A 70-year-old male with history of hypertension, hyperlipidemia, TIA with known carotid stenosis and atrial fibrillation presents for sudden onset vision loss of the right eye. Left eye unchanged. No prior eye pathology. Described as curtain falling over vision. Unable to assess visual acuity of right eye and left eye is below baseline with positive Marcus-Gunn pupil. Fundoscopy shows “box car” vessels and retinal whitening.  Ocular ultrasound is unremarkable. What is the diagnosis and management?

A. Central Retinal Artery Occlusion (CRAO)+ immediate ophthalmology consult, ocular massage, hyperventilation, Timolol.

B. Central Retinal Venous Occlusion (CRVO)+ immediate ophthalmology consult.

C. Retinal Detachment + early ophthalmology consult for surgical repair

D. Amaurosis Fugax + ophthalmology consult and neurology consult for stroke work up.

E. Vitreous Hemorrhage + ophthalmology consult, head of bed 30 degrees, correct anticoagulation and avoid Aspirin, NSAIDs, anticoagulation.

Answer: A – CRAO

 This is a stroke of the eye and needs to be managed with urgency.

 Generally occurs in patients with atherosclerotic risk factors and often secondary to embolus in carotid artery disease.

Clinical à Presents with sudden, painless, mono-ocular vision loss described as curtain falling down over visual field.

Examà Afferent pupillary defect and fundoscopy shows ischemic retinal whitening with cherry red fovea and boxcar blood vessels.

 Managementà goal is to restore blood flow in 90 minutes by dislodging clot + increase pCO2 for vasodilation + decreasing intraocular pressure (IOP).

Immediate ophthalmology consult for evaluation and can offer more advanced treatment

            Acetazolamide or Mannitol or sublingual nitro to dilate retinal artery.

            Carbogen to help increase pCO2.

            Timolol to decrease IOP.

            Anterior chamber paracentesis.

            tPA

Ocular massage to dislodge clot à firm pressure to closed eyelid for 15 seconds followed by 15-second break for 5 cycles.

Hyperventilate into paper bag to increase pCO2 à do for 10 minutes every 1 hour.