What are the symptoms of central retinal artery occlusion in a patient with potential underlying vascular disease, such as hypertension, diabetes, and hyperlipidemia?

Symptoms of Central Retinal Artery Occlusion

Central retinal artery occlusion presents with sudden, painless monocular loss of visual acuity and peripheral vision. 1

Primary Clinical Presentation

The hallmark symptom is sudden, painless vision loss in one eye that occurs without warning and represents an ophthalmologic emergency analogous to acute cerebral stroke. 1

Visual Acuity Loss

• In more than 80% of patients, initial visual acuity is "count fingers" or worse, representing severe and profound vision loss 1
• Visual acuity may be nearly normal if a cilioretinal artery is present (occurs in approximately one-third of patients), as this vessel supplies the fovea from a separate circulation and can preserve central vision while peripheral vision remains severely impaired 1
• The degree of visual loss is variable but typically dramatic and immediate 1

Associated Visual Symptoms

• Impaired color vision proportional to the degree of visual acuity loss 1
• Complete loss of peripheral vision in the affected eye, even when central vision is partially preserved by cilioretinal artery sparing 1

Physical Examination Findings

While not "symptoms" per se, these objective findings confirm the diagnosis and are critical for clinicians to recognize:

Pupillary Abnormalities

• Most patients have an ipsilateral relative afferent pupillary defect (RAPD), though this may be absent if contralateral optic neuropathy exists 1

Funduscopic Findings

• Retinal edema appearing as diffuse retinal whitening 1
• Cherry red spot at the macula 1
• Attenuated retinal arteries with possible visible emboli 1
• Possible "boxcarring" (segmental blood flow) in retinal arteries 1

Important Clinical Context for Patients with Vascular Disease

Timing and Presentation Pattern

• The mean time from onset to presentation is approximately 31 hours, though 58% of patients present within 20 hours of vision loss 2
• Symptoms are sudden and complete at onset, not gradual or progressive 1

Risk Factor Profile

Patients with hypertension, diabetes, and hyperlipidemia have significantly elevated risk, with studies showing 73% have hypertension, 49% have hypercholesterolemia, and 14% have diabetes among CRAO patients. 1 These patients also frequently have:

• Ipsilateral carotid artery stenosis (37-40% have ≥70% stenosis) 1, 3
• Cardiac arrhythmias (20% have atrial fibrillation) 1
• Cardiac valvular disease (17%) 1

Critical Pitfall: Giant Cell Arteritis

In patients over 50 years old with sudden monocular vision loss, Giant Cell Arteritis (GCA) must be immediately considered and excluded, as this represents an ophthalmologic emergency requiring immediate high-dose corticosteroid treatment to prevent vision loss in the fellow eye. 4, 5

GCA-Specific Symptoms to Screen For:

• Headaches and scalp tenderness 4
• Jaw claudication 4
• Malaise, fatigue, fever 4
• Polymyalgia rheumatica symptoms 4
• Diplopia 4

Urgent Management Implications

CRAO should be treated as a stroke equivalent requiring immediate triage to an emergency department, as the therapeutic window for potential interventions is narrow (within 4.5 hours), and these patients have high risk of subsequent cerebral stroke. 1 The American Heart Association emphasizes that sudden, painless monocular visual loss should be recognized by the public as a symptom of potential stroke, equivalent to sudden weakness, facial droop, or speech difficulty. 1