A 52 year-old man presents with sudden onset loss of vision in his right eye. He has no other symptoms.

His past medical history is notable for hypertension, hyperlipidemia and angina. His medications include aspirin, atenolol, and atorvastatin. He can barely detect hand movements with his right eye and has a relative afferent pupillary defect.

 Fundoscopy shows this appearance: From tedmontgomery.com

Questions Q1. What is the diagnosis? Answer and interpretation Central retinal artery occlusion (CRAO) The diagnosis must be suspected in any case of sudden painless loss of vision, and is clinched by the appearance of the retina (see Q2). Q2. What features on history and examination should be looked for? Answer and interpretation History sudden and painless loss of vision (seconds) Consider underlying causes: emboli, thrombosis, GCA, CTDs, hypercoagualtion, trauma, migraine, syphilis, sickle cell disease, Behcets. Examination Visual acuity markedly reduced e.g. <6/60 Marcus-Gunn pupils (RAPD) Red reflex abnormal and asymmetrical Fundoscopy a pale retina with areas of cilioretinal sparing and a classic cherry red spot in the macula (may be subtle). Arteriolar and venular narrowing and box-car appearance. Q3. What is the investigation and management? Answer and interpretation CRAO, like chemical injuries to the eyes, is a true ophthalmological emergency. Urgent ophthalmology referral, and a physician to work up underlying causes. Urgent ESR and CRP to exclude GCA. TIA and vasculitis work up as per amaurosis fugax. Treatment is unproven but includes: immediate ocular massage anterior chamber paracentesis IOP reduction with acetazolamide (e.g. 500mg IV) or timolol (0.5% topical drops bd) Breathe into a paper bag (respiratory acidosis induces retinal vasodilation) Q4. How does an opthalmic artery occlusion differ from this condition? Answer and interpretation Ther is no cherry red spot and vision is reduced to light perception. The entire retina is whitened. The treatment is the same.