Follow-up Insufficient After Retinal Infarction

Pauline Anderson

February 07, 2018

LOS ANGELES — Patients with retinal infarction appear to be falling through the cracks when it comes to appropriate evaluation for risk for further stroke.

A new study shows that only 8% of patients with a retinal infarction are seen by a neurologist even though  they're at high risk for an ischemic stroke.

Furthermore, only about a third of these patients get brain imaging or receive heart rhythm monitoring, and less than a quarter undergo echocardiography.

"That's really concerning," study author Alexander E. Merkler, MD, assistant professor of neurology, Weill Cornell Medicine, Brain and Mind Research Institute, New York City, told Medscape Medical News.

"It's telling us that we're not evaluating risk factors for stroke in these patients, so we're not doing a good job of preventing another stroke."

The study was presented here at the International Stroke Conference (ISC) 2018.

Vision Loss

Retinal infarction is a form of stroke that occurs when blood flow is blocked in the arteries of the retina. Painless sudden vision loss, either complete or partial, is a common symptom, said Dr Merkler. "Transient loss of vision is definitely a concerning warning sign."

Patients with retinal infarction are at increased risk for a brain infarction. Risk factors for the two types of stroke — including hypertension, diabetes, atrial fibrillation, and heart failure — are the same.

The retrospective cohort study used inpatient and outpatient data from a nationally representative sample of 5% of Medicare beneficiaries over age 65 years from 2009 to 2015. Retinal infarction was documented by an ophthalmologist.

Primary outcomes within 90 days of the infarction were cervical carotid imaging, heart rhythm testing, echocardiography, and evaluation by a neurologist.

The researchers found that of 5688 Medicare patients with retinal infarction, only 34.1% (95% confidence interval [CI], 32.8% - 35.3%) had cervical carotid imaging, 28.6% (95% CI, 27.7% - 29.9%) had heart rhythm monitoring, and 23.3% (95% CI, 22.2% - 24.4%) had echocardiography.

Most patients with traditional stroke will get these tests, and most will also be seen by a neurologist. However, in this study, only 8.4% (95% CI, 7.7% - 9.2%) of those with retinal infarction were referred to a neurologist.

The problem is that "no one sort of follows up with these patients" to carry out evaluations, said Dr Merkler. "This needs to change."

Results showed that the cumulative rate of ischemic stroke according to validated diagnostic codes was 1.0% (95% CI, 0.8% - 1.3%) at 90 days after retinal infarction. This, said Dr Merkler, is significantly higher than in the general population.

Although he is not keen to lay blame for the lack of risk factor evaluation, Dr Merkler does urge better education of both the public and doctors, including ophthalmologists and internists, who may be the first to see patients with a retinal infarction.

"We need to make sure that doctors are aware that if they diagnose someone with a retinal infarction, they need to refer that patient to a neurologist" or ensure that appropriate evaluations are carried out.

Neurologists also need to do a better job of "spreading the word" that patients who have a retinal infarction urgently need this type of care, said Dr Merkler.

He would like to see better communication between ophthalmologists and neurologists and agreed "100 percent" that a neurologist should be included on the medical care team.

Stroke Harbinger

Philip B. Gorelick, MD, professor, translational science and molecular medicine, Michigan State University College of Human Medicine, East Lansing, and chief medical officer of Thorek Memorial Hospital, Chicago, Illinois), who chaired the media session featuring this research. told Medscape Medical News that the study underlines the importance of retinal infarction as a "harbinger of subsequent stroke."

The study highlights the need for ophthalmologists and primary care physicians to recognize this risk for stroke after retinal infarction, noted Dr Gorelick. "They may be in the position to make an initial assessment of such patients."

The findings also suggest that involving a vascular neurologist or neurologist in the "timely care" of these patients may be important, he added.

"This could ensure that an adequate diagnostic work-up is carried out to seek out remediable causes for subsequent stroke, such as extracranial carotid artery stenosis and atrial fibrillation, and other cardiac causes of stroke, and to ensure that proper stroke prevention treatments are administered." 

Dr Merkler has disclosed no relevant financial relationships.

International Stroke Conference (ISC) 2018. Poster TMP 76. Presented January 25, 2018.

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