Top Things to Know: Management of Central Retinal Artery Occlusion
Published: March 08, 2021
Prepared by Anne Leonard MPH, BSN, RN Senior Science and Medicine Advisor - Lead
- Ischemic stroke is defined as an “episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction.” In the case of central retinal artery occlusion (CRAO), fewer than 20% of affected patients regain functional visual acuity in the affected eye. CRAO is associated with the risk of recurrent vascular events; 95% of cases are a result of thromboembolic disease.
- Central retinal artery occlusion (CRAO) refers to compromise of blood flow via the central retinal artery to the inner layers of the retina. This may result in infarction of the retina, and it is an infarction that conforms to the diagnosis of acute ischemic stroke.
- The age- and sex-adjusted incidence of CRAO is 1.9/100,000 person-years in the United States. This risk increases with age and in the presence of vascular risk factors such as hypertension, hyperlipidemia, diabetes mellitus, tobacco exposure, and obesity.
- The diagnosis of CRAO is made by identifying classic clinical findings of sudden, painless monocular vision loss, a relative afferent pupillary defect (asymmetric pupillary reaction), and funduscopic findings indicative of retinal hypoperfusion.
- Treatment includes:
- Rapid triage to the nearest emergency department.
- Intravenous alteplase (thrombolysis) might be considered in patients who have disabling visual deficits, but who meet criteria for systemic alteplase administration.
- Intra-arterial thrombolysis (IAT) might be considered in centers capable of deploying endovascular therapy, but as this is an unproven therapy, it will only be used in the case of devastating visual outcome associated with CRAO.
- Conservative treatments such as ocular massage, anterior chamber paracentesis, and hemodilution have not been proven effective and could be harmful to the patient.
- Emerging treatments such as hyperbaric oxygen and intra-arterial alteplase are showing promise but require further study. Other potential treatment modalities that require further study include evaluation of novel thrombolytics such as Tenecteplase and novel neuroprotectants for use in tandem with recanalization therapy.
- Systems for urgent recognition, triage, and management are lacking but need to be developed similarly to systems developed for acute ischemic stroke.
- Pragmatic, randomized, placebo-controlled, double-blind clinical trials comparing alteplase with placebo as treatment for patients with CRAO presenting during early time points are needed. Exploration of biomarkers of retinal viability that may complement existing, time-based approaches to thrombolytic therapy are needed for future research.
- Secondary prevention (including monitoring for complications) must be a collaborative effort between neurology, ophthalmology, and primary care medicine. Risk factor modification includes lifestyle and pharmacological interventions.
- CRAO is a medical emergency where swift triage, acute medical management, and secondary prevention are needed to mitigate permanent vision loss.
Citation
Mac Grory B, Schrag M, Biousse V, Furie KL, Gerhard-Herman M, Lavin PJ, Sobrin L, Tjoumakaris SI, Weyand CM, Yaghi S; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; and Council on Peripheral Vascular Disease. Management of central retinal artery occlusion: a scientific statement from the American Heart Association [published online ahead of print March 8, 2021]. Stroke. doi: 10.1161/STR.0000000000000366