What is the management of central retinal artery stenosis?

From the Guidelines

Management of central retinal artery stenosis requires urgent intervention to restore blood flow and prevent permanent vision loss. The most recent and highest quality study on this topic is from the American Heart Association, published in 2021 1. According to this study, immediate measures include:

• Digital ocular massage, which involves applying gentle pressure to the eye for 5-15 seconds then releasing, repeated for several minutes to dislodge emboli
• Breathing into a paper bag or receiving carbogen therapy (95% oxygen, 5% carbon dioxide) to induce vasodilation
• Administering intravenous acetazolamide (500 mg) or oral acetazolamide (250 mg) to reduce intraocular pressure
• Anterior chamber paracentesis, performed by an ophthalmologist, to suddenly reduce intraocular pressure and potentially dislodge emboli
• Providing supplemental oxygen at 100% concentration For patients presenting within 4-6 hours of symptom onset, thrombolytic therapy may be considered in specialized centers 1. After acute management, underlying causes must be addressed, including carotid artery disease, cardiac emboli, or inflammatory conditions. Long-term management typically includes antiplatelet therapy (aspirin 81-325 mg daily), statins for hyperlipidemia, and strict control of vascular risk factors such as hypertension and diabetes 1. The goal of treatment is to restore retinal perfusion quickly, as retinal tissue can only survive 90-120 minutes of complete ischemia before permanent damage occurs. It is also important to note that the etiological workup should be done urgently to unmask concurrent disease that requires prompt intervention, and that high-grade stenosis of the ipsilateral carotid artery should be identified rapidly and treated as symptomatic carotid stenosis 1.

Some key points to consider in the management of central retinal artery stenosis include:

• The importance of urgent intervention to restore blood flow and prevent permanent vision loss
• The use of digital ocular massage, carbogen therapy, and acetazolamide to induce vasodilation and reduce intraocular pressure
• The potential benefits of thrombolytic therapy in specialized centers for patients presenting within 4-6 hours of symptom onset
• The need for long-term management to address underlying causes and prevent recurrent vascular events
• The importance of strict control of vascular risk factors such as hypertension and diabetes to prevent further vascular events.

Overall, the management of central retinal artery stenosis requires a comprehensive approach that includes urgent intervention, addressing underlying causes, and long-term management to prevent recurrent vascular events and improve outcomes.

From the Research

Management of Central Retinal Artery Stenosis

• The management of central retinal artery stenosis involves various treatment approaches, including intra-arterial thrombolysis, intravenous thrombolysis, and hyperbaric oxygen therapy 2, 3, 4, 5.
• Intra-arterial thrombolysis has been shown to be effective in achieving complete recanalization and improving visual acuity in some patients with central retinal artery occlusion (CRAO) 2, 3.
• Intravenous thrombolysis has also been found to be feasible and safe in the management of acute CRAO, with a study showing that it can be delivered within 6 hours of onset with a low risk of adverse events 4.
• Hyperbaric oxygen therapy has been used to treat CRAO, with the goal of oxygenating the ischemic inner retinal layers until recanalization of the central retinal artery occurs 5.
• The clinical approach to managing CRAO involves treating the acute event, finding the source of the vascular occlusion, and preventing further vascular events from occurring 6.
• It is essential to exclude giant cell arteritis as a potentially treatable cause of CRAO in patients over 50 years old 6.
• The management of CRAO may involve a combination of these treatment approaches, and the choice of treatment depends on the individual patient's condition and the availability of resources 3, 4, 5.
• Early treatment is crucial in preventing irreversible ischemic damage and improving visual outcomes in patients with CRAO 2, 3, 4, 5.