Central Retinal Artery Occlusion Medication
- Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD more...
Medical therapy is directed toward lowering IOP, increasing retinal perfusion, and increasing oxygen delivery to hypoxic tissues. The first goal is accomplished by using the same drugs as those used in glaucoma. Retinal perfusion may be increased by vasodilatory drugs although this is unproven, increasing arterial pCO2, or by giving intravascular thrombolytics to remove the offending embolus. Some also advocate aspirin use in the acute phase. Oxygen delivery is improved by breathing higher concentrations of oxygen or with hyperbaric oxygen.
Carbonic anhydrase inhibitors
Carbonic anhydrase is an enzyme found in many tissues of the body, including the eye. The reversible reaction it catalyzes involves the hydration of carbon dioxide and the dehydration of carbonic acid.
Reduces rate of aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP. Used most frequently as single diuretic agent in acute management of CRAO. Other diuretics may be added if sufficient decrease in IOP is not attained.
Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Lower IOP by creating an osmotic gradient between the ocular fluids and plasma (not for long-term use). Hemoconcentration is potentially an issue with this form of therapy.
Reduces elevated IOP when the pressure cannot be lowered by other means. Initially assess for adequate renal function in adults by administering a test dose of 200 mg/kg, given IV over 3-5 min. It should produce a urine flow of at least 30-50 mL/h of urine over 2-3 h. In children, assess for adequate renal function by administering a test dose of 200 mg/kg, given IV over 3-5 min. It should produce a urine flow of at least 1 mL/h over 1-3 h.
Used in glaucoma to interrupt acute attacks. Oral osmotic agent for reducing IOP. Able to increase tonicity of blood until finally metabolized and eliminated by the kidneys. Maximum reduction of IOP usually occurs 1 h after glycerin administration. Effect usually lasts approximately 5 h.
Lower IOP mainly by increasing outflow and reducing the production of aqueous humor. The combination of a miotic and a sympathomimetic has additive effects in lowering IOP. Each may be added in rotation after a 5-minute interval, until target IOP is reached.
Reduces elevated, as well as normal, IOP whether or not accompanied by glaucoma. Apraclonidine is a relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.
Dipivefrin (AKPro, Propine)
Converted to epinephrine in eye by enzymatic hydrolysis. Appears to act by decreasing aqueous production and enhancing outflow facility. Has same therapeutic effect as epinephrine with fewer local and systemic side effects. May be used as an initial therapy or as an adjunct with other antiglaucoma agents for the control of IOP.
Beta-adrenergic blocking agents
Lower IOP by decreasing the rate of aqueous humor production and possibly outflow. They may be more effective than either pilocarpine or epinephrine alone and have the advantage of not affecting pupil size or accommodation.
May reduce elevated and normal IOP, with or without glaucoma by reducing the production of aqueous humor or by outflow.
Used in arterial occlusion only when temporal arteritis (GCA) is the suspected or confirmed etiology.
Useful in the treatment of inflammatory and allergic reactions. May decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear lymphocyte activity.
Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. 1980 Jan. 87(1):75-8. [Medline].
Chang YS, Chu CC, Weng SF, Chang C, Wang JJ, Jan RL. The risk of acute coronary syndrome after retinal artery occlusion: a population-based cohort study. Br J Ophthalmol. 2014 Aug 21. [Medline].
Chen Y, Wang W, Li J, Yu Y, Li L, Lu N. Fundus artery occlusion caused by cosmetic facial injections. Chin Med J (Engl). 2014. 127(8):1434-7. [Medline].
Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol. 2014 May. 132(5):637-9. [Medline].
Schumacher M, Schmidt D, Jurklies B, Gall C, Wanke I, Schmoor C, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology. 2010 Jul. 117(7):1367-75.e1. [Medline].
Ahn SJ, Kim JM, Hong JH, Woo SJ, Ahn J, Park KH, et al. Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion. Invest Ophthalmol Vis Sci. 2013 Nov 21. 54(12):7746-55. [Medline].
Fieß A, Cal Ö, Kehrein S, Halstenberg S, Frisch I, Steinhorst UH. Anterior chamber paracentesis after central retinal artery occlusion: a tenable therapy?. BMC Ophthalmol. 2014 Mar 10. 14:28. [Medline]. [Full Text].
Rudkin AK, Lee AW, Aldrich E, Miller NR, Chen CS. Clinical characteristics and outcome of current standard management of central retinal artery occlusion. Clin Experiment Ophthalmol. 2010 Jul. 38(5):496-501. [Medline].
Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke. 2008 Jun. 39(6):1746-50. [Medline].
Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating acute nonarteritic central retinal artery occlusion. Ophthalmology. 1995 Dec. 102(12):2029-34; discussion 2034-5. [Medline].
Augsburger JJ, Magargal LE. Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol. 1980 Dec. 64(12):913-7. [Medline].
Beiran I, Reissman P, Scharf J, Nahum Z, Miller B. Hyperbaric oxygenation combined with nifedipine treatment for recent-onset retinal artery occlusion. Eur J Ophthalmol. 1993 Apr-Jun. 3(2):89-94. [Medline].
