Скачать или смотреть Central Retinal Artery Occlusion (CRAO) 👁️ Internal Medicine & Ophthalmology | USMLE Step 2 CK

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👁️ Central Retinal Artery Occlusion (CRAO) | Internal Medicine & Ophthalmology | USMLE Step 2 CK

Central Retinal Artery Occlusion (CRAO) is an ophthalmic emergency that results from sudden, painless, and profound monocular vision loss, typically due to embolism or thrombosis of the central retinal artery—a branch of the ophthalmic artery stemming from the internal carotid. It is a high-yield topic on USMLE Step 2 CK, particularly in patients with underlying atherosclerosis, carotid artery disease, atrial fibrillation, or giant cell arteritis.

Patients classically present with a sudden onset of complete vision loss in one eye that is painless and often described as a "curtain descending". Visual acuity is severely reduced, and there may be an afferent pupillary defect (Marcus Gunn pupil). On fundoscopic examination, the hallmark findings include a pale retina due to ischemia and a cherry-red spot at the fovea, where the thinner foveal region contrasts with the surrounding pale retina. Boxcar segmentation of retinal vessels may also be seen.

Etiologies include embolism from carotid atherosclerosis or cardiac sources (especially in atrial fibrillation), thrombosis in situ, vasculitis (especially in elderly patients, such as giant cell arteritis), or hypercoagulable states in younger patients. Therefore, CRAO not only requires ophthalmologic intervention but also a systemic vascular workup to prevent further ischemic events.

Immediate management focuses on restoring retinal perfusion within the first few hours to prevent permanent vision loss, although outcomes are often poor.

Emergency treatments include:
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Ocular massage to dislodge the embolus

Lowering intraocular pressure with medications (e.g., acetazolamide, mannitol, or topical beta-blockers)

Anterior chamber paracentesis in some cases

High-concentration inhaled carbogen (95% O₂, 5% CO₂) to promote vasodilation and oxygen delivery

Hyperbaric oxygen therapy (in select centers)

Further evaluation includes ESR and CRP in patients over 50 to assess for giant cell arteritis, as CRAO may be the initial manifestation. Carotid Doppler ultrasound and echocardiography are essential to detect embolic sources. Long-term management may include antiplatelet therapy, statins, and treatment of underlying cardiovascular risk factors.

On USMLE Step 2 CK, expect CRAO in a vignette describing a sudden, painless monocular vision loss in a patient with AFib, carotid bruits, or temporal tenderness, accompanied by cherry-red spot on fundoscopy. Be ready to initiate emergent interventions, recognize systemic associations, and recommend vascular imaging and inflammatory markers when appropriate.

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