Central retinal artery occlusion

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Central retinal artery occlusion
Specialty Ophthalmology, Neurology

Central retinal artery occlusion (CRAO) is a disease of the eye where the flow of blood through the central retinal artery is blocked (occluded). There are several different causes of this occlusion; the most common is carotid artery atherosclerosis.

Contents

Signs and symptoms

Cherry red spot in a person with central retinal artery occlusion Cherry red spot in patient with central retinal artery occlusion (CRAO).jpg
Cherry red spot in a person with central retinal artery occlusion

Central retinal artery occlusion is characterized by painless, acute vision loss in one eye. [1] Upon fundoscopic exam, one would expect to find: cherry-red spot (90%) (a morphologic description in which the normally red background of the choroid is sharply outlined by the swollen opaque retina in the central retina), retinal opacity in the posterior pole (58%), pallor (39%), retinal arterial attenuation (32%), and optic disk edema (22%). [1] During later stages of onset, one may also find plaques, emboli, and optic atrophy. [1]

Diagnosis

Fluorescein angiogram of a person with central retinal artery occlusion Fluorescein angiogram of patient with central retinal artery occlusion (CRAO).jpg
Fluorescein angiogram of a person with central retinal artery occlusion
Ocular coherence tomogram (OCT) of a person with central retinal artery occlusion Ocular coherence tomogram (OCT) of a patient with central retinal artery occlusion.jpg
Ocular coherence tomogram (OCT) of a person with central retinal artery occlusion

One diagnostic method for the confirmation of CRAO is Fluorescein angiography, it is used to examine the retinal artery filling time after the fluorescein dye is injected into the peripheral venous system. [2] In an eye with CRAO some branches of the retinal artery may not fill or the time it takes for the branches of the retinal artery to fill will be increased, which is visualized by the leading edge of the fluorescein moving slower than normal through the retinal artery branches to the edges of the retina. [2] Fluorescein angiography can also be used to determine the extent of the occlusion as well as classify it into one of four types non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, transient non-arteritic CRAO and arteritic CRAO. [3] Optical coherence tomography (OCT) may also be used to confirm the diagnosis of CRAO. [4]

Causes

CRAO can be classified based on it pathogenesis, as arteritic versus non-arteritic. [5] [1] [6] Non-arteritic CRAO is most commonly caused by an embolus and occlusion at the narrowest part of the carotid retinal artery due to plaques in the carotid artery resulting in carotid retinal artery atherosclerosis. [1] [5] [6] Further causes of non-arteritic CRAO may include vasculitis and chronic systemic autoimmune diseases. [5] Arteritic CRAO is most commonly caused by giant cell arteritis. [5] [6] Other causes can include dissecting aneurysms and arterial spasms, and as a complication of patient positioning causing external compression of the eye compressing flow to the central retinal artery (e.g. in spine surgeries in the prone position). [7]

Mechanism

The ophthalmic artery branches off into the central retinal artery which travels with the optic nerve until it enters the eye. [8] This central retinal artery provides nutrients to the retina of the eye, more specifically the inner retina and the surface of the optic nerve. [8] Variations, such as branch retinal artery occlusion, can also occur. [8] Central retinal artery occlusion is most often due to emboli blocking the artery and therefore prevents the artery from delivering nutrients to most of the retina. [9] These emboli originate from the carotid arteries most of the time but in 25% of cases, this is due to plaque build-up in the ophthalmic artery. [9] The most frequent site of blockage is at the most narrow part of the artery which is where the artery pierces the dura covering the optic nerve. [9] Some people have cilioretinal arterial branches, [10] which may or may not be included in the blocked portion. [9]

Treatment

While no treatment has been clearly demonstrated to be benefit for CRAO in large systematic reviews of randomized clinical trials, many of the following are frequently used: [11]

To achieve the best outcome for a person with CRAO, it is important to identify the condition in a timely manner and to refer to the appropriate specialist. [11]

Prognosis

The artery can re-canalize over time and the edema can clear. However, optic atrophy leads to permanent loss of vision. Irreversible damage to neural tissue can occur after approximately 15 minutes of complete blockage to the central retinal artery, but this time may vary between people. [12] Two thirds of people experience 20/400 vision while only one in six will experience 20/40 vision or better. [13]

Epidemiology

The incidence of CRAO is approximately 1 in 100,000 people in the general population. [14] Risk factors for CRAO include the following: being over 50 years of age, male gender, smoking, hypertension, tranexamic acid, diabetes mellitus, dyslipidemia, angina, valvular disease, transient hemiparesis, cancer, hypercoagulable blood conditions, lupus, or a family history of cerebrovascular or cardiovascular issues. [14] [15]

See also

Related Research Articles

<span class="mw-page-title-main">Choroid</span> Vascular layer of the eye

The choroid, also known as the choroidea or choroid coat, is a part of the uvea, the vascular layer of the eye. It contains connective tissues, and lies between the retina and the sclera. The human choroid is thickest at the far extreme rear of the eye, while in the outlying areas it narrows to 0.1 mm. The choroid provides oxygen and nourishment to the outer layers of the retina. Along with the ciliary body and iris, the choroid forms the uveal tract.

