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Central and branch retinal artery occlusion

Thomas R Hedges, III, MD
Section Editors
Paul W Brazis, MD
Jonathan Trobe, MD
Deputy Editor
Janet L Wilterdink, MD


Central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO) present with acute, painless loss of monocular vision. These disorders are considered a form of stroke, with a similar clinical approach and management; the clinician attempts to treat the acute event, find the source of the vascular occlusion, and prevent further vascular events from occurring.

Issues related to central and branch retinal artery occlusion will be reviewed here. Other ocular ischemic syndromes are discussed separately. (See "Amaurosis fugax (transient monocular or binocular visual loss)".)


Blood flowing to the retina travels through blood vessels that are subject to varying environments and external pressures [1]. The central retinal artery arises from the ophthalmic artery, itself a branch of the internal carotid artery. The ophthalmic artery departs from the intracranial portion of the carotid artery at a sharp angle, after which it travels intracranially for a short distance before entering the orbit, usually with the optic nerve. Once entering the orbit, the central retinal artery leaves the ophthalmic artery to enter the cerebral spinal fluid space and then travel within the optic nerve, after which it enters the eye, where it is subjected to intraocular pressure.

The central retinal artery supplies the inner retina and the surface of the optic nerve. In about 15 percent of individuals, it is assisted by a branch of the ciliary circulation, the cilioretinal artery, which may supply a portion of the retina, including the macula. This allows for preservation of vision in some patients with central retinal artery occlusion.

The physiology of central retinal artery function is poorly understood, but it is primarily autoregulated [2]. This means that under a range of systemic mean arterial pressures, ocular blood flow remains constant. (See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults", section on 'Mechanisms of vascular injury'.)

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Literature review current through: Nov 2017. | This topic last updated: Aug 14, 2015.
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  1. Hayreh SS. Orbital vascular anatomy. Eye (Lond) 2006; 20:1130.
  2. Hedges TR. Ocular ischemia. In: Brain Ischemia: Basic Concepts and Clinical Relevance, Caplan LR (Ed), Springer Verlag, London 1995. p.61.
  3. Rumelt S, Dorenboim Y, Rehany U. Aggressive systematic treatment for central retinal artery occlusion. Am J Ophthalmol 1999; 128:733.
  4. Leavitt JA, Larson TA, Hodge DO, Gullerud RE. The incidence of central retinal artery occlusion in Olmsted County, Minnesota. Am J Ophthalmol 2011; 152:820.
  5. Yuzurihara D, Iijima H. Visual outcome in central retinal and branch retinal artery occlusion. Jpn J Ophthalmol 2004; 48:490.
  6. Smit RL, Baarsma GS, Koudstaal PJ. The source of embolism in amaurosis fugax and retinal artery occlusion. Int Ophthalmol 1994; 18:83.
  7. Karjalainen K. Occlusion of the central retinal artery and retinal branch arterioles. A clinical, tonographic and fluorescein angiographic study of 175 patients. Acta Ophthalmol Suppl 1971; 109:1.
  8. Warrasak S, Tapaneya-Olarn W, Euswas A, et al. Fibromuscular dysplasia: a rare cause of cilioretinal artery occlusion in childhood. Ophthalmology 2000; 107:737.
  9. Wong TY, Klein R. Retinal arteriolar emboli: epidemiology and risk of stroke. Curr Opin Ophthalmol 2002; 13:142.
  10. Hayreh SS, Podhajsky PA, Zimmerman MB. Retinal artery occlusion: associated systemic and ophthalmic abnormalities. Ophthalmology 2009; 116:1928.
  11. Rudkin AK, Lee AW, Chen CS. Vascular risk factors for central retinal artery occlusion. Eye (Lond) 2010; 24:678.
  12. Greven CM, Slusher MM, Weaver RG. Retinal arterial occlusions in young adults. Am J Ophthalmol 1995; 120:776.
  13. Brown GC, Magargal LE, Shields JA, et al. Retinal arterial obstruction in children and young adults. Ophthalmology 1981; 88:18.
