A review of the management of central retinal artery occlusion

Central retinal artery occlusion (CRAO), the ocular analog of a cerebral stroke, is an ophthalmic emergency. The visual prognosis for overall spontaneous visual recovery in CRAO is low. Furthermore, the risk of future ischemic heart disease and cerebral stroke is increased due to the underlying atherosclerotic risk factors. There is currently no guideline-endorsed treatment for CRAO. This review will describe the anatomy, pathophysiology, epidemiology, and clinical features of CRAO, and investigate the current and future management strategies.

Intravenous Prostaglandin E1 Infusion for Acute Central Retinal Artery Occlusion

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of systemic prostaglandin E1 (PGE1) infusion within the first 24 hours of acute central retinal artery occlusion (CRAO).

PATIENTS AND METHODS

Best corrected visual acuity (BCVA) was analyzed in a case series of six eyes from six patients (mean age: 69.33 years) with acute CRAO who were treated with twice-daily intravenous infusion of 40 μg PGE1. Therapy continued until the patient no longer experienced visual acuity improvements for 24 hours.

RESULTS

Average time to presentation was 8.33 hours (range: 2 to 12 hours). The logMAR BCVA at presentation was 2.73. BCVA at the final visit 1 month after initial presentation was 1.48 (P = .025). All patients experienced vision improvement. No systemic adverse events were experienced.

CONCLUSION

Intravenous PGE1 infusion resulted in significant visual improvement in patients presenting with acute CRAO and is well tolerated with few adverse effects. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:S5-S8.].

Retinal Artery Occlusion in Young Patients: A 6-Year Review

Purpose:

This article describes the characteristics, management, and etiology of retinal artery occlusions (RAOs) in young patients.

Methods:

A retrospective chart review of patients <50 years of age with ophthalmic and RAOs was conducted. Data were collected on demographics, clinical presentation, laboratory and imaging evaluation, management, and outcome.

Results:

Seventeen eyes of 15 patients younger than 50 (mean age, 34±8 years; 71% male, 29% female) with RAOs were identified. AOs included: 8 (47%) central RAOs (CRAOs), 5 (29%) branch RAOs (BRAOs), 3 (18%) ophthalmic AOs (OAOs), and 1 (6%) combined CRAO and vein occlusion (CRAO/CRVO). Logarithm of the minimum angle of resolution visual acuity (VA) at presentation was 2.6±4 (Snellen range 20/15 to no light perception). Systemic diseases in patients with BRAO included Susac disease (n = 1), sickle cell disease (n = 2), patent foramen ovale (PFO) (n = 1), and HIV (n = 1). CRAO was diagnosed in 4 patients after invasive surgery (3 after neurosurgery and 1 after cardiac surgery). Other patients had hypertension (n = 3), hypercoagulability due to uterine cancer (n = 1), and PFO (n = 1). OAOs were noted in 1 patient with Saturday night retinopathy and in 1 with ruptured internal carotid aneurysm at the level of the ophthalmic artery. Two eyes with CRAO were treated with tissue plasminogen activator (1 intraophthalmic artery through catheterization and 1 intravenously) without any change in final VA. In these patients, VA remained poor (VA hand motions – counting fingers) at 6 months or greater follow-up visits.

Conclusion:

RAO in young patients is uncommon. In this series, one-fourth of occlusions were seen during the perioperative period. A significant number of patients had concurrent uncontrolled hypertension. Other associated systemic findings included PFO, hypercoagulability, sickle cell disease, Susac disease, and HIV.

Update on the Management of Central Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) is caused by partial or complete occlusion of the central retinal artery, most commonly by an embolus from the ipsilateral carotid artery, aortic arch, or heart, and is the ocular equivalent of an acute cerebral ischemic event. The risk factors for a CRAO and acute cerebral ischemia are very similar, if not identical. Because no current therapeutic intervention has been shown to improve visual outcomes compared with the natural history of CRAO, management of CRAO should be focused on secondary prevention of vascular events, such as cerebral ischemia, myocardial infarction, and cardiovascular death.

Treatment options for central retinal artery occlusion

OPINION STATEMENT

Central retinal artery occlusion (CRAO) is an ocular emergency and is the ocular analogue of cerebral stroke. It results in profound, usually monocular vision loss, and is associated with significant functional morbidity. The risk factors for CRAO are the same atherosclerotic risk factors as for stroke and heart disease. As such, individuals with CRAO may be at risk of ischemic end organ damage such as a cerebral stroke. Therefore, the management of CRAO is not only to restore vision, but at the same time to manage risk factors that may lead to other vascular conditions. There are a number of therapies that has been used in the treatment of CRAO in the past. These include carbogen inhalation, acetazolamide infusion, ocular massage and paracentesis, as well as various vasodilators such as intravenous glyceryl trinitrate. None of these "standard agents" have been shown to alter the natural history of disease definitively. There has been recent interest shown in the use of thrombolytic therapy, delivered either intravenously or intra-arterially by direct catheterisation of the ophthalmic artery. Whilst a number of observational series have shown that the recovery of vision can be quite dramatic, two recent randomised controlled trials have not demonstrated efficacy. On the contrary, intra-arterial delivery of thrombolytic may result in an increased risk of intracranial and systemic haemorrhage, while the intravenous use of tissue plasminogen activator (tPA) was not shown to be efficacious within 24 h of symptom onset. Nevertheless, both of these studies have shown one thing in common, and that is for treatment to be effective in CRAO, it must be deployed within a short time window, probably within 6 h of symptom onset. Therefore, while CRAO is a disease that does not have a treatment, nevertheless it needs to follow the same principles of treatment as any other vascular end organ ischaemic disease. That is, to attempt to reperfuse ischemic tissue as quickly as possible and to institute secondary prevention early.

Thrombolytic therapy in central retinal artery occlusion: cutting edge therapy, standard of care therapy, or impractical therapy?

PURPOSE OF REVIEW

Numerous therapeutic options have been suggested for the treatment of central retinal artery occlusion (CRAO) such as ocular massage, anterior chamber paracentesis, physical exercise, and medication-induced reduction of intraocular pressure. Because of the lack of a proven effective treatment for CRAO, there has been a strong effort to develop alternative therapies. Recently, thrombolytic therapy has been suggested as a viable therapy for CRAO. The aim of this review is to provide an update on the progress of thrombolytic therapy for CRAO.

RECENT FINDINGS

Although there is no consensus on a standardized treatment regimen for CRAO, emerging evidence suggests that thrombolytic therapy may be effective if administered promptly. Despite the benefit of thrombolytic therapy, on the basis of the results of case reports and case series, randomized controlled studies are necessary to ultimately prove the effectiveness of the treatment.

SUMMARY

Thrombolytic therapy has yet to be validated as an effective treatment of CRAO. The execution of randomized, controlled trials is greatly needed to establish whether thrombolytic therapy can be considered standard of care therapy for CRAO.

Management of acute central retinal artery occlusion

Central retinal artery occlusion (CRAO) is considered to be an acute stroke of the eye that results in profound visual loss. Spontaneous recovery rates are poor. Most CRAOs are caused by thromboembolism in the central retinal artery. Current standard therapies for CRAO that aim to restore perfusion to the retina and optic nerve head have not been shown to alter the natural course of the disease. Thrombolytic therapy for acute management of CRAO has shown promise in nonrandomized studies with regard to improving visual outcomes. A randomized controlled trial will be required to confirm the efficacy of thrombolytic therapy before it can be recommended for use in CRAO in daily clinical practice.