<span class="mw-page-title-main">Amaurosis fugax</span> Medical condition

Amaurosis fugax is a painless temporary loss of vision in one or both eyes.

<span class="mw-page-title-main">Fluorescein angiography</span> Technique for examining the circulation of the retina and choroid of the eye

Fluorescein angiography (FA), fluorescent angiography (FAG), or fundus fluorescein angiography (FFA) is a technique for examining the circulation of the retina and choroid using a fluorescent dye and a specialized camera. Sodium fluorescein is added into the systemic circulation, the retina is illuminated with blue light at a wavelength of 490 nanometers, and an angiogram is obtained by photographing the fluorescent green light that is emitted by the dye. The fluorescein is administered intravenously in intravenous fluorescein angiography (IVFA) and orally in oral fluorescein angiography (OFA). The test is a dye tracing method.

<span class="mw-page-title-main">Optic disc</span> Optic nerve head, the point of exit for ganglion cell axons leaving the eye

The optic disc or optic nerve head is the point of exit for ganglion cell axons leaving the eye. Because there are no rods or cones overlying the optic disc, it corresponds to a small blind spot in each eye.

Anterior ischemic optic neuropathy (AION) is a medical condition involving loss of vision caused by damage to the optic nerve as a result of insufficient blood supply (ischemia). This form of ischemic optic neuropathy is generally categorized as two types: arteritic AION, in which the loss of vision is the result of an inflammatory disease of arteries in the head called temporal arteritis, and non-arteritic AION, which is due to non-inflammatory disease of small blood vessels.

<span class="mw-page-title-main">Ophthalmic artery</span> Artery of the head

The ophthalmic artery (OA) is an artery of the head. It is the first branch of the internal carotid artery distal to the cavernous sinus. Branches of the ophthalmic artery supply all the structures in the orbit around the eye, as well as some structures in the nose, face, and meninges. Occlusion of the ophthalmic artery or its branches can produce sight-threatening conditions.

<span class="mw-page-title-main">Central retinal artery</span>

The central retinal artery branches off the ophthalmic artery, running inferior to the optic nerve within its dural sheath to the eyeball.

<span class="mw-page-title-main">Hollenhorst plaque</span> Medical condition

A Hollenhorst plaque is a cholesterol embolus that is seen in a blood vessel of the retina. It is usually found when a physician performs ophthalmoscopy, during which a plaque will appear as a small, bright crystal that is refractile and yellow. This is a medical exam finding, and is not a medical condition, though it may be related to cardiovascular conditions such as atherosclerosis of the internal carotid artery. It was first described by American ophthalmologist Robert Hollenhorst in 1961.

Eales disease is a type of obliterative vasculopathy, also known as angiopathia retinae juvenilis, periphlebitis retinae or primary perivasculitis of the retina. It was first described by the British ophthalmologist Henry Eales (1852–1913) in 1880 and is a rare ocular disease characterized by inflammation and possible blockage of retinal blood vessels, abnormal growth of new blood vessels (neovascularization), and recurrent retinal and vitreal hemorrhages.

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The central retinal vein is a vein that drains the retina of the eye. It travels backwards through the centre of the optic nerve accompanied by the central retinal artery before exiting the optic nerve together with the central retinal artery to drain into either the superior ophthalmic vein or the cavernous sinus.

<span class="mw-page-title-main">Fundus photography</span> Medical imaging of the eyes

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<span class="mw-page-title-main">Central retinal vein occlusion</span> Medical condition

Central retinal vein occlusion, also CRVO, is when the central retinal vein becomes occluded, usually through thrombosis. The central retinal vein is the venous equivalent of the central retinal artery and both may become occluded. Since the central retinal artery and vein are the sole source of blood supply and drainage for the retina, such occlusion can lead to severe damage to the retina and blindness, due to ischemia and edema (swelling).

<span class="mw-page-title-main">Bonnet–Dechaume–Blanc syndrome</span> Medical condition

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Sohan Singh Hayreh was an ophthalmologist, clinical scientist, and professor emeritus of ophthalmology at the University of Iowa. As one of the pioneers in the field of fluorescein angiography, he was generally acknowledged to be a leading authority in vascular diseases of the eye and the optic nerve. For over 60 years, Hayreh was actively involved in basic, experimental, and clinical research in ophthalmology, publishing over 400 original peer-reviewed articles in various international ophthalmic journals, six classical monographs and books in his field of research, and more than 50 chapters in ophthalmic books. He made many seminal observations dealing with the ocular circulation in health and disease, the optic disc and the optic nerve, retinal and choroidal vascular disorders, glaucomatous optic neuropathy, fundus changes in malignant arterial hypertension, ocular neovascularization, rheumatologic disorders of the eye, and nocturnal arterial hypotension. He was an elected fellow of the National Academy of Medical Sciences.

<span class="mw-page-title-main">Branch retinal artery occlusion</span> Medical condition

Branch retinal artery occlusion (BRAO) is a rare retinal vascular disorder in which one of the branches of the central retinal artery is obstructed.

<span class="mw-page-title-main">Branch retinal vein occlusion</span> Medical condition

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References

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