Biousse V, Calvetti O, Bruce BB, Newman NJ. Thrombolysis for central retinal artery occlusion. J Neuroophthalmol. 2007 Sep. 27(3):215-30. [Medline].
Brown G. Retinal arterial occlusive disease. Guyer DR, ed. Retina-Vitreous-Macula. WB Saunders; 1999. Vol. 1: 271-85.
Brown GC. Retinal artery obstructive disease. Ryan SJ, ed. Retina. Mosby-Year Book; 1994. Vol 2: 1361-77.
Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young adults. Ophthalmology. 1981 Jan. 88(1):18-25. [Medline].
Carrero JL, Sanjurjo FJ. Bilateral cilioretinal artery occlusion in antiphospholipid syndrome. Retina. 2006 Jan. 26(1):104-6. [Medline].
Chen CS, Lee AW. Management of acute central retinal artery occlusion. Nat Clin Pract Neurol. 2008 Jul. 4(7):376-83. [Medline].
Feist RM, Emond TL. Translumenal Nd:YAG laser embolysis for central retinal artery occlusion. Retina. 2005 Sep. 25(6):797-9. [Medline].
Ffytche TJ, Bulpitt CJ, Kohner EM, Archer D, Dollery CT. Effect of changes in intraocular pressure on the retinal microcirculation. Br J Ophthalmol. 1974 May. 58(5):514-22. [Medline].
Hattenbach LO, Kuhli-Hattenbach C, Scharrer I, Baatz H. Intravenous thrombolysis with low-dose recombinant tissue plasminogen activator in central retinal artery occlusion. Am J Ophthalmol. 2008 Nov. 146(5):700-6. [Medline].
Hayreh SS. Prevalent misconceptions about acute retinal vascular occlusive disorders. Prog Retin Eye Res. 2005 Jul. 24(4):493-519. [Medline].
Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol. 2005 Sep. 140(3):376-91. [Medline].
Hayreh SS, Zimmerman MB. Fundus changes in central retinal artery occlusion. Retina. 2007 Mar. 27(3):276-89. [Medline].
Hertzog LM, Meyer GW, Carson S. Central retinal artery occlusion treated with hyperbaric oxygen. Journal of Hyperbaric Medicine. 1992. 7:33-42.
Knoop K, Trott A. Ophthalmologic procedures in the emergency department--Part I: Immediate sight-saving procedures. Acad Emerg Med. 1994 Jul-Aug. 1(4):408-12. [Medline].
Lacy C, Armstrong LL, Ingram N. Drug Information Handbook. 4th ed. Cleveland: Lexi-Comp, Inc; 1996.
Magargal LE, Goldberg RE. Anterior chamber paracentesis in the management of acute nonarteritic central retinal artery occlusion. Surg Forum. 1977. 28:518-21. [Medline].
Mangat HS. Retinal artery occlusion. Surv Ophthalmol. 1995 Sep-Oct. 40(2):145-56. [Medline].
Miyake Y, Horiguchi M, Matsuura M. Hyperbaric oxygen therapy in 72 eyes with retinal arterial occlusion. 9th International Symposium on Underwater and Hyperbaric Physiology. Underwater and Hyperbaric Medical Society; 1987. 949-53.
Noble J, Weizblit N, Baerlocher MO, Eng KT. Intra-arterial thrombolysis for central retinal artery occlusion: a systematic review. Br J Ophthalmol. 2008 May. 92(5):588-93. [Medline].
Ozdemir H, Karacorlu S, Karacorlu M. Optical coherence tomography findings in central retinal artery occlusion. Retina. 2006 Jan. 26(1):110-2. [Medline].
Rhee DJ, Pyfer M. Central retinal artery occlusion. Wills Eye Manual: Office & Emergency Room Diagnosis & Treatment of Eye Disease. Lippincott Williams & Wilkins; 2000. 331-5.
Schmidt D, Schumacher M, Wakhloo AK. Microcatheter urokinase infusion in central retinal artery occlusion. Am J Ophthalmol. 1992 Apr 15. 113(4):429-34. [Medline].
Scott I, Flynn H, Rosa R. Other retinal vascular disease. Atlas of Ophthalmology. New York: Springer-Verlag; 2000. 297.
Shinoda K, Yamada K, Matsumoto CS, Kimoto K, Nakatsuka K. Changes in retinal thickness are correlated with alterations of electroretinogram in eyes with central retinal artery occlusion. Graefes Arch Clin Exp Ophthalmol. 2008 Jul. 246(7):949-54. [Medline].
Weber J, Remonda L, Mattle HP, et al. Selective intra-arterial fibrinolysis of acute central retinal artery occlusion. Stroke. 1998 Oct. 29(10):2076-9. [Medline].
Wolintz RJ. Carotid endarterectomy for ophthalmic manifestations: is it ever indicated?. J Neuroophthalmol. 2005 Dec. 25(4):299-302. [Medline].
Wray SH. The management of acute visual failure. J Neurol Neurosurg Psychiatry. 1993 Mar. 56(3):234-40. [Medline].
Yanoff M, Fine B. Ocular Pathology: A Color Atlas. Lippincott-Raven; 1988. 133-5.