Acute retinal arterial occlusive disorders

Abstract

The initial section deals with basic sciences; among the various topics briefly discussed are the anatomical features of ophthalmic, central retinal and cilioretinal arteries which may play a role in acute retinal arterial ischemic disorders. Crucial information required in the management of central retinal artery occlusion (CRAO) is the length of time the retina can survive following that. An experimental study shows that CRAO for 97 minutes produces no detectable permanent retinal damage but there is a progressive ischemic damage thereafter, and by 4 hours the retina has suffered irreversible damage. In the clinical section, I discuss at length various controversies on acute retinal arterial ischemic disorders. Classification of acute retinal arterial ischemic disorders These are of 4 types: CRAO, branch retinal artery occlusion (BRAO), cotton wools spots and amaurosis fugax. Both CRAO and BRAO further comprise multiple clinical entities. Contrary to the universal belief, pathogenetically, clinically and for management, CRAO is not one clinical entity but 4 distinct clinical entities – non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, arteritic CRAO associated with giant cell arteritis (GCA) and transient non-arteritic CRAO. Similarly, BRAO comprises permanent BRAO, transient BRAO and cilioretinal artery occlusion (CLRAO), and the latter further consists of 3 distinct clinical entities - non-arteritic CLRAO alone, non-arteritic CLRAO associated with central retinal vein occlusion and arteritic CLRAO associated with GCA. Understanding these classifications is essential to comprehend fully various aspects of these disorders. Central retinal artery occlusion The pathogeneses, clinical features and management of the various types of CRAO are discussed in detail. Contrary to the prevalent belief, spontaneous improvement in both visual acuity and visual fields does occur, mainly during the first 7 days. The incidence of spontaneous visual acuity improvement during the first 7 days differs significantly (p<0.001) among the 4 types of CRAO; among them, in eyes with initial visual acuity of counting finger or worse, visual acuity improved, remained stable or deteriorated in nonarteritic CRAO in 22%, 66% and 12% respectively; in nonarteritic CRAO with cilioretinal artery sparing in 67%, 33% and none respectively; and in transient nonarteritic CRAO in 82%, 18% and none respectively. Arteritic CRAO shows no change. Recent studies have shown that administration of local intra-arterial thrombolytic agent not only has no beneficial effect but also can be harmful. Prevalent multiple misconceptions on CRAO are discussed. Branch retinal artery occlusion Pathogeneses, clinical features and management of various types of BRAO are discussed at length. The natural history of visual acuity outcome shows a final visual acuity of 20/40 or better in 89% of permanent BRAO cases, 100% of transient BRAO and 100% of nonarteritic CLRAO alone. Cotton wools spots These are common, non-specific acute focal retinal...

Transient retinal artery occlusion during phacoemulsification cataract surgery

“…4,5 A duration of anoxia of 44 h exceeds the retina's maximal survival time, 6 although neuronal cell death may occur within 97 min. 7 TRAO of very short duration may not produce visual symptoms, 1 and further investigation will not be sought. An intermediate duration of occlusion will result in symptoms 1,3,8 despite arteriolar reperfusion proven on FFA; these patients are labelled as having suffered TRAO.…”

A review of central retinal artery occlusion: clinical presentation and management

“…Carotid stenosis and the heart are other important sources of emboli. 9 In all, 74% of these emboli are shown to be made of cholesterol, 10.5% were calcific material, and 15.5% were fibrin. 12 It is equally probable that an occlusive thrombus 13 at the level immediately posterior to the lamina cribrosa also causes CRAO.…”

“…From here it divides into two main branches (superior and inferior); these then further divide into temporal and nasal branches, which supply blood to the four quadrants of the retina. 9 The outer retina is supplied by the choriocapillaris of the choroid that branches off the ciliary artery. Both of these must be functioning to maintain retinal function, as both CRA and ciliary artery originate from the OA.…”

“…In all, 52% had an abnormal echocardiogram, suggesting a cardioembolic source. 9 Table 1 summarizes the recommended investigations for vascular workup.…”

“…The efficacy of such therapy varies between 6 and 49%, with a mean visual improvement rate of 15-21%. 5,49 Owing to the observational nature of much of the data, some report a superior outcome to natural history, 9 but overall these therapies do not alter the outcome more than the natural history of the disease. 43,[50][51][52] To date, there have been two randomized controlled trials investigating conservative treatments in the setting of CRAO.…”