Eyes & Vision

Central Retinal Artery Occlusion (CRAO)

Central retinal artery occlusion is an ocular stroke causing sudden, painless monocular visual loss; it needs immediate stroke and ophthalmology assessment, with urgent exclusion and treatment of giant cell arteritis when clinically suspected.

In a nutshell

CRAO is an ocular stroke causing sudden, painless monocular visual loss, often with a relative afferent pupillary defect and pale retina with a cherry-red spot. Treat it as an emergency: activate stroke and same-day ophthalmology pathways, urgently exclude GCA in people aged 50 years or over, give immediate high-dose glucocorticoids if GCA is strongly suspected, and complete embolic-source work-up and secondary prevention.

Classic presentation

An older patient with vascular risk factors suddenly loses profound vision painlessly in one eye; the eye is white, a relative afferent pupillary defect is present, and fundoscopy may show a pale retina with a cherry-red spot.

Key points

CRAO is a retinal/ocular stroke and should be jointly managed by ophthalmology and stroke services.
Sudden painless monocular visual loss needs emergency referral; record the exact onset or last-known-well time.
In patients aged 50 years or over, ask about GCA and obtain FBC, CRP and ESR urgently; if GCA is strongly suspected, start high-dose glucocorticoids without waiting for results.
The stroke team should investigate carotid and cardiac embolic sources and start indicated secondary prevention.
Any reperfusion treatment is specialist-led and protocol-dependent; do not delay referral for ocular manoeuvres or routine outpatient review.
Follow-up must include neovascular complications, visual rehabilitation, functional safety and driving advice.

First-line investigation

Immediate visual acuity, fields, pupils, neurological assessment and fundoscopy, plus urgent FBC/CRP/ESR when GCA is possible and stroke-team-directed vascular/cardiac assessment.

Management

Activate stroke and ophthalmology pathways

Sudden painless monocular visual loss is an emergency: document onset/last-known-well time and arrange immediate stroke assessment plus same-day ophthalmology/eye-casualty review.^2,3,1

Exclude and treat GCA

In people aged 50 years or over, obtain FBC, CRP and ESR urgently; if GCA is strongly suspected, start high-dose glucocorticoids immediately and do not wait for blood results or biopsy/scan confirmation.^4,5

Complete urgent stroke and embolic work-up

Stroke services should direct brain/vascular imaging, ECG or telemetry, cardiac assessment when indicated and vascular-risk blood tests; look for carotid disease, atrial fibrillation and other embolic sources.^2,6

Keep reperfusion decisions specialist-led

Very-early reperfusion strategies, including any off-label thrombolysis, are considered only by specialist stroke/ophthalmology teams under local protocol; do not delay emergency transfer or perform invasive ocular treatment in primary care.^7,3

Prevent recurrence and support function

Use indicated antiplatelet or anticoagulation, risk-factor management and carotid treatment; monitor ophthalmically for neovascularisation and provide low-vision, rehabilitation, driving and safety support.^2,6,1

Exam traps

CRAO is usually painless with a white eye; a painful red eye suggests another emergency such as keratitis or acute angle closure.
A normal or only mildly abnormal ESR/CRP does not override a strong clinical suspicion of GCA.
Do not manage CRAO as an isolated eye problem: stroke and embolic-source assessment are required.
Do not wait for inflammatory markers before treating strongly suspected GCA; the first steroid dose can be given while diagnostic confirmation is arranged.
Amaurosis fugax is transient retinal ischaemia and a warning of embolic risk, not reassurance that the event is benign.

Illustrations

Cherry-red spot in CRAOA fundus image showing diffuse pale retinal whitening from inner-retinal ischaemia with a cherry-red spot at the fovea. Label it as an illustrative clinical image, not a substitute for urgent examination.Dr. Gopal Bisht, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.