What is the management of ocular stroke?

Management of Ocular Stroke

Patients with ocular stroke (retinal artery occlusion) should be immediately referred to the nearest emergency department affiliated with a certified stroke center for urgent evaluation and management, as this condition represents an ocular emergency with high risk for subsequent cerebral stroke. 1, 2

Immediate Evaluation

1. Initial Triage and Diagnosis

   • Urgent ophthalmological examination to confirm diagnosis of retinal artery occlusion
   • Differentiate between Central Retinal Artery Occlusion (CRAO) and Branch Retinal Artery Occlusion (BRAO)
   • Optical Coherence Tomography (OCT) is valuable for early diagnosis, especially in hyperacute cases 3

2. Comprehensive Stroke Workup (within 24 hours of symptom onset)

   • Brain imaging:
     • MRI with diffusion-weighted imaging (preferred)
     • CT if MRI unavailable
   • Vascular imaging from aortic arch to vertex:
     • MR angiography or CT angiography
     • Carotid ultrasound/transcranial Doppler as alternatives
   • Cardiac evaluation:
     • Electrocardiography
     • Echocardiography (transthoracic or transesophageal)
     • Cardiac monitoring (inpatient telemetry or Holter)
   • Laboratory tests:
     • Complete blood count, chemistry panel, HbA1c
     • Lipid panel
     • Coagulation studies
     • ESR and CRP (especially in patients >50 years to rule out giant cell arteritis) 1, 2

Acute Treatment

1. Thrombolytic Therapy

   • Consider intravenous tissue plasminogen activator (tPA) if within 4.5 hours of symptom onset
   • Dose: 0.9 mg/kg (10% as bolus, remainder over 59 minutes) 2
   • Note: While recommended by some guidelines, evidence for efficacy remains limited

2. Antiplatelet Therapy

   • Initiate promptly to prevent further ischemic events
   • Consider dual antiplatelet therapy for patients with recent stroke 2

3. Hospitalization Criteria (if presenting within 72 hours)

   • Abnormal brain DWI-MRI showing acute cerebral infarction
   • Large artery atherosclerosis on vascular imaging
   • Abnormal cardiac evaluation
   • Recurrent episodes (crescendo TIAs)
   • Inability to provide expedited outpatient follow-up 1

Secondary Prevention

1. Medical Management

   • Antiplatelet therapy
   • Statin therapy for hyperlipidemia
   • Blood pressure control
   • Diabetes management if applicable 1, 2

2. Surgical Intervention

   • Carotid endarterectomy for significant carotid stenosis (ideally within 14 days) 1

3. Ophthalmological Management

   • Anti-VEGF agents (e.g., aflibercept 2mg) for macular edema
   • Initial dosing: every 4 weeks for first 5 injections, then every 8 weeks
   • Monitor for neovascularization
   • Consider panretinal photocoagulation if neovascularization develops 2

Follow-up Care

1. Neurological Follow-up

   • Arrange outpatient follow-up with stroke neurologist within 2 weeks
   • Review test results and optimize secondary prevention 1

2. Ophthalmological Follow-up

   • Regular monitoring for complications
   • Visual rehabilitation services for patients with significant vision loss 2

Important Considerations

• Time is Critical: Visual outcomes are poor with delayed treatment; each 30-minute delay decreases probability of good outcome by 8-14% 2
• Stroke Risk: CRAO patients have high risk of subsequent cerebral stroke, especially in first few days
• Visual Prognosis: Approximately 80% of untreated CRAO patients maintain visual acuity of "counting fingers" or worse 2
• Common Pitfall: Failure to recognize ocular stroke as a medical emergency requiring immediate stroke center referral
• Diagnostic Challenge: In hyperacute cases, fundus may appear normal; OCT can reveal inner retinal changes even when fundoscopy appears normal 3

By treating ocular stroke as a true emergency and following this structured approach, clinicians can potentially improve visual outcomes and reduce the risk of subsequent cerebrovascular events.