What is the appropriate management and treatment for a patient with an ocular stroke, potentially with underlying conditions such as hypertension, diabetes, or hyperlipidemia?

Management of Ocular Stroke (Central or Branch Retinal Artery Occlusion)

Patients with ocular stroke (CRAO or BRAO) require immediate emergency department transfer to a certified stroke center within 4.5 hours for potential thrombolysis, as this is a stroke equivalent with devastating visual prognosis and high risk of subsequent cerebral or cardiac ischemic events. 1, 2

Immediate Triage and Referral

• Eye care providers must serve as "gate-keepers" for rapid diagnosis, then immediately refer to a stroke center without attempting further testing in the office. 1, 2
• Call ahead to the stroke center stating "a stroke patient is on the way" with a note indicating "Ocular TIA" or "Ocular Stroke." 1
• The American Heart Association defines CRAO as an acute ischemic stroke equivalent requiring the same emergency protocols as cerebral stroke. 1, 2
• Even patients presenting days after the event require urgent stroke workup, though they can be evaluated as outpatients by a neurologist with stroke expertise; start antiplatelet therapy immediately. 1

Critical Diagnostic Pitfall

• Never assume vision improvement eliminates stroke risk—the risk of cerebral stroke remains highest in the first 7 days even if vision improves. 2
• Up to 25% of CRAO patients have concurrent silent brain infarction on MRI, and up to 70% have significant carotid stenosis. 2
• The stroke risk is 9.6% at 1 year, with 33.8% occurring within the first month and 43.9% within 6 months. 1

Emergency Department Evaluation Protocol

Hospitalization is reasonable if presenting within 72 hours and any of the following are present: 1

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

Immediate Diagnostic Workup (within 23-hour observation period):

• Brain MRI with diffusion-weighted imaging (DWI-MRI) to identify concurrent stroke in up to 24% of retinal vascular events 1, 2
• Vascular imaging (CTA or MRA) to assess carotid stenosis—40% of CRAO patients have ≥70% ipsilateral carotid stenosis 1, 2
• Cardiac monitoring for arrhythmias, particularly atrial fibrillation 1
• Transthoracic echocardiography is reasonable, especially when no cause is identified by other workup elements 1
• Transesophageal echocardiography is reasonable when identification of left atrial thrombus, patent foramen ovale, aortic arch atherosclerosis, or valvular disease will alter management 1

Giant Cell Arteritis Screening (Critical in Patients >50 Years):

• ESR and CRP must be evaluated in all patients over 50 years, regardless of whether classic symptoms are present. 2
• ESR >60 mm/h has high likelihood ratio for GCA diagnosis. 2
• If GCA is suspected, start empiric high-dose steroids immediately to prevent vision loss in the contralateral eye. 2
• Jaw claudication is the most specific symptom, followed by scalp tenderness, temporal tenderness, headaches, and constitutional symptoms. 2

Acute Treatment Considerations

Thrombolysis:

• Intravenous tPA within 4.5 hours is theoretically reasonable based on stroke equivalence, though evidence remains limited. 1, 3
• In one systematic review, 54% of 111 patients received IV tPA within 4.5 hours with no symptomatic intracranial or ocular hemorrhage, and most studies demonstrated benefit when administered very early. 3
• Intra-arterial tPA has been used but only 13.4% of patients were treated within 6 hours; adverse events were minimal. 3
• Future research is needed for pragmatic randomized controlled trials comparing tPA with placebo. 1

Treatments to Avoid:

• Ocular massage, anterior chamber paracentesis, and hemodilution may be harmful. 1

Secondary Prevention (Discharge Management)

All patients require comprehensive secondary stroke prevention regardless of visual outcome: 1

Antiplatelet Therapy:

• For cryptogenic or atherosclerotic etiology: 21 days of dual antiplatelet therapy (aspirin + clopidogrel or ticagrelor) followed by long-term single agent (aspirin 81 mg daily or clopidogrel 75 mg daily). 1
• This applies to patients with presenting National Institutes of Health Stroke Scale score ≤3 or equivalent. 1

Anticoagulation:

• If atrial fibrillation or cardioembolic source is detected, anticoagulation is appropriate for secondary prevention. 1

Carotid Stenosis Management:

• High-grade symptomatic carotid stenosis (≥50%) requires immediate treatment—either surgical revascularization or intensive medical management. 1
• The number needed to treat is 5 when carotid endarterectomy is performed within 2 weeks. 1

Risk Factor Modification:

• Statin therapy for hyperlipidemia 1
• Blood pressure control—for stroke prevention, blood pressure lowering is more important than the choice of drug 1
• Diabetes management—strict glycemic control in critically ill patients improves mortality and morbidity 1
• Smoking cessation 1
• Plant-based diet and regular physical activity 1
• Treatment of obstructive sleep apnea and obesity 1

Multidisciplinary Follow-up

• Outpatient follow-up with a neurologist with stroke expertise within 2 weeks after discharge to review tests and optimize secondary prevention 1
• Ophthalmological follow-up for optimization of residual vision, serial visual assessment, monitoring for neovascularization-related complications, and preservation of contralateral eye health 1
• Primary care physician or internist to control modifiable risk factors 1

Prognosis and Risk Stratification

• The natural history of CRAO shows only 17% achieve functional visual acuity in the affected eye. 2
• Risk of acute coronary syndrome is 5.4% at 1 year (9.6% for CRAO vs. 4.1% for BRAO). 1
• Risk factors increasing stroke risk include hypertension (present in 38-77% of patients), diabetes (22-61%), hyperlipidemia (10-74%), and age ≥65-70 years. 1