CRAO

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CRAO

  1. 1. New England Eye Centre Grand Rounds Meher Yepremyan, MD January 18, 2001
  2. 2. New England Eye Centre Grand Rounds – Case Presentation <ul><li>A 71-year-old Asian man presented to the New England Eye Centre complaining of sudden loss of vision in the right eye and a headache. </li></ul><ul><li>One month prior to presentation the patient experienced blurry vision for less than an hour with complete resolution. Three weeks later, however, he again experienced blurry vision without improvement that eventually culminated in total loss of vision four days later. </li></ul>
  3. 3. New England Eye Centre Grand Rounds - History <ul><li>He also reported 5 out of 10 intermittent bitemporal and occipital headaches for the last few days. The patient denied other related symptoms. </li></ul><ul><li>POH: Normal tension glaucoma -- well controlled </li></ul><ul><li>PMH: </li></ul><ul><ul><li>Hypercholesterolemia </li></ul></ul><ul><ul><li>Colon cancer </li></ul></ul><ul><ul><li>Partial colectomy 1985 </li></ul></ul><ul><li>Meds: </li></ul><ul><ul><li>Cosopt </li></ul></ul><ul><ul><li>Brimonidine (alphagan) </li></ul></ul><ul><li>All: NKDA </li></ul>
  4. 4. New England Eye Centre Grand Rounds - Examination <ul><li>The patient had an arterial blood pressure of 175/90 mmHg. No temporal tenderness was appreciated. </li></ul><ul><li>His best-corrected visual acuity was finger counting at one foot in the right eye and 20/50 +1 in the left eye. </li></ul><ul><li>There was no relative afferent pupillary defect. </li></ul><ul><li>Extraocular movements were full bilaterally. </li></ul><ul><li>Intraocular pressures were 8 mmHg in the right eye and 11 mmHg in the left eye. </li></ul><ul><li>Slit-lamp examination was remarkable for bilateral 2+ nuclear sclerosis. </li></ul>
  5. 5. New England Eye Centre Grand Rounds - Examination 17/10/94 2/11/00
  6. 6. New England Eye Centre Grand Rounds - Examination 2/11/00 - OD 2/11/00 - OS
  7. 7. New England Eye Centre Grand Rounds - Examination 2/11/00 – OD Red Free 2/11/00 – OS
  8. 8. New England Eye Centre Grand Rounds - Examination <ul><li>Dilated fundus examination revealed acute changes in the right eye: slight pallor to the optic nerve head, diffuse retinal whitening, arteriolar constriction, cherry-red spot, and cotton-wool spots. There also was bilateral peri-papillary atrophy and posterior vitreous detachments. </li></ul>
  9. 9. New England Eye Centre Grand Rounds <ul><li>Differential Diagnosis </li></ul><ul><ul><li>Central retinal artery occlusion </li></ul></ul><ul><ul><li>Ophthalmic artery occlusion </li></ul></ul><ul><ul><li>Anterior ischaemic optic neuropathy </li></ul></ul><ul><ul><li>Branch retinal artery occlusion </li></ul></ul><ul><ul><li>Cilioretinal artery obstruction </li></ul></ul>
  10. 10. New England Eye Centre Grand Rounds - Diagnosis <ul><li>Based on symptoms and physical findings, an initial working diagnosis of right central retinal artery occlusion was made. A diagnostic and therapeutic work-up was initiated to confirm the diagnosis, rule out other causes, as well as to establish aetiology and prognosis. Meanwhile, the patient was started on oral prednisone 60 mg and aspirin. </li></ul>
  11. 11. New England Eye Centre Grand Rounds - Examination 0.34 OD 1.15 OD 5.02 OD 5.21 OS
  12. 12. New England Eye Centre Grand Rounds - Examination <ul><li>Fluorescein Angiography </li></ul><ul><ul><li>Fluorescein angiography revealed an abnormally long arteriovenous transit time with late filling of retinal vessels. Background choroidal circulation was intact. </li></ul></ul>
  13. 13. New England Eye Centre Grand Rounds - Examination <ul><li>Optical Coherence Tomography OD </li></ul>7/9/99 2/11/00
