Sudden Monocular Vision Loss with a Cherry-Red Spot
A 66-year-old man presents 4 hours after sudden painless loss of vision in the left eye. Visual acuity is counting fingers OS and 20/20 OD. There is a left relative afferent pupillary defect. The left fundus shows a pale, opaque retina with a cherry-red spot at the macula and no visible emboli. Intraocular pressure is 14 mmHg in both eyes. Blood pressure is 178/96 mmHg. He smokes 20 cigarettes daily and has untreated hypertension. He has no jaw claudication, scalp tenderness, or polymyalgia symptoms. He takes no anticoagulants. He has no history of stroke, atrial fibrillation, or carotid surgery. He reports no pain, no flashes, no floaters, and no trauma. The other eye is normal. He asks whether eye massage will restore his vision.
1. What is the immediate management, and what should not delay it?
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This is central retinal artery occlusion, which is a stroke equivalent. I would activate the stroke pathway immediately: check glucose, CBC, lipids, and ESR/CRP if there is any GCA concern, obtain an ECG, and arrange carotid imaging and echocardiography. Start aspirin 325 mg loading then 81 mg daily if no contraindication, and involve stroke neurology. Ocular massage or anterior chamber paracentesis is not proven and should not delay systemic workup. I would not lower blood pressure aggressively in the acute phase unless there is a hypertensive emergency. The eye has a poor visual prognosis, but the priority is preventing stroke, myocardial infarction, and fellow-eye involvement.
2. Does the 4-hour window justify hyperbaric oxygen or thrombolysis?
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Some centres consider hyperbaric oxygen or intra-arterial thrombolysis within roughly 4–6 hours, but evidence is limited and these are not standard of care. I would discuss with stroke neurology and only use them within a protocol, after weighing systemic bleeding risk. The patient has untreated hypertension and smoking, so secondary prevention is more important. I would not offer unproven therapy as if it were routine, and I would document the uncertainty. If giant cell arteritis were suspected-older age, elevated ESR/CRP, jaw claudication-I would start steroids immediately, but this patient has none of those features.
3. What counselling and follow-up would you arrange?
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Explain that vision in the left eye may not recover and that the main risk is future stroke. Arrange smoking cessation support, blood pressure control, statin therapy, diabetes screening, and antiplatelet therapy. Follow up with stroke neurology and ophthalmology; the fellow eye should be examined and the patient warned about sudden visual loss. If atrial fibrillation is found, anticoagulation would be considered by the stroke team. I would also document the RAPD and fundus findings. The patient should understand that eye massage is not a reliable treatment.