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Sudden unilateral painless loss of vision

BMJ 2014; 349 doi: (Published 01 July 2014) Cite this as: BMJ 2014;349:g4117
  1. Ilias Georgalas, consultant ophthalmic surgeon; assistant professor1,
  2. Dionisis Pagoulatos, specialist registrar1,
  3. Chryssanthi Koutsandrea, consultant ophthalmic surgeon; professor1,
  4. Mitrofanis Pavlidis, consultant ophthalmic surgeon; associate professor2
  1. 1Department of Ophthalmology, University of Athens, 15452 Athens, Greece
  2. 2Department of Ophthalmology, University of Munster, Germany
  1. Correspondence to: I Georgalas igeorgalas{at}

A 72 year old man was referred by his general practitioner to our emergency department because of a three day history of sudden painless loss of vision affecting his right eye. His medical history included hypertension and heavy smoking. Ophthalmic assessment showed visual acuity of light perception only in the right eye and 6/9 in the left eye. The intraocular pressure was 14 mm Hg in the right eye and 15 mm Hg in the left eye. A relative afferent pupillary defect was present on the right side. Apart from early cataracts, examination of the anterior segment was unremarkable. Dilated fundus examination showed diffuse whitening of the posterior pole, with sparing of the fovea (fig 1). On further questioning the patient admitted that he had previously experienced episodes of vision loss in the same eye, which lasted from a few seconds to a few minutes.

Fig 1 Colour photo of the fundus of the right eye, showing central retinal artery occlusion with a “cherry red spot”


  • 1. What is the most likely underlying diagnosis?

  • 2. What is the underlying mechanism of the retinal changes?

  • 3. What are the causes of this condition?

  • 4. How should this condition be treated?

  • 5. Do patients with this condition need further investigations?


1. What is the most likely underlying diagnosis?

Short answer

Central retinal artery occlusion (CRAO).

Long answer

Patients with CRAO have sudden painless visual loss, usually with an initial visual acuity of counting fingers or worse.1 Some have a history of transient visual loss (amaurosis fugax) before the onset of CRAO.2 The arterial supply of the eye is provided by several branches of the ophthalmic artery, which derives from the internal carotid artery. These branches include the central retinal artery, the short and long posterior ciliary arteries, and the anterior ciliary arteries. The retina is supplied by the central retinal artery …

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