Rethinking the standard of care for patients with central retinal artery occlusion [abstract]
- View All
Study Objectives: Central retinal artery occlusion (CRAO) is an emergency causing unilateral, sudden, painless vision loss. Although generally due to thromboembolic vascular occlusion of arteries in the cerebral circulation, CRAO has historically not been worked up in the same manner as a thromboembolic stroke. Recently, there has been a push for stroke workup in CRAO patients including admission, but there is little published data supporting such recommendations. We present a retrospective review of CRAO patients referred to a large urban medical center for hyperbaric oxygen therapy (HBO). These CRAO patients also received an emergency department and inpatient diagnostic workup similar to thromboembolic stroke. This review was performed to assess findings of the stroke workup in CRAO patients. Methods: Patients who presented between November 2014 and July 2016 were included in this retrospective review. Patients received a standardized workup in the emergency department that included bedside ocular ultrasound, lab draw, neurology/stroke consult, ophthalmology consult with dilated eye exam, and HBO consult. Chart review of the electronic medical record was used to compile a dataset of the co-morbidities, stroke workup, and interventions in CRAO patients. Inpatient workup included brain magnetic resonance imaging (MRI), echocardiogram, carotid imaging, lipid panel, and hemoglobin A1c. Results: During the study period, 58 CRAO patients were treated. An acute or subacute brain infarct was identified on 15 of 47 patients (32%) who received an MRI. Intracardiac shunt was identified on 11 of 55 patients (20%) who received echocardiography. 44 of 58 patients (76%) had addition or modification of anticoagulation or antiplatelet medications. 34 of 58 patients (59%) were either started on a statin, changed to a more potent statin, or had a dose increase. Findings from carotid imaging led to interventionalist consult or follow-up for 11 of 58 patients (19%), two of whom had carotid stenting during the initial hospitalization. One patient returned with an acute thromboembolic stroke 8 days after CRAO presentation. Conclusions: The findings of this study strongly support recommendations that in the emergency department, CRAO patients should receive workup and treatment similar to that for thromboembolic stroke patients. The MRI findings that 32% had acute or subacute brain infarct further demonstrate the high risk of these patients necessitating workup and admission from the emergency department.