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?

[accordion clicktoclose=true tag=p]

[accordion-item title=”History of CV risk factors? (click to show/hide)”]

Yes. h/o TIA 6 months ago, FH of early MI (uncle and father had MI before age 55 yo), hypercholesterolemia.

[/accordion-item]

[accordion-item title=”Duration of symptoms? (click to show/hide)”]

Started 1 day ago. Began as a dark spot centrally which progressed peripherally.

[/accordion-item]

[accordion-item title=”Associated symptoms? (click to show/hide)”]

None that I can think of.
Specifically denies jaw claudication, HA, nausea, or vomiting.

[/accordion-item]

[accordion-item title=”Prior episodes? (click to show/hide)”]

No. This has never happened before.

[/accordion-item]

[/accordion]

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?

[accordion clicktoclose=true tag=p]

[accordion-item title=”VA¬†(click to show/hide)”]

OD 20/40, OS CF 5

[/accordion-item]

[accordion-item title=”Extra-ocular movements (click to show/hide)”]

EOMI

[/accordion-item]

[accordion-item title=”Swinging flashlight test (click to show/hide)”]

RAPD left eye

[/accordion-item]

[accordion-item title=”Scalp tenderness (click to show/hide)”]

Negative

[/accordion-item]

[accordion-item title=”Carotid bruit (click to show/hide)”]

Present on left

[/accordion-item]

[accordion-item title=”Fundoscopy (click to show/hide)”]

[/accordion-item]

[/accordion]

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?

[accordion clicktoclose=true tag=p]

[accordion-item title=”CRAO (click to show/hide)”]

Correct: Most likely option because of age, CV risk factors, sudden painless monocular loss of vision, carotid bruit, and characteristic fundoscopic appearance.

[/accordion-item]

[accordion-item title=”CRVO (click to show/hide)”]

Incorrect: Less likely, based on fundoscopic appearance.

[/accordion-item]

[accordion-item title=”GCA (click to show/hide)”]

Less Likely: Possible cause of CRAO (5-10% of cases), but less likely given absence of signs & symptoms of GCA (HA, jaw claudication, PMR, scalp tenderness). Get ESA to rule out.

[/accordion-item]

[accordion-item title=”Angle closure glaucoma (click to show/hide)”]

Incorrect: Unlikely with the absence of red eye or eye pain. Visual loss is not expected to be complete monocular loss of vision. Also would expect nausea and vomiting with glaucoma. Fundoscopic changes in glaucoma include cupping and increased cup:disc ratio.

[/accordion-item]

[accordion-item title=”Retinal detachment (click to show/hide)”]

Not Likely: Not as likely as complete monocular loss of vision. Would be seen on Fundoscopy. Symptoms would include floaters and flashing lights.

[/accordion-item]

[/accordion]

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?

[accordion clicktoclose=true tag=p]

[accordion-item title=”Ocular massage with heal of hand (click to show/hide)”]

Correct: Ocular massage is your best temporizing measure to attempt to dislodge the embolus.

[/accordion-item]

[accordion-item title=”Place a 30G needle in the anterior chamber and draw off some of the fluid. (click to show/hide)”]

Correct: However this should only be done by an ophthalmologist. Removing some of the fluid in the anterior chamber has been used to attempt to decrease the pressure in the eye and thus dislodge the clot.

[/accordion-item]

[accordion-item title=”Give tPA stat. (click to show/hide)”]

Controversial: tPA has been used in the thought that it may help dissolve a clot in the central retinal artery, but has not been proven to change outcomes.

[/accordion-item]

[accordion-item title=”Urgent admission for embolectomy (click to show/hide)”]

Controversial: Again has not been shown to change outcomes.

[/accordion-item]

[accordion-item title=”Allow home with reassurance (click to show/hide)”]

Incorrect: Start ocular massage and call ophthalmology for an urgent consult.

[/accordion-item]

[accordion-item title=”Start Plavix & ASA and discharge home (click to show/hide)”]

Incorrect: Plavix and ASA, while useful for MI, have no role in the emergent treatment of CRAO. Start ocular massage and call ophthalmology immediately!

[/accordion-item]

[/accordion]

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.