What is the initial management of Central Retinal Artery Occlusion (CRAO)?

Initial Management of Central Retinal Artery Occlusion (CRAO)

Immediately triage the patient to an emergency department for urgent evaluation and consideration of intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset. 1, 2

Emergency Department Triage

CRAO is a stroke equivalent requiring the same urgency as cerebral stroke—do not delay transfer to obtain outpatient testing or institute other treatments. 1, 2

Parallel Workflow Upon Arrival

The following evaluations should occur simultaneously: 1

• Funduscopic examination to confirm diagnosis (look for retinal whitening with cherry-red spot) and exclude vitreous or retinal hemorrhage 1
• Neurological assessment using National Institutes of Health Stroke Scale 1
• Non-contrast head CT to exclude intracranial hemorrhage 1
• Screen for giant cell arteritis (GCA) in patients over 50 years—check ESR, CRP, and temporal artery examination; initiate immediate corticosteroids if GCA is suspected to preserve vision in the contralateral eye 1, 3

Laboratory Studies (if high suspicion for coagulopathy)

• Platelet count 1
• PT/INR and aPTT 1

Thrombolytic Therapy Decision

Intravenous tPA (alteplase 0.9 mg/kg: 10% bolus over 1 minute, remainder over 59 minutes) should be strongly considered if the patient presents within 4.5 hours of symptom onset and has no contraindications to thrombolysis. 1, 2

Evidence Supporting Early Treatment

• Meta-analysis data shows 50% clinical recovery rate when any thrombolytic is administered within 4.5 hours 1
• Visual recovery is defined as improvement from 20/200 or worse to 20/100 or better—representing functional clinical improvement 1
• The therapeutic window may extend to 6 hours in some cases, though efficacy decreases with time 2, 4

Important Nuance

While randomized controlled trials have not definitively proven efficacy, observational data is strong enough that more than half of academic neurologists treat selected CRAO patients with IV tPA within the 4.5-hour window. 1 The American Heart Association's 2021 scientific statement supports this approach based on the strength of observational evidence and absence of other effective treatments. 1

Common Pitfalls to Avoid

• Never delay emergency referral to perform additional outpatient testing—the narrow therapeutic window makes every minute critical 1, 2
• Do not miss GCA as the underlying cause, particularly in patients over 50 years, as this requires immediate steroid therapy to prevent bilateral blindness 1, 3
• Do not treat if GCA is confirmed—the efficacy of thrombolysis has not been evaluated in arteritic CRAO 1

Post-Acute Management

After the acute window, focus shifts to: 2, 3

• Vascular risk factor evaluation: carotid imaging, echocardiography, cardiac rhythm monitoring 2, 3
• Secondary stroke prevention: antiplatelet therapy and risk factor modification 3
• Monitoring for neovascularization: requires panretinal photocoagulation if it develops 2, 3

Prognosis Context

Without treatment, nearly 80% of CRAO patients have visual acuity of "count fingers" or worse at follow-up, with only 17.7% achieving functional visual recovery naturally. 1 This poor natural history, combined with the 50% recovery rate seen with early thrombolysis, justifies aggressive acute intervention despite the lack of definitive randomized trial data. 1