What is the treatment for ocular stroke?

Treatment for Ocular Stroke

Immediate referral to a stroke center with advanced care capabilities is essential for patients with suspected ocular stroke (ischemic monocular vision loss), as intravenous thrombolysis with tissue plasminogen activator (tPA) may be considered when administered within 4.5 hours of symptom onset. 1

Diagnosis and Initial Management

• Urgent Evaluation:

  • Immediate ophthalmological examination including fundoscopy and optical coherence tomography (OCT) 1, 2
  • Urgent brain imaging (CT or MRI) and vascular studies from aortic arch to vertex 1
  • Carotid ultrasonography to evaluate for stenosis 1
  • Cardiac evaluation including ECG and echocardiogram to identify embolic sources 1
  • Laboratory tests including ESR and CRP to rule out Giant Cell Arteritis 1

• Acute Treatment Options:

  • Intravenous thrombolysis (tPA) at 0.9 mg/kg (10% as bolus, remainder over 59 minutes) if within 4.5 hours of symptom onset 1
  • Immediate measures to lower intraocular pressure to potentially dislodge emboli 3
  • Antiplatelet therapy should be initiated promptly 1

Secondary Prevention and Management

• Medication Therapy:

  • Antiplatelet agents to prevent further ischemic events 1
  • Dual antiplatelet therapy may be reasonable in patients with recent stroke 1
  • Statins for hyperlipidemia management 1
  • Blood pressure control is essential 1

• Management of Complications:

  • Anti-VEGF agents (e.g., aflibercept 2mg) for macular edema secondary to retinal vascular occlusions 1
  • Regular monitoring for neovascularization 1
  • Panretinal photocoagulation may be required if neovascularization develops 1
  • Visual rehabilitation services for patients with significant vision loss 1

Prognosis and Important Considerations

• Time is critical - delay in referral decreases probability of good outcome by 8-14% for every 30 minutes 1
• Visual prognosis for untreated Central Retinal Artery Occlusion (CRAO) is generally poor, with approximately 80% of patients maintaining visual acuity of "counting fingers" or worse 1
• Only 17.7% of untreated patients show functional visual recovery 1
• Patients with ocular arterial occlusive disorders have significantly increased risk of subsequent stroke 4

Risk Factor Management

• Address underlying risk factors:
  • Hypertension (present in 48% of retinal vascular occlusions) 1
  • Hyperlipidemia (present in 20% of cases) 1
  • Diabetes mellitus (present in 5% of cases) 1

Common Pitfalls to Avoid

1. Delayed recognition: In hyperacute settings, the ocular fundus may appear normal, making diagnosis challenging without specialized imaging like OCT 2
2. Missing systemic disease: Always test for Giant Cell Arteritis in older patients with ESR and CRP 1
3. Inadequate follow-up: Patients require monitoring for both ocular complications and future stroke risk 4
4. Focusing only on the eye: Ocular stroke is considered a form of ischemic stroke by the American Heart Association and requires comprehensive vascular evaluation 1

Remember that ocular stroke represents a medical emergency requiring the same urgency as cerebral stroke, with treatment efficacy highly time-dependent.