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retinal artery occlusion

Etiology: - thromboembolism from the heart, carotid artery or temporal artery - Susac syndrome - risk factors: - atherosclerosis: carotid artery stenosis, coronary artery disease - hypertension - dyslipidemia [2] - endocarditis, atrial fibrillation, atrial myxoma Epidemiology: - 50-70 years of age Pathology: - embolism or thrombosis in the ophthalmic artery Clinical manifestations: 1) sudden transient or permanent monocular visual impairment 2) painless 3) often occurs in early morning 4) clear cornea 5) red eye 6) pupil may be dilated & poorly reactive to light - afferent pupillary defect - may react to light in contralateral eye Laboratory: - blood cultures if endocarditis suspected Special laboratory: - funduscopy: a) pale fundus b) attenuation of post-occulsion retinal arteries c) infarcted retina is pale & masks the underlying choroidal circulation except at the macula, where the thinness of the tissue allows it to be seen resulting in the so-called 'cherry-red spot' d) 'box-car' effect may be seen in venous drainage [1] e) emboli visible in 60% [2] - echocardiogram vs transesophageal echocardiogram - atrial myxoma, endocarditis. * image (funduscopy) [5] Differential diagnosis: - temporal arteritis Complications: - permanent visual loss may occur within 100 minutes of onset - associated with 24% risk of ischemic stroke [3] - 5% risk of ischemic stroke within 30 day window of central retinal artery occlusion [4] Management: - place patient in supine position - reduce intraocular pressure with ocular digital massage - intravenous mannitol - oral acetazolamide - oral nitrates - referral to an ophthalmologist - prognosis - better vision at presentation predicts better prognosis [2]

Related

central retinal artery (Zinn artery)

Specific

central retinal artery occlusion (CRAO) Hollenhorst plaque

General

retinal vascular occlusion arterial disease ischemia

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2018.
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  3. Helenius J et al. Concurrent acute brain infarcts in patients with monocular visual loss. Ann Neurol 2012 Aug; 72:286 PMID: 22926859
  4. Chodnicki KD, Pulido JS, Hodge DO, Klaas JP, Chen JJ. Stroke risk before and after central retinal artery occlusion in a US cohort. Mayo Clin Proc 2019 Feb; 94:236 PMID: 30711121 https://www.mayoclinicproceedings.org/article/S0025-6196(18)30853-X/fulltext
  5. Tamez H, Patel SN Retinal Artery Occlusion After a Dog Bite in a 55-Year-Old Man. JAMA Ophthalmol. Published online May 6, 2021 PMID: 33956084 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2779737 - AMA Ed Hub. JN Learning https://edhub.ama-assn.org/jn-learning/module/2779737