Central Retinal Artery Occlusion - PowerPoint Presentation

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Central Retinal Artery Occlusion

M.AKHLAGHI MD

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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 Occlusion

Background

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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

Occlusion

pathophysiology

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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 Occlusion

Pathophysiology

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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

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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

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Sudden

, painless loss of vision in one eye.

May have a history of amaurosis

fugax

prior to presentationVision loss usually in the range of

20/20

to hand motions. Unlikely to be no light perception

Central Retinal Artery Occlusion

symptoms

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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 Occlusion

symptoms

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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 Occlusion

signs

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Differential Diagnoses for Cherry-Red Spot

Central Retinal Artery Occlusion (CRAO)

Tay

-Sachs disease

GM1

gangliosidosis

Niemann

-Pick disease

mucolipidosis

Central Retinal Artery Occlusion

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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

Occlusion

Para clinic

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Early phase fluorescein angiogram shows absence of retinal artery filling except in

cilioretinal

artery and superior temporal arcade

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OCT

Central Retinal Artery Occlusion

Para clinic

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Central Retinal Artery Occlusion

Para clinic

ERG

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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 Occlusion

Management

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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 Occlusion

Management

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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

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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

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Most

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

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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

Occlusion

Prognosis

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