What is the management plan for a patient with retinal artery stenosis?

Management of Retinal Artery Stenosis

Immediate Emergency Referral

Patients with retinal artery stenosis presenting with acute visual symptoms must be immediately referred to the nearest emergency department or stroke center within 24 hours of symptom onset, as this represents an ocular stroke requiring urgent intervention. 1, 2

• Communicate clearly to emergency providers that the patient has experienced an "eye stroke" to ensure appropriate triage and avoid delays in evaluation 3, 2
• Do not delay emergency referral to obtain outpatient workup or institute other treatments 2
• Transport immediately to the closest facility prepared for acute stroke care, preferably a designated stroke center 4

Acute Phase Management (Within 4.5 Hours)

For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) should be considered using standard dose alteplase 0.9 mg/kg. 3, 2

• Hyperbaric oxygen therapy (100% oxygen over 9 hours) may be beneficial over observation alone 3, 2
• If giant cell arteritis is suspected (particularly in patients >50 years), immediate steroid therapy is indicated to preserve vision in the contralateral eye 3, 2

Emergency Diagnostic Workup

All patients require urgent comprehensive evaluation to identify the embolic source and prevent subsequent stroke, as 37-40% have ipsilateral critical carotid disease (≥70% stenosis). 1

Immediate Testing (Within 24 Hours):

• Brain imaging: MRI with diffusion-weighted imaging is preferred over CT, as 19-25% of patients have concurrent silent cerebral infarctions 1, 3, 2
• Vascular imaging: Noninvasive cervicocephalic vessel imaging (MRA, CTA, or carotid ultrasound/transcranial Doppler) to assess for carotid stenosis 1, 2
• Cardiac evaluation: Electrocardiography immediately, followed by prolonged cardiac monitoring (inpatient telemetry or Holter monitor) to detect atrial fibrillation 1
• Inflammatory markers: ESR and CRP in patients >50 years to screen for giant cell arteritis 1, 3, 2
• Echocardiography: At least transthoracic echocardiography, with transesophageal echocardiography if initial workup is unrevealing 1

Hospitalization Criteria

Hospitalization is reasonable if the patient presents within 72 hours and has any of the following: 1

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

Secondary Prevention Strategy

All patients require aggressive secondary stroke prevention, as the risk of subsequent stroke is highest within the first 7 days and remains elevated for 30 days. 3, 2

Mandatory Interventions:

• Antiplatelet therapy: Initiate immediately for secondary stroke prevention 3, 2
• Statin therapy: For hyperlipidemia management regardless of baseline cholesterol 1
• Blood pressure control: Target appropriate levels based on stroke guidelines 3, 4
• Carotid revascularization: Consider if ≥50% stenosis identified, with number needed to treat of 5 when surgery performed within 2 weeks 1
• Anticoagulation: For cardioembolic sources (atrial fibrillation, valvular disease), with timing individualized based on infarct size 4
• Smoking cessation: Mandatory counseling 3, 2

Long-Term Monitoring

Regular ophthalmologic follow-up is essential to monitor for neovascular complications, which require prompt treatment. 3, 2

• If iris or retinal neovascularization develops, perform panretinal photocoagulation (PRP) with or without anti-VEGF therapy 3, 2
• In acute cases, intravitreal anti-VEGF agents may be used off-label to supplement PRP treatment 3, 2

Critical Pitfalls to Avoid

The most common error is treating retinal artery stenosis as a non-urgent ophthalmologic problem rather than a stroke equivalent. 1

• Up to 70% of patients have a new significant systemic cardiovascular condition (typically clinically significant carotid stenosis) discovered during workup 3, 2
• 24% of patients have concurrent cerebrovascular accident on diffusion-weighted MRI despite isolated visual symptoms 3, 2
• Patients with retinal artery occlusion have 19.6% risk of stroke at 3 years, with 25.2% occurring within 1 month and 59.3% within 6 months 1
• Delays in evaluation are common: only 35% of ophthalmologists report sending acute cases to emergency departments immediately 1
• The effectiveness of carotid endarterectomy is highly time-dependent, making urgent evaluation critical 1