  14. Ahuja RM, Chaturvedi S, Eliott D, et al. Mechanisms of retinal arterial occlusive disease in African American and Caucasian patients. Stroke 1999; 30:1506.
  15. Appen RE, Wray SH, Cogan DG. Central retinal artery occlusion. Am J Ophthalmol 1975; 79:374.
  16. Sharma S, Brown GC, Pater JL, Cruess AF. Does a visible retinal embolus increase the likelihood of hemodynamically significant carotid artery stenosis in patients with acute retinal arterial occlusion? Arch Ophthalmol 1998; 116:1602.
  17. Tomsak RL, Hanson M, Gutman FA. Carotid artery disease and central retinal artery occlusion. Cleve Clin Q 1979; 46:7.
  18. Shah HG, Brown GC, Goldberg RE. Digital subtraction carotid angiography and retinal arterial obstruction. Ophthalmology 1985; 92:68.
  19. Sheng FC, Quinones-Baldrich W, Machleder HI, et al. Relationship of extracranial carotid occlusive disease and central retinal artery occlusion. Am J Surg 1986; 152:175.
  20. Douglas DJ, Schuler JJ, Buchbinder D, et al. The association of central retinal artery occlusion and extracranial carotid artery disease. Ann Surg 1988; 208:85.
  21. Brown GC, Magargal LE. Central retinal artery obstruction and visual acuity. Ophthalmology 1982; 89:14.
  22. Merchut MP, Gupta SR, Naheedy MH. The relation of retinal artery occlusion and carotid artery stenosis. Stroke 1988; 19:1239.
  23. Babikian V, Wijman CA, Koleini B, et al. Retinal ischemia and embolism. Etiologies and outcomes based on a prospective study. Cerebrovasc Dis 2001; 12:108.
  24. Wolintz RJ. Carotid endarterectomy for ophthalmic manifestations: is it ever indicated? J Neuroophthalmol 2005; 25:299.
  25. Recchia FM, Brown GC. Systemic disorders associated with retinal vascular occlusion. Curr Opin Ophthalmol 2000; 11:462.
  26. Sharma S, Sharma SM, Cruess AF, Brown GC. Transthoracic echocardiography in young patients with acute retinal arterial obstruction. RECO Study Group. Retinal Emboli of Cardiac Origin Group. Can J Ophthalmol 1997; 32:38.
  27. Sharma S, Naqvi A, Sharma SM, et al. Transthoracic echocardiographic findings in patients with acute retinal arterial obstruction. A retrospective review. Retinal Emboli of Cardiac Origin Group. Arch Ophthalmol 1996; 114:1189.
  28. Sharma S, Brown GC, Cruess AF. Accuracy of visible retinal emboli for the detection of cardioembolic lesions requiring anticoagulation or cardiac surgery. Retinal Emboli of Cardiac Origin Study Group. Br J Ophthalmol 1998; 82:655.
  29. Hayreh SS. Pathogenesis of occlusion of the central retinal vessels. Am J Ophthalmol 1971; 72:998.
  30. Mokhtari F, Massin P, Paques M, et al. Central retinal artery occlusion associated with head or neck pain revealing spontaneous internal carotid artery dissection. Am J Ophthalmol 2000; 129:108.
  31. McDonough RL, Forteza AM, Flynn HW Jr. Internal carotid artery dissection causing a branch retinal artery occlusion in a young adult. Am J Ophthalmol 1998; 125:706.
  32. Evans LS, Van de Graaff WB, Baker WH, Trimble SN. Central retinal artery occlusion after neck irradiation. Am J Ophthalmol 1992; 114:224.
  33. Noble KG. Central retinal artery occlusion: the presenting sign in radiation retinopathy. Arch Ophthalmol 1994; 112:1409.
