>> CRAO/CRVO
CRAO: Occlusion of the main artery that supplies the retina or its branches (BRAO); typically due to an embolus from proximal atherosclerotic disease
CRVO: Occlusion of the main veins draining the retina; results in secondary hemorrhage and ischemia
Risk Factors: Older age, Vasculopathy
History:
Sudden painless monocular vision loss or partial loss
Can be transient, stuttering, or permanent
Exam:
Classic fundoscopy findings of CRAO: pale retina with a cherry red spot over the macula as a result of ischemia and edema
Classic fundoscopic finding of CRVO: blood and thunder
Fundoscopic findings may be subtle in:
Pts who present early
Pts with intermittent symptoms
Pts with branched retinal artery occlusions (BRAO)
Management:
Most therapies that have been studied are not very effective
Eyeball massage and globe paracentesis are sometimes used for CRAO
Intra-arterial tPA has also been used for CRAO
>> Retinal Detachment
Overview:
May occur as a result of trauma, but the majority of cases are spontaneous
Typically preceded by posterior vitreous detachment (PVD)
As the vitreous humor dehydrates and shrinks with age, it can detach from retina
The resulting traction on the retina then puts the pt at risk for retinal detachment
The symptoms of PVD are primarily floaters and flashers
Most cases of PVD are self-limited
However, the risk of progression to retinal detachment is high in the days and weeks following the initial symptoms
Can be difficult to distinguish PVD from early retinal detachment!
Unless symptoms are chronic and unchanging, consider retinal detachment when pts present acutely with flashers and floaters
Risk factors: Older age, Severe myopia (nearsightedness), Glaucoma, Cataract surgery, Diabetic retinopathy
History:
Early warning sign is acute onset of flashers and floaters
Curtains moving across visual field
Visual field cuts
Painless monocular vision loss
Exam:
Visual acuity may be completely normal if early; it is important to test visual fields
An advanced detachment can be seen with direct fundoscopy
Management:
Macula on: vision is preserved; emergent surgery may halt progression and preserve vision
Macula off (the macula has detached): severe vision loss in central visual field
Presumed retinal detachment requires emergent Ophthalmologic evaluation to preserve the pt's vision!
>> Vitreous Hemorrhage
Risk factors: Diabetes, Hypertension, Vasculopathy
History:
Sudden or staggered loss of monocular vision
May present similarly to PVD or RD
May also present as blurry vision
Exam:
Decreased red reflex; may be difficult to see fundus
Ultrasound is very effective at identifying blood in the vitreous!
Management:
Pts may follow up urgently in Ophthalmology clinic for treatment
Return precautions for worsening symptoms/pain
Anticoagulation is generally not discontinued