What is the treatment for an ocular stroke?

Treatment of Ocular Stroke

Patients with acute 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 both an ocular emergency and a warning sign for systemic stroke. 1

Immediate Management

• Patients with suspected ocular stroke (central retinal artery occlusion [CRAO] or branch retinal artery occlusion [BRAO]) should be treated as medical emergencies requiring immediate referral to an emergency department or stroke center within 24 hours of symptom onset 1
• Immediate triage to an emergency department should not be delayed to obtain further outpatient evaluation or institute other treatments 1
• Eye care providers should establish relationships with certified stroke centers to create efficient pathways for rapid evaluation of patients with suspected vascular visual loss 1

Acute Treatment Options

• For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be considered 1
  • The standard dose is alteplase 0.9 mg/kg with 10% given over 1 minute and the remainder over 59 minutes 1
  • Observational studies show 50% rate of clinical recovery when treated within 4.5 hours of onset 1
• Hyperbaric oxygen therapy (100% oxygen over 9 hours) has demonstrated efficacy over observation alone in several small randomized trials 1, 2
• For suspected arteritic CRAO (giant cell arteritis), immediate steroid therapy is indicated to preserve vision in the contralateral eye 1
• Patients seen a few days after visual loss should still receive urgent stroke workup and be started on an antiplatelet agent without delay 1

Diagnostic Evaluation in Emergency Setting

• Immediate ophthalmological examination in parallel with structured neurological assessment 1
• Brain imaging (CT scan without contrast) 1
• Screening for giant cell arteritis (consider ESR, CRP) 1, 3
• Vascular imaging to assess carotid artery status 1, 4
• MRI with diffusion-weighted imaging to identify concurrent silent brain infarctions (present in 19-25% of patients) 1

Management of Complications

• Panretinal photocoagulation (PRP) with or without anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended for patients who develop iris or retinal neovascularization 1
• In acute cases, intravitreal anti-VEGF agents may be used (off-label) to supplement or facilitate PRP treatment 1
• For ocular ischemic syndrome associated with carotid stenosis, carotid revascularization (endarterectomy or stenting) may improve or stabilize visual outcomes 4

Long-term Management

• Secondary stroke prevention with antiplatelet therapy 1
• Identification and management of vascular risk factors (hypertension, diabetes, lipid disorders) 1
• Smoking cessation counseling 1
• Regular follow-up to monitor for neovascular complications 1

Important Considerations and Pitfalls

• The risk of stroke is highest within the first 7 days after ocular stroke and remains elevated for 30 days 1
• Up to 24% of patients with acute retinal artery occlusion have concurrent cerebrovascular accident on diffusion-weighted MRI 1
• A new significant systemic cardiovascular condition (typically clinically significant carotid stenosis) is discovered in up to 70% of patients with symptomatic CRAO 1
• In very acute presentations, the ocular fundus may appear "normal," making recognition challenging without specialized imaging like optical coherence tomography (OCT) 5
• Delayed diagnosis is a major limitation to effective treatment, emphasizing the need for rapid recognition and referral 5

The treatment of ocular stroke requires a coordinated approach between ophthalmologists, optometrists, and stroke specialists to ensure prompt diagnosis and management, with the primary goal of preserving vision and preventing subsequent stroke and cardiovascular events 1.