Central retinal artery occlusion - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:03Z

Strip excess bold

← Older revision		Revision as of 09:26, 22 March 2026
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	==Background==		==Background==
	*Acute interruption of blood flow to the retinal artery causing retinal ischemia		*Acute interruption of blood flow to the retinal artery causing retinal ischemia
	*A ~~'''~~stroke equivalent~~'''~~ — 15-25% of patients will have an acute stroke or TIA within 1 week<ref name="lee">Lee J, et al. Risk of stroke in patients hospitalized with central retinal artery occlusion. ''Stroke''. 2013;44(4):967-971. PMID 23399955.</ref>		*A stroke equivalent — 15-25% of patients will have an acute stroke or TIA within 1 week<ref name="lee">Lee J, et al. Risk of stroke in patients hospitalized with central retinal artery occlusion. ''Stroke''. 2013;44(4):967-971. PMID 23399955.</ref>
	*'''Ophthalmologic emergency''' — retinal tolerance for ischemia is approximately 90-100 minutes		*'''Ophthalmologic emergency''' — retinal tolerance for ischemia is approximately 90-100 minutes
	*Permanent vision loss occurs in most patients despite treatment		*Permanent vision loss occurs in most patients despite treatment
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	==Clinical Features==		==Clinical Features==
	*~~'''~~Sudden, painless, monocular vision loss~~'''~~ — often described as "lights went out"		*Sudden, painless, monocular vision loss — often described as "lights went out"
	*Typically develops over seconds		*Typically develops over seconds
	*Severe visual acuity loss (often counting fingers or light perception only)		*Severe visual acuity loss (often counting fingers or light perception only)
	*~~'''~~Relative afferent pupillary defect~~'''~~ (APD / Marcus Gunn pupil)		*Relative afferent pupillary defect (APD / Marcus Gunn pupil)
	*Fundoscopy:		*Fundoscopy:
	**~~'''~~Pale/white retina~~'''~~ with ~~'''~~cherry-red spot~~'''~~ at fovea (pathognomonic)		**Pale/white retina with cherry-red spot at fovea (pathognomonic)
	**Box-car segmentation of retinal vessels (intermittent blood flow)		**Box-car segmentation of retinal vessels (intermittent blood flow)
	**Retinal edema		**Retinal edema
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	*'''ESR and CRP''' — '''stat''' to evaluate for giant cell arteritis (ESR >50 in GCA)		*'''ESR and CRP''' — '''stat''' to evaluate for giant cell arteritis (ESR >50 in GCA)
	**If GCA suspected: start treatment immediately (see below)		**If GCA suspected: start treatment immediately (see below)
	*~~'''~~Fundoscopic exam~~'''~~ — cherry-red spot diagnostic		*Fundoscopic exam — cherry-red spot diagnostic
	*~~'''~~Intraocular pressure (IOP)~~'''~~ — rule out [[Acute angle-closure glaucoma\|acute glaucoma]]		*Intraocular pressure (IOP) — rule out [[Acute angle-closure glaucoma\|acute glaucoma]]
	*~~'''~~CT/CTA head and neck~~'''~~ — evaluate for stroke, carotid stenosis		*CT/CTA head and neck — evaluate for stroke, carotid stenosis
	**May also obtain CTA to look for embolic source		**May also obtain CTA to look for embolic source
	*~~'''~~ECG~~'''~~ — evaluate for atrial fibrillation		*ECG — evaluate for atrial fibrillation
	*~~'''~~Echocardiogram~~'''~~ — evaluate for cardiac embolic source		*Echocardiogram — evaluate for cardiac embolic source
	*Labs: CBC, BMP, coagulation studies, lipid panel, HbA1c		*Labs: CBC, BMP, coagulation studies, lipid panel, HbA1c
	*~~'''~~MRI with DWI~~'''~~ — assess for concurrent acute stroke		*MRI with DWI — assess for concurrent acute stroke

