Central retinal artery occlusionMANAGEMENT

OPHTHALMOLOGIC PRESENTATIONS · 12 SECTIONS

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427 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Acute angle-closure glaucoma Central retinal artery occlusion Central Retinal Vein Occlusion Chemical eye injury Corneal abrasion Corneal ulcer Globe rupture Hyphema Iritis-Uveitis Ocular foreign body Optic Neuritis Orbital cellulitis Orbital Floor Fracture (Blowout)Retinal detachment Vitreous Hemorrhage

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp29

Time-critical priorities

›Time-critical stabilization

›Airway protection for reduced level of consciousness

›Stroke code activation for concurrent focal neurologic deficits

›Hemodynamic stability

›Persistent hypotension trigger for shock workup and resuscitation

›Glucose bedside

›Hypoglycemia mimic threshold 3.9 mmol/L

›Symptom onset time last-known-well

›Treatment window relevance for reperfusion consideration

›Immediate ophthalmology and stroke team notification

›CRAO treated as ocular ischemic stroke (Class I consensus)

Immediate decision points

›Immediate decision points

›Monocular painless vision loss with sudden onset

›Central retinal artery occlusion until proven otherwise

›If giant cell arteritis concern

›Immediate corticosteroids prior to confirmatory testing (Class I)

›If within 4.5 hours and no contraindications

›IV thrombolysis pathway consideration with stroke team (Class IIb)

