What is the treatment for central retinal artery occlusion?

Treatment for Central Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) requires immediate triage to an emergency department for evaluation and possible intervention with intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset. 1, 2

Immediate Management

• CRAO is a medical emergency and should be treated as a stroke equivalent, requiring the same urgency as cerebral stroke 2
• Immediate triage to an emergency department is necessary and should not be delayed for outpatient evaluation or other treatments 1
• The therapeutic window for effective treatment is narrow, with best outcomes when treated within 4.5 hours of symptom onset 1, 2

Emergency Department Protocol

• The treatment sequence should include: 1
  • Immediate ophthalmological examination to confirm diagnosis
  • Parallel structured neurological assessment (National Institutes of Health Stroke Scale)
  • CT scan of the brain without contrast
  • Screening for giant cell arteritis (GCA) in suspicious cases

Primary Treatment Options

• Intravenous tPA (alteplase): 1

  • Dosage: 0.9 mg/kg with 10% given over 1 minute and remainder over 59 minutes
  • Meta-analysis shows 50% rate of clinical recovery when administered within 4.5 hours
  • Currently administered in 5.8% of CRAO patients in the United States
  • Visual recovery defined as improvement from 20/200 or worse to 20/100 or better

• For arteritic CRAO (due to GCA): 1, 2

  • Immediate steroid therapy is indicated to preserve vision in the contralateral eye
  • This is critical as thrombolysis has not been evaluated for arteritic CRAO

Prognosis and Outcomes

• Without intervention, only 17.7% of untreated CRAO patients exhibit functional visual recovery 1
• Unilateral visual loss is associated with increased likelihood of falls (odds ratio 2.86) and functional dependence (odds ratio 7.50) 1
• Patients with moderate to severe vision loss experience limitations in physical and social functioning 1

Secondary Prevention

• After acute management, focus should shift to secondary prevention of vascular events 3
• Patients require monitoring for development of neovascularization, which may require panretinal photocoagulation if it occurs 2

Key Pitfalls to Avoid

• Delaying emergency referral to perform additional outpatient testing 1, 2
• Failing to recognize CRAO as a stroke equivalent requiring immediate intervention 2
• Missing giant cell arteritis as a potential cause, which requires different treatment 1, 2
• Waiting beyond the therapeutic window of 4.5 hours, which significantly reduces chances of visual recovery 1, 2