In our recent article in the American Journal of Ophthalmology we reported that our patients with central retinal artery occlusion (CRAO) had a very high rate of stroke and stroke risk factors. In fact, their risk of stroke was equivalent to the high-risk category of transient ischemic attacks (TIAs).
Dr. Anthony Arnold from UCLA wrote an editorial discussing this discovery, arguing that patients with CRAO must have an urgent evaluation, just like a patient with TIA or stroke, to prevent future cerebrovascular events. He says, “The paradigm for management of acute retinal ischemia has changed.”
Neuroophthalmologist Valerie Biousse and Nancy Newman, Chair of ophthalmology at Emory University, echoed this sentiment in a correspondence to the Journal. “It is critical that the cause of CRAO be quickly and accurately identified in order to allow for appropriate secondary stroke prevention (which may require urgent surgical intervention) based on the mechanism of CRAO. … Eye care providers play an essential role in evaluating patients with acute visual loss urgently and by making the correct diagnosis of acute retinal ischemia. Once the diagnosis is established, they should follow existing guidelines and send these patients immediately to the nearest stroke center.”
Never-the-less, this conclusion has been controversial. Dr. Sohan Hayreh, ophthalmologist from the University of Iowa and noted expert in the management of vascular retinal disease, argues these patients should be treated in the ophthalmology clinic, saying “for proper management of non-arteritic-CRAO, urgent evaluations of carotid artery, heart, fasting lipid levels, and complete blood count constitute the most important investigations, rather than neurologic evaluations—unless, of course, there are neurologic symptoms. This has been my policy of management of these disorders for about half a century.”
Biousse and Newman respond to this controversy saying “these results clearly highlight the need to expedite the evaluation and treatment of CRAO patients. Unfortunately, this is still a matter of some debate in the United States and many ophthalmologists continue to delay this process by not sending acute CRAO patients immediately to an emergency department affiliated with a stroke center. … Urgent evaluation in an emergency department affiliated with a stroke center is not “controversial.” Rather, it is standard of care, as recommended by the American Heart Association and the American Stroke Association.”
We discuss these results and other aspects of our work on CRAO on The Retina Channel podcast, here.