Thanks to Dr. Guy for today’s Morning Report (presented on 4/9/2012)!
Central Retinal Artery Occlusion
Epidemiology:
- 55% mortality rate over 9 years
- 2% bilateral involvement
- mean age 62
Pathophysiology:
- emboli in retinal artery/ branches
- ophthalmic artery from intraorbital branch of internal carotid artery
- ischemia and edema
- irreversible cell injury occurs after 90-100 minutes
Presentation:
- acute painless vision loss
- non-progressive vision loss
- branch retinal artery occlusion:
- Amaurosis fugax- transient visual acuity loss preceding persistent loss of vision
- peripheral vision field loss
Risk factors:
- Systemic hypertension seen in 2/3 of patients
- atherosclerosis
- myopia
- DM
- CAD
- atrial fibrillation
- valvular disease ¼
- cardiac abnormalities
- ss disease
- ocd
- vasculitis
- embolism
- cholesterol, calcific, bacteria, endocarditis, coaguloopathies, antiphospholilipid syndromes
Exam:
- boxcar appearance of the blood column can be seen in both arteries and vein
- afferent pupillary defect
- cherry red spot and ground glass retina- 1 hour after development
- pale optic disk seen days to weeks after event
- emboli seen 20%
Management:
- Emergency- call ophthalmology
- Controversy exists regarding the optimal window of treatment in humans
- Conservative approach involves treatment up to 24 hours
- Directed towards lowering IOP and increasing perfusion
- Only 25% regain baseline vision
- Give O2, peripheral thrombolytics, ocular massage, aspirin, hyperbarics
- Long term risk modifications
Thanks for reading! Leave your comments below, we would love to hear from you.
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Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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2 Comments
Ian deSouza · April 12, 2012 at 6:02 pm
Are “peripheral thrombolytics” really part of the management? It is mentioned quite matter-of-factly after “O2” and before “ocular massage”.
jkhadpe · April 13, 2012 at 3:40 pm
For me, CRAO is one of those frustrating dx that we all learn about is a true “emergency” but with no therapy that has proved to be particularly effective. I don’t think there is good evidence supporting any of the therapies suggested. There are some case series and reports about the use of lytics- both IV and intra-arterial, but no good RCT. Part of the problem, I think, is this is a rare disease so it is difficult to get the numbers to demonstrate a benefit. So, there may be some ophto people out there that may be using it, but definitely not standard of care.