What is the workup for Central Retinal Artery Occlusion (CRAO) during admission?

From the Guidelines

For a patient admitted with central retinal artery occlusion (CRAO), a comprehensive workup should be initiated immediately to identify the underlying cause and prevent further vascular events. Begin with urgent neuroimaging including brain MRI/MRA and carotid imaging to evaluate for stroke, carotid stenosis, or other vascular abnormalities, as recommended by the American Heart Association 1. Order a complete blood count, comprehensive metabolic panel, lipid profile, hemoglobin A1c, ESR, CRP, and coagulation studies to assess for potential risk factors and comorbidities. Additional testing should include echocardiogram (preferably transesophageal) to evaluate for cardiac sources of emboli, and specialized tests like homocysteine levels, antiphospholipid antibodies, and hypercoagulability panel, as suggested by the Preferred Practice Pattern for retinal and ophthalmic artery occlusions 1. Consider temporal artery biopsy in patients over 50 to rule out giant cell arteritis, particularly if ESR/CRP are elevated, as this condition can cause CRAO and requires prompt treatment. Neurology and cardiology consultations are essential for comprehensive evaluation and management, as CRAO shares risk factors with cerebrovascular disease and approximately 25% of patients have evidence of concurrent brain infarction. While performing the workup, manage the patient with aspirin 325mg daily, blood pressure control, and statin therapy, as these interventions can help reduce the risk of further vascular events. This thorough approach is necessary because CRAO represents ocular stroke and identifying the underlying cause is crucial for preventing further vascular events in both the affected and contralateral eye, as well as other vascular territories, as emphasized by the American Heart Association 1.

Some key points to consider in the workup and management of CRAO include:

• Urgent neuroimaging and carotid imaging to evaluate for stroke and carotid stenosis
• Comprehensive laboratory testing to assess for potential risk factors and comorbidities
• Echocardiogram and specialized tests to evaluate for cardiac sources of emboli and other potential causes
• Temporal artery biopsy in patients over 50 to rule out giant cell arteritis
• Neurology and cardiology consultations for comprehensive evaluation and management
• Management with aspirin, blood pressure control, and statin therapy to reduce the risk of further vascular events.

By taking a comprehensive and multidisciplinary approach to the workup and management of CRAO, clinicians can help identify the underlying cause and prevent further vascular events, ultimately improving outcomes for patients with this condition, as supported by the latest evidence from the American Heart Association 1 and the Preferred Practice Pattern for retinal and ophthalmic artery occlusions 1.

From the Research

CRAO Workup During Admission

• The workup for Central Retinal Artery Occlusion (CRAO) during admission may involve various tests and evaluations, as there is no consensus on a standardized approach 2.
• Carotid imaging is routinely obtained by 89% of programs, magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, laboratory screening for an inflammatory state by 27%, and retinal angiography by 30% 2.
• The thoroughness of vascular risk factors' screening is greater in programs that routinely refer acute CRAO cases to the emergency department 2.
• Comprehensive medical evaluation should be initiated to exclude systemic vascular disease 3.

Treatment Approaches

• There is significant variability in treatment practices for acute CRAO, with some institutions offering intravenous fibrinolysis, anterior chamber paracentesis, ocular massage, and hyperbaric oxygen therapy 2.
• The use of thrombolytics remains controversial, and the available evidence for all treatments is insufficient to conclude that any treatment will influence the natural history of this disorder 4.
• Management of CRAO patients should focus on reducing the risk of subsequent ischemic events, including cerebral stroke 4, 5.

Diagnostic Considerations

• CRAO is caused by partial or complete occlusion of the central retinal artery, most commonly by an embolus from the ipsilateral carotid artery, aortic arch, or heart 5.
• The risk factors for CRAO and acute cerebral ischemia are very similar, if not identical 5.
• Central retinal artery occlusion is characterized by sudden, painless visual loss due to blockage of retinal blood flow 3.