Introduction Central retinal artery occlusion (CRAO) is an ophthalmologic emergency that can result in permanent, devastating vision loss. Timing and use of interventions such as ocular digital massage, anterior chamber paracentesis, acetazolamide, topical beta-blockers, and thrombolysis have unclear efficacy and guidelines in the literature, and over 25% of CRAO are associated with cerebral ischemia. In the advent of intra-arterial treatment algorithms for stroke, there may be new opportunities to treat CRAO in an emergent, multidisciplinary approach similar to that of ischemic stroke to improve outcomes. This study examines the institutional practices at Wake Forest Baptist Medical Center (WFBMC) in an effort to establish a formalized approach to treatment of CRAO.
Methods This is a retrospective review including patients who were diagnosed or treated for acute non-arteritic (NA) CRAO from January 2017 to January 2019 at WFBMC. Time to presentation, services consulted for evaluation of patients with CRAO, standard stroke work-up carried out during the admission, treatments implemented specifically for the diagnosis of CRAO, and complications from treatment were recorded. Descriptive statistics were utilized.
Results Of 144 patients who were seen at WFBMC for CRAO during this timeframe, we identified 64 patients who received initial diagnostics and management for acute NA-CRAO. The cohort was 65.6% male, and the average age was 66.4 years. The most frequent comorbidity was hypertension (67.2%), with current or former smoking as the second most frequent comorbidity (62.5%). 18.8% of patients presented within 4 hours of symptoms, 39% presented between 4 and 24 hours, and 42.2% of patients presented greater than 24 hours after symptom onset. Ophthalmology, neurology stroke, and neurosurgery were consulted in 76.6%, 75%, and 10.9% of cases, respectively. Overall workup included CT (32.8%), MRI (70.3%), CTA or MRA (48.4%), visual acuity (82.8%), fundoscopic exam (84.8%), ocular pressures (78.1%), carotid doppler (67.2%), transthoracic echocardiogram (79.7%), CBC (84.4%), lipid panel (70.3%), A1C (68.6%), ESR (64.1%), and CRP (62.5%). 10.9% of patients had finding of acute stroke on MRI, and an additional 3.1% were diagnosed with transient ischemic attack. Ipsilateral internal carotid artery stenosis > 50% was found in 21.9% of patients. 59.4% of patients did not receive any treatment for CRAO (ocular digital massage, anterior chamber paracentesis, acetazolamide, etc.), and 43.8% of patients did not receive any escalation in home antiplatelet or anticoagulation regimen. Patients had a more complete workup and treatment when they presented within 24 hours of symptom onset.
Conclusions The management of acute CRAO is inconsistent and usually errs on the side of conservative management at our institution. Given the similarities to stroke and the significant number of patients with concomitant stroke risk factors and symptoms, multidisciplinary stroke algorithms should be considered for this disease. At our institution, we will begin a randomized, controlled trial for CRAO ‘eye stroke’ to mirror recent protocols in stroke care that allow for rapid mobilization and multidisciplinary treatment of patients. This will help streamline patient care and ensure that each patient receives all available and indicated therapies for maximum preservation and return of visual acuity.
Disclosures K. Lee: None. S. Coffman: None. C. Tschoe: None. K. Fargen: None. S. Wolfe: None.
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