Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Recognize CRAO; activate stroke-like pathway; check for GCA in older patients (start steroids when suspected).
- Consider thrombolysis per local protocol if within window; lower IOP and attempt ocular massage early.
- Complete carotid/cardiac workup; start secondary prevention and arrange ophthalmology/neuro-ophthalmology follow-up.
Clinical Synopsis & Reasoning
Sudden, painless monocular vision loss. Treat as an ocular stroke: activate stroke pathway, exclude giant cell arteritis in older patients, consider time-sensitive thrombolysis protocols per center, lower IOP, and start secondary prevention after vascular workup.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Fundus exam/OCT ± fluorescein angiography | Diagnosis | Pale retina with cherry-red spot | Confirms CRAO |
| ESR/CRP and temporal artery eval (if >50 or symptoms) | Rule out GCA | Elevated markers | Start steroids if suspected |
| Carotid duplex/CTA and cardiac evaluation | Etiology | Atherosclerotic/embolic source | Guide prevention |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Vision loss <4.5–6 h | Potential salvage | Immediate stroke activation; consider thrombolysis protocols per center |
| Giant cell arteritis suspected (older with jaw claudication) | Prevent bilateral blindness | Start steroids; temporal artery workup |
| Carotid/cardiac source | Recurrent emboli | Vascular/cardiac evaluation |
| IOP elevated | Perfusion compromise | IOP-lowering agents |
| Hypercoagulable state | Recurrence risk | Hematology workup |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Oxygen, ocular massage (if very early), IOP-lowering drops/acetazolamide | Temporizing | Minutes | Attempt to improve perfusion | Limited evidence |
| Thrombolysis protocols (center-specific) | Reperfusion | Hours | Select patients within time window | Risk/benefit individualized |
| Antiplatelet therapy and vascular risk reduction | Secondary prevention | Hours-days | Prevent recurrence | Manage AF if present |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AHA/ASA scientific statement on CRAO; ophthalmology society updates — Link