CENTRAL RETINAL ARTERY OCCLUSION(CRAO)Final ophthalmology
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Transcript of CENTRAL RETINAL ARTERY OCCLUSION(CRAO)Final ophthalmology
Case 1BCase 1BABELLO, ANTHONYABELLO, ANTHONY
ACERO, RIAACERO, RIAACOSTA, ANDREACOSTA, ANDRE
AGCAOILI, NIKKIAGCAOILI, NIKKIAGCAOILI, ROMARICOAGCAOILI, ROMARICO
HISTORYHISTORY
62 year old, female62 year old, female
Sudden loss of vision in her right eye an Sudden loss of vision in her right eye an hour agohour ago
HISTORYHISTORY
Vision was hand movement right eyeVision was hand movement right eye
20/20 left eye20/20 left eye
Right pupil – does not respond to light Right pupil – does not respond to light directly; reacts consensuallydirectly; reacts consensually
Left pupil – responds to light directly; Left pupil – responds to light directly; does not react consensuallydoes not react consensually
Pale retina with a reddish spot on macular Pale retina with a reddish spot on macular areaarea
DIAGNOSISDIAGNOSIS
Central Retinal Artery Central Retinal Artery OcclusionOcclusion
Central Retinal Artery Central Retinal Artery OcclusionOcclusion
Painless catastrophic visual loss Painless catastrophic visual loss occurring over a period of few secondsoccurring over a period of few seconds
Antecedent Transient Visual Loss Antecedent Transient Visual Loss (amaurosis fugax)(amaurosis fugax)
Visual acuity ranges between counting Visual acuity ranges between counting fingers and light perception in 90% of fingers and light perception in 90% of eyes at initial examinationeyes at initial examination
Central Retinal Artery Central Retinal Artery OcclusionOcclusion
Afferent pupillary defect can appear Afferent pupillary defect can appear within seconds, preceding the fundus within seconds, preceding the fundus abnormalities by an hourabnormalities by an hour
25% of eyes with CRAO have cilioretinal 25% of eyes with CRAO have cilioretinal arteries that spare macular retinaarteries that spare macular retina potentially preserving central visionpotentially preserving central vision
Pathophysiology of signs Pathophysiology of signs and symptomsand symptoms
PathophysiologyPathophysiologyObstruction of the central
retinal artery
Loss of blood supply to the inner layer of the retina
Inner layer edema and pyknosis of the ganglion cell nuclei
Ischemic Necrosis Visual Loss
PathophysiologyPathophysiology
CausesCauses Systemic hypertension seen in two thirds of Systemic hypertension seen in two thirds of
patientspatients Diabetes mellitusDiabetes mellitus Cardiac valvular disease seen in one fourth Cardiac valvular disease seen in one fourth
of patientsof patients
PathophysiologyPathophysiology
CausesCauses EmbolismEmbolism
This is most commonly cholesterol but can be This is most commonly cholesterol but can be calcific, bacterial, or talc from intravenous calcific, bacterial, or talc from intravenous drug abuse.drug abuse.
This is associated with poorer visual acuity This is associated with poorer visual acuity and higher morbidity and mortality.and higher morbidity and mortality.
Emboli from the heart are the most common Emboli from the heart are the most common cause of CRAO in patients younger than 40 cause of CRAO in patients younger than 40 years.years.
PathophysiologyPathophysiology
CausesCauses Atherosclerotic changesAtherosclerotic changes
Carotid atherosclerosis is seen in 45% of Carotid atherosclerosis is seen in 45% of cases of CRAO, with 60% or greater stenosis cases of CRAO, with 60% or greater stenosis in 20% of cases.in 20% of cases.
Atherosclerotic disease is the leading cause Atherosclerotic disease is the leading cause of CRAO in patients aged 40-60 years.of CRAO in patients aged 40-60 years.
