What is the treatment for a retinal embolus?

Treatment of Retinal Embolus

For patients with retinal embolus, immediate referral to a stroke center for urgent evaluation is the recommended first-line management approach, as these patients have a high risk of concurrent or subsequent stroke. 1

Urgent Evaluation and Management

Initial Assessment

• Determine if symptoms are acute (within 24 hours) or chronic
• Check for signs of giant cell arteritis (GCA) in patients over 50 years:
  • Temporal tenderness
  • Jaw claudication
  • Weight loss
  • Proximal myalgia
  • Fever
  • Elevated C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)

Immediate Management

1. For suspected GCA: Immediate systemic corticosteroid therapy to prevent vision loss in the fellow eye 1
2. For acute non-arteritic retinal artery occlusion: Urgent referral to stroke center for evaluation 1
   • Silent brain infarction is present in 19-25% of retinal artery occlusion patients 1
   • DWI-MRI abnormalities are found in 27-76.4% of CRAO patients 1

Treatment Options

Evidence-Based Treatments

• There are no proven therapies to reverse vision loss from retinal emboli 1
• Hyperbaric oxygen therapy (100% oxygen over 9 hours) has shown some efficacy over observation alone in small randomized trials 1

Historical Treatments (Limited Evidence)

The following have been attempted but lack strong evidence for efficacy:

• Digital ocular massage
• Anterior chamber paracentesis
• Vasodilation
• Breathing into a paper bag
• Carbogen therapy
• Topical pressure-lowering therapies

Systemic Management

1. Antiplatelet therapy for most patients 1
2. Statin therapy for most patients 1
3. Carotid evaluation - consider endarterectomy for >70% carotid stenosis 1
4. Risk factor modification:
   • Smoking cessation
   • Blood pressure control
   • Diabetes management
   • Hyperlipidemia treatment 1

Monitoring for Complications

• Regular follow-up to monitor for:

  • Retinal neovascularization
  • Anterior segment neovascularization
  • Neovascular glaucoma

• If neovascularization develops:

  • Panretinal photocoagulation (PRP) is recommended 1
  • Consider anti-VEGF agents to optimize visualization when hemorrhage is present 1

Prognosis and Special Considerations

• Prognosis varies by embolus type:

  • Cholesterol emboli: Associated with significantly reduced life expectancy and increased stroke risk 2
  • Calcific emboli: May be associated with calcific aortic valve stenosis 3
  • Platelet-fibrin emboli: May be associated with cardiovascular conditions like atrial fibrillation 4

• The natural history of retinal emboli includes:

  • <10% of non-arteritic CRAO patients experience meaningful visual recovery 1
  • Patients with cholesterol emboli have significantly higher risk of subsequent stroke 2

Caution

• Avoid delaying evaluation - retinal emboli represent a medical emergency with systemic implications
• Do not rely on conservative therapies alone, as eyes receiving only conservative therapy may have worse outcomes than controls 1
• Remember that even asymptomatic retinal emboli warrant systemic evaluation, as 18% of asymptomatic patients may have significant carotid stenosis 5