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For further information, see CMDT Part 7-18: Central & Branch Retinal Artery Occlusions

Key Features

Essentials of Diagnosis

  • Sudden monocular loss of vision

  • No pain or redness

  • Widespread or sectoral retinal pallid swelling

General Considerations

  • In patients aged 50 years or older with central retinal artery occlusion, consider giant cell arteritis

  • Carotid and cardiac sources of emboli must be sought so that treatment can be given to reduce the risk of stroke

  • In young patients, causes include

    • Migraine

    • Oral contraceptives

    • Systemic vasculitis

    • Congenital or acquired hypercoagulable states (thrombophilia) (see below)

  • Internal carotid artery dissection should be considered when there is neck pain or a recent history of neck trauma

  • In all patients, consider

    • Diabetes mellitus

    • Hyperlipidemia

    • Systemic hypertension

  • Giant cell arteritis should be considered in cases of central retinal artery occlusion without visible emboli

Clinical Findings

Symptoms and Signs

  • Central retinal artery occlusion

    • Presents as sudden profound monocular visual loss

    • Visual acuity is usually reduced to counting fingers or worse

    • Visual field is restricted to an island of vision in the temporal field

  • Branch retinal artery occlusion

    • May also present with sudden loss of vision if the fovea is involved, but more commonly sudden loss of a discrete area in visual field in one eye is the presenting complaint

    • Fundus signs of retinal swelling and adjacent cotton-wool spots are limited to the area of retina supplied by the occluded artery

  • Identify risk factors for a cardiac source of emboli including arrhythmia, particularly atrial fibrillation, and cardiac valvular disease; and check the blood pressure

  • Clinical features of giant cell arteritis include

    • Jaw claudication (which is very specific)

    • Headache

    • Scalp tenderness

    • General malaise

    • Weight loss

    • Polymyalgia rheumatica: shoulder and hip girdle pain

    • Tenderness or thickening of, or absence of pulse in, the superficial temporal arteries


Laboratory Tests

  • Test for diabetes (fasting serum glucose, hemoglobin A1C) and hyperlipidemia (fasting serum cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) in all patients

  • Erythrocyte sedimentation rate and C-reactive protein are usually markedly elevated in giant cell arteritis but one or both may be normal

  • Consider testing for other types of vasculitis (eg, antinuclear antibody, rheumatoid factor, anticytoplasmic neutrophil antibody)

  • In younger patients, consider tests for congenital or acquired hypercoagulable states (thrombophilia)

    • Antiphospholipid antibody syndrome (lupus anticoagulant)

    • Activated protein C resistance/Factor V Leiden

    • Protein C, protein S deficiency

    • Antithrombin deficiency

    • Hyperprothrombinemia (G20210A prothrombin gene mutation)

    • Increased Factor VIII activity

    • Hyperhomocysteinemia

Imaging Studies

  • Obtain duplex ultrasonography of the carotid arteries, ECG, and echocardiography (with transesophageal echocardiography, if necessary), to identify carotid and cardiac sources of emboli

  • When indicated, obtain CT or MR angiography studies for internal carotid artery dissection

Diagnostic Studies


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