From the Guidelines
The initial workup and management for central retinal artery occlusion (CRAO) should prioritize urgent intervention, including a parallel workflow to determine candidacy for thrombolysis and exclude giant cell arteritis (GCA), as outlined in the American Heart Association's scientific statement 1.
Key Steps in Workup and Management
- Determine the time last known well and establish a timeline for symptom onset
- Screen for contraindications to thrombolysis
- Perform a CT brain scan to rule out other causes of symptoms
- Assess for GCA through temporal artery palpation and consider ESR/CRP if there is high clinical suspicion 1
- Measure visual function, including baseline visual acuity with correction and confrontation visual fields
Considerations for Treatment
- Consider high-dose intravenous methylprednisolone for patients with suspected GCA
- Evaluate the patient's candidacy for intravenous thrombolysis with tissue plasminogen activator (tPA), considering the time from symptom onset and the presence of contraindications 1
- For patients who are not candidates for IV thrombolysis, consider intra-arterial tPA if the patient presents within 6 hours of symptom onset and is at an IA-capable center
Additional Recommendations
- Patients with CRAO should undergo urgent workup for stroke risk factors, including carotid ultrasound, echocardiogram, complete blood count, erythrocyte sedimentation rate, C-reactive protein, and lipid panel 1
- Antiplatelet therapy with aspirin 325 mg should be initiated unless contraindicated
- CRAO represents an ocular stroke with poor visual prognosis if not treated within hours of onset, and prompt referral to both ophthalmology and neurology is necessary for comprehensive management 1
From the Research
Initial Workup for Central Retinal Artery Occlusion
The initial workup for central retinal artery occlusion (CRAO) involves a comprehensive evaluation to determine the underlying cause and to assess the risk of further vascular events.
- The workup should include a thorough medical history, including a review of atherosclerotic risk factors such as hypertension, diabetes, and hyperlipidemia 2.
- A physical examination should be performed to assess for signs of vascular disease, such as carotid bruits or peripheral artery disease 2.
- Laboratory tests, including complete blood count, blood chemistry, and coagulation studies, may be ordered to rule out underlying conditions that may contribute to CRAO 3.
- Imaging studies, such as carotid ultrasound or magnetic resonance angiography, may be performed to evaluate for carotid artery disease or other vascular abnormalities 4.
Timing of Presentation and Diagnosis
The timing of presentation and diagnosis is critical in the management of CRAO.
- Studies have shown that patients who present within 4.5 hours of symptom onset have a better chance of receiving timely treatment, including thrombolytic therapy 5.
- However, many patients with CRAO experience delays in presentation and diagnosis, with some waiting over 24 hours before seeking medical attention 5.
- Public health educational campaigns and infrastructure optimization are needed to speed up presentation times and decrease the time to ophthalmic diagnosis 5.
Management of CRAO
The management of CRAO involves a multidisciplinary approach, including ophthalmology, neurology, and vascular medicine.
- Treatment options for CRAO are limited, and there is no proven therapy that can restore vision in all patients 2.
- Thrombolytic therapy may be considered in select patients, but its use is still controversial and requires further study 2, 6, 3.
- Secondary prevention measures, such as management of atherosclerotic risk factors and antiplatelet therapy, are essential to reduce the risk of further vascular events 2, 4.