  14. 14. New England Eye Centre Grand Rounds - Examination <ul><li>Optical Coherence Tomogram OD </li></ul><ul><ul><li>Optical Coherence Tomogram showed a central macular thickness of 180 microns, slightly increased from 150 microns of baseline thickness. </li></ul></ul>
  15. 15. New England Eye Centre Grand Rounds - Examination <ul><li>Laboratory work-up </li></ul><ul><ul><li>The following laboratory tests were negative: CBC, platelets, PT, PTT, C-reactive protein, VDRL. Erythrocyte sedimentation rate (ESR), however, was elevated at 54. </li></ul></ul><ul><li>Systemic Imaging </li></ul><ul><ul><li>Carotid ultrasound found very mild plaque in the right common carotid artery at the bifurcation with patent internal carotid artery. </li></ul></ul><ul><ul><li>Transoesophageal echocardiography revealed essentially normal cardiac findings and a moderate, immobile plaque in the transverse and descending aorta. The plaques could unlikely be an embolic source to the right retinal artery. </li></ul></ul>
  16. 16. New England Eye Centre Grand Rounds - Examination <ul><li>Right Temporal Artery Biopsy </li></ul><ul><ul><li>Portions of temporal artery showed intimal thickening without evidence of temporal arteritis. </li></ul></ul>
  17. 17. New England Eye Centre Grand Rounds - Clinical Course <ul><li>Based on ancillary tests, the diagnosis of central retinal artery occlusion (CRAO) was established and prednisone was stopped. </li></ul><ul><li>The patient was examined again in the clinic in three weeks. He reported partially recovered peripheral vision in the right eye, though his central vision improved slightly at finger counting at four feet. </li></ul><ul><li>Examination revealed slight pallor of the optic disc with some attenuated arteries. There were no residual effects of CRAO. There was no neovascularization of the anterior/posterior segments. </li></ul>
  18. 18. New England Eye Centre Grand Rounds – Clinical Course 2/11/00 21/11/00 Red Free Photographs - OD
  19. 19. New England Eye Centre Grand Rounds - Clinical Course 0.31 OD 1.02 OD 5.23 OD 5.46 OS Fluorescein Angiography
  20. 20. New England Eye Centre Grand Rounds – Clinical Course 27/1/00 21/11/00
  21. 21. New England Eye Centre Grand Rounds – Clinical Course <ul><li>No further treatment was recommended at that point. The patient was suggested to maintain follow up for early detection and treatment of possible neovascularization. </li></ul>
  22. 22. New England Eye Centre Grand Rounds - Discussion <ul><li>Central retinal artery obstruction (CRAO) in a patient with endocarditis and multiple systemic emboli was first described by von Graefe in 1859. </li></ul><ul><li>The frequency of CRAO is about 1 per 10,000 outpatient visits. It typically occurs in elder adults, more commonly in men, but can also be seen in children. It rarely involves both eyes. </li></ul><ul><li>Recent studies showed a 41% incidence of internal carotid artery stenosis in Caucasian patients compared with 3.4% incidence in African Americans </li></ul>
  23. 23. New England Eye Centre Grand Rounds – Discussion <ul><ul><li>Patients with acute CRAO usually present with severe, painless visual loss occurring over several seconds. Often, there is a preceding history of amaurosis fugax. The visual acuity ranges between finger counting to light perception. </li></ul></ul><ul><ul><li>The anterior segment examination is most often initially normal but an afferent pupillary defect usually develops within seconds after obstruction. </li></ul></ul><ul><ul><li>The retina assumes an opacified and yellow-white appearance except in the region of foveola, where a cherry-red spot is present. </li></ul></ul><ul><ul><li>In most cases the opacification resolves over 4 to 6 weeks leaving a pale optic disc and narrowed retinal vessels. </li></ul></ul>
