Interventions for Retinal Artery Occlusion
For patients with retinal artery occlusion, immediate referral to a stroke center is the most critical intervention, as there are no proven therapies to reverse vision loss, but urgent evaluation may prevent subsequent stroke and cardiovascular events. 1
Initial Management
Immediate Actions
- Urgent referral to stroke center (or emergency department if stroke center unavailable) 1
- This should not be delayed for additional testing or other treatments
- Must occur within 4.5 hours of symptom onset if possible for consideration of thrombolytic therapy 1
- Systemic medical evaluation targeted to patient presentation and medical history 1
- For patients >50 years: Screen for giant cell arteritis (GCA) 1
- If GCA is diagnosed or highly suspected, urgent systemic corticosteroid therapy should be initiated
Diagnostic Evaluation at Stroke Center
- Ophthalmological examination (to confirm diagnosis) 1
- Structured neurological assessment 1
- CT scan of brain without contrast 1
- Vascular imaging (carotid arteries, aortic arch) 1, 2
- Cardiac evaluation for embolic sources 2
- Laboratory tests:
Acute Interventions
Thrombolytic Therapy
- Intravenous tissue plasminogen activator (tPA) may be considered for patients presenting within 4.5 hours of symptom onset 1, 3
Traditional Interventions (Limited Evidence)
The following interventions have been historically used but lack strong evidence of efficacy 1:
- Digital ocular massage
- Anterior chamber paracentesis
- Vasodilation
- Breathing into a paper bag/carbogen therapy
- Topical pressure-lowering therapies
- Hyperbaric oxygen
Management of Specific Types of RAO
Central Retinal Artery Occlusion (CRAO)
- Most cases are embolic in origin and require urgent stroke evaluation 4, 5
- Visual outcomes vary by type of CRAO 4:
- Non-arteritic CRAO: 22% show spontaneous improvement in first 7 days
- CRAO with cilioretinal artery sparing: 67% show improvement
- Transient CRAO: 82% show improvement
Branch Retinal Artery Occlusion (BRAO)
- Requires same urgent systemic evaluation as CRAO 1
- Generally better visual prognosis than CRAO 1
- No proven treatments beyond natural history of the disease 1
Arteritic CRAO (due to GCA)
- Immediate high-dose systemic corticosteroid therapy 1
- Typically shows no spontaneous visual improvement 4
- Primary goal is to prevent vision loss in the contralateral eye 1
Long-term Management
Prevention of Neovascular Complications
- Regular follow-up to monitor for development of neovascularization 1
- Panretinal photocoagulation (PRP) is indicated when ocular neovascularization develops 1
- Off-label intravitreal anti-VEGF agents may be helpful:
- To optimize visualization when hemorrhage limits view for PRP
- To minimize treatment-related complications like macular edema 1
Secondary Prevention
- Antiplatelet therapy for most patients 1
- Statin therapy for most patients 1
- Carotid endarterectomy for symptomatic carotid disease with >70% occlusion 1
- Less certain benefit for 50-70% occlusion
- Aggressive control of vascular risk factors (hypertension, diabetes, hyperlipidemia) 5
Prognosis and Follow-up
- Visual outcomes depend on type of RAO and time to treatment 4
- Regular follow-up is essential to monitor for:
- Development of neovascularization
- Need for PRP
- Recurrent vascular events
Common Pitfalls to Avoid
- Delaying emergency referral to perform additional testing in the outpatient setting 1
- Relying on unproven traditional therapies (ocular massage, anterior chamber paracentesis) instead of urgent stroke evaluation 1
- Failing to screen for GCA in patients over 50 years 1
- Missing the opportunity for thrombolytic therapy by delayed presentation/referral 1, 3
- Inadequate follow-up for neovascular complications 1
RAO represents an ocular emergency that requires immediate action focused on both preserving vision when possible and preventing subsequent stroke and cardiovascular events.