Central Retinal Artery Occlusion (CRAO) Management

Algorithm Steps

1. ▶

   Start

   Suspected CRAO

   Sudden, painless, monocular vision loss. Cherry-red spot, pallid retina, box-carring vessels on fundoscopy

   1. ◆

      Decision

      Symptom Onset <24 hours?

      CRAO is a stroke equivalent. Irreversible retinal ischemia can occur in as little as 90 minutes

      1. ●

         Action

         Activate Stroke Alert

         CRAO = CNS infarction per AHA/ASA. Immediate referral to nearest stroke center for evaluation of acute intervention

         • Call stroke team/code stroke
         • Do NOT delay for ophthalmology workup
         • Stroke risk highest in first 2 weeks to 1 month
         1. ◆

            Decision

            Patient Age ≥50 years?

            Giant cell arteritis (GCA) must be ruled out in older patients

            1. ●

               Action

               GCA Workup

               URGENT: Rule out giant cell arteritis to prevent contralateral vision loss

               • Check ESR, CRP immediately
               • Ask about headache, jaw claudication, scalp tenderness, PMR symptoms
               • If GCA suspected: start IV methylprednisolone 1g/day BEFORE biopsy
               • Arrange temporal artery biopsy within 2 weeks
               1. ●

                  Action

                  Systemic Stroke Evaluation

                  Look for embolic source - carotid disease, cardiac source

                  • Carotid ultrasound/CTA
                  • Echocardiogram (TTE ± TEE)
                  • ECG/Holter for AF
                  • CBC, lipids, HbA1c, coagulation
                  • Consider hypercoagulability panel if <50 years
                  1. ⚠

                     Warning

                     ⚠️ Monitor for Neovascularization

                     Increased risk of iris/retinal neovascularization after CRAO

                     • Follow-up examination in 1-2 weeks
                     • More frequent follow-up if greater ischemia
                     • PRP if neovascularization develops
                     1. ●

                        Action

                        Secondary Stroke Prevention

                        Address modifiable risk factors to prevent future events

                        • Antiplatelet therapy (aspirin)
                        • Statin therapy
                        • Blood pressure control
                        • Diabetes management
                        • Smoking cessation
                        • Carotid endarterectomy if significant stenosis
                        1. ✓

                           Outcome

                           Acute Management Complete

                           Patient evaluated by stroke team. Etiology identified. Prevention measures initiated

                        2. ✓

                           Outcome

                           Retina Follow-up

                           Schedule retina clinic follow-up for neovascularization monitoring and visual rehabilitation

      2. ●

         Action

         Late Presentation (>24h)

         No proven treatments to reverse established vision loss. Focus on stroke prevention and etiology workup