Retinal Artery Occlusion Clinical Presentation

  • Author: Neil Jain, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Apr 13, 2012
 

History

  • The most common presenting complaint is an acute persistent painless loss of vision. In central artery occlusions, visual loss is central and dense. In branch artery occlusions, visual loss may go unnoticed if only a section of the peripheral visual field space is affected.
  • A complete visual field defect suggests central retinal artery occlusion (CRAO).
  • A sectional visual field defect suggests branch retinal artery occlusion (BRAO) and may be an altitudinal defect affecting the upper or lower hemifield but never respecting a vertical axis.
  • A history of hypertension or diabetes mellitus is elicited in 67% and 25% of patients with CRAO, respectively.
  • Query about any medical problems that could predispose patients to embolus formation (eg, atrial fibrillation, endocarditis, coagulopathies, atherosclerotic disease).
  • Prolonged direct pressure to the globe during drug-induced stupor or improper positioning during surgery also may lead to CRAO.
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Physical

  • Determine the degree of vision loss (eg, no light perception, hand movement, counting fingers); the prognosis for recovery is directly related to initial visual loss.
  • Document hand movement, finger counts, and visual fields at a standard distance of 1' to 3'. Documentation of distance will provide concise communication with consultants and for standardization of repeated examinations.
  • Funduscopic examination
    • An afferent pupillary defect (ie, paradoxical dilatation of the pupil when a light is shined from the unaffected eye to the affected eye) may be observed within seconds of the occlusive event.
    • The cherry red spot and a ground-glass retina are the classic findings but 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 observed in approximately 20% of patients with CRAO.
    • A dilated funduscopic examination is required to see the pathological signs of RAO.
    • BRAO presents with whitening of the retina along the distribution of the occluded vessel.
    • Boxcar segmentation of the blood column is observed most often in BRAO and is a sign of severe occlusion and slowing of circulation.
  • Direct the physical examination to evaluate for murmurs, carotid bruits, or other signs of cardiovascular disease.
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Causes

Causes of central retinal artery occlusion (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.

  • Embolism
    • Embolism is usually caused by cholesterol, but it can be calcific, bacterial, or talc from IV drug abuse.
    • It is associated with poorer visual acuity and higher morbidity and mortality than other retinal artery occlusions.
    • Embolus from the heart is 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 common etiologies for CRAO in patients younger than 30 years.
  • Atherosclerotic changes
    • Carotid atherosclerosis is observed in 45% of CRAO cases, with 60% or more stenosis occurring in 20% of cases.
    • Atherosclerotic disease is the leading cause of CRAO in patients aged 40-60 years.
  • Inflammatory endarteritis
    • Occurrence is rare (only 2% of cases).
    • Suspect inflammatory endarteritis in elderly patients if no other etiology is observed.
    • Inflammatory endarteritis can affect the second eye within hours if untreated.
  • Migraines are rare causes of CRAO but are most common in patients younger than 30 years.
  • Hydrostatic arterial occlusion
  • Moya moya disease
  • Thrombophilia
  • Carotid dissection
  • Increased intraocular pressure (IOP) from glaucoma or prolonged direct pressure to the globe in unconscious patients can precipitate CRAO.
    • Low retinal blood pressure from carotid stenosis or severe hypotension may lead to CRAO.
    • Transection of the retinal artery, transection of the optic nerve, or retrobulbar hemorrhage can cause visual loss.
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Contributor Information and Disclosures
Author

Neil Jain, MD  Staff Physician, Yale University School of Medicine, Department of Surgery, Section of Emergency Medicine

Neil Jain, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Pascal SC Juang, MD  Medical Director, ED Information Systems, Department of Emergency Medicine, Hoag Memorial Hospital Presbyterian

Pascal SC Juang, MD, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

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

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Kilbourn Gordon III, MD, and Enoch Huang, MD, to the development and writing of this article.

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The cherry red spot of central retinal artery occlusion.
 
 
 
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