Sections

Sections Central Retinal Artery Occlusion (CRAO)
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
Questions & Answers
References

Medication

Medication Summary

Medical therapy is directed toward lowering IOP, increasing retinal perfusion, and increasing oxygen delivery to hypoxic tissues. The first goal is accomplished by using the same drugs as those used in glaucoma. Retinal perfusion may be increased by administration of vasodilatory drugs although this is unproven, increasing arterial pCO₂, or by giving intravascular thrombolytics to remove the offending embolus. Some physicians also advocate aspirin use in the acute phase. Oxygen delivery is improved by breathing higher concentrations of oxygen or with hyperbaric oxygen.^{[1, 2]}

Class Summary

Carbonic anhydrase is an enzyme found in many tissues of the body, including the eye. The reversible reaction it catalyzes involves the hydration of carbon dioxide and the dehydration of carbonic acid.

Acetazolamide (Diamox)

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Reduces rate of aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP. Used most frequently as single diuretic agent in acute management of CRAO. Other diuretics may be added if sufficient decrease in IOP is not attained.

Dorzolamide (Trusopt)

Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.

Class Summary

Lower IOP by creating an osmotic gradient between the ocular fluids and plasma (not for long-term use). Hemoconcentration is potentially an issue with this form of therapy.

Mannitol (Osmitrol)

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Reduces elevated IOP when the pressure cannot be lowered by other means. First, assess for adequate renal function in adults by administering a test dose of 200 mg/kg, given IV over 3-5 min. It should produce a urine flow of at least 30-50 mL/h of urine over 2-3 h. In children, assess for adequate renal function by administering a test dose of 200 mg/kg, given IV over 3-5 min. It should produce a urine flow of at least 1 mL/h over 1-3 h.

Glycerin

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Used in glaucoma to interrupt acute attacks. Oral osmotic agent for reducing IOP. Able to increase tonicity of blood until finally metabolized and eliminated by the kidneys. Maximum reduction of IOP usually occurs 1 h after glycerin administration. Effect usually lasts approximately 5 h.

Class Summary

Lower IOP mainly by increasing outflow and reducing the production of aqueous humor. The combination of a miotic and a sympathomimetic has additive effects in lowering IOP. Each may be added in rotation after a 5-minute interval, until target IOP is reached.

Apraclonidine (Iopidine)

Reduces elevated, as well as normal, IOP whether or not accompanied by glaucoma. Apraclonidine is a relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.

Dipivefrin (AKPro, Propine)

Converted to epinephrine in eye by enzymatic hydrolysis. Appears to act by decreasing aqueous production and enhancing outflow facility. Has same therapeutic effect as epinephrine with fewer local and systemic side effects. May be used as an initial therapy or as an adjunct with other antiglaucoma agents for the control of IOP.

Class Summary

Lower IOP by decreasing the rate of aqueous humor production and possibly outflow. They may be more effective than either pilocarpine or epinephrine alone and have the advantage of not affecting pupil size or accommodation.

Timolol ophthalmic (Timoptic)

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May reduce elevated and normal IOP, with or without glaucoma by reducing the production of aqueous humor or by outflow.

Questions

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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. 2010 Jul. 117 (7):1367-75.e1. [QxMD MEDLINE Link].
Page PS, Khattar NK, White AC, Cambon AC, Brock GN, Rai SN, et al. Intra-Arterial Thrombolysis for Acute Central Retinal Artery Occlusion: A Systematic Review and Meta-Analysis. Front Neurol. 2018. 9:76. [QxMD MEDLINE Link].
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Ahn SJ, Kim JM, Hong JH, Woo SJ, Ahn J, Park KH, et al. Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion. Invest Ophthalmol Vis Sci. 2013 Nov 21. 54(12):7746-55. [QxMD MEDLINE Link].
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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. 2008 Jun. 39(6):1746-50. [QxMD MEDLINE Link].
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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, American Medical Association, Arizona Ophthalmological Society

Disclosure: Nothing to disclose.

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 Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Chief Editor

Andrew G Lee, MD Chair, Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch School of Medicine; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine

Andrew G Lee, MD is a member of the following medical societies: American Academy of Ophthalmology, American Geriatrics Society, Houston Neurological Society, Houston Ophthalmological Society, International Council of Ophthalmology, North American Neuro-Ophthalmology Society, Texas Ophthalmological Association

Disclosure: Received ownership interest from Credential Protection for other.

Additional Contributors

Ashwini Kini, MD, FRCS Clinical Fellow in Neuro-Ophthalmology, Department of Ophthalmology, Houston Methodist Hospital

Ashwini Kini, MD, FRCS is a member of the following medical societies: All India Ophthalmological Society, Indian Medical Association

Disclosure: Nothing to disclose.

Claudia Maria Prospero Ponce, MD Neuro-Ophthalmologist; Fellow in Ocular Pathology, Houston Methodist Hospital

Claudia Maria Prospero Ponce, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association of Ophthalmic Oncologists and Pathologists, Association for Research in Vision and Ophthalmology, North American Neuro-Ophthalmology Society, Texas Society of Pathologists

Disclosure: Nothing to disclose.

Aroucha Vickers, DO Neurologist and Neuro-Ophthalmologist, Las Vegas Neurology Center; Adjunct Instructor of Neurology and Psychiatry, Touro University College of Osteopathic Medicine

Aroucha Vickers, DO is a member of the following medical societies: American Academy of Neurology, American Osteopathic Association, North American Neuro-Ophthalmology Society

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.

Sections Central Retinal Artery Occlusion (CRAO)
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
Questions & Answers
References

Central Retinal Artery Occlusion (CRAO) Medication

Medication Summary

Carbonic anhydrase inhibitors