What is the immediate management for an elderly patient with sudden painless vision loss and a cherry spot macula, suggestive of Central Retinal Artery Occlusion (CRAO)?

Immediate Management of Central Retinal Artery Occlusion

Immediately transfer this patient to a stroke center or emergency department without delay—CRAO is an ocular stroke requiring emergent evaluation and treatment within 4.5 hours for potential thrombolysis. 1

Time-Critical Actions (Do Not Delay Transfer)

• Do not delay emergency department referral to obtain further outpatient evaluation or institute other treatments 1
• Communicate clearly to emergency providers that the patient has experienced an "eye stroke" to ensure appropriate triage 1
• The therapeutic window for meaningful intervention is extremely narrow—ideally within 4.5 hours of symptom onset for IV tPA consideration 1

Emergency Department Management

Immediate Interventions (Parallel Processing)

For patients presenting within 4.5 hours of symptom onset:

• Consider intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (10% given over 1 minute, remainder over 59 minutes) 2, 1
• Hyperbaric oxygen therapy (100% oxygen over 9 hours) has demonstrated efficacy in small randomized trials and should be considered if available 1, 3

For patients over 50 years of age:

• Rule out giant cell arteritis (GCA) immediately—this is critical to prevent vision loss in the contralateral eye 2, 1
• Obtain ESR and CRP urgently 1
• If GCA is diagnosed or highly suspected, initiate immediate high-dose systemic corticosteroids (typically IV methylprednisolone 1g daily for 3 days) 1

Urgent Diagnostic Evaluation

Perform these studies in parallel with treatment:

• Funduscopic examination to confirm diagnosis (retinal whitening with cherry-red spot) 4
• Brain MRI with diffusion-weighted imaging—19-25% of patients have concurrent silent brain infarctions 1
• Vascular imaging to assess carotid artery status—up to 70% have clinically significant carotid stenosis 1
• CT scan without contrast 1
• Complete blood count with platelets 1

Critical Timing Considerations

The natural history of untreated CRAO is devastating:

• Over 80% of patients present with visual acuity of "count fingers" or worse 4
• Only 17.7% of untreated patients achieve functional visual recovery (improvement from 20/200 or worse to 20/100 or better) 4
• Nearly 80% of patients have visual acuity of "count fingers" or worse at follow-up without intervention 4
• Experimental models show the ischemic time window before permanent retinal damage is approximately 90 minutes, though clinical recovery may occur up to 24 hours with incomplete occlusion 3

Stroke Risk Assessment

CRAO is a harbinger of systemic vascular disease:

• The risk of stroke is highest within the first 7 days after CRAO and remains elevated for 30 days 1
• Up to 24% of patients have concurrent cerebrovascular accident on diffusion-weighted MRI 1
• Systematic evaluation for carotid occlusive disease, cardiac valve disease, and thromboembolic disease is mandatory 2

Common Pitfalls to Avoid

• Do not waste time with traditional "temporizing measures" like ocular massage or anterior chamber paracentesis in isolation—these have not been shown to alter natural history definitively and delay definitive stroke center evaluation 5
• Do not delay transfer for ophthalmology consultation—the patient needs stroke center resources immediately 1
• Do not miss GCA in elderly patients—this is the one immediately treatable cause that can prevent bilateral blindness 2, 1
• Do not assume vision loss is permanent—spontaneous improvement can occur, particularly within the first 7 days, but treatment must be initiated urgently to maximize this possibility 6

Quality of Life Impact

Unilateral uncorrectable visual loss significantly impacts morbidity:

• Increased likelihood of falls (odds ratio 2.86) 4
• Increased functional dependence (odds ratio 7.50) 4
• May be disabling enough to warrant placement in long-term care facility 4
• Limitations in physical and social functioning with emotional distress 4