A 72-year-old male patient presented to our ophthalmology clinic reporting a sudden, painless loss of vision in the right eye that had occurred approximately 24 hours before examination.
His medical history was significant for arterial hypertension, well controlled under pharmacological treatment; no other systemic comorbidities or vascular risk factors were reported.
On ophthalmic examination, visual acuity in the right eye was limited to light perception, while the left eye had normal visual acuity. The anterior segment of both eyes was unremarkable.
Fundus examination of the right eye revealed diffuse retinal whitening consistent with ischemia, with foveal sparing resulting in a cherry-red spot. A small peripapillary area perfused by a cilioretinal artery was observed, and there is a diffuse peripapillary whitening suggestive of axoplasmic stasis. Retinal vessels exhibited a segmented, “boxcarring” appearance.
Optical coherence tomography (OCT) demonstrated diffuse thickening and hyperreflectivity of the inner retinal layers due to intraretinal edema, accompanied by shadowing and relative hyporeflectivity of the outer retinal layers. Findings were consistent with acute ischemic retinal edema secondary to central retinal artery occlusion.
Systemic evaluation, including carotid Doppler ultrasonography and echocardiography, was recommended to identify potential sources of emboli. Laboratory work-up for cardiovascular risk factors and coagulation abnormalities was also initiated.
CRAO is considered the ocular analogue of cerebral stroke and often reflects underlying systemic vascular pathology. The main risk factors include hypertension, diabetes mellitus, hyperlipidemia, carotid atherosclerosis, and cardiac disease. In this patient, long-standing hypertension likely contributed to vascular endothelial damage and subsequent arterial occlusion.
The diagnosis of CRAO is primarily clinical, supported by characteristic fundoscopic findings, such as retinal pallor with a foveal “cherry-red spot” and a segmental (“boxcarring”) vascular appearance, as well as multimodal imaging, including OCT, which demonstrates acute ischemic edema of the inner retina. Fluorescein angiography, when performed, may show delayed or absent filling of the central retinal artery.
Therapeutic interventions are time-sensitive and may include ocular massage, anterior chamber paracentesis, or tPA therapy.
Credit
Giovanni Di Fiore, M.D. Naples
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