  24. 24. New England Eye Centre Grand Rounds - Discussion <ul><li>The yellow cholesterol embolus (Hollenhorst plaque), which arises from atherosclerotic deposits in the carotid arteries and aortic arch, is visible in 20% of eyes. It is associated with increased mortality. </li></ul><ul><li>The incidence of rubeosis iridis after CRAO was previously thought to be in the 1 to 5% range. More recently, however, Duker and associates in a prospective study found that 18.2% of eyes progress to develop rubeosis iridis in 4 to 5 weeks. </li></ul><ul><li>Neovascularization of the optic disc develops in about 3% of eyes. Laser PRP is effective in causing regression of the new iris vessels in 65% of eyes . </li></ul>
  25. 25. New England Eye Centre Grand Rounds – Discussion <ul><ul><li>Intravenous fluorescein angiography reveals a delay in retinal arterial filling and in retinal arteriovenous transit time. The choroidal vascular bed usually fills normally. </li></ul></ul><ul><ul><li>The retinal circulation re-establishes following an acute obstruction; therefore, arterial narrowing and visual loss may persist, but the angiogram can revert to normal at varying times after the insult. </li></ul></ul><ul><ul><li>Electroretinography typically discloses a reduction of the b-wave. </li></ul></ul><ul><ul><li>Visual field studies frequently demonstrate a remaining temporal island of vision because of choroidal nourishment. </li></ul></ul>
  26. 26. New England Eye Centre Grand Rounds – Pathophysiology <ul><li>The aetiology of CRAO is impossible to ascertain in many instances. </li></ul><ul><li>The majority of cases in elderly patients include the following associated systemic conditions: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Carotid atherosclerosis </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Cardiac valvular disease </li></ul></ul><ul><li>The finding of CRAO generally merits a complete systemic work-up to look for aetiologic factors. It should include ESR and neck and cardiac ultrasound. </li></ul>
  27. 27. New England Eye Centre Grand Rounds - Prognosis <ul><ul><li>Experiments in primates suggests that the retina sustains irreversible damage when the central retinal artery has been obstructed for 90 to 100 minutes. This was confirmed in more recent morphometric studies in rhesus monkeys. </li></ul></ul><ul><ul><li>In the human clinical situation, however, the central retinal artery is rarely completely obstructed. In fact, recovery of good vision has been noted to occur as long as three days after CRAO. Therefore, ocular treatment should be given if a patient is seen within 24 hours after the onset of visual loss. </li></ul></ul>
  28. 28. New England Eye Centre Grand Rounds – Prognosis <ul><ul><li>Ocular massage and repeated increased pressure for 10 to 15 seconds followed by a sudden release can be attempted immediately to dislodge an obstructing embolus. </li></ul></ul><ul><ul><li>Therapeutic steps also include anterior chamber paracentesis and intravenous acetazolomide to reduce intraocular pressure. </li></ul></ul><ul><ul><li>A mixture of 95% oxygen and 5% carbon dioxide (carbogen) can be applied systemically to achieve better oxygenation and vasodilation. In the absence of carbogen, rebreathing into a paper bag can be considered in the office. </li></ul></ul><ul><ul><li>It is uncertain, nevertheless, whether the treatment yields better vision than the natural course of the disease. </li></ul></ul>