	==Management==		==Management==
	*'''No proven treatment''' reliably restores vision; most interventions have limited evidence<ref name="mac">Mac Grory B, et al. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. ''Stroke''. 2021;52(6):e282-e294. PMID 33843236.</ref>		*'''No proven treatment''' reliably restores vision; most interventions have limited evidence<ref name="mac">Mac Grory B, et al. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. ''Stroke''. 2021;52(6):e282-e294. PMID 33843236.</ref>
	*Traditional temporizing measures (limited evidence):		*Traditional temporizing measures (limited evidence):
	**~~'''~~Ocular massage~~'''~~ — intermittent digital pressure over closed eyelid (10-15 seconds on, 5 seconds off)		**Ocular massage — intermittent digital pressure over closed eyelid (10-15 seconds on, 5 seconds off)
	**Attempt to dislodge embolus distally		**Attempt to dislodge embolus distally
	*Emergent ophthalmology consultation		*Emergent ophthalmology consultation
	*~~'''~~If GCA suspected (age >50, elevated ESR, headache, jaw claudication):~~'''~~		*If GCA suspected (age >50, elevated ESR, headache, jaw claudication):
	**~~'''~~Methylprednisolone 1 g IV daily x 3 days~~'''~~ or ~~'''~~Prednisone 1 mg/kg PO~~'''~~		**Methylprednisolone 1 g IV daily x 3 days or Prednisone 1 mg/kg PO
	**Do NOT wait for temporal artery biopsy to start treatment		**Do NOT wait for temporal artery biopsy to start treatment
	*Stroke workup: same as [[TIA]] / [[Stroke (main)\|stroke]]		*Stroke workup: same as [[TIA]] / [[Stroke (main)\|stroke]]
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	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ for stroke workup (telemetry, vascular imaging, echocardiography)		*Admit for stroke workup (telemetry, vascular imaging, echocardiography)
	*Emergent ophthalmology consultation		*Emergent ophthalmology consultation
	*If GCA suspected: admit for IV steroids and temporal artery biopsy within 1-2 weeks		*If GCA suspected: admit for IV steroids and temporal artery biopsy within 1-2 weeks
	*Treat as ~~'''~~stroke equivalent~~'''~~ with aggressive risk factor modification		*Treat as stroke equivalent with aggressive risk factor modification

	==See Also==		==See Also==

Danbot: Major expansion: stroke equivalent emphasis, GCA workup, AHA statement reference, management

2026-03-21T18:37:21Z

Major expansion: stroke equivalent emphasis, GCA workup, AHA statement reference, management

Show changes

Danbot: Add MedicationDose entries (acetazolamide, timolol) with SMW annotations

2026-03-20T18:37:47Z

Add MedicationDose entries (acetazolamide, timolol) with SMW annotations

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 *[[Acetazolamide]], 500mg IV or PO
 *[[Mannitol]]
 ==Disposition==

Rossdonaldson1: /* Background */

2020-12-16T20:57:30Z

Background

← Older revision		Revision as of 20:57, 16 December 2020
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	==Background==		==Background==
			[[File:Schematic diagram of the human eye en.png\|thumb\|Eye anatomy.]]
	*Abbreviation: CRAO		*Abbreviation: CRAO
	*The first branch of internal carotid artery is the ophthalmic artery		*The first branch of internal carotid artery is the ophthalmic artery

Rossdonaldson1: /* Fundoscopy */

2020-02-10T18:17:34Z

Fundoscopy

← Older revision		Revision as of 18:17, 10 February 2020
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	===[[Fundoscopy]]===		===[[Fundoscopy]]===
	[[File:CRAO.png\|thumb\|Typical central retinal artery occlusion with cherry-red spot, retinal ~~oedema~~ and narrowing of the vessels.]]		[[File:CRAO.png\|thumb\|Typical central retinal artery occlusion with cherry-red spot, retinal edema and narrowing of the vessels.]]
	*Pale retina, cherry red macula		*Pale retina, cherry red macula
	*Boxcar segmentation of blood column		*Boxcar segmentation of blood column

Rossdonaldson1: /* Fundoscopy */

2020-02-10T18:16:03Z

Fundoscopy

← Older revision		Revision as of 18:16, 10 February 2020
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	*APD		*APD

	===Fundoscopy===		===[[Fundoscopy]]===
	[[File:CRAO.png\|thumb\|Typical central retinal artery occlusion with cherry-red spot, retinal oedema and narrowing of the vessels.]]		[[File:CRAO.png\|thumb\|Typical central retinal artery occlusion with cherry-red spot, retinal oedema and narrowing of the vessels.]]
	*Pale retina, cherry red macula		*Pale retina, cherry red macula