  34. Chace R, Hedges TR 3rd. Retinal artery occlusion due to moyamoya disease. J Clin Neuroophthalmol 1984; 4:31.
  35. Sher NA, Reiff W, Letson RD, Desnick RJ. Central retinal artery occlusion complicating Fabry's disease. Arch Ophthalmol 1978; 96:815.
  36. Katz B. Migrainous central retinal artery occlusion. J Clin Neuroophthalmol 1986; 6:69.
  37. Mansi IA, Alkhunaizi AM, Al-Khatti AA. Bilateral central retinal artery occlusion secondary to sickle cell disease. Am J Hematol 2000; 64:79.
  38. Rumelt S, Rehany U. Central retinal artery occlusion associated with primary antiphospholipid syndrome. Eye (Lond) 1999; 13 ( Pt 5):699.
  39. Dori D, Beiran I, Gelfand Y, et al. Multiple retinal arteriolar occlusions associated with coexisting primary antiphospholipid syndrome and factor V Leiden mutation. Am J Ophthalmol 2000; 129:106.
  40. Talmon T, Scharf J, Mayer E, et al. Retinal arterial occlusion in a child with factor V Leiden and thermolabile methylene tetrahydrofolate reductase mutations. Am J Ophthalmol 1997; 124:689.
  41. Dhar-Munshi S, Ayliffe WH, Jayne D. Branch retinal arteriolar occlusion associated with familial factor V Leiden polymorphism and positive rheumatoid factor. Arch Ophthalmol 1999; 117:971.
  42. Golub BM, Sibony PA, Coller BS. Protein S deficiency associated with central retinal artery occlusion. Arch Ophthalmol 1990; 108:918.
  43. Greven CM, Weaver RG, Owen J, Slusher MM. Protein S deficiency and bilateral branch retinal artery occlusion. Ophthalmology 1991; 98:33.
  44. Nelson ME, Talbot JF, Preston FE. Recurrent multiple-branch retinal arteriolar occlusions in a patient with protein C deficiency. Graefes Arch Clin Exp Ophthalmol 1989; 227:443.
  45. Cohen RG, Hedges TR 3rd, Duker JS. Central retinal artery occlusion in a child with T-cell lymphoma. Am J Ophthalmol 1995; 120:118.
  46. Goodman GK, Winkler CF, Eiferman RA, Yam LT. Bilateral occlusion of the central retinal artery associated with hyperglobulinemia in hairy cell leukemia. Can J Ophthalmol 1982; 17:124.
  47. Mohan K, Gupta A, Jain IS, Banerjee CK. Bilateral central retinal artery occlusion in occult temporal arteritis. J Clin Neuroophthalmol 1989; 9:270.
  48. Eagling EM, Sanders MD, Miller SJ. Ischaemic papillopathy. Clinical and fluorescein aniographic review of forty cases. Br J Ophthalmol 1974; 58:990.
  49. Read RW, Chong LP, Rao NA. Occlusive retinal vasculitis associated with systemic lupus erythematosus. Arch Ophthalmol 2000; 118:588.
  50. Dougal MA, Evans LS, McClellan KR, Robinson J. Central retinal artery occlusion in systemic lupus erythematosus. Ann Ophthalmol 1983; 15:38.
  51. Mirza S, Raghu Ram AR, Bowling BS, Nessim M. Central retinal artery occlusion and bilateral choroidal infarcts in Wegener's granulomatosis. Eye (Lond) 1999; 13 ( Pt 3a):374.
  52. Solomon SM, Solomon JH. Bilateral central retinal artery occlusions in polyarteritis nodosa. Ann Ophthalmol 1978; 10:567.
  53. Galetta SL, Wulc AE, Goldberg HI, et al. Rhinocerebral mucormycosis: management and survival after carotid occlusion. Ann Neurol 1990; 28:103.
