What causes central retinal artery occlusion (CRAO)?

Updated: Jun 11, 2019
  • Author: Robert H Graham, MD; Chief Editor: Andrew G Lee, MD  more...
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Answer

Emboli dislodged from the carotid artery are the most common cause of CRAO, from either an unstable atherosclerotic plaque or a cardiac source.

The probable causes of CRAO vary depending on the age of the patient. A detailed analysis of comorbid disease is necessary to elucidate the cause of the acute visual loss. See the following:

  • Systemic hypertension, seen in two-thirds of patients
  • Diabetes mellitus
  • Cardiac valvular disease, seen in a quarter of patients
  • Cardiac anomalies, such as patent foramen ovale (PFO)
  • Embolism, as follows:
    • Cholesterol is the most common type, but it can also be from calcium, bacteria, or talc from intravenous drug use.
    • This is associated with poorer visual acuity and higher overall morbidity and mortality.
    • Emboli from the heart are the most common cause of CRAO in patients younger than 40 years.
  • Atherosclerotic changes, as follows:
    • Carotid atherosclerosis is seen in 45% of cases of CRAO, with 60% or greater stenosis in 20% of cases. Callizo et al found that ipsilateral carotid stenosis was the most significant risk factor for CRAO. [12]
    • Atherosclerotic disease is the leading cause of CRAO in patients aged 40-60 years.
    • Chang et al have found an increased risk of acute coronary syndrome (indicative of coronary atherosclerosis) in patients with retinal arterial occlusions. [13]
  • Amaurosis fugax preceding persistent vision loss suggests transient CRAO, branch retinal artery occlusion (BRAO), or temporal arteritis.
  • A hypercoagulable state, such as in patients with sickle cell anemia, polycythemia, or antiphospholipid syndrome or in those taking oral contraceptives, is a common etiology of CRAO in patients younger than 30 years.
  • Giant cell arteritis, as follows:
    • Giant cell arteritis should be considered in elderly patients
    • Giant cell arteritis may produce CRAO, cilioretinal artery occlusion, ischemic optic neuropathy, or a combination of these findings
  • Giant cell arteritis needs to be treated immediately with corticosteroids to preserve vision in the fellow eye.
  • Collagen vascular disease
  • Polyarteritis nodosa
  • Increased intraocular pressure due to glaucoma
  • Hydrostatic arterial occlusion
  • Iatrogenic: With the increasing popularity of cosmetic facial filler injections, Chen et al and Carle et al report that these injections are a cause of retinal artery occlusions. [14, 15] Other associations with CRAO, such as extracapsular cataract extraction with retrobulbar anesthesia, [16] strangulation, [17] or injection of stem cells for scalp baldness, [18] have been published.

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