fibrillation (A 24-to evaluate for possible atrial fibrillation (A 24-

h Holter monitor may be necessary if arrhythmia is h Holter monitor may be necessary if arrhythmia is suspected but not detected on ECG testing.)suspected but not detected on ECG testing.)

• ElectroretinogramElectroretinogram– shows a diminished b-wave corresponding to Muller shows a diminished b-wave corresponding to Muller

and/or bipolar cell ischemia.and/or bipolar cell ischemia.

• Echocardiogram (not necessarily an emergency Echocardiogram (not necessarily an emergency department test)department test)– To evaluate valvular disease, wall motion To evaluate valvular disease, wall motion

abnormalities, and mural thrombiabnormalities, and mural thrombi– To evaluate vegetations that may cause septic To evaluate vegetations that may cause septic

emboliemboli

ManagementManagement

Aim of ManagementAim of Management

restore the blood circulation to the restore the blood circulation to the retina as quickly as possible retina as quickly as possible increasing the perfusion of blood through increasing the perfusion of blood through

the arterythe artery

ManagementManagement

Reduction of intraocular pressure Reduction of intraocular pressure by ocular hypotensive drugs by ocular hypotensive drugs

(acetazolamide IV)(acetazolamide IV) intermittent digital massage over the intermittent digital massage over the

closed eyelidclosed eyelid 5-15 seconds repeated for up to 15 minutes.5-15 seconds repeated for up to 15 minutes.

anterior chamber paracentesis anterior chamber paracentesis dislodge an embolus dislodge an embolus

inhalation of a mixture of 5% carbon inhalation of a mixture of 5% carbon dioxide and 90% oxygendioxide and 90% oxygen

Complications & Complications & PrognosisPrognosis

ComplicationsComplications

Neovascularization and the development of Neovascularization and the development of neovascular glaucoma - occurs in about 16% neovascular glaucoma - occurs in about 16% of patients and warrants treatment.of patients and warrants treatment.

Partial or complete loss of vision in the Partial or complete loss of vision in the affected eyeaffected eye

Similar problem occurring again in the Similar problem occurring again in the same or the other eyesame or the other eye

PrognosisPrognosis

Patients with a retinal artery occlusion Patients with a retinal artery occlusion often maintain good to fair vision, but often maintain good to fair vision, but vision loss is often profound with central vision loss is often profound with central artery occlusion, even with treatment.artery occlusion, even with treatment.

Once Once retinal infarction retinal infarction has occurred, has occurred, vision loss is permanent.vision loss is permanent.

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CENTRAL RETINAL ARTERY OCCLUSION(CRAO)Final ophthalmology