Central Retinal Artery Occlusion Clinical Presentation

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 16, 2012
 

History

  • The most common presenting complaint is an acute, persistent, painless loss of vision in the range of counting fingers to light perception in 90% of patients. Consider ophthalmic artery occlusion if visual acuity is worse.
  • Some patients may reveal a history of amaurosis fugax involving transient loss of vision lasting seconds to minutes but which may last up to 2 hours. The vision usually returns to baseline after an episode of amaurosis fugax.
  • Ask about symptoms of temporal arteritis in the older population. Patients complain of sudden, painless, nonprogressive vision loss in one eye. History of headaches, jaw claudication, scalp tenderness, proximal muscle and joint aches, anorexia, weight loss, or fever may be elicited.
  • Ask about any medical problems that could predispose to embolus formation (eg, atrial fibrillation, endocarditis, coagulopathies, atherosclerotic disease, hypercoagulable state).
  • Prolonged direct pressure to the globe during drug-induced stupor or improper positioning during surgery may lead to CRAO.
  • Ask about drug history.
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Physical

  • Determine the degree of vision loss (eg, no light perception, hand movement, counting fingers).
  • Ocular examination includes the following:
    • Check for afferent pupillary defect.
    • Perform an optic nerve examination to look for signs of temporal arteritis. Critical signs include afferent pupillary defect and pale/swollen optic nerve with splinter hemorrhages.
    • Cherry-red spot and a ground-glass retina may take hours to develop.
    • The funduscopic findings typically resolve within days to weeks of the acute event, sometimes leaving a pale optic disc as the only physical finding.
    • Emboli can be seen in about 20% of patients with CRAO.
    • Boxcar segmentation can be seen in both arteries and veins. This is a sign of severe obstruction.
    • Perform a cardiovascular examination for murmurs or carotid bruits.
    • Perform a systemic examination for temporal tenderness, jaw claudication, muscle weakness, and fever to evaluate for temporal arteritis.
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Causes

Causes of CRAO vary depending on the age of the patient. A detailed analysis of comorbid disease is necessary to elucidate the cause of the acute visual loss.

  • Systemic hypertension seen in two thirds of patients
  • Diabetes mellitus
  • Cardiac valvular disease seen in one fourth of patients
  • Cardiac anomalies, such as patent foramen ovale
  • Embolism
    • This is most commonly cholesterol but can be calcific, bacterial, or talc from intravenous drug abuse.
    • This is associated with poorer visual acuity and higher morbidity and mortality.
    • Emboli from the heart are the most common cause of CRAO in patients younger than 40 years.
    • Amaurosis fugax preceding persistent loss of vision suggests branch retinal artery occlusion (BRAO) or temporal arteritis and may represent emboli causing temporary occlusion of the retinal artery.
    • Coagulopathies from sickle cell anemia or antiphospholipid antibodies are more common etiologies for CRAO in patients younger than 30 years.
  • Atherosclerotic changes
    • Carotid atherosclerosis is seen in 45% of cases of CRAO, with 60% or greater stenosis in 20% of cases.
    • Atherosclerotic disease is the leading cause of CRAO in patients aged 40-60 years.
  • Giant cell arteritis
    • Giant cell arteritis should be considered in patients older than 65 years, but do not ignore in younger patients.
    • Giant cell arteritis may produce CRAO or ischemic optic neuropathy.
    • Giant cell arteritis needs to be treated to preserve vision in the fellow eye.
  • Hypercoagulable state
  • Collagen vascular disease
  • Oral contraceptives
  • Polycythemia
  • Polyarteritis nodosa
  • Rare causes
  • Consider in younger patients
  • Behçet disease
  • Syphilis
  • Sickle cell disease
  • Migraine
  • Increased intraocular pressure from glaucoma or prolonged direct pressure to the globe in unconscious patients
  • Hydrostatic arterial occlusion
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Contributor Information and Disclosures
Author

Robert H Graham, MD  Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society

Disclosure: WebMD/eMedicine Salary Employment

Coauthor(s)

Shehab A Ebrahim, MD  Assistant Professor, Department of Ophthalmology, Tulane University; Vitreoretinal Surgeon, The Retina Institute, LLC

Shehab A Ebrahim, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

V Al Pakalnis, MD, PhD  Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians and Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Other; Topcon Medical Lasers Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors, Enoch Huang, MD, MPH, and DooHo Brian Kim, BA, to the development and writing of this article.

References

  1. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. Jan 1980;87(1):75-8. [Medline].

  2. Schumacher M, Schmidt D, Jurklies B, Gall C, Wanke I, Schmoor C, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology. Jul 2010;117(7):1367-75.e1. [Medline].

  3. Rudkin AK, Lee AW, Aldrich E, Miller NR, Chen CS. Clinical characteristics and outcome of current standard management of central retinal artery occlusion. Clin Experiment Ophthalmol. Jul 2010;38(5):496-501. [Medline].

  4. Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke. Jun 2008;39(6):1746-50. [Medline].

  5. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating acute nonarteritic central retinal artery occlusion. Ophthalmology. Dec 1995;102(12):2029-34; discussion 2034-5. [Medline].

  6. Augsburger JJ, Magargal LE. Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol. Dec 1980;64(12):913-7. [Medline].

  7. Beiran I, Reissman P, Scharf J, Nahum Z, Miller B. Hyperbaric oxygenation combined with nifedipine treatment for recent-onset retinal artery occlusion. Eur J Ophthalmol. Apr-Jun 1993;3(2):89-94. [Medline].

