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Home PANCE Blueprint EENT (6%) Vascular disorders (PEARLS)

Vascular disorders (PEARLS)

PANCE Blueprint EENT (6%)

The NCCPA™ PANCE EENT Content Blueprint => disorders of the eye => vascular disorders

Central Retinal Artery Occlusion (CRAO) Central Retinal Vein Occlusion (CRVO)
Pathophysiology Supply Problem: Embolism or thrombosis leads to retinal ischemia (an "eye stroke"). Drainage Problem: Thrombus in the central retinal vein causes back pressure and congestion.
Presentation Sudden, profound, painless monocular vision loss. Often permanent. Sudden or subacute, painless monocular vision loss. Variable severity.
Fundoscopic Findings Pale, edematous retina with a cherry-red spot (macula) and "box-carring" of vessels. "Blood and thunder" appearance: diffuse hemorrhages, optic disc edema, and tortuous veins.
Primary Risk Factors Carotid artery disease, A-fib, temporal arteritis (GCA), and atherosclerosis. Hypertension, diabetes, glaucoma, and hypercoagulable states.
Management Goals Emergent: Decrease IOP (acetazolamide, ocular massage) to dislodge the clot; rule out GCA. Consultation: Manage macular edema (anti-VEGF) and prevent neovascular glaucoma.
PANCE Trigger Pale retina + Cherry-red spot. Blood and thunder + Disc edema.
Retinal vascular occlusion
Patient will present as → a 74-year-old man with sudden vision loss in his right eye. He has a medical history of hypertension, coronary artery disease, and new-onset atrial fibrillation. On physical exam, a carotid bruit is auscultated. His visual acuity is light perception. Confrontational visual fields reveal a dense scotoma, and a penlight examination shows an afferent pupillary defect. Dilated funduscopic examination shows retinal whitening with a cherry-red spot in the fovea.

Central retinal artery occlusion (cherry-red spot, ischemic retina)

  • Flow-through CRA occluded
  • Atherosclerotic thrombosis, embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis
  • Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax)

DX: Fundoscopy

  • Look for perifoveal atrophy (cherry-red spot) and pale opaque fundus with red fovea and arterial attenuation
    • Arteriolar narrowing, separation of arterial flow, retinal edema, and ganglionic death lead to optic atrophy and pale retina
  • Rule out carotid artery stenosis by carotid ultrasound

TX: Emergent ophthalmologic consult - Immediate treatment is indicated if occlusion occurs within 24 hours of presentation

  • Reduction of intraocular pressure with ocular hypotensive drugs (e.g., topical timolol 0.5%, acetazolamide 500 mg IV or PO)
  • Intermittent digital message over the closed eyelid or anterior chamber paracentesis
  • If patients present within the first few hours of occlusion, some centers catheterize the carotid/ophthalmic artery and selectively inject thrombolytic drugs
  • Workup and management of atherosclerotic disease
  • Irreversible damage to the retina after 90 min; Poor prognosis

Patient will present as → a 65-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department complaining of unilateral sudden, painless vision loss in his right eye that started 2 hours ago. On examination, his visual acuity in the right eye is 20/200, and fundoscopy reveals retinal hemorrhages, dilated and tortuous retinal veins, and cotton-wool spots. There is no evidence of neovascularization.

Central retinal vein occlusion (blood and thunder fundus)

  • Sudden, painless, unilateral vision loss. Blurred vision or complete visual loss
  • Most common in ages 50+, associated with HTN, primary open-angle glaucoma (POAG), diabetes, hyperlipidemia, hyperviscosity states (polycythemia, leukemia)
  • Usually occurs secondary to a thrombotic event

DX: Funduscopy: retinal hemorrhages in all quadrants, optic disc swelling; blood and thunder retina (dilated veins, hemorrhages, edema, exudates)

TX: vision resolves with time (partially); workup for thrombosis

  • Neovascularization treated with intravitreal injection of VEGF inhibitors
Retinopathy (Lecture) (Prev Lesson)
(Next Lesson) Retinal vascular occlusion (Lecture)
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