Case 2

A 83-year-old with loss of vision in one eye

Q1

A 83 yo male presents to the ED with sudden painless loss of vision in his left eye.

What additional history do you want to obtain?

Q2

A 83 yo male presents to the ED with sudden painless loss of vision in his left eye.

Which physical examinations would you perform?

Q3

A 83 yo male presents to the ED with sudden painless loss of vision in his left eye.

What is the most likely diagnosis?

Q4

A 83 yo male presents to the ED with sudden painless loss of vision in his left eye.

What is your treatment plan for this patient?

Summary

CRAO is an emergent ophthalmological condition, that results from occlusion of the central retinal artery by an embolus (most common), or thrombus, or by inflammatory change to the vessel.

Risk factors include hypertension, hypercholesterolemia, diabetes mellitus, vascular disease, prior myocardial infarction, cardiac stenting procedures, carotid endaeterectomy, and transient ischemic attacks/stroke.

Presenting symptoms are a sudden painless loss of vision that does not improve. On exam, VA should be greatly reduced in that eye to HM or LP, there will be a RAPD, and opthalmoscopy will reveal the classic pale retina with a cherry red fovea.

Once the diagnosis is made, there are a few options to attempt to limit the amount of damage to the retina. These are all aimed at dislodging the embolus into a smaller branch of the central retinal artery and thus sacrificing less retinal real estate.

Immediate outpatient therapy consists of ocular massage, with the theory being that sudden compression and release of the eyeball will create a vacuum effect which may dislodge the embolus to a more distal location. Urgent ophthalmology consult is warranted! Carbogen (95% Oxygen with 5% Carbon Dioxide) is sometimes given via facemask in an attempt to dilate vasculature. Needle decompression of the anterior chamber is usually done to attempt to decrease the IOP, and thus create a vacuum effect to pull the embolus further down the vascular tree. Lower IOP pharmacologically (timolol is usually the first choice given its quick onset of action). Embolectomy and thrombolysis have been tried without much success.