›If transient monocular vision loss

›Amaurosis fugax pathway

›High short-term stroke risk evaluation

Monitoring and access

›Monitoring and access

›Cardiac monitoring

›Atrial fibrillation screening

›IV access

›Thrombolysis-ready access if eligible

›Blood pressure targets

›Avoid iatrogenic hypotension

›Post-thrombolysis targets per stroke protocol if treated

02History/hx45

Presenting features

›Symptom characterization

›Sudden monocular vision loss

›Painless onset

›Curtain or blackout description

›Time last-known-normal

›Exact time documentation

›Progression

›Persistent vs transient episodes

›Associated neurologic symptoms

›Weakness

›Speech disturbance

›Ataxia

›Facial droop

Vascular and embolic risk

›Vascular risk profile

›Hypertension

›Medication adherence

›Diabetes mellitus

›Recent control context

›Dyslipidemia

›Statin use

›Tobacco

›Current use

›Prior stroke or TIA

›Antithrombotic regimen

›Atrial fibrillation history

›Anticoagulant use

›Valvular disease

›Endocarditis risk factors

›Recent vascular procedures

›Carotid interventions

›Cardiac catheterization

Giant cell arteritis screen

›Giant cell arteritis features

›Age 50 years or older

›New headache

›Jaw claudication

›Scalp tenderness

›Polymyalgia rheumatica symptoms

›Proximal stiffness

›Constitutional symptoms

›Fever

›Weight loss

›Visual symptoms in other eye

›Diplopia

›Prior transient vision loss

›Recurrent episodes

03Physical Exam/exam41

General and neurologic

›Neurovascular exam

›Vital signs

›Fever trigger for inflammatory or infectious considerations

›Focused neurologic exam

›NIHSS elements

›Posterior circulation signs

›Cardiovascular exam

›Irregularly irregular rhythm

›New murmur

›Carotid exam

›Bruit presence

›Asymmetry

Eye exam

›Ocular assessment

›Visual acuity each eye

›Pinhole response

›Pupils

›Relative afferent pupillary defect

›Visual fields

›Confrontation deficits

›Extraocular movements

›Pain with movement trigger for optic neuritis considerations

›Intraocular pressure

›Elevated pressure alternative diagnosis consideration

›Slit lamp

›Corneal clarity

›Anterior chamber depth

›Fundoscopy

›Retinal whitening

›Cherry-red spot

›Boxcarring segmentation

›Visible embolus

›Optic disc edema considerations

Giant cell arteritis exam

›Giant cell arteritis exam

›Temporal artery

›Tenderness

›Reduced pulse

›Nodularity

›Scalp tenderness

›Comb pain history correlation

›Musculoskeletal

›Shoulder or hip girdle tenderness

04Differential Diagnosis/ddx33

Vision-threatening ocular causes

›Ocular differentials

›Central retinal artery occlusion

›ICD-10 H34.1

›SNOMED CT central retinal artery occlusion

›Branch retinal artery occlusion

›Sectoral vision loss pattern

›Central retinal vein occlusion

›Fundus hemorrhages and venous tortuosity

›Retinal detachment

›Flashes and floaters

›Vitreous hemorrhage

›Hazy view

›Acute angle-closure glaucoma

›Painful red eye

›Optic neuritis

›Pain with eye movement

›Ischemic optic neuropathy

›Disc swelling

›Arteritic vs non-arteritic

Neurovascular and systemic

›Neurovascular and systemic differentials

›Occipital stroke

›Homonymous field deficit

›Transient ischemic attack

›Amaurosis fugax

›Giant cell arteritis

›Arteritic ischemic optic neuropathy

›Migraine aura

›Positive visual phenomena

›Functional vision loss

›Inconsistent exam findings

›Carotid dissection

›Neck pain

›Horner syndrome

05Laboratory Tests/lt33

Core labs for stroke and embolic workup

›Stroke pathway labs

›Point-of-care glucose

›Hypoglycemia mimic threshold 3.9 mmol/L

›Complete blood count

›Anemia contribution to ischemia

›Electrolytes and renal function

›Thrombolysis medication safety context

›Coagulation studies

›INR for warfarin exposure

›aPTT for heparin exposure

›Troponin

›Concurrent myocardial ischemia screening

›Lipid panel

›Secondary prevention baseline

›HbA1c

›Long-term risk stratification

Giant cell arteritis evaluation

›Giant cell arteritis labs

›ESR

›Elevated values support diagnosis

›Normal value does not exclude

›CRP

›Elevated values support diagnosis

›Often more sensitive than ESR

›Platelets

›Thrombocytosis supportive

Additional tests when indicated

›Additional indicated labs

›Blood cultures

›Infective endocarditis concern

›Hypercoagulable testing

›Young patient without risk factors

›Recurrent arterial thrombosis

›Pregnancy test

›Reproductive age with imaging or medication implications

06Diagnostic Tests/dt46

Scoring Systems

›Severity and outcome scoring

›NIH Stroke Scale

›Baseline neurologic deficit quantification

›Thrombolysis pathway documentation

›Modified Rankin Scale

›Baseline functional status

›Disposition planning

›ABCD2 score

›Transient monocular vision loss risk stratification adjunct

›Not a substitute for urgent vascular imaging

MRI

›MRI-based evaluation

›MRI brain with diffusion-weighted imaging

›Concurrent silent cerebral infarct detection

›Risk stratification for early stroke

›MRI orbits

›Alternative optic nerve pathology consideration

›Contraindications screening

›Implanted devices

›Claustrophobia and sedation considerations

›Timing limitations

›ED throughput constraints

›CT-based evaluation

›Non-contrast CT head

›Alternative intracranial pathology exclusion

›Hemorrhage exclusion if considering thrombolysis for concurrent neurologic deficits

