A 74-year-old woman is brought to the emergency department due to the sudden onset of painless vision loss in her right eye that began 30 minutes ago. She has a history of atrial fibrillation and carotid artery disease. On physical examination, her visual acuity in the right eye is limited to hand motion only. An afferent pupillary defect is present on the right. Funduscopic examination of the right eye shows a pale, opaque retina with a prominent cherry-red spot in the fovea. There is noticeable segmentation of blood flow in the retinal arterioles.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
A) Emergent ocular massage
The patient is presenting with a central retinal artery occlusion (CRAO), an ophthalmologic emergency analogous to an ischemic stroke of the eye. The classic presentation is sudden, painless, profound monocular vision loss with a cherry-red spot on funduscopy, which is caused by the contrast between the pale, ischemic retina and the preserved choroidal circulation under the thin fovea. Management must be immediate to attempt to dislodge the embolus and restore blood flow. Emergent ocular massage is a standard initial maneuver to fluctuate intraocular pressure and encourage the embolus to move more distally into the arterial tree. Other immediate interventions include high-flow oxygen and medications to lower intraocular pressure.
Answer choice B: Intravenous methylprednisolone, is incorrect. High-dose systemic corticosteroids are the treatment of choice for giant cell arteritis (GCA), which can cause vision loss via anterior ischemic optic neuropathy. While GCA can cause CRAO, it usually presents with systemic symptoms such as headache and jaw claudication and an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). In this patient with cardiovascular risk factors and cherry-red spot morphology, embolic CRAO is more likely, and mechanical displacement is the priority.
Answer choice C: Intravitreal ranibizumab, is incorrect. Ranibizumab is a vascular endothelial growth factor (VEGF) inhibitor used to treat wet age-related macular degeneration or macular edema secondary to retinal vein occlusion. It has no role in the acute management of central retinal artery occlusion.
Answer choice D: Laser panretinal photocoagulation, is incorrect. This procedure is used to treat proliferative diabetic retinopathy or the neovascular complications following a retinal vein occlusion. It is not used in the acute phase of an arterial occlusion.
Answer choice E: Topical timolol, is incorrect. While lowering intraocular pressure (IOP) is a goal in treating CRAO to increase the pressure gradient and encourage arterial flow, topical timolol alone is insufficient. While it may be used as an adjunct, the physical maneuver of ocular massage or more aggressive IOP-lowering measures (like anterior chamber paracentesis) are prioritized in the hyperacute setting to physically move the obstruction.
Key Learning Point
Central retinal artery occlusion is an ocular emergency presenting with sudden, painless vision loss and a "cherry-red spot" on fundoscopy. Immediate management focuses on dislodging the embolus via ocular massage and rapidly lowering intraocular pressure to restore retinal perfusion.
