Sudden painless loss of vision in an elderly female due to central retinal artery occlusion (CRAO)

Author: V. Dimov, M.D., Assistant Professor, University of Chicago
Reviewer: S. Randhawa, M.D.

An 83-year-old female was admitted with sudden loss of vision in her right eye which started last nigh. She had a hip replacement surgery for right hip fracture 2 weeks ago and has been in rehabilitation since then. One day prior to this admission, she heard a "pop" while twisting her right hip and the X-ray showed a periprosthetic fracture. The orthopedics consult suggested a hip revision within a week.

Past medical history (PMH)

Rheumatoid arthritis, hypertension (HTN), atrial fibrillation (AFib).

Medications

Prednisone, warfarin, metoprolol, lisinopril.

Physical examination

Blindness in right eye, otherwise unremarkable.

What is the most likely diagnosis?

Central retinal artery occlusion.

What would you do?

Urgent ophthalmology consultation.
CBCD, CMP, INR.
ESR, CRP.
Carotid duplex.
TTE/TEE.

What happened?

An urgent ophthalmology consult was called who confirmed the diagnosis of central retinal artery occlusion (CRAO). Fundoscopy revealed retinal edema and emboli in the branches of the right retinal artery.

Heparin IV was started but patient's vision did not improve.

ESR was 46 mm/hr, lower than the baseline value of 51 mm/hr recorded 2 months ago, CRP was 1.4 mg/dL. INR was 2.9.

The carotid duplex did not show hemodynamically significant stenosis in either carotid bifurcation on gray scale imaging and color Doppler analysis. Velocity parameters and waveforms were compatible with stenosis in the 0-29% range in each ICA by NASCET criteria. There was antegrade flow bilateral cervical vertebral arteries.

TEE did not show thrombi in the left atrium.

The most likely reason for central retinal artery occlusion in this patient was fat embolism from hip fracture.

What happened next?

In 2 days, the patient was able to see fingers in the peripheral visual field of her right eye but not to count them. The serial ophthalmoscopy exams confirmed the diagnosis of CRAO. She had a revision of right hip replacement and was discharged to a rehabilitation facility with ophthalmology follow-up.

Final diagnosis

Central retinal artery occlusion.

Summary

CRAO is an ocular emergency. It presents with acute, painless loss of monocular vision. CRAO is rare with an incidence of approximately 1 to 10 in 100,000 and is considered a form of stroke.

Mean age of patients is 60-65 years, more than 90% of patients with CRAO are over the age of 40 years. CRAO almost never occurs in both eyes simultaneously, but it may occur sequentially. The vision loss is severe, usually leaving no more than a small temporal island of vision. Most affected patients can see only hand motions.


Figure 1. BRAO (Branched Retinal Artery Occlusion). Multiple yellowish refractile bodies can be seen scattered throughout the arterioles in the superior arcuate region. Source: University of Iowa allows visitors/health care professionals to duplicate portions of the site for personal or educational use without seeking permission from the authors.

On funduscopic examination, ischemic retinal whitening is seen immediately after an occlusion of the central retinal artery. A "cherry red spot" appears in the macula, where the retina is thinner and the retinal pigment epithelium and choroidal vasculature can be seen.

ESR and CRP should be measured in all patients over age 50 with CRAO to exclude GCA. Cardiogenic embolism should be ruled out in patients in whom carotid disease has been excluded.

CRAO has a poor prognosis for spontaneous recovery of vision since irreversible retinal injury occurs within 100 minutes of arterial occlusion. No treatment has been proven to improve visual outcomes.

Preliminary reports of intraarterial thrombolysis appear promising if the procedure is performed within six hours of onset of CRAO.

References

Central and branch retinal artery occlusion. UpToDate 15.2, accessed 08/28/2007.
Central retinal artery occlusion. Robert Bendheim Digital Atlas of Ophthalmology.
Central retinal artery occlusion. Robert Bendheim Digital Atlas of Ophthalmology.
Free Ophthalmology Atlas. CasesBlog, 05/2007.
Retinal Arteriolar Cholesterol Emboli. NEJM Images, 02/2008.
Central Hemiretinal Arterial Occlusion. NEJM, 06/2008.
Ophthalmology Self-Guided Study Activity - ACP 2011 .

PowerPoint presentations

Ocular Emergencies. University of Alberta - Edmonton, Alberta, Canada.
Vision Loss. University of Alberta - Edmonton, Alberta, Canada.

Published: 08/28/2007
Updated: 07/15/2010

7 comments:

  1. I do not understand how an fat embolus passed through the pulmonary capillary bed to reach the retinal artery. Was there any right to left shunt in the heart?

    ReplyDelete
  2. I was 46 when I had two occlusions within two months of one another. I had ocular migraines for years that suddenly begin increasing six months before the occlusion. I also had a major increase in headaches that no medical person bothered to question. They were migraine headaches and I had been treating them with OTC sinus medications. No cause was ever found and the occlusions were attributed to the migraines. I have to wonder if I had been treated with migraine medication (and chewing up an aspirin immediately upon noticing any visual disturbance), whether the occlusions would have occured.

    The other thing that no one ever mentions is that emergency rooms and clinics seem to be clueless how to treat a retinal artery occlusion and the physicians and/or nurses wait for the on-call opthamologist to get to the hospital. This is simply unacceptable with something that causes damage if treatment is delayed. In both instances, ocular massage and chamber paracentesis moved the blockage but too much time had passed.

    My thought to physicians. If you have a patient with ocular migraines, teach them how to do the ocular massage.

    Oh, and if you have a patient with a CRAO, tell them about Charles Bonnet syndrome. I spent a very scary night in a hospital bed with a phantom man in a long black coat. To this day, I still see spiders, bugs and crabs. Yes, it's funny but it can be terrifying and disconcerting when it first happens.

    ReplyDelete
  3. Appreciated the anonymous information since I never heard of Charles Bonnet syndrome or ocular massage.
    I agree it's unacceptable to not teach physicians this.. along with a lot of other key issues we need to know. Instead we learn and are tested on useless "zebra" disease trivia that we'll send to a specialist anyway...

    ReplyDelete
  4. Could this patient have had Giant Cell Arteritis? With her baseline ESR and CRP high, it might be a hidden 2nd diagnosis?

    ReplyDelete
  5. MAXIDEX DEXAMETHASONE WARNING

    I had eye surgery and in the post-op pack was MAXIDEX(dexamethasone) drops by ALCON LABS.

    Two days later I was BLIND

    Use Google and enter EPOCRATES MAXIDEX REACTION to verify

    OR CALL 800-757-9195

    ReplyDelete
  6. this is a good case to be presented and i got alot benifit from it thank you

    ReplyDelete
  7. MAXIDEX DEXAMETHASONE WARNING

    I had eye surgery and in the post-op pack was AXIDEX(dexamethasone) drops by ALCON LABS.

    Two days later I was BLIND

    Use Google and enter EPOCRATES MAXIDEX REACTION to verify

    Or call 800-757-9195

    ReplyDelete