Luca.ratibondi: /* Clinical Features */

2020-02-05T09:55:27Z

Clinical Features

← Older revision		Revision as of 09:55, 5 February 2020
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	===Fundoscopy===		===Fundoscopy===
			[[File:CRAO.png\|thumb\|Typical central retinal artery occlusion with cherry-red spot, retinal oedema and narrowing of the vessels.]]
	*Pale retina, cherry red macula		*Pale retina, cherry red macula
	*Boxcar segmentation of blood column		*Boxcar segmentation of blood column

ClaireLewis at 16:11, 5 October 2019

2019-10-05T16:11:21Z

← Older revision		Revision as of 16:11, 5 October 2019
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	===Etiology===		===Etiology===
	*Embolism		*[[thromboembolism\|Embolism]]
	*Thrombosis		*Thrombosis
	*[[Temporal Arteritis]]		*[[Temporal Arteritis]]
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	*[[Sickle Cell Disease]]		*[[Sickle Cell Disease]]
	*[[Blunt orbital trauma\|Trauma]]		*[[Blunt orbital trauma\|Trauma]]
	*Vasospasm (migraine)		*Vasospasm ([[migraine]])
	*[[Acute_Angle-Closure_Glaucoma\|Glaucoma]]		*[[Acute_Angle-Closure_Glaucoma\|Glaucoma]]
	*Low retinal blood flow ([[carotid stenosis]] or [[hypotension]])		*Low retinal blood flow ([[carotid stenosis]] or [[hypotension]])
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	==Clinical Features==		==Clinical Features==
	*Sudden, [[Acute vision loss (noninflamed)\|painless, monocular vision loss]]		*Sudden, [[Acute vision loss (noninflamed)\|painless, monocular vision loss]]
	**Often preceded by episodes of amaurosis fugax		**Often preceded by episodes of [[amaurosis fugax]]
			*APD

	===Fundoscopy===		===Fundoscopy===
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	==Evaluation==		==Evaluation==
	*APD
	*Etiology work-up		*Etiology work-up
	**ESR and CRP		**ESR and CRP
	**Carotid US		**Carotid [[ultrasound\|US]]
	**[[ECG]]		**[[ECG]]
	**[[Echocardiography]] for embolus or atrial shunt		**[[Echocardiography]] for embolus or atrial shunt
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	==Management==		==Management==
	;Consult ophtho with goals for reducing [[intraocular pressure]], dislodging the embolus or increasing arterial flow		*Consult ophtho with goals for reducing [[intraocular pressure]], dislodging the embolus or increasing arterial flow

	;Start high dose systemic [[corticosteroids]] if high ESR/CRP (especially high CRP) and sudden vision loss		*Start high dose systemic [[corticosteroids]] if high ESR/CRP (especially high CRP) and sudden vision loss
	*Median starting PO [[prednisone]] 80mg/day, with 40% of patients on > 100mg/day		**Median starting PO [[prednisone]] 80mg/day, with 40% of patients on > 100mg/day
	*Treat until BOTH ESR and CRP stabilize (~2-3 wks)<ref>Hayreh SS. Anterior Ischemic Optic Neuropathy. [Internet]. 2013 Available from: http://www.medicine.uiowa.edu/eye/AION-part2/.</ref>		**Treat until BOTH ESR and CRP stabilize (~2-3 wks)<ref>Hayreh SS. Anterior Ischemic Optic Neuropathy. [Internet]. 2013 Available from: http://www.medicine.uiowa.edu/eye/AION-part2/.</ref>

	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: <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>
	#Ocular massage		*Ocular massage
	#*Intermittent direct digital pressure applied through closed eyelid x 10-15 sec with rapid release to create pressure gradient to dislodge embolism		**Intermittent direct digital pressure applied through closed eyelid x 10-15 sec with rapid release to create pressure gradient to dislodge embolism
	#[[Timolol]] ophthalmic 0.5% to decrease intraocular pressure		*[[Timolol]] ophthalmic 0.5% to decrease intraocular pressure
	#*Alternative [[acetazolamide]] 500mg IV or PO<ref>Gerstenblith BI, Fecarotta CM. The Wills Eye Manual. Lippincott 2012.</ref>		**Alternative [[acetazolamide]] 500mg IV or PO<ref>Gerstenblith BI, Fecarotta CM. The Wills Eye Manual. Lippincott 2012.</ref>
	#Increase PCO2 leading to retinal artery vasodilation/increased retinal blood flow		*Increase PCO2 leading to retinal artery vasodilation/increased retinal blood flow
	#*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)<ref>Atebara N. Efficacy of anterior chamber paracentesis and carbogen in treating nonarteritic central retinal artery occlusion. Ophthalmology 1995; 102:2029-2038</ref>
	#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 or low dose systemic [[thrombolytics]]<ref>Schumacher M, et al: Central retinal artery occlusion: Local intraarterial fibrinolysis versus conservative treatment, a multicenter
	randomized trial. Ophthalmology 2010; 117:1367-1375</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>		randomized trial. Ophthalmology 2010; 117:1367-1375</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]], 500mg IV or PO		*[[Acetazolamide]], 500mg IV or PO
	#[[Mannitol]]		*[[Mannitol]]

