Acute central retinal artery occlusion requires urgent evaluation

The authors evaluated the usefulness of an expedited inpatient evaluation of cerebrovascular risk factors in patients presenting with an acute central retinal artery occlusion (CRAO).

Study design

This retrospective analysis included 103 patients presenting with acute CRAO over a 9-year period. Evaluated risk factors included vital signs, LDL level, hemoglobin A1C, erythrocyte sedimentation rate, C-reactive protein level, platelet counts and troponin levels. In addition, patients received echocardiography, cardiac telemetry, MRI as well as cerebrovascular imaging.

Primary clinical outcomes included a frequency of stroke as seen on MRI, hypertensive crisis, critical cardiac or carotid disease, new heart attacks and arrhythmias.

Outcomes

Investigators found that 36.7% of patients had critical carotid disease, 37.3% had coincident acute stroke, 33% presented with hypertensive emergency, 20% had a myocardial infarction or critical structural cardiac disease and 25% underwent an urgent surgical intervention. Overall, 93% of patients had a change in medication as a result of the inpatient evaluation.

Patients with CRAO had a comparable risk of subsequent stroke, myocardial infarction and death as patients with high-risk transient ischemic attack (TIA).

Limitations

This was a single-center study with a relatively small number of patients over a long period. During that time, there may have been significant changes to treatment and evaluation. Not all patients obtained all tests. For example, only two-thirds of the patients had an MRI. Presumably, there was some overlap in the outcomes reported, and some patients may have had multiple manifestations of ischemia.

Clinical significance

Although TIAs and strokes are managed as a medical emergencies that require immediate evaluation and intervention, CRAO has traditionally been viewed as something different, even when an emboli is visible in the eye. There has been a slow shift in the approach of patients with CRAO to treat them for what they are: stroke patients. This paper adds to the growing literature suggesting that patients with an acute embolic event to the eye should be evaluated promptly to look for modifiable risk factors that may help protect the patients’ long-term wellbeing.  

As ophthalmologists diagnose patients with an acute CRAO, we must decide the urgency of an out-patient versus an in-patient evaluation to determine the etiology of the CRAO. As practice patterns vary greatly, it may not be practical to send every patient with a CRAO to an emergency room or to admit to a hospital for a stroke or cardiac work-up. However, it is clear that such patients need urgent evaluation by a neurologist, cardiologist and/or primary care physician to assess each patient’s risk for such an event and to order appropriate cardiac testing.

In an accompanying editorial, Anthony Arnold, MD, emphasized the importance of immediately identifying more severely involved patients, because these patients are at a greater risk for new events within 72 hours from the time of the CRAO.