COMMENTARY

A Review of Central Retinal Artery Occlusion

Philippe Gabriel Steg, MD

Disclosures

October 25, 2021

This interview is a translation of a video blog posted on Medscape France. It has been edited for clarity.

Philippe Gabriel Steg, MD: Hello. Today, I would like to address a subject that many cardiologists may not be familiar with, although, like any specialists dealing with vascular pathologies, they may have encountered it: central retinal artery occlusion.

I will discuss a comprehensive overview, recently published in Stroke by the American Heart Association (AHA), of the epidemiology, pathophysiology, diagnosis, and management of central retinal artery occlusions, which I urge you to read. The primary author is Brian Mac Grory, MD, from the Department of Neurology at the Duke University School of Medicine in Durham, North Carolina.

This condition is both serious and urgent. Serious because more than 80% of people presenting with central retinal artery occlusion will be left with significant ocular sequelae, often accompanied by functional impotence on the affected side. And urgent because it is a genuine ischemic stroke and, therefore, the window for treatment is quite short, just a few hours.

The diagnosis is quite simple. It is based on a sudden, complete, or partial, painless amaurosis requiring immediate consultation in the emergency room. If possible, an ophthalmology specialist should be consulted and asked to perform an ocular fundus examination to rule out retinal ischemia. In the case of central retinal artery occlusion, the exam will reveal retinal edema and pallor, a red spot indicating that choroidal circulation remains intact, features of reduced arterial blood flow, and other, more specialized ophthalmologic indications that make the diagnosis almost certain.

Critical Assessment of Treatments

The big question, of course, is, 'What is the treatment?' The AHA review includes a critical assessment of treatments used, with an overview of the available evidence to support their use.

Like with any ischemic stroke, the first step is intravenous thrombolysis to restore blood flow. There are some observational data to suggest that this treatment is effective, although no real hard evidence from randomized clinical trials exists. These trials are still ongoing; there are at least three current randomized clinical trials on the subject.

The selective administration of intra-arterial thrombolytic agents is even more complicated and cumbersome to implement, and there is even less evidence to support its use.

There is also a whole series of conventional treatments that is widely used, from use of the carbonic anhydrase inhibitor acetazolamide to massaging the eyeball in an attempt to promote the mechanical restoration of blood flow in the central retinal artery. While these treatments may not be dangerous, their efficacy is unclear.

Then there is hyperbaric oxygen therapy, which is a logical approach, in that it improves passive oxygen diffusion from choroidal circulation; however, it too is based on rather tenuous data. We do not, as yet, have any firm evidence of its benefits.

So we have a condition that is serious and urgent, but for which treatment is still not well standardized.

Etiological Profile and Secondary Prevention

As in all ischemic strokes, these patients are prone to experiencing recurring atherosclerotic strokes, either in the same place or in a different area, notably in the coronary or peripheral arteries. Therefore, etiologic assessment and secondary prevention are absolutely essential. This is truly a traditional approach for cardiologists and all other vascular pathology specialists, including neurologists, angiologists, and internists, who are called upon to examine and treat these patients.

Once again, this is an absolutely fascinating review. I learned a great deal. Most important, perhaps, are how much we don't know (which could be considered the first step toward wisdom) and what is yet to be discovered in the treatment of central retinal artery occlusion. I sincerely encourage you to read this captivating article.

There you have it.

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