Review Question - QID 107686

This patient has a central retinal artery occlusion (CRAO) likely secondary to atherosclerotic disease. The treatment for this condition can include manual massage of the globe, decompression of the anterior chamber within first hour of onset, carbogen (95% O2, 5% CO2), and IV acetazolamide.

Retinal artery occlusions present with sudden painless vision loss in the affected eye. Fundoscopy will demonstrate a pale retina, cherry red spot at the fovea and edema. Management for central retinal artery occlusion is imperfect as interventions to alleviate the obstruction are too delayed. First line therapies involve non-invasive interventions such as ocular massage (to dislodge the clot to a less impactful location), second line therapy includes the more invasive thrombolytics.

Pokhrel et al. review the management of ocular emergencies, which includes mechanical injury, acute angle glaucoma, chemical injury, retinal detachment and CRAO. During any of these events, patients should be brought to the emergency department or an ophthalmologist. Visual fields, acuity and ocular movement should be investigated. Additionally, it is important to perform a pupillary and fundoscopic exam, if possible.

Varma et al. discuss in detail the management of a CRAO. As stated above acute management can include, massage, decompression and acetazolamide. Sublingual nitrates, IV mannitol and thrombolytics are other options. Future management includes prevention of neovascular complications (anti-VEGF) and treating systemic sequelae (as a CRAO indicates there is likely significant atherosclerosis and/or carotid disease).

Figure A: Fundoscopic exam of patient's right retina.

Incorrect Answers:
Answer 1: IV acetazolamide, pilocarpine, and laser iridotomy is the treatment for acute angle glaucoma. Acute angle closure glaucoma presents with eye pain and stiffness, loss of peripheral vision and possible nausea and vomiting.
Answer 2: Laser or cryotherapy to reattach the retina is the treatment for retinal detachment. Retinal detachment can present with photopsia and the "curtain coming down over eye" phenomenon.
Answer 4: Ranibizumab is one of several treatments for retinal vein occlusion. It functions through anti-angiogenic properties. Retinal vein occlusion can present nearly the same way as an arterial occlusion. Fundoscopy will offer definitive diagnosis.
Answer 5: Observation with elevation of the head of the bed at nighttime is conservative treatment for vitreous hemorrhage. It can present with a painless sudden loss of vision in one eye or with "floaters". Diabetic retinopathy is a major risk factor.