What bloodwork or testing is important for a pre-operative evaluation in a patient with a history of central retinal artery (CRA) occlusion?

From the Guidelines

For a patient with a history of distant retinal artery blood clot, a comprehensive preoperative evaluation should include a thorough thrombophilia workup and cardiovascular assessment to minimize the risk of perioperative thrombotic events and bleeding complications. This approach is based on the most recent guidelines and evidence, including the 2021 scientific statement from the American Heart Association on the management of central retinal artery occlusion 1. The evaluation should consist of:

• Complete blood count
• Coagulation studies (PT, PTT, INR)
• Lipid panel
• Fasting blood glucose
• Hemoglobin A1c
• Inflammatory markers like ESR and CRP
• Additional testing for homocysteine levels, protein C and S activity, antithrombin III levels, factor V Leiden mutation, prothrombin gene mutation, antiphospholipid antibodies, and lupus anticoagulant
• Cardiovascular evaluation with an ECG, echocardiogram, and carotid ultrasound to identify potential embolic sources The initial evaluation of patients with transient retinal or hemispheric neurological symptoms of possible ischemic origin should include noninvasive imaging for the detection of extracranial carotid and vertebral artery disease, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. Medication management is crucial, particularly for patients on anticoagulants like warfarin, aspirin, or clopidogrel, and consultation with both ophthalmology and cardiology is recommended to balance the risk of perioperative thrombotic events against bleeding complications 1. The goal of this comprehensive approach is to minimize the risk of morbidity, mortality, and long-term disability, and to improve the patient's quality of life.

From the Research

Pre-Operative Evaluation for Patients with a History of Distant Retinal Artery Blood Clot

The following bloodwork and testing are important for a pre-operative evaluation:

• Thrombophilia measures:
  • Factor V Leiden 2
  • Prothrombin 2
  • C677T MTHFR 2
  • Platelet glycoprotein PlA1/A2 2
• Serologic thrombophilia measures:
  • Protein C 2, 3
  • Protein S (total and free) 2
  • Antithrombin III 2, 3
  • Homocysteine 2, 3
  • Lupus anticoagulant 2
  • Anticardiolipin antibodies IgG-IgM 2
  • Factors VIII and XI 2
• Serologic hypofibrinolysis measures:
  • Lp(a) 2
  • Plasminogen activator inhibitor activity 2
  • Plasminogen activator inhibitor-1 4G4G 2
• Coagulation tests:
  • Prothrombin fragment 1+2 (F1+2) 3
  • Thrombin-antithrombin III complex (TAT) 3
  • D-dimer 3 These tests can help identify potential thrombophilic or hypofibrinolytic conditions that may increase the risk of another retinal artery blood clot or other thrombotic events during surgery 2, 3.