OtherOther
PathophysiologyPathophysiology• Retina becomes Retina becomes opacified and opacified and yellow-white in yellow-white in appearanceappearance– takes as little as takes as little as
15 minutes to 15 minutes to several hours before several hours before becoming evident becoming evident
– resolves in 4-6 resolves in 4-6 weeksweeks
• Foveal cherry red Foveal cherry red spotspot– Visualization of the Visualization of the
choroidal pigment choroidal pigment and retinal pigment and retinal pigment epitheliumepithelium
Diagnostic ProceduresDiagnostic Procedures
Diagnostic ProceduresDiagnostic Procedures
• Laboratory StudiesLaboratory Studies– helpful in determining the etiology of central retinal helpful in determining the etiology of central retinal
artery occlusion (CRAO)artery occlusion (CRAO)
• CBC countCBC count– to evaluate anemia, polycythemia, and platelet disordersto evaluate anemia, polycythemia, and platelet disorders
• Erythrocyte Sedimentation Rate (ESR)Erythrocyte Sedimentation Rate (ESR)– evaluation for giant cell arteritisevaluation for giant cell arteritis
• Fibrinogen, antiphospholipid antibodies, prothrombin Fibrinogen, antiphospholipid antibodies, prothrombin time/activated partial thromboplastin time (PT/aPTT), time/activated partial thromboplastin time (PT/aPTT), and serum protein electrophoresisand serum protein electrophoresis– to evaluate for coagulopathiesto evaluate for coagulopathies
Diagnostic ProceduresDiagnostic Procedures
Fasting blood sugar, cholesterol, Fasting blood sugar, cholesterol, triglycerides, and lipid panel triglycerides, and lipid panel to evaluate for atherosclerotic diseaseto evaluate for atherosclerotic disease
Blood culturesBlood cultures to evaluate for bacterial endocarditis and to evaluate for bacterial endocarditis and
septic emboliseptic emboli
Diagnostic ProceduresDiagnostic Procedures
• Imaging studiesImaging studies– helpful in determining the etiology of CRAOhelpful in determining the etiology of CRAO
• Carotid ultrasound imagingCarotid ultrasound imaging– to evaluate atherosclerotic disease. This to evaluate atherosclerotic disease. This
appears to be more sensitive than carotid appears to be more sensitive than carotid Doppler, which only determines the flow.Doppler, which only determines the flow.
• Magnetic resonance angiogramMagnetic resonance angiogram– may be more accurate in detecting may be more accurate in detecting
obstruction.obstruction.
Diagnostic ProceduresDiagnostic Procedures
• Fluorescein angiogramFluorescein angiogram– Delay in arteriovenous transit time (<11 seconds is Delay in arteriovenous transit time (<11 seconds is
in the reference range)in the reference range)– Delay in retinal arterial fillingDelay in retinal arterial filling– Normal choroidal filling (begins 1-2 seconds before Normal choroidal filling (begins 1-2 seconds before
retinal filling and completely filled within 5 retinal filling and completely filled within 5 seconds of dye appearance in healthy eyes). A delay seconds of dye appearance in healthy eyes). A delay of 5 seconds or greater is seen in 10% of patients. of 5 seconds or greater is seen in 10% of patients. Consider ophthalmic artery occlusion or carotid Consider ophthalmic artery occlusion or carotid artery obstruction if there is a significant delay artery obstruction if there is a significant delay in choroidal filling.in choroidal filling.
– Arterial narrowing with normal fluorescein transit Arterial narrowing with normal fluorescein transit after recanalizationafter recanalization
Other Diagnostic Other Diagnostic ProceduresProcedures
• ECGECG– to evaluate for possible atrial fibrillation (A 24-to evaluate for possible atrial fibrillation (A 24-
h Holter monitor may be necessary if arrhythmia is h Holter monitor may be necessary if arrhythmia is suspected but not detected on ECG testing.)suspected but not detected on ECG testing.)
• ElectroretinogramElectroretinogram– shows a diminished b-wave corresponding to Muller shows a diminished b-wave corresponding to Muller
and/or bipolar cell ischemia.and/or bipolar cell ischemia.
• Echocardiogram (not necessarily an emergency Echocardiogram (not necessarily an emergency department test)department test)– To evaluate valvular disease, wall motion To evaluate valvular disease, wall motion
abnormalities, and mural thrombiabnormalities, and mural thrombi– To evaluate vegetations that may cause septic To evaluate vegetations that may cause septic
emboliemboli
ManagementManagement
Aim of ManagementAim of Management
restore the blood circulation to the restore the blood circulation to the retina as quickly as possible retina as quickly as possible increasing the perfusion of blood through increasing the perfusion of blood through
the arterythe artery
ManagementManagement
Reduction of intraocular pressure Reduction of intraocular pressure by ocular hypotensive drugs by ocular hypotensive drugs
(acetazolamide IV)(acetazolamide IV) intermittent digital massage over the intermittent digital massage over the
closed eyelidclosed eyelid 5-15 seconds repeated for up to 15 minutes.5-15 seconds repeated for up to 15 minutes.
anterior chamber paracentesis anterior chamber paracentesis dislodge an embolus dislodge an embolus
inhalation of a mixture of 5% carbon inhalation of a mixture of 5% carbon dioxide and 90% oxygendioxide and 90% oxygen
Complications & Complications & PrognosisPrognosis
ComplicationsComplications
Neovascularization and the development of Neovascularization and the development of neovascular glaucoma - occurs in about 16% neovascular glaucoma - occurs in about 16% of patients and warrants treatment.of patients and warrants treatment.
Partial or complete loss of vision in the Partial or complete loss of vision in the affected eyeaffected eye
Similar problem occurring again in the Similar problem occurring again in the same or the other eyesame or the other eye
PrognosisPrognosis
Patients with a retinal artery occlusion Patients with a retinal artery occlusion often maintain good to fair vision, but often maintain good to fair vision, but vision loss is often profound with central vision loss is often profound with central artery occlusion, even with treatment.artery occlusion, even with treatment.
Once Once retinal infarction retinal infarction has occurred, has occurred, vision loss is permanent.vision loss is permanent.