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Central Retinal Artery Occlusion Workup

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 12, 2015
 

Laboratory Studies

Laboratory studies are helpful in determining the etiology of central retinal artery occlusion (CRAO), as follows:

  • CBC count to evaluate anemia, polycythemia, and platelet disorders
  • Erythrocyte sedimentation rate (ESR) evaluation for giant cell arteritis
  • Fibrinogen, antiphospholipid antibodies, prothrombin time/activated partial thromboplastin time (PT/aPTT), and serum protein electrophoresis to evaluate for coagulopathies
  • Fasting blood sugar, cholesterol, triglycerides, and lipid panel to evaluate for atherosclerotic disease
  • Blood cultures to evaluate for bacterial endocarditis and septic emboli
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Imaging Studies

Imaging studies are helpful in determining the etiology of CRAO.

Carotid ultrasound imaging to evaluate for atherosclerotic plaque. This appears to be more sensitive than carotid Doppler, which only determines the flow.

Magnetic resonance angiogram may be more accurate in detecting obstruction.

Fluorescein angiogram (see list below) is not mandatory as it doesn not influence therapy.

  • Delay in arteriovenous transit time (< 11 seconds is in the reference range)
  • Delay in retinal arterial filling
  • Normal choroidal filling (begins 1-2 seconds before retinal filling and completely filled within 5 seconds of dye appearance in healthy eyes). A delay of 5 seconds or greater is seen in 10% of patients. Consider ophthalmic artery occlusion or carotid artery obstruction if there is a significant delay in choroidal filling.
  • Arterial narrowing with normal fluorescein transit after recanalization
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Other Tests

See the list below:

  • ECG to evaluate for possible atrial fibrillation (A 24-h Holter monitor may be necessary if arrhythmia is suspected but not detected on ECG testing.)
  • Electroretinogram shows a diminished b-wave corresponding to Muller and/or bipolar cell ischemia.
  • Echocardiogram (not necessarily an emergency department test)
    • To evaluate valvular disease, wall motion abnormalities, and mural thrombi
    • To evaluate vegetations that may cause septic emboli
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Procedures

The mainstay of therapy is procedure and pharmacologic therapy (see Medical Care and Medication).

Ocular massage

Apply direct pressure for 5-15 seconds, then release. Repeat several times.

A fundus contact lens or digital massage may be used.

Ocular massage can dislodge the embolus to a point further down the arterial circulation and improve retinal perfusion.

Anterior chamber paracentesis

Administer local anesthesia. Use a 30-gauge needle on a tuberculin syringe.

Enter the eye at the limbus with bevel up.

Ensure that the needle does not damage the lens.

Withdraw fluid until the anterior chamber shallows slightly (0.1-0.2 cc).

Administer a postprocedure topical antibiotic.

A decrease in intraocular pressure is believed to allow greater perfusion, pushing emboli further down the vascular tree.

Intra-arterial fibrinolysis

This procedure is controversial.[5]

Limited evidence of improved visual acuity with urokinase is available. A few cases of intra-arterial tissue plasminogen activator (tPA) administration have been observed to be successful.

Systemic complications include transient ischemic attack (TIA), stroke, and hematoma.

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Contributor Information and Disclosures
Author

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

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

Disclosure: Partner received salary from Medscape/WebMD for 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, Association for Research in Vision and Ophthalmology, American Society of Retina Specialists

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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

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