Central Retinal Artery Occlusion

1. See Also
   1. Transient Ischemic Attack
   2. Acute Vision Loss
2. Risk Factors
   1. Age over 70
   2. Cardiovascular disease risks
      1. Coronary Artery Disease
      2. Diabetes Mellitus
      3. Hypertension
      4. Hyperlipidemia
      5. Hypercoagulable state
   3. Migraine Headaches
   4. Collagen vascular disease (e.g. Systemic Lupus Erythematosus)
   5. Temporal Arteritis
   6. Sickle Cell Anemia
3. Causes: Ophthalmic artery Occlusion
   1. See Transient Ischemic Attack
   2. Cholesterol emboli
   3. Thrombotic emboli
   4. Vasculitis
4. Symptoms
   1. See Transient Monocular Blindness (Amaurosis Fugax)
   2. May be associated with other focal neurologic deficits
      1. See Transient Ischemic Attack
      2. Affects ipsilateral Carotid Artery circulation
5. Signs
   1. Pupil dilated with slow reaction
   2. Fundoscopic exam
      1. Retina appears pale due to Retinal edema
      2. Macula with cherry-red spot on white-yellow background
      3. Box-Carring of Retinal vessels
         1. Retinal vessels with interrupted columns of blood appear as train box cars
      4. Hollenhorst Plaques (emboli)
         1. "Glistening orange yellow flakes"
         2. Represent fragmented emboli at arteriole bifurcation
6. Differential Diagnosis
   1. See Acute Vision Loss
7. Labs
   1. Erythrocyte Sedimentation Rate (ESR)
      1. Increased in Temporal Arteritis
8. Imaging: Obtain after acute stabilization (see management below)
   1. See Transient Ischemic Attack
   2. Internal Carotid Evaluation
      1. Neck evaluation for Carotid Bruit
      2. Carotid Doppler Ultrasound
      3. Carotid Arteriography
9. Management
   1. Immediate Ophthalmology consultation without delay
      1. Irreversible damage begins in the first 2 hours
   2. Lower Intraocular Pressure
      1. Lie patient supine
      2. Ballot the eye
         1. Apply intermittent pressure to eyeball: 15 sec/min
      3. Consider topical or oral agents
         1. Apply Beta Blocker or Pilocarpine drops to eye
         2. Oral Nitroglycerin
      4. Consider IV agents to reduce Aqueous Humor production
         1. Mannitol 1 g/kg IV for 1 dose AND
         2. Acetazolamide 500 mg IV for 1 dose
10. References
    1. Beatty (2000) J Accident Emerg Med 17:324-9
    2. Pokhrel (2007) Am Fam Physician 76:829-36