What is the treatment for retinal artery occlusion?

Treatment of Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) should be treated as a medical emergency with immediate referral to the nearest stroke center for consideration of intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset. 1

Initial Assessment and Diagnosis

• Immediate diagnostic evaluation should include:

  • Structured neurological assessment using NIH Stroke Scale
  • CT brain without contrast to rule out hemorrhage
  • Ophthalmological examination confirming CRAO:
    • Relative afferent pupillary defect
    • Cherry-red spot in macula
    • Pale retina
    • Visual acuity testing 1

• In patients over 50 years, screen for giant cell arteritis (GCA) which accounts for 5% of CRAO cases 2, 1

  • If GCA is suspected, urgent systemic corticosteroid therapy should be initiated 2

Acute Treatment Options

First-Line Treatment

• Intravenous tPA (Alteplase) at 0.9 mg/kg when administered within 4.5 hours of symptom onset 1
  • Has demonstrated a 50% rate of clinical recovery when given within this timeframe
  • Should be administered at a stroke center with appropriate monitoring

Alternative Treatments

• In specialized centers with endovascular capabilities, intra-arterial thrombolysis may be considered 1
  • Delivered via selective catheterization of the ophthalmic artery
  • tPA administered in increments of 15 mg with serial ophthalmological examinations
  • Continued until visual acuity improves or maximum dose of 50 mg reached

Ineffective Treatments

The following should not be relied upon as primary treatments and should not delay definitive care:

• Anterior chamber paracentesis
• Ocular massage
• Topical intraocular pressure-lowering agents
• Sublingual isosorbide dinitrate
• Hemodilution 2, 1

Secondary Prevention and Follow-up

• Comprehensive vascular workup is essential as CRAO patients have high risk of subsequent stroke 2, 1:

  • Carotid imaging to identify stenosis
  • Transthoracic echocardiography for cardioembolic sources
  • Ambulatory cardiac rhythm monitoring for atrial fibrillation
  • Aggressive control of vascular risk factors (hypertension, diabetes, hyperlipidemia)

• Systemic evaluation based on age:

  • Under 50 years: Workup for vasculitis or hypercoagulability
  • Over 50 years: Embolic workup 2

• Regular ophthalmological follow-up to monitor for neovascularization

  • Patients with greater retinal ischemia require closer monitoring
  • Panretinal photocoagulation (PRP) is recommended if iris or retinal neovascularization develops 2

Prognosis

• Natural history of untreated CRAO is poor:

  • Only 17.7% of untreated patients achieve functional visual recovery
  • Nearly 80% have "count fingers" vision or worse at follow-up 1
  • Increases risk of falls and functional dependence

• Time is critical - the experimental ischemic time window before permanent retinal damage is approximately 90 minutes, though in clinical settings where occlusion may be incomplete, vision recovery may be possible after delays of 8-24 hours 3

Collaborative Management

Optimal care requires collaboration between:

• Neurologist
• Ophthalmologist
• Internist/Primary care physician 1

This multidisciplinary approach ensures both acute management of vision loss and appropriate secondary prevention of future vascular events, recognizing that CRAO is the ocular equivalent of cerebral stroke and requires similar urgency and comprehensive care.