What are the management options for retinal artery occlusion?

Management of Retinal Artery Occlusion

Retinal artery occlusion should be treated as an ocular emergency equivalent to cerebral stroke, with rapid triage to the emergency department and consideration of intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset in eligible patients after thorough benefit/risk discussion. 1

Initial Management

1. Immediate Triage and Assessment

   • Rapid referral to emergency department for patients with suspected retinal artery occlusion
   • Structured neurological assessment using NIH Stroke Scale
   • CT brain without contrast to rule out hemorrhage
   • Ophthalmological examination to confirm diagnosis 1

2. Acute Interventions (Time-Sensitive)

   • Consider IV tPA within 4.5 hours of symptom onset in eligible patients
   • Risk of symptomatic intracranial hemorrhage appears low when tPA is administered within this timeframe 2
   • Thorough discussion of benefits/risks with patient is essential given current equipoise in the literature 2, 1

3. Specialized Center Considerations

   • Intra-arterial thrombolysis may be considered in centers with endovascular capabilities
   • Particularly for patients who are not candidates for IV tPA 1
   • Technical challenges exist due to small vessel size (ophthalmic artery 1.3mm, central retinal artery 160μm) 2

Important Caveats

• "Conservative treatments" including anterior chamber paracentesis, ocular massage, topical intraocular pressure-lowering agents, and sublingual isosorbide have no compelling evidence of effectiveness 1
• Only 17% of untreated patients achieve functional visual acuity 1
• The EAGLE trial (only prospective randomized controlled study of intra-arterial thrombolysis) was stopped prematurely due to failure of treatment group to outperform conservative treatment, but mean time to treatment was 13 hours, with no patients treated within 4.5 hours 2

Secondary Prevention

1. Comprehensive Vascular Workup

   • Carotid imaging (most common source of emboli) 3
   • Echocardiography
   • Cardiac rhythm monitoring 1

2. Screening for Giant Cell Arteritis

   • Essential in patients over 50 years (accounts for 5% of CRAO cases)
   • If suspected, initiate urgent systemic corticosteroid therapy 1

3. Risk Factor Management

   • Aggressive control of vascular risk factors (hypertension, diabetes, hyperlipidemia)
   • Management focused on secondary prevention of future vascular events (cerebral ischemia, myocardial infarction, cardiovascular death) 4

Types of Retinal Artery Occlusion

Retinal artery occlusion consists of four distinct clinical entities with different prognoses 5:

1. Non-arteritic CRAO (NA-CRAO)
2. Transient NA-CRAO
3. NA-CRAO with cilioretinal artery sparing
4. Arteritic CRAO

Follow-up and Monitoring

• Regular ophthalmological follow-up to monitor for neovascularization
• Patients with greater retinal ischemia require closer monitoring
• Panretinal photocoagulation recommended if iris or retinal neovascularization develops 1
• Collaborative management between neurologist, ophthalmologist, and primary care physician 1

Clinical Pearls

• Time is critical - only 48% of CRAO patients are seen by an in-hospital ophthalmologist within the potential 20-hour therapeutic window 6
• Establishing efficient direct referral pathways to in-hospital ophthalmologists is essential to improve treatment delivery 6
• Spontaneous improvement in visual acuity and visual fields can occur, mainly during the first 7 days, with different rates depending on the type of CRAO 5
• Recent studies suggest intra-arterial thrombolysis may not only lack benefit but could potentially be harmful in some cases 5