Central Retinal Artery OcclusionM.AKHLAGHI MD

In 1859, Van Graefe first described central retinal artery occlusion (CRAO) as an embolic event to the central retinal artery in a patient with endocarditis.

Central Retinal Artery OcclusionBackground

Acutely, obstruction of the central retinal artery results in inner layer edema and pyknosis of the ganglion cell nuclei. Ischemic necrosis results, and the retina becomes opacified and yellow-white in appearance.

Central Retinal Artery Occlusionpathophysiology

The opacification takes as little as 15 minutes to several hours before becoming evident

Whit time edema resolves in 4-6 weeks.

Pigmentary changes are typically absent

Central Retinal Artery OcclusionPathophysiology

Age > 40 years old. Risk factors may include: Hypertension, Hypercholesterolemia, Diabetes Vascular disease, Prior myocardial infarction, Cardiac stenting procedures, Transient ischemic attacks, Stroke

Central Retinal Artery Occlusion EPIDEMIOLOGY

CRAO in younger patients may associated whit collagen vascular diseases, cardiac valvular disease or hypercoagulopathies

CRAO is associated with giant cell arteritis in 1-2% of cases.

Central Retinal Artery Occlusion EPIDEMIOLOGY

Sudden, painless loss of vision in one eye.

May have a history of amaurosis fugax prior to presentation

Vision loss usually in the range of 20/20 to hand motions. Unlikely to be no light perception

Central Retinal Artery Occlusionsymptoms

Approximately 25% of eyes with acute CRAO have cilioretinal artery.

In 10% of eyes, the cilioretinal artery supplies some or all of the foveola. In such an eye, the visual acuity generally returns to 20/50 or better in 80% of eyes over a 2-week period.

Central Retinal Artery Occlusionsymptoms

Cherry red spot: The lack of arterial perfusion to the inner layers of the retina results in edema of the retina. In the fovea, the underlying choroid with intact RPE is visible and appears as a "cherry red spot" when compared to the cloudy, edematous retina adjacent to it

Vascular attenuation

May see an embolus in vessel on optic nerve.

Central Retinal Artery Occlusionsigns

Differential Diagnoses for Cherry-Red Spot

Central Retinal Artery Occlusion (CRAO) Tay-Sachs disease GM1 gangliosidosis Niemann-Pick disease mucolipidosis

Central Retinal Artery Occlusion

Fluorescein angiography Normal choroidal filling Delay in retinal arterial filling (begins

normally 1-2 seconds after choroidal filling) Arterial narrowing with normal fluorescein

transit after recanalization

Central Retinal Artery OcclusionPara clinic

Early phase fluorescein angiogram shows absence of retinal artery filling except in cilioretinal artery and superior temporal arcade

OCT

Central Retinal Artery OcclusionPara clinic

Central Retinal Artery OcclusionPara clinic ERG

Therapy for CRAO should be undertaken without delay.

Steps include reduction in lOP by ocular massage, anterior chamber paracentesis, or use of retrobulbar anesthesia.

Mechanism of decrease in IOP?

Even with these treatments, improvement in visual acuity is rare.

Central Retinal Artery OcclusionManagement

Treatments advocated in the past have included inhalation therapy with a 95% oxygen-5% carbon dioxide mixture and the use of oral acetazolamide and aspirin. these treatments are no longer advocated.

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

Central Retinal Artery OcclusionManagement

To evaluate etiology, workup may include: ◦ -Neurology evaluation for workup and

modification of risk factors. ◦ Fasting blood sugar, cholesterol, triglycerides, and

lipid panel to evaluate for atherosclerotic disease◦ -ESR/CRP and giant cell arteritis review of

systems. ◦ -carotid ultrasound -EKG -cardiac echography ◦ -CBC, PT/PTT, consider ANA, syphilis serology if

indicated.

Central Retinal Artery Occlusion Work-up

A follow-up ophthalmic examination should be performed 1-4 weeks after the.

Neovascularization of the iris occurs in 20% of patients at an average of 4-5 weeks after the event. The range is 1-15 weeks.

Neovascularization of the disc occurs in 2-3% of patients.

A complete systemic workup should be performed by a primary care provider.

Central Retinal Artery Occlusion Follow-up

Most patients continue to experience severe vision loss in the counting fingers to hand motion range.

As many as 10% of patients retain central vision because of the presence of a cilioretinal artery

Life expectancy of patients with central retinal

artery occlusion (CRAO) is 5.5 years compared to 15.4 years for an age-matched population without CRAO.

Central Retinal Artery OcclusionPrognosis

THANK YOU