AHA: Symptom recognition, data on treatment of central retinal artery occlusion lacking
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The American Heart Association issued a scientific statement with recommendations for the diagnosis, treatment and secondary prevention of central retinal artery occlusion, or CRAO.
Published in Stroke, the scientific statement is endorsed by the North American Neuro-Ophthalmology Society, the American Academy of Ophthalmology Quality of Care Secretariat and the American Academy of Optometry.
“Central retinal artery occlusion is a cardiovascular problem disguised as an eye problem. It is less common than stroke affecting the brain but is a critical sign of ill health and requires immediate medical attention,” Brian C. Mac Grory, MBBCh, BAO, MRCP, assistant professor of neurology and staff neurologist at the Duke Comprehensive Stroke Center at Duke University School of Medicine and chair of the statement writing committee, said in a press release. “Unfortunately, a CRAO is a warning sign of other vascular issues, so ongoing follow-up is critical to prevent a future stroke or heart attack.”
In the scientific statement, the writing committee, composed of experts in fields including cardiology, ophthalmology and neurology, summarized the current knowledge base on the management of CRAO.
According to the statement, CRAO with retinal infarction occurs at a rate of approximately 1.9 per 100,000 person-years in the U.S. and conforms to the diagnosis of acute ischemic stroke.
The most common outcomes from CRAO include sudden, painless, monocular visual loss resulting from optic neuropathy, retinal detachment or intraocular hemorrhage. CRAO can affect visual acuity, peripheral vision, color vision and stereovision, and only 17% of patients achieve functional visual acuity in the affected eye, the authors wrote.
According to the statement, risk increases with age and in the presence of vascular risk factors such as hypertension, hyperlipidemia, diabetes, tobacco exposure and obesity. In most cases, CRAO occurs because of thromboembolic disease.
Funduscopic examination is necessary for diagnosis of CRAO and to rule out intraocular hemorrhage, according to the authors.
Treatment and secondary prevention
According to the statement, public education should emphasize painless, monocular visual loss as a symptom of stroke.
“We know acute CRAO is a medical emergency requiring early recognition and triage to emergency medical treatment,” Mac Grory said in the release. “There is a narrow time window for effective treatment of CRAO and a high rate of serious related illness. So, if a person is diagnosed in a doctor’s office or other outpatient clinic, they should be immediately sent to a hospital emergency department for further evaluation and treatment.”
The committee recommended that administration of IV tissue plasminogen activator, also used to treat strokes in the brain and/or carotid arteries, may be considered in patients who have disabling visual deficits due to CRAO and would otherwise meet use criteria.
Among centers capable of deploying endovascular therapy, intra-arterial tissue plasminogen activator may be considered, particularly if a patient is not a candidate for IV tissue plasminogen activator.
The committee added that there is no compelling evidence that more conservative treatment strategies for CRAO are effective. In addition, observational literature has suggested that ocular massage, anterior chamber paracentesis and hemodilution may actually be harmful, according to the statement.
“To date, there have been no adequate randomized clinical trials of intravenous tissue plasminogen activator because previous attempts were limited as a result of difficulty with patient enrollment,” the committee wrote. “Since the publication of the meta-analysis of observational studies, intravenous tissue plasminogen activator was reevaluated in four modern cohorts with acute CRAO within 4.5 hours of onset. An updated meta-analysis including these modern cohorts again demonstrated a strong effect with treatment within 4.5 hours.”
Secondary prevention
According to the statement, a multidisciplinary approach to secondary prevention should follow established guidelines for cerebral ischemic stroke and include pharmacological and lifestyle modifications.
“The optimal approach to long-term secondary prevention in patients with CRAO should be guided by a multidisciplinary collaboration among a neurologist, an ophthalmologist, and a primary care physician or an internist. Patients with CRAO require ophthalmological follow-up for optimization of residual vision, serial visual assessment, monitoring for neovascularization-related complications, and preservation of the health of the contralateral eye,” the committee wrote. “The neurologist’s role is to determine the cause, initiate an appropriate pharmacological secondary prevention strategy, and work in concert with the patient’s internist/primary care physician to control modifiable risk factors.”
Recommendations for pharmacological secondary prevention include antiplatelet therapy when the cause of CRAO is cryptogenic or attributed to atherosclerosis; anticoagulation if atrial fibrillation or another cardioembolic source is detected; or surgical intervention if severe stenosis of the carotid artery valves is found.
“There is an unmet need for a pragmatic, multicenter, randomized, double-blind, placebo-controlled clinical trial comparing intravenous tissue plasminogen activator with placebo at early time points in patients with CRAO,” the committee wrote. “Prospective multicenter observational registries will aid in feasibility testing and sample size calculations for such a clinical trial. Future research should be directed toward the development of novel biomarkers of retinal tissue viability that can be deployed in real time and complement existing time-based decision-making algorithms, potentially allowing the use of tissue plasminogen activator at delayed time points in selected patients.”
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