What is the primary care management for a patient with multiple retinal hemorrhages found by an ophthalmologist?

Primary Care Management of Multiple Retinal Hemorrhages

Patients with multiple retinal hemorrhages found on ophthalmologic examination should be urgently referred to a stroke center or emergency department within 24 hours for comprehensive neurological evaluation, as these findings may represent an ocular stroke equivalent with high risk for concurrent cerebrovascular events. 1

Immediate Management

• Treat retinal hemorrhages as a potential medical emergency requiring prompt referral to an emergency department or stroke center, especially when multiple hemorrhages are present 2, 1
• Do not delay referral to obtain further outpatient evaluation or institute other treatments 1
• Establish communication with the ophthalmologist who made the finding to understand the specific type, location, and extent of the hemorrhages 2
• Determine if the patient has any symptoms of giant cell arteritis (GCA) if over 50 years old, including headaches, scalp tenderness, jaw claudication, or temporal tenderness 1, 3

Diagnostic Workup to Initiate or Coordinate

• Brain imaging with MRI and diffusion-weighted imaging should be performed urgently, as up to 24% of patients with retinal vascular events have concurrent silent brain infarctions 2, 1
• Vascular imaging to assess carotid artery status is essential, as clinically significant carotid stenosis is discovered in up to 70% of patients with symptomatic retinal vascular events 2, 1
• Order inflammatory markers (ESR, CRP) and complete blood count with platelets, especially if GCA is suspected 2, 3
• Evaluate for cardiovascular risk factors including hypertension, diabetes, and hyperlipidemia 2, 1

Etiology Assessment

• Retinal hemorrhages may indicate:
  • Retinal artery occlusion (central or branch) 2
  • Retinal vein occlusion 2
  • Diabetic retinopathy 2
  • Hypertensive retinopathy 2
  • Other vascular disorders or hematologic abnormalities 4

Ongoing Management After Initial Evaluation

• Implement secondary stroke prevention with antiplatelet therapy as recommended by neurology 1
• Optimize control of chronic systemic diseases (diabetes, hypertension, lipid disorders) 2, 1
• Provide smoking cessation counseling if applicable 2
• Ensure regular ophthalmologic follow-up to monitor for neovascular complications 2

Monitoring for Complications

• Watch for development of iris or retinal neovascularization, which may require panretinal photocoagulation (PRP) with or without anti-VEGF therapy 2
• Monitor for signs of neovascular glaucoma, which can result from new vessels growing on the iris and anterior chamber angle structures 2
• Be alert for visual changes that could indicate progression or complications 2

Important Considerations and Pitfalls

• The risk of stroke is highest within the first 7 days after retinal vascular events and remains elevated for 30 days 2, 3
• Do not assume that retinal hemorrhages are benign findings, even if the patient is asymptomatic 4
• Establish effective communication with the patient's ophthalmologist about the status of the retinal disease and its relation to systemic disease 2
• Remember that retinal vascular events are considered stroke equivalents by the American Heart Association 2

Follow-up Schedule

• Ensure patient follows up with ophthalmology within 1-2 weeks of initial finding 2
• Schedule primary care follow-up within 1 week to review results of neurological evaluation 1
• Coordinate care between neurology, ophthalmology, and primary care 2, 1