›CTA head and neck

›Carotid stenosis or occlusion detection

›Carotid dissection evaluation

›CT perfusion

›Stroke team protocol dependent

›Radiation and contrast considerations

›Renal function context

›Contrast allergy history

Ultrasound

›Ultrasound evaluation

›Carotid duplex ultrasound

›Carotid stenosis assessment

›Plaque characterization

›Point-of-care ocular ultrasound

›Retinal detachment exclusion support

›Vitreous hemorrhage support

›Temporal artery ultrasound

›Giant cell arteritis supportive findings

›Operator dependence limitation

›Echocardiography

›Cardioembolic source evaluation

›Bubble study for shunt when indicated

07Disposition/dispo26

Level of care

›Disposition planning

›Stroke unit admission

›CRAO as ocular stroke pathway

›High early ischemic stroke risk

›Telemetry bed

›Atrial fibrillation detection need

›ICU criteria

›Thrombolysis received

›Hemodynamic instability

›Large vessel occlusion with neurologic deficits

Transfer and consultation

›Consultation and transfer

›Ophthalmology emergent involvement

›Fundus confirmation and ocular interventions

›Neurology or stroke team involvement

›Secondary prevention initiation

›Thrombolysis consideration within window

›If hyperbaric oxygen considered and locally unavailable

›Transfer pathway to hyperbaric-capable center (Class IIb)

Discharge criteria

›Discharge considerations

›Not typical for confirmed CRAO

›Transient monocular vision loss without persistent deficit possible discharge after expedited workup

›Reliable follow-up within 24 to 72 hours

›Ophthalmology

›Stroke clinic or neurology

›Antithrombotic and risk factor plan in place

›Medication access confirmed

08Treatment/t77

Reperfusion and acute ocular measures

›Acute reperfusion considerations

›IV alteplase within 4.5 hours

›Candidate selection by stroke team (Class IIb)

›Contraindications per acute ischemic stroke protocol

›Dose 0.9 mg/kg IV

›Maximum 90 mg

›10% as IV bolus

›Remainder over 60 minutes

›Intra-arterial thrombolysis or thrombectomy

›Specialized center protocol dependent (Class IIb)

›Evidence uncertainty acknowledgment

›Hyperbaric oxygen therapy

›Early presentation consideration (Class IIb)

›Contraindications screening

›Untreated pneumothorax

›Acute ocular temporizing measures

›Ocular massage

›Ophthalmology-directed due to limited evidence (ACEP Level C)

›Intraocular pressure lowering

›Acetazolamide 500 mg IV or PO

›Sulfonamide allergy caution

›Renal impairment caution

›Timolol 0.5% ophthalmic

›1 drop affected eye

›Bradycardia and asthma contraindications

›Apraclonidine 0.5% or 1% ophthalmic

›1 drop affected eye

›Cardiovascular caution

›Anterior chamber paracentesis

›Ophthalmology-only procedure

›Complication risks

›Hyphema

›Infection

Giant cell arteritis pathway

›Giant cell arteritis treatment

›If clinical suspicion high

›Methylprednisolone 500 to 1000 mg IV daily

›3 days commonly used for vision-threatening presentations

›Transition to oral prednisone per specialist

›Prednisone 40 to 60 mg PO daily

›Alternative when IV not indicated

›Do not delay for biopsy or imaging (Class I)

›Temporal artery biopsy planning

›Corticosteroids do not preclude biopsy yield in early period

Secondary prevention

›Antithrombotic therapy

›Antiplatelet for non-cardioembolic CRAO

›Aspirin 160 to 325 mg PO load

›Maintenance 81 mg PO daily

›If aspirin allergy

›Clopidogrel 300 mg PO load

›Dual antiplatelet therapy for minor stroke or high-risk TIA pathway

›Aspirin plus clopidogrel for 21 days (Class I for selected minor stroke or high-risk TIA frameworks)

›Anticoagulation for atrial fibrillation

›DOAC initiation timing per stroke team

›Warfarin for mechanical valve

›Lipid management

›High-intensity statin

›Atorvastatin 40 to 80 mg PO daily

›Secondary prevention pathway (Class I)

›Rosuvastatin 20 to 40 mg PO daily

›Alternative high-intensity option

›Blood pressure and risk factors

›Hypertension management

›Long-term targets per guidelines

›Avoid acute aggressive lowering unless indicated

›Diabetes optimization

›Referral to primary care or endocrinology

›Smoking cessation

›Nicotine replacement therapy offering

›Carotid stenosis management

›Vascular surgery consult for symptomatic high-grade stenosis (Class I)

