Biggest Risk Factor for Retinal Artery Occlusion
Age is the single most important risk factor for retinal artery occlusion, with incidence peaking near age 80 years and following a pattern similar to cerebral stroke. 1
Primary Risk Factor: Age
The American Academy of Ophthalmology's 2020 guidelines explicitly identify age as the key risk factor for retinal artery occlusions (RAOs). 1 The incidence increases progressively with advancing age, peaking in the 8th decade of life, and occurs more frequently in men. 1 In the Blue Mountains Eye Study 10-year follow-up, age emerged as the dominant risk factor for retinal emboli, with a 3% cumulative risk in survivors, and notably without significant gender predilection. 1
Critical Modifiable Risk Factors
While age is non-modifiable and represents the strongest predictor, several modifiable cardiovascular risk factors substantially increase RAO risk and must be aggressively managed: 1
Cardiovascular and Embolic Sources
- Carotid artery disease: Present in 37-45% of RAO patients, with platelet-fibrin-cholesterol emboli (Hollenhorst plaques) commonly originating from carotid arteries, heart valves, or aortic arch 1, 2, 3
- Cardiac disease: Including atrial fibrillation (20% of patients) and valvular disease (17-25% of patients) 1, 2, 4
- Hypertension: Present in 65-73% of RAO patients 1, 2, 4
- Hyperlipidemia: Found in 49% of CRAO patients, with hyperlipidemia being the most commonly undiagnosed risk factor (36%) at time of presentation 1, 2, 5
- Diabetes mellitus: Present in 14-25% of patients 1, 2, 4
- Cigarette smoking: Identified as an important modifiable risk factor 1
Special Consideration: Giant Cell Arteritis
In patients over 50 years old, Giant Cell Arteritis (GCA) represents a critical non-embolic cause that must be immediately excluded, as it is the most common non-embolic etiology and constitutes an ophthalmologic emergency. 6, 2 GCA causes vessel wall thickening and inflammatory occlusion, requiring immediate high-dose corticosteroid treatment to prevent vision loss in the fellow eye. 1, 6
Clinical Context for Risk Stratification
In the specific context of older adults with hypertension, diabetes, hyperlipidemia, and smoking history—all these factors synergistically increase RAO risk, but age remains the foundational risk factor upon which these other conditions exert their pathologic effects. 1 The combination creates an atherosclerotic and thromboembolic milieu that makes retinal arterial occlusion increasingly likely as patients advance in age. 7, 4
Important Clinical Pitfall
Do not overlook that RAO patients have a 19-25% rate of concurrent silent brain infarctions and 3-6% risk of ischemic stroke within the first 1-4 weeks after presentation. 1, 8 This underscores that the same age-related vascular pathology affecting retinal arteries simultaneously threatens cerebral circulation, mandating immediate stroke center referral. 1, 6, 2