  29. 29. New England Eye Centre Grand Rounds – Prognosis <ul><ul><li>Other treatment modalities such as antifibrinolytic agents, systemic anticoagulation, retrobulbar injection of vasodilators and stepwise aggressive systematic treatment have questionable efficacy but serious complications. </li></ul></ul><ul><ul><li>Most recently, multiple experimental surgical techniques of recanulization of occluded retinal vasculature were evaluated. </li></ul></ul><ul><ul><li>The visual prognosis appears to correlate with presenting visual acuity, duration of impairment, cause of arterial occlusion, and the nature of occlusive emboli. </li></ul></ul><ul><ul><li>It is generally poor with most patients sustaining severe and permanent visual loss, whether treated or not. </li></ul></ul>
  30. 30. New England Eye Centre Grand Rounds – Conclusion <ul><li>A 71-year-old man presented with sudden, severe, and painless loss of vision in the right eye. He was diagnosed with central retinal artery occlusion based on history, fundus examination, and fluorescein angiography. </li></ul>
  31. 31. New England Eye Centre Grand Rounds – References <ul><ul><ul><li>Ullman EV: Albrecht von Graefe: The man in his time. Am J Ophthalmol 38:525, 695 and 791, 1954. </li></ul></ul></ul><ul><ul><ul><li>Noble JD et al: Fluorescein angiography in central retinal artery occlusion. Arch Ophthalmol 77:619-629, 1967. </li></ul></ul></ul><ul><ul><ul><li>Gold D: Retinal artery occlusion. Trans Am Acad Ophthalmol Otolaryngol 83:392-408, 1977. </li></ul></ul></ul><ul><ul><ul><li>Augsburger J et al: Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol 64:913-917, 1980. </li></ul></ul></ul><ul><ul><ul><li>Hayreh SS et al: Ocular neovascularization with retinal vascular occlusion. Arch Ophthalmol 100:1585-1596, 1982. </li></ul></ul></ul>
  32. 32. New England Eye Centre Grand Rounds – References <ul><ul><ul><li>Brown GC et al: Central retinal artery obstruction and visual acuity. Ophthalmology 89:14-19, 1982. </li></ul></ul></ul><ul><ul><ul><li>Duker JD et al: Iris neovascularization associated with obstruction of the central retinal artery. Ophthalmology 95:1244-1250, 1988. </li></ul></ul></ul><ul><ul><ul><li>Duker et al: Neovascularization of the optic disc associated with obstruction of the central retinal artery. Ophthalmology 96:87-91, 1989. </li></ul></ul></ul><ul><ul><ul><li>Duker et al: A prospective study of acute central retinal artery obstruction. Arch Ophthalmol 109:339-342, 1991. </li></ul></ul></ul><ul><ul><ul><li>Atebara NH et al: Efficacy of anterior chamber paracentesis and carbogen in treating acute nonarteritic central artery occlusion. Ophthalmology 102:2029-2035, 1995. </li></ul></ul></ul>
  33. 33. New England Eye Centre Grand Rounds – References <ul><ul><ul><li>Sagripanti A et al: Blood coagulation parameters in retinal artery occlusion. Graefe’s Arch Clin Exp Ophthalmol 237:480-483, 1999. </li></ul></ul></ul><ul><ul><ul><li>Rumelt S et al: Aggressive systematic treatment for central retinal artery occlusion. Am J Ophthalmol 128:733-738, 1999. </li></ul></ul></ul><ul><ul><ul><li>Ahuja R et al: Mechanisms of retinal arterial occlusive disease in African American and Caucasian patients. Stroke 30:1506-1509, 1999. </li></ul></ul></ul><ul><ul><ul><li>Hayreh SS et al: Optic disc and retinal nerve fiber layer damage after transient central retinal artery occlusion: An experimental study in rhesus monkeys. Am J Ophthalmol 129:786-795, 2000. </li></ul></ul></ul><ul><ul><ul><li>Tang WM et al: A study of surgical approaches to retinal vascular occlusions. Arch Ophthalmol 118:138-143, 2000. </li></ul></ul></ul><ul><ul><ul><li>Beatty S et al: Local intra-arterial fibrinolysis for acute occlusion of the central retinal artery: a meta-analysis. Br J Ophthalmol 84:914-916, 2000. </li></ul></ul></ul>

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