Supportive care

›Supportive care

›Analgesia as needed

›Avoid sedating agents that impair neuro exam when possible

›Antiemetics if nausea

›Ondansetron 4 mg IV or ODT

›Eye protection

›Avoid pressure patches unless directed

09Special Populations/sp32

Pregnancy

›Pregnancy considerations

›Imaging selection

›CTA head and neck risk-benefit discussion

›MRI without gadolinium preference when feasible

›Thrombolysis

›Pregnancy not an absolute contraindication

›Maternal-fetal risk discussion with stroke team

›Antithrombotics

›Aspirin low-dose generally acceptable

›Anticoagulation selection per obstetrics and neurology

›Preeclampsia context

›Severe hypertension evaluation if present

Geriatric

›Geriatric considerations

›Giant cell arteritis prevalence

›Lower threshold for steroid initiation

›Polypharmacy

›Drug interaction review for antithrombotics

›Frailty and baseline function

›mRS documentation relevance

›Renal impairment

›Contrast risk mitigation

›Acetazolamide caution

Pediatrics

›Pediatric considerations

›CRAO rarity

›Congenital heart disease embolic sources

›Sickle cell disease risk

›Hypercoagulable evaluation

›Inherited thrombophilias consideration

›Weight-based medication dosing

›Thrombolysis protocols pediatric specialist-only

›Non-accidental trauma differential

›Retinal findings correlation and safeguarding pathway

10Background/b28

Epidemiology

›Epidemiologic context

›CRAO as ocular ischemic stroke

›Similar risk factors to cerebral ischemic stroke

›Age distribution

›Predominantly older adults

›Major etiologies

›Carotid atherosclerotic emboli

›Cardioembolic sources

›Giant cell arteritis in older adults

Pathophysiology

›Pathophysiology

›Retinal ischemia due to central retinal artery obstruction

›Embolus

›Thrombosis

›Vasculitis

›Retinal tissue vulnerability

›Time-dependent irreversible injury risk

›Funduscopic correlates

›Inner retinal whitening from edema

›Cherry-red spot from preserved choroidal circulation

Therapeutic Considerations

›Therapeutic principles

›Time dependence

›Earlier reperfusion associated with better visual outcomes

›Evidence limitations for ocular maneuvers

›Massage and IOP lowering uncertain benefit

›Stroke risk reduction priority

›High early risk of cerebral ischemic events

›Giant cell arteritis urgency

›Steroids prevent contralateral eye involvement (Class I)

11Patient Discharge Instructions/pdi21

Copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Sudden loss of vision can be a stroke of the eye

›Medications

›Antiplatelet or anticoagulant as prescribed

›Statin as prescribed

›Activity and safety

›No driving until cleared

›Fall precautions for impaired vision

›Follow-up

›Ophthalmology within 24 to 72 hours or as directed

›Neurology or stroke clinic urgent follow-up

›Primary care for risk factor management

›Return immediately for

›New weakness

›New speech difficulty

›New facial droop

›New severe headache

›Vision loss in the other eye

›Chest pain

›Syncope

12References/r16

Clinical guidelines and key sources

›Key guidance

›AHA scientific statement on central retinal artery occlusion as acute ischemic stroke of the retina

›Recommendations for emergent stroke systems evaluation

›Ophthalmology society guidance on CRAO evaluation and urgent referral

›Funduscopic diagnostic features

›Stroke secondary prevention guidelines for antiplatelet therapy and high-intensity statin use

›Class I recommendations for risk reduction

›Giant cell arteritis diagnostic and treatment guidance

›Immediate corticosteroids for vision-threatening suspicion (Class I)

Evidence summaries and reviews

›Evidence summaries

›Meta-analyses and cohort studies on thrombolysis in CRAO

›Mixed outcomes and selection bias limitations

›Studies on silent brain infarcts after CRAO

›Support for MRI DWI in evaluation

›Carotid stenosis and cardioembolic source prevalence studies in CRAO cohorts

›Support for vascular and cardiac workup

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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