  54. Solley WA, Martin DF, Newman NJ, et al. Cat scratch disease: posterior segment manifestations. Ophthalmology 1999; 106:1546.
  55. Cho NC, Han HJ. Central retinal artery occlusion after varicella. Am J Ophthalmol 1992; 114:235.
  56. Chiang E, Goldstein DA, Shapiro MJ, Mets MB. Branch retinal artery occlusion caused by toxoplasmosis in an adolescent. Case Rep Ophthalmol 2012; 3:333.
  57. Sullivan KL, Brown GC, Forman AR, et al. Retrobulbar anesthesia and retinal vascular obstruction. Ophthalmology 1983; 90:373.
  58. Devenyi P, Schneiderman JF, Devenyi RG, Lawby L. Cocaine-induced central retinal artery occlusion. CMAJ 1988; 138:129.
  59. Yamamoto S, Takatsuna Y, Sato E, Mizunoya S. Central retinal artery occlusion after radial optic neurotomy in a patient with central retinal vein occlusion. Am J Ophthalmol 2005; 139:206.
  60. Egbert JE, Schwartz GS, Walsh AW. Diagnosis and treatment of an ophthalmic artery occlusion during an intralesional injection of corticosteroid into an eyelid capillary hemangioma. Am J Ophthalmol 1996; 121:638.
  61. Johnson LN, Krohel GB, Hong YK, Wood G. Central retinal artery occlusion following transfemoral cerebral angiography. Ann Ophthalmol 1985; 17:359.
  62. Treiman RL, Bloemendal LC, Foran RF, et al. Ipsilateral blindness: a complication of carotid endarterectomy. Arch Surg 1977; 112:928.
  63. Jumper JM, Horton JC. Central retinal artery occlusion after manipulation of the neck by a chiropractor. Am J Ophthalmol 1996; 121:321.
  64. Locastro A, Novak KD, Biglan AW. Central retinal artery occlusion in a child after general anesthesia. Am J Ophthalmol 1991; 112:91.
  65. Grossman W, Ward WT. Central retinal artery occlusion after scoliosis surgery with a horseshoe headrest. Case report and literature review. Spine (Phila Pa 1976) 1993; 18:1226.
  66. Fang IM, Huang JS. Central retinal artery occlusion caused by expansion of intraocular gas at high altitude. Am J Ophthalmol 2002; 134:603.
  67. Mames RN, Snady-McCoy L, Guy J. Central retinal and posterior ciliary artery occlusion after particle embolization of the external carotid artery system. Ophthalmology 1991; 98:527.
  69. Kim IT, Choi JB. Occlusions of branch retinal arterioles following amniotic fluid embolism. Ophthalmologica 2000; 214:305.
  70. von Hanno T, Kinge B, Fossen K. Retinal artery occlusion following intravitreal anti-VEGF therapy. Acta Ophthalmol 2010; 88:263.
  71. Mansour AM, Bynoe LA, Welch JC, et al. Retinal vascular events after intravitreal bevacizumab. Acta Ophthalmol 2010; 88:730.
  72. Jang YJ, Chun JW, Lee SW, Kim HC. A case of central retinal artery occlusion after chiropractic manipulation of the neck. Korean J Ophthalmol 2012; 26:132.
  73. Werner MS, Latchaw R, Baker L, Wirtschafter JD. Relapsing and remitting central retinal artery occlusion. Am J Ophthalmol 1994; 118:393.
  74. Brown GC, Shields JA. Cilioretinal arteries and retinal arterial occlusion. Arch Ophthalmol 1979; 97:84.
  75. Savino PJ, Glaser JS, Cassady J. Retinal stroke. Is the patient at risk? Arch Ophthalmol 1977; 95:1185.
  76. Wilson LA, Warlow CP, Russell RW. Cardiovascular disease in patients with retinal arterial occlusion. Lancet 1979; 1:292.
