Central retinal artery occlusion

Background

• Internal carotid -> ophthalmic -> central retinal artery
• 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
• 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
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

1. Consult ophtho
2. No evidence supporting or refuting the following treatments:
   1. Ocular massage
      1. 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
      
      1. Rebreathe into paper bag x10 min q hr
      2. Inhale 95% O2 and 5% CO2 (Carbogen)
         
   4. Anterior chamber paracentesis
      1. Causes acute drop in IOP to dislodge embolism
   5. Intraarterial fibrinolysis
   6. Acetazolamide, 500 mg IV or PO
   7. Mannitol

Dispo

• D/c w/ ophtho f/u in 1-4wk

See Also

• Acute Vision Loss (Noninflamed)

Source

• Tintinalli
• UpToDate
• Rosen's