Treatment of Retinal Stroke
Patients with retinal stroke (retinal artery occlusion) must be immediately referred to a specialized stroke center or emergency department without delay—eye care providers should not attempt further testing themselves before referral. 1
Immediate Triage and Referral
- Treat retinal artery occlusion as a stroke equivalent requiring emergency management within 24 hours of symptom onset. 1
- Communicate clearly to emergency providers that the patient has experienced an "eye stroke" to ensure appropriate triage. 2, 3
- The risk of cerebral stroke is highest within the first 7 days after retinal stroke and remains elevated for 30 days. 2, 3
- Up to 24% of patients with acute retinal artery occlusion have concurrent silent cerebral infarction on MRI. 3, 4
Acute Treatment Options (Within 4.5 Hours)
For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) should be considered using the standard stroke dose of alteplase 0.9 mg/kg. 2, 3, 5
- Recent real-world data from comprehensive stroke centers demonstrate that IV thrombolysis for retinal artery occlusion is feasible and safe, with no intracranial or extracranial hemorrhage events reported. 5
- Patients receiving reperfusion therapies show significantly higher rates of visual improvement (33.3% vs 5.9%) compared to observation alone. 6
- Hyperbaric oxygen therapy (100% oxygen over 9 hours) may be beneficial as an alternative or adjunct treatment. 2, 3
Emergency Diagnostic Workup
The following evaluations must be performed urgently in the emergency setting:
- Immediate ophthalmological examination with dilated fundoscopy alongside structured neurological assessment. 2, 3
- Brain imaging with CT scan without contrast to rule out hemorrhagic stroke before thrombolysis. 2, 3
- MRI with diffusion-weighted imaging is critical—it identifies concurrent silent brain infarctions present in 19-25% of patients and helps guide secondary prevention. 2, 3, 4
- Vascular imaging to assess carotid artery status, as clinically significant carotid stenosis is discovered in up to 70% of patients with symptomatic retinal artery occlusion. 2, 3
- Screening for giant cell arteritis with ESR and CRP, particularly in patients over 50 years—if arteritic retinal artery occlusion is suspected, immediate high-dose steroid therapy is mandatory to preserve vision in the contralateral eye. 2, 3
- Complete blood count with platelets and fasting lipid profile. 2, 7
Secondary Stroke Prevention
Long-term management focuses on preventing recurrent cerebrovascular and cardiovascular events:
- Initiate antiplatelet therapy for secondary stroke prevention. 2, 3
- Aggressively manage vascular risk factors including hypertension, diabetes, and hyperlipidemia. 2, 3
- Smoking cessation counseling is essential. 2, 3
- Carotid revascularization may be indicated based on imaging findings. 6
- Screen for and treat newly diagnosed atrial fibrillation, which is commonly discovered during workup. 6
Monitoring for Ocular Complications
- Regular ophthalmologic follow-up to monitor for iris or retinal neovascularization. 2, 3
- If neovascularization develops, panretinal photocoagulation (PRP) with or without intravitreal anti-VEGF therapy is indicated. 2, 3
- Monitor for neovascular glaucoma, which occurs in approximately 13-20% of patients. 6
Critical Pitfalls to Avoid
- Do not delay emergency referral to obtain outpatient ophthalmologic workup or institute unproven treatments—this is the most common error leading to poor outcomes. 1
- Do not assume retinal stroke is less serious than cerebral stroke—they share identical mechanisms, causes, and require the same urgent management. 1
- The majority of patients (75%) present outside the 4.5-hour treatment window, emphasizing the need for public education about recognizing sudden monocular vision loss as a medical emergency. 5
- Patients with identifiable causes on diffusion-weighted MRI have significantly higher probability of discovering treatable etiologies (100% vs 36%). 4