Central Retinal Artery Occlusion (CRAO) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Manage as stroke
   Sudden painless monocular vision loss — predominantly arteritic? (An 'eye stroke' = acute ischemic stroke of the retina. Sudden painless monocular vision loss (within seconds), relative afferent pupillary defect (RAPD), fundus showing retinal pallor + a cherry-red macula ± a visible embolus. Usually a carotid/cardiac embolus (ipsilateral carotid disease in ~50%), or giant cell arteritis (arteritic).)
   • Suspected predominantly arteritic (GCA) → Suspected GCA → immediate steroids
   • Non-arteritic / generally embolic → Acute CRAO → manage as stroke
2. [End] Suspected GCA → immediate steroids
   Age >50 with headache/jaw claudication/temporal tenderness/PMR/high inflammatory markers — suspect giant cell arteritis (GCA): immediate high-dose corticosteroids (IV methylprednisolone 1 g/day × 1–3 days) to protect the fellow eye, check ESR/CRP, rheumatology/ophthalmology consult, temporal artery biopsy; also assess as CRAO.
3. [End] Acute CRAO → manage as stroke
   Manage as an acute stroke ('time is retina', emergency stroke center): within 4.5 h of onset, IV thrombolysis (alteplase, assess contraindications per the stroke pathway) may be considered; ocular massage/anterior chamber paracentesis/IOP lowering have limited evidence — do not delay stroke evaluation. Urgent work-up: assess GCA in those >50 (ESR/CRP), carotid imaging, cardiac (echo/ECG), brain MRI (often with concurrent stroke); secondary prevention (antiplatelet, risk-factor control). Do not manage as an outpatient follow-up.

Source guidelines & references

• AHA scientific statement on CRAO management; AAO retinal artery occlusion guidance

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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