Central / Branch Retinal Artery Occlusion

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Most Common Causes

  • Atherosclerosis: Occlusion at the level of the lamina cribrosa in central retinal artery occlusion (CRAO)
  • Emboli: carotid artery, calcified heart valves, cardiac thrombus
  • Vasculitis: Giant cell arteritis


  • History (emboli or arteritis)
  • Check pupils, relative afferent pupillary defect (RAPD)
  • Visual acuity (often only counting fingers)
  • Fundus examination in miosis, compare bilaterally (initial mydriasis not required)
    • Cherry-red spot usually visible only after a few hours
    • “Box-carring” may be observed, indicating interruption of the blood column
    • Emboli
  • Inspection and palpation of the temporal artery: temporal arteritis?
  • OCT: hyper-reflective inner retinal layers


  • Laboratory tests (blood count, CRP, ESR) if suspected giant cell arteriitis or to rule out in patients >50 years
  • Referral to Stroke Unit/Neurology for further assessment (stroke work-up)
  • Prescribe 100mg/d aspirin after consultation with the neurologist
  • In patients < 50 years, in addition to TTE and 24h ECG: consider screening for thrombophilia and vasculitis
  • If suspected arteritic origin –> Plan duplex sonography of extracranial vessels and temporal artery biopsy

Acute Phase Treatment

Note: No recognized treatment regimen, as there is no clear data, no obligation for treatment (except for arteritic origin)

  • Ocular massage for 3-5 minutes with 3-mirror contact lens or digital massage (can also be performed by patient)
  • Consider reducing intraocular pressure with Diamox 500mg i.v. + topical Timolol 0.5% gtt
  • Paracentesis is not recommended
  • Consider intravenous fibrinolysis, up to 4.5 hours after the onset
  • For suspected arteritic origin: hospitalisation and treatment with high-dose steroids


  • After 2, 4, 8, and 24 weeks, possibly more frequently
  • Fluorescein angiography not mandatory but helpful for detecting neovascularisation and assessing perfusion


  • Generally poor, with most patients having permanently reduced visual acuity (< 0.05)
  • Spontaneous improvement in vision in 1-8% of patients, typically in cases involving the cilioretinal artery
  • <5% develop neovascular glaucoma