From the Guidelines
The treatment for central retinal artery occlusion (CRAO) requires immediate intervention to restore blood flow to the retina, with the most effective approach being a combination of ocular massage, carbogen therapy, and intra-arterial thrombolysis with tissue plasminogen activator (tPA) if presentation is within 4.5 hours of symptom onset, as recommended by the American Heart Association 1. Initial management includes:
- Ocular massage, which involves applying pressure to the eye for 5-15 seconds then releasing, repeated for several minutes to dislodge the embolus
- Patients should breathe into a paper bag or receive carbogen therapy (95% oxygen, 5% carbon dioxide) to induce vasodilation
- Intravenous acetazolamide (500mg) or oral acetazolamide (500mg) can be administered to reduce intraocular pressure
- Anterior chamber paracentesis, performed by an ophthalmologist, involves removing a small amount of aqueous humor to decrease pressure and potentially move the embolus
- Hyperbaric oxygen therapy within 24 hours may improve outcomes by increasing oxygen delivery to the ischemic retina Beyond these acute interventions, it's crucial to identify and address underlying causes such as carotid artery disease, cardiac emboli, or hypercoagulable states to prevent recurrence and involvement of the other eye, as highlighted in the management guidelines 1. Visual prognosis depends largely on time to treatment, with best outcomes when therapy begins within 90-120 minutes of symptom onset, emphasizing the need for prompt referral to a stroke center or emergency department for evaluation and treatment, as recommended by the American Heart Association 1. Additionally, patients with CRAO should undergo a systemic evaluation for carotid occlusive and thromboembolic disease, and those with suspected giant cell arteritis should be considered for urgent systemic corticosteroid therapy to preserve or recover vision in the affected eye and prevent involvement of the contralateral eye, as outlined in the preferred practice pattern for retinal and ophthalmic artery occlusions 1.
From the Research
Treatment Options for Central Retinal Artery Occlusion
The treatment for central retinal artery occlusion (CRAO) is focused on restoring vision and managing risk factors to prevent other vascular conditions 2, 3. Some of the treatment options that have been used in the past include:
- Carbogen inhalation
- Acetazolamide infusion
- Ocular massage
- Paracentesis
- Vasodilators such as intravenous glyceryl trinitrate
Thrombolytic Therapy
There has been recent interest in the use of thrombolytic therapy, delivered either intravenously or intra-arterially by direct catheterisation of the ophthalmic artery 2, 4. However, two recent randomised controlled trials have not demonstrated efficacy, and intra-arterial delivery of thrombolytic may result in an increased risk of intracranial and systemic haemorrhage 2.
Emergency Treatment
Emergency treatment for CRAO includes intravenous acetazolamide, digital ocular massage, and inhalation of 5% carbon dioxide -- 95% oxygen for ten minutes 5. Immediate ophthalmologic referral and consultation is required, as well as comprehensive medical evaluation to exclude systemic vascular disease.
Secondary Prevention
Management of CRAO should be focused on secondary prevention of vascular events, such as cerebral ischemia, myocardial infarction, and cardiovascular death 2, 3. This includes attempting to reperfuse ischemic tissue as quickly as possible and instituting secondary prevention early.
Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy (HBOT) has been used in the treatment of CRAO, either alone or in combination with thrombolysis 4. Case studies have shown improvement in visual acuity and visual fields with HBOT, but further clinical trials are needed to determine its efficacy.