	==Disposition==		==Disposition==

ClaireLewis at 14:13, 14 September 2019

2019-09-14T14:13:42Z

← Older revision		Revision as of 14:13, 14 September 2019
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	*Thrombosis		*Thrombosis
	*[[Temporal Arteritis]]		*[[Temporal Arteritis]]
	*Vasculitis		*[[Vasculitis]]
	*[[Sickle Cell Disease]]		*[[Sickle Cell Disease]]
	*[[Blunt orbital trauma\|Trauma]]		*[[Blunt orbital trauma\|Trauma]]
	*Vasospasm (migraine)		*Vasospasm (migraine)
	*[[Acute_Angle-Closure_Glaucoma\|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, [[Acute vision loss (noninflamed)\|painless, monocular vision loss]]		*Sudden, [[Acute vision loss (noninflamed)\|painless, monocular vision loss]]
	**Often preceded by episodes of amaurosis fugax		**Often preceded by episodes of amaurosis fugax

			===Fundoscopy===
			*Pale retina, cherry red macula
			*Boxcar segmentation of blood column
			*Cherry red spot
			**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

	==Differential Diagnosis==		==Differential Diagnosis==
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	**Carotid US		**Carotid US
	**[[ECG]]		**[[ECG]]
	**~~Echo~~ for embolus or atrial shunt		**[[Echocardiography]] for embolus or atrial shunt
	**CBC, coags, ANA, syphilis		**CBC, coags, ANA, syphilis

	~~===Fundoscopy===~~
	*Pale retina, cherry red macula
	*Boxcar segmentation of blood column
	*Cherry red spot
	**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

	==Management==		==Management==
	;Consult ophtho with goals for reducing ~~itraocular~~ pressure, dislodging the embolus or increasing arterial flow		;Consult ophtho with goals for reducing [[intraocular pressure]], dislodging the embolus or increasing arterial flow

	;Start high dose systemic corticosteroids if high ESR/CRP (especially high CRP) and sudden vision loss		;Start high dose systemic [[corticosteroids]] if high ESR/CRP (especially high CRP) and sudden vision loss
	*Median starting PO [[prednisone]] 80mg/day, with 40% of patients on > 100mg/day		*Median starting PO [[prednisone]] 80mg/day, with 40% of patients on > 100mg/day
	*Treat until BOTH ESR and CRP stabilize (~2-3 wks)<ref>Hayreh SS. Anterior Ischemic Optic Neuropathy. [Internet]. 2013 Available from: http://www.medicine.uiowa.edu/eye/AION-part2/.</ref>		*Treat until BOTH ESR and CRP stabilize (~2-3 wks)<ref>Hayreh SS. Anterior Ischemic Optic Neuropathy. [Internet]. 2013 Available from: http://www.medicine.uiowa.edu/eye/AION-part2/.</ref>
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	#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 or low dose systemic [[thrombolytics]]<ref>Schumacher M, et al: Central retinal artery occlusion: Local intraarterial fibrinolysis versus conservative treatment, a multicenter
	randomized trial. Ophthalmology 2010; 117:1367-1375</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>		randomized trial. Ophthalmology 2010; 117:1367-1375</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]], 500mg IV or PO		#[[Acetazolamide]], 500mg IV or PO
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	==Disposition==		==Disposition==

	*Immediate ophthalmology consult		*Immediate ophthalmology consult

Jbenoit: /* Disposition */

2018-12-27T23:21:04Z

Disposition

← Older revision		Revision as of 23:21, 27 December 2018
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	==Disposition==		==Disposition==

	*~~Discharge with ophtho follow up in 1-4wk~~		*Immediate ophthalmology consult

	==See Also==		==See Also==