Case 19 - Retina and vascular pathology
70-year-old man - Sudden complete painless monocular vision loss - Cherry- red spot - Fellow eye normal
A 70-year-old man suffered a sudden and total loss of vision in one eye without pain or other symptoms. The fundus of the involved eye is depicted. The opposite eye remains normal.
CHERRY-RED SPOT at fovea (fovea thin -> no inner retinal layers -> underlying choroidal red-orange visible, contrasting with surrounding white opaque ischemic retina). PALE RETINAL EDEMA (inner retinal ischemic cytotoxic edema = axoplasmic stasis). BOXCARRING of arterioles (segmented blood column). ATTENUATED thread-like arterioles (no flow). Pale, edematous optic disc.
Vascular: CRAO (this case - cherry-red spot + pale retina), BRAO (sectoral VL, embolic), Arteritic AION/GCA (chalky disc + systemic symptoms), NAION (altitudinal field, small C/D). Retinal: RD (curtain shadow + floaters/flashes), Vitreous hemorrhage (floaters + red haze). Optic nerve: optic neuritis (usually painful, younger patients), PION (normal disc acutely).
TRUE EMERGENCY - inner retina tolerates ischemia only ~90-100 minutes. While awaiting ophthalmology: (1) Digital ocular massage x 15 min (dislodge embolus distally). (2) Rebreathing into paper bag (CO₂ vasodilation). (3) Topical β-blocker + IV acetazolamide (down IOP -> up perfusion). (4) EMERGENT STROKE PROTOCOL - 25% of CRAO have concurrent cerebral emboli: carotid duplex, echocardiography, ESR/CRP (rule out GCA), antiplatelet therapy. AC paracentesis by ophthalmologist.
CRAO = OCULAR STROKE. Cherry-red spot = fovea perfused by intact choroid + surrounding white ischemic inner retina. Treat like a TIA/stroke - same embolic sources (carotid atherosclerosis), same urgency. Inner retina tolerates ischemia ~90-100 minutes. Visual prognosis is poor (<20% recover useful vision) but systemic workup is mandatory to prevent cerebral stroke. Always rule out GCA with ESR/CRP in the elderly.
Findings CHERRY-RED SPOT at fovea (fovea thin -> no inner retinal layers -> underlying choroidal red-orange visible, contrasting with surrounding white opaque ischemic retina). PALE RETINAL EDEMA (inner retinal ischemic cytotoxic edema = axoplasmic stasis). BOXCARRING of arterioles (segmented blood column). ATTENUATED thread-like arterioles (no flow). Pale, edematous optic disc. DDx for acute painless monocular VL Vascular: CRAO (this case - cherry-red spot + pale retina), BRAO (sectoral VL, embolic), Arteritic AION/GCA (chalky disc + systemic symptoms), NAION (altitudinal field, small C/D). Retinal: RD (curtain shadow + floaters/flashes), Vitreous hemorrhage (floaters + red haze). Optic nerve: optic neuritis (usually painful, younger patients), PION (normal disc acutely). Immediate treatment TRUE EMERGENCY - inner retina tolerates ischemia only ~90-100 minutes. While awaiting ophthalmology: (1) Digital ocular massage x 15 min (dislodge embolus distally). (2) Rebreathing into paper bag (CO₂ vasodilation). (3) Topical β-blocker + IV acetazolamide (down IOP -> up perfusion). (4) EMERGENT STROKE PROTOCOL - 25% of CRAO have concurrent cerebral emboli: carotid duplex, echocardiography, ESR/CRP (rule out GCA), antiplatelet therapy. AC paracentesis by ophthalmologist. TEACHING PEARL CRAO = OCULAR STROKE. Cherry-red spot = fovea perfused by intact choroid + surrounding white ischemic inner retina. Treat like a TIA/stroke - same embolic sources (carotid atherosclerosis), same urgency. Inner retina tolerates ischemia ~90-100 minutes. Visual prognosis is poor (<20% recover useful vision) but systemic workup is mandatory to prevent cerebral stroke. Always rule out GCA with ESR/CRP in the elderly.
