This document describes a case of central retinal artery occlusion in a 21-year-old female patient who presented with sudden painless vision loss in her right eye. Standard treatments were ineffective given her late presentation over 36 hours after onset. She was treated with hyperbaric oxygen therapy which rapidly reduces tissue anoxia and mitigates reperfusion injury. After 3 sessions of HBOT over 3 days, her vision improved significantly from counting fingers to 6/6p. HBOT helps the inner retinal layers obtain oxygen via diffusion from the choroidal circulation when exposed to elevated oxygen pressures until revascularization can restore vision.

1. Dr Rajeshwari Pardeshi
Dr Ketan Jathar , Dr RenuAgarkhedkar

2.  is the occlusion of the central retinal artery (CRA) with resultant infarction of the
retina and vision loss. It was first described as an embolic occlusion of the CRA in
a patient with endocarditis by von Graefe .(1)
 mostly seen in the elderly with clinical findings suggestive of atheromatous
emboli. (2)
 Uncommon in the young population. (3,4)
 In a a young patient risk factors which should be considered are :diferent
proatherogenic states- hyperhomocystenemia, factorV Leiden, protein C and S,
antithrombin deficiencies, antiphospholipid syndrome, prothrombin gene
mutations, sickle cell disease, vasculitis, oral contraceptive use, intravenous drug
use, migraine due to vasospasm, and paraneoplastic syndromes.
1. Graefes AV. Ueber Embolie der Arteria centralis retinae als Ursache plotzlicher Erblindung. Arch Ophthalmol;5:136–157
2. Kollarits CR, Lubow M, Hissong SL. Retinal Strokes: I: Incidence of carotid atheromata. JAMA. 1972;222:1273–5.
3. Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young
adults. Ophthalmology. 1981;88:18–25.
4. Greven CM, Slusher MM, Weaver RG. Retinal arterial occlusion in young adults. Am J Ophthalmol. 1995;120:776–83.
2
Central retinal artery occlusion (CRAO):

3.  A 21yrs old unmarried female
 Presentation:
- sudden painless loss of vision in Right eye since 36 hours.
- H/o 3 transient ischemic attacks on the same day each lasting for 30 sec
at 5min interval.
 Systemic illness: k/c/o Asthma
 No history/evidence of any predisposing risk factors
 Examination on 1st visit
3
RIGHT EYE LEFT EYE
BCVA CF AT 2MTRS 6/6
COLOUR VISION COULD IDENTIFY ONLY 1ST
PLATE
16/16 CORRECT
RESPONSES
ANTERIOR CHAMBER QUIET QUIET
PUPIL RAPD NORMAL SIZED &
REACTION TO LIGHT
AMSLER GRID CENTRAL SCOTOMA WNL

4. 4
Dilated fundus examination of
Right eye on 1st visit :
cherry red spot
retinal whitening
Dilated fundus examination of Left
eye on 1st visit :
normal macula , blood vessels
and optic disc.

5. 5
OCT macula Right eye:
Retinal edema
OCT macula Left eye:
Normal findings

6.  Haematological Investigations-
 FBS, PPBS, TC, DC, ESR,
 lipid profile, coagulation profile, vasculitis screening
all above were within normal limits
 On cardiovascular evaluation- 2D ECHO was normal
 Carotid Doppler Ultrasonography – normal
6

7. 7
 Therapies that have been used in the treatment of CRAO :
 carbogen inhalation, acetazolamide infusion, ocular massage ,
paracentesis, various vasodilators such as intravenous glyceryl trinitrate.
-None of these “standard agents” have been shown to alter the natural
history of disease definitively.
 Recent interest :use of thrombolytic therapy either intravenously or intra-
arterially by direct catheterisation of the ophthalmic artery. Recovery of
vision can be quite dramatic, but intra-arterial delivery of thrombolytic
may result in an increased risk of intracranial and systemic haemorrhage.
 Hyperbaric Oxygen Therapy (HBO)

8.  In this patient, considering late presentation (after 36 hrs) Hyperbaric Oxygen Therapy
(HBO) was used as mode of treatment.
 Preparation:
-Jewellary , watch removed
-cotton clothing specifically for use in the hyperbaric chamber.
- vital signs recorded.
 Monoplace chamber designed to treat a single person pressurized with 100% oxygen.
 3 sessions of 2.5ATA HBOT for 90 min on 3 consecutive days with supplemental 100%
oxygen for 10min every 2 hourly .
 close monitoring of the patient including vital signs.
8

9. 9
12hrs after 1st
session of HBOT
After 3 sessions of
HBOT
RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
BCVA 6/9 6/6 6/6p 6/6
COLOUR VISION 5/16 CORRECT
RESPONSES
16/16 CORRECT
RESPONSES
5/16 CORRECT
RESPONSES
16/16 CORRECT
RESPONSES
ANTERIOR
CHAMBER
QUIET QUIET QUIET QUIET
PUPIL NORMAL SIZED &
REACTION TO LIGHT;
NO RAPD
NORMAL SIZED &
REACTION TO
LIGHT
NORMAL SIZED &
REACTION TO
LIGHT;
NO RAPD
NORMAL SIZED &
REACTION TO
LIGHT;
NO RAPD
AMSLER GRID WNL WNL WNL WNL
•After 3 sessions of HBOT , Patient was started on oral steroids started with 50mg
wysolone and then tapering dose for 5 weeks..

10.  FFA done after 3 sessions showed revascularisation of retina.
14 sec 1min 24 sec
5 min 27 sec 8 min 20 sec
5 min 27 sec 8 min 20 sec
Following 6 weeks after HBOT vision stabilized to 6/6p,N6 in Right eye 10

11.  Rationale For Hyperbaric Oxygen Therapy (HBO) In The
Management Of Central Retinal Artery Occlusion (CRAO) :
 In CRAO, the inner retinal layers (ganglion cell layer and inner nuclear
layer), which are normally served by the retinal circulation, may obtain
enough oxygen via diffusion from the choroidal circulation to function
normally if the individual is exposed to elevated partial pressures of
oxygen.
 Normally, the choroidal circulation supplies the majority of the oxygen to
the retina. Under normoxic conditions, approximately 60% of the retina’s
oxygen comes from the choroidal circulation. Under hyperoxic conditions,
the choroid is capable of supplying 100% of the oxygen needed by the
retina.
 If supplemental O2 is provided, oxygen from choroidal circulation diffuses
in adequate quantity to inner retinal layers to maintain function till
revascularization and restores vision. 11

12.  The retina has the highest rate of oxygen consumption of any organ in the
body. Therefore, it is very sensitive to ischemia. In order to be effective,
the administration of supplemental oxygen must be continued until such
time as flow through the retinal artery has resumed to a level sufficient to
maintain inner retinal viability under normoxic conditions
 HBOT rapidly reduces acute tissue anoxia and mitigates reperfusion injury.
As patient had presented after 36 hours of onset, traditional methods of
treatment have proven to be ineffective and thus HBOT was tried as an
option which helped restore vision .
 Conclusion
12
Discussion…
Hyperbaric oxygen therapy (HBOT) can be considered as
treatment option to improve the visual outcome in central
retinal artery occlusion.
Conclusion…