  8. Biousse V, Calvetti O, Bruce BB, Newman NJ. Thrombolysis for central retinal artery occlusion. J Neuroophthalmol. Sep 2007;27(3):215-30. [Medline].

  9. Brown G. Retinal arterial occlusive disease. In: Guyer DR, ed. Retina-Vitreous-Macula. Vol. 1. WB Saunders; 1999:271-85.

  10. Brown GC. Retinal artery obstructive disease. In: Ryan SJ, ed. Retina. Vol 2. Mosby-Year Book; 1994:1361-77.

  11. Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young adults. Ophthalmology. Jan 1981;88(1):18-25. [Medline].

  12. Carrero JL, Sanjurjo FJ. Bilateral cilioretinal artery occlusion in antiphospholipid syndrome. Retina. Jan 2006;26(1):104-6. [Medline].

  13. Chen CS, Lee AW. Management of acute central retinal artery occlusion. Nat Clin Pract Neurol. Jul 2008;4(7):376-83. [Medline].

  14. Feist RM, Emond TL. Translumenal Nd:YAG laser embolysis for central retinal artery occlusion. Retina. Sep 2005;25(6):797-9. [Medline].

  15. Ffytche TJ, Bulpitt CJ, Kohner EM, Archer D, Dollery CT. Effect of changes in intraocular pressure on the retinal microcirculation. Br J Ophthalmol. May 1974;58(5):514-22. [Medline].

  16. Hattenbach LO, Kuhli-Hattenbach C, Scharrer I, Baatz H. Intravenous thrombolysis with low-dose recombinant tissue plasminogen activator in central retinal artery occlusion. Am J Ophthalmol. Nov 2008;146(5):700-6. [Medline].

  17. Hayreh SS. Prevalent misconceptions about acute retinal vascular occlusive disorders. Prog Retin Eye Res. Jul 2005;24(4):493-519. [Medline].

  18. Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol. Sep 2005;140(3):376-91. [Medline].

  19. Hayreh SS, Zimmerman MB. Fundus changes in central retinal artery occlusion. Retina. Mar 2007;27(3):276-89. [Medline].

  20. Hertzog LM, Meyer GW, Carson S. Central retinal artery occlusion treated with hyperbaric oxygen. Journal of Hyperbaric Medicine. 1992;7:33-42.

  21. Knoop K, Trott A. Ophthalmologic procedures in the emergency department--Part I: Immediate sight-saving procedures. Acad Emerg Med. Jul-Aug 1994;1(4):408-12. [Medline].

  22. Lacy C, Armstrong LL, Ingram N. Drug Information Handbook. 4th ed. Cleveland: Lexi-Comp, Inc; 1996.

  23. Magargal LE, Goldberg RE. Anterior chamber paracentesis in the management of acute nonarteritic central retinal artery occlusion. Surg Forum. 1977;28:518-21. [Medline].

  24. Mangat HS. Retinal artery occlusion. Surv Ophthalmol. Sep-Oct 1995;40(2):145-56. [Medline].

  25. Miyake Y, Horiguchi M, Matsuura M. Hyperbaric oxygen therapy in 72 eyes with retinal arterial occlusion. In: 9th International Symposium on Underwater and Hyperbaric Physiology. Underwater and Hyperbaric Medical Society; 1987:949-53.

  26. Noble J, Weizblit N, Baerlocher MO, Eng KT. Intra-arterial thrombolysis for central retinal artery occlusion: a systematic review. Br J Ophthalmol. May 2008;92(5):588-93. [Medline].

  27. Ozdemir H, Karacorlu S, Karacorlu M. Optical coherence tomography findings in central retinal artery occlusion. Retina. Jan 2006;26(1):110-2. [Medline].

  28. Rhee DJ, Pyfer M. Central retinal artery occlusion. In: Wills Eye Manual: Office & Emergency Room Diagnosis & Treatment of Eye Disease. Lippincott Williams & Wilkins; 2000:331-5.

  29. Schmidt D, Schumacher M, Wakhloo AK. Microcatheter urokinase infusion in central retinal artery occlusion. Am J Ophthalmol. Apr 15 1992;113(4):429-34. [Medline].

  30. Scott I, Flynn H, Rosa R. Other retinal vascular disease. In: Atlas of Ophthalmology. New York: Springer-Verlag; 2000:297.

  31. Shinoda K, Yamada K, Matsumoto CS, Kimoto K, Nakatsuka K. Changes in retinal thickness are correlated with alterations of electroretinogram in eyes with central retinal artery occlusion. Graefes Arch Clin Exp Ophthalmol. Jul 2008;246(7):949-54. [Medline].

  32. Weber J, Remonda L, Mattle HP, et al. Selective intra-arterial fibrinolysis of acute central retinal artery occlusion. Stroke. Oct 1998;29(10):2076-9. [Medline].

  33. Wolintz RJ. Carotid endarterectomy for ophthalmic manifestations: is it ever indicated?. J Neuroophthalmol. Dec 2005;25(4):299-302. [Medline].

  34. Wray SH. The management of acute visual failure. J Neurol Neurosurg Psychiatry. Mar 1993;56(3):234-40. [Medline].

  35. Yanoff M, Fine B. Ocular Pathology: A Color Atlas. Lippincott-Raven; 1988:133-5.

 
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