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C3 - Vision Loss -Central Retinal Artery and Vein Occlusion (CRAO and CRVO)

Mel Herbert, MD MBBS FAAEM, Jessica Mason, MD, and Stuart Swadron, MD, FRCPC
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C3 2019 01 January - Vision Loss Written Summary 317 KB - PDF

C3 - Vision Loss - CRAO and CRVO

Jessica Mason MD, Stuart Swadron MD, Mel Herbert MD

Peer Reviewer Nicholas Testa, MD

* Drug doses are a guide only, always check a second source and follow local practice guideline

CENTRAL RETINAL ARTERY AND VEIN OCCLUSION (CRAO and CRVO)

  • Background
    • CRAO is an occlusion of the main artery that supplies the retina or its branches (BRAO); it is typically due to an embolus from proximal atherosclerotic disease
    • CRVO is an occlusion of the main veins draining the retina; it results in secondary hemorrhage and ischemia
  • Risk Factors
    • Older age
    • Vasculopathy
  • History
    • Sudden painless monocular vision loss or partial loss
    • Can be transient, stuttering, or permanent
  • Examination
    • In addition to the complete eye exam, a full neurological examination is important; CRAO and CRVO are central nervous system vascular emergencies and may be associated with other stroke findings
    • Classic fundoscopy findings of CRAO are a pale retina with a “cherry red spot” over the macula as a result of ischemia and edema
    • In patients presenting early, those with stuttering symptoms, and in those with branched retinal artery occlusions (BRAO) fundoscopic findings may be subtle
    • Fluorescein angiography (by ophthalmology) can help to diagnose CRAO in these cases
    • The classic fundoscopic finding of CRVO is “blood and thunder,” can appear very dramatic
  • Management

 

CRAO

CRVO

Presentation

Acute monocular vision loss

Transient, stuttering, or persistent

+/- Afferent pupillary defect

Poor visual acuity

Patients prone to vascular disease

Typically subacute monocular vision loss

+/- Afferent pupillary defect

Poor visual acuity

Patients prone to vascular disease

Fundoscopy

Pale retina with cherry red spot on macula from ischemia

Blood and thunder fundus (retinal hemorrhages and tortuous veins) from venous congestion

Treatment

Consult ophtho

No effective treatments

Can try ocular massage

Ophtho may try ocular paracentesis or ocular hypotensive agents

Weak evidence for intra-arterial tPA (not systemic)

Consult ophtho

No effective treatments

Most providers will give aspirin

 

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C3 - Vision Loss Full episode audio for MD edition 54:23 min - 51 MB - M4AC3 2019 01 January Vision Loss Board Review Answers 242 KB - PDFC3 2019 01 January Vision Loss Board Review Questions 237 KB - PDFC3 2019 01 January - Vision Loss Individual MP3s 74 MB - ZIPC3 2019 01 January - Vision Loss Written Summary 317 KB - PDF