  77. Russell RW. The source of retinal emboli. Lancet 1968; 2:789.
  78. Murthy RK, Grover S, Chalam KV. Sequential spectral domain OCT documentation of retinal changes after branch retinal artery occlusion. Clin Ophthalmol 2010; 4:327.
  79. Ikeda F, Kishi S. Inner neural retina loss in central retinal artery occlusion. Jpn J Ophthalmol 2010; 54:423.
  80. Ritter M, Sacu S, Deák GG, et al. In vivo identification of alteration of inner neurosensory layers in branch retinal artery occlusion. Br J Ophthalmol 2012; 96:201.
  81. David NJ, Norton EW, Gass JD, Beauchamp J. Fluorescein angiography in central retinal artery occlusion. Arch Ophthalmol 1967; 77:619.
  82. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology 1980; 87:75.
  83. Hayreh SS, Zimmerman MB, Kimura A, Sanon A. Central retinal artery occlusion. Retinal survival time. Exp Eye Res 2004; 78:723.
  84. Hayreh SS, Weingeist TA. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 1980; 64:818.
  85. Duker JS, Brown GC. Recovery following acute obstruction of the retinal and choroidal circulations. A case history. Retina 1988; 8:257.
  86. Augsburger JJ, Magargal LE. Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol 1980; 64:913.
  87. Stone R, Zink H, Klingele T, Burde RM. Visual recovery after central retinal artery occlusion: two cases. Ann Ophthalmol 1977; 9:445.
  88. Fraser SG, Adams W. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane Database Syst Rev 2009; :CD001989.
  89. Rudkin AK, Lee AW, Aldrich E, et al. Clinical characteristics and outcome of current standard management of central retinal artery occlusion. Clin Exp Ophthalmol 2010; 38:496.
  90. Matzkin DC, Slamovits TL, Sachs R, Burde RM. Visual recovery in two patients after intravenous methylprednisolone treatment of central retinal artery occlusion secondary to giant-cell arteritis. Ophthalmology 1992; 99:68.
  91. Richard G, Lerche RC, Knospe V, Zeumer H. Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator. Ophthalmology 1999; 106:768.
  92. Schmidt D, Schumacher M, Wakhloo AK. Microcatheter urokinase infusion in central retinal artery occlusion. Am J Ophthalmol 1992; 113:429.
  93. Weber J, Remonda L, Mattle HP, et al. Selective intra-arterial fibrinolysis of acute central retinal artery occlusion. Stroke 1998; 29:2076.
  94. Beatty S, Au Eong KG. Local intra-arterial fibrinolysis for acute occlusion of the central retinal artery: a meta-analysis of the published data. Br J Ophthalmol 2000; 84:914.
  95. Plant GT, Landau K. Thrombolysis for central retinal artery occlusion. J Neurol Neurosurg Psychiatry 2005; 76:160.
  96. Hazin R, Dixon JA, Bhatti MT. Thrombolytic therapy in central retinal artery occlusion: cutting edge therapy, standard of care therapy, or impractical therapy? Curr Opin Ophthalmol 2009; 20:210.
  97. Schmidt DP, Schulte-Mönting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment. AJNR Am J Neuroradiol 2002; 23:1301.
  98. Arnold M, Koerner U, Remonda L, et al. Comparison of intra-arterial thrombolysis with conventional treatment in patients with acute central retinal artery occlusion. J Neurol Neurosurg Psychiatry 2005; 76:196.
  99. Butz B, Strotzer M, Manke C, et al. Selective intraarterial fibrinolysis of acute central retinal artery occlusion. Acta Radiol 2003; 44:680.
  100. Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke 2008; 39:1746.
  101. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 2010; 117:1367.
  102. Chen CS, Lee AW, Campbell B, et al. Study of the efficacy of intravenous tissue plasminogen activator in central retinal artery occlusion. Int J Stroke 2011; 6:87.
  103. Tang WM, Han DP. A study of surgical approaches to retinal vascular occlusions. Arch Ophthalmol 2000; 118:138.
  104. Tang WM, Topping TM. Vitreous surgery for central retinal artery occlusion. Arch Ophthalmol 2000; 118:1586.
  105. Reynard M, Hanscom TA. Neodymium:yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol 2004; 137:196.
  106. Shalchi MH, Daneshvar R. Transluminal Nd:YAG laser embolysis in a case of hemiretinal arterial occlusion. East Mediterr Health J 2009; 15:1613.
  107. Nielsen NV. Treatment of acute occlusion of the retinal arteries. Acta Ophthalmol (Copenh) 1979; 57:1078.
  108. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating acute nonarteritic central retinal artery occlusion. Ophthalmology 1995; 102:2029.
  109. Incandela L, Cesarone MR, Belcaro G, et al. Treatment of vascular retinal disease with pentoxifylline: a controlled, randomized trial. Angiology 2002; 53 Suppl 1:S31.
  110. Kuritzky S. Nitroglycerin to treat acute loss of vision. N Engl J Med 1990; 323:1428.
  111. Herzog LM, Meyer GW, Carson S, et al. Central retinal artery occlusion treated with hyperbaric oxygen. J Med 1992; 7:33.
  112. Beiran I, Goldenberg I, Adir Y, et al. Early hyperbaric oxygen therapy for retinal artery occlusion. Eur J Ophthalmol 2001; 11:345.
  113. Rumelt S, Brown GC. Update on treatment of retinal arterial occlusions. Curr Opin Ophthalmol 2003; 14:139.
  114. Menzel-Severing J, Siekmann U, Weinberger A, et al. Early hyperbaric oxygen treatment for nonarteritic central retinal artery obstruction. Am J Ophthalmol 2012; 153:454.
  115. Duker JS, Brown GC. Iris neovascularization associated with obstruction of the central retinal artery. Ophthalmology 1988; 95:1244.
  116. Duker JS, Sivalingam A, Brown GC, Reber R. A prospective study of acute central retinal artery obstruction. The incidence of secondary ocular neovascularization. Arch Ophthalmol 1991; 109:339.
  117. Duker JS, Brown GC. Neovascularization of the optic disc associated with obstruction of the central retinal artery. Ophthalmology 1989; 96:87.
  118. Henkind P, Wise GN. Retinal neovascularization, collaterals, and vascular shunts. Br J Ophthalmol 1974; 58:413.
  119. Hayreh SS, Podhajsky P. Ocular neovascularization with retinal vascular occlusion. II. Occurrence in central and branch retinal artery occlusion. Arch Ophthalmol 1982; 100:1585.
  120. Lorentzen SE. Occlusion of the central retinal artery. A follow-up. Acta Ophthalmol (Copenh) 1969; 47:690.
  121. Hankey GJ, Slattery JM, Warlow CP. Prognosis and prognostic factors of retinal infarction: a prospective cohort study. BMJ 1991; 302:499.
  122. Gass JD, Tiedeman J, Thomas MA. Idiopathic recurrent branch retinal arterial occlusion. Ophthalmology 1986; 93:1148.
  123. Kramer M, Goldenberg-Cohen N, Shapira Y, et al. Role of transesophageal echocardiography in the evaluation of patients with retinal artery occlusion. Ophthalmology 2001; 108:1461.
  124. Mouradian M, Wijman CA, Tomasian D, et al. Echocardiographic findings of patients with retinal ischemia or embolism. J Neuroimaging 2002; 12:219.
  125. Greven CM, Weaver RG, Harris WR, et al. Transesophageal echocardiography for detecting mitral valve prolapse with retinal artery occlusions. Am J Ophthalmol 1991; 111:103.
  126. Salomon O, Huna-Baron R, Moisseiev J, et al. Thrombophilia as a cause for central and branch retinal artery occlusion in patients without an apparent embolic source. Eye (Lond) 2001; 15:511.