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Retinal Artery Occlusion Treatment & Management

  • Author: Benjamin Feldman, MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: Dec 14, 2015
 

Prehospital Care

No specific prehospital treatment is available for retinal artery occlusion. The prognosis for visual recovery is related directly to the promptness in treatment; thus, rapid transport to the ED is essential.

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Emergency Department Care

The 2 phases of ED care must occur. The first phase involves rapid detection and treatment of visual loss. The second phase involves a thorough investigation for the cause of visual loss.

No randomized controlled trials to support one treatment modality over any others are underway, but anecdotal reports and case series have suggested many modalities of treatment.

Immediate lowering of IOP to a target pressure of 15 mm Hg using medical management, ocular massage, and anterior chamber paracentesis

Ocular massage

Apply direct pressure for 5-15 seconds, then release. Repeat several times.

Increased IOP causes a reflexive dilation of retinal arterioles by 16%.

A sudden drop in IOP with release increases the volume of flow by 86%.

Ocular massage dislodges the embolus to a point further down the arterial circulation and improves retinal perfusion.

Anterior chamber paracentesis

Advocated when visual loss has been present for less than 24 hours

Early paracentesis is associated with increased visual recovery.

Slit-lamp removal of 0.1-0.4 mL of aqueous humor via tuberculin syringe and a 27-gauge needle may decrease IOP to 3 mm Hg.

Decrease in IOP is thought to allow greater perfusion, pushing emboli further down the vascular tree.

Other treatments

See Medication for details and mechanisms of action for medications.

Start timolol early in the treatment of CRAO, as this is readily available in most emergency departments. Acetazolamide and mannitol should also be used when CRAO is suspected because there are few downsides to starting these medications early.

In carbogen therapy (5% carbon dioxide, 95% oxygen), carbon dioxide dilates retinal arterioles, and oxygen increases oxygen delivery to ischemic tissues.

Thrombolytics may be useful if initiated within 4-6 hours of visual loss, but they may not be much help if the embolus is cholesterol, talc, or calcific. Thrombolytics are introduced via the proximal ophthalmic artery, delivering increased concentrations directly to the retinal artery and minimizing systemic complications.[3] Results of noncontrolled retrospective studies have been mixed. As of 2007, a European controlled study is underway.[4]

Hyperbaric oxygen (HBO) therapy may be beneficial if initiated within 2-12 hours of onset of symptoms. Institute treatment with other interventions first; transport to a chamber may usurp precious time. Results from noncontrolled studies have been mixed. A 2001 controlled study in Israel showed a benefit in the treatment group.[5] In this study, all patients were treated within 8 hours of symptom onset.

Treatment with IV thrombolytics as with cerebral infarction has been discussed[6, 7, 8] but currently is not the standard of care.

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Consultations

Ophthalmologist

Immediate evaluation is imperative for any patient with acute CRAO.

Ophthalmologists can decide with which further treatment (eg, thrombolytics, hyperbaric oxygen, retrobulbar block) to proceed.

Early treatment (< 2 h from onset of symptoms) with HBO may be associated with increased visual recovery, but HBO can be considered if the duration of visual loss is less than 12 hours. Inhalation of 100% oxygen at 2 atm can provide an arterial pO2 of 1000-1200 mm Hg, resulting in a 3-fold increase in oxygen diffusion distance through ischemic retinal tissues. Some studies show a 40% improvement of 2 or more levels of visual acuity.

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Contributor Information and Disclosures
Author

Benjamin Feldman, MD Resident Physician, Department of Emergency Medicine, University of California, Irvine, School of Medicine

Benjamin Feldman, MD is a member of the following medical societies: American Academy of Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Pascal SC Juang, MD Medical Director, ED Information Systems, Department of Emergency Medicine, Hoag Memorial Hospital Presbyterian

Pascal SC Juang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Assaad J Sayah, MD, FACEP Chief, Department of Emergency Medicine; Senior Vice President, Primary and Emergency Care, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Neil Jain, MD Staff Physician, Yale University School of Medicine, Department of Surgery, Section of Emergency Medicine

Neil Jain, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Kilbourn Gordon III, MD, and Enoch Huang, MD, to the development and writing of this article.

References
  1. Youm DJ, Ha MM, Chang Y, Song SJ. Retinal vessel caliber and risk factors for branch retinal vein occlusion. Curr Eye Res. 2012 Apr. 37(4):334-8. [Medline].

  2. Klein R, Klein BE, Moss SE, Meuer SM. Retinal emboli and cardiovascular disease: the Beaver Dam Eye Study. Arch Ophthalmol. 2003 Oct. 121(10):1446-51. [Medline].

  3. Ratra D, Dhupper M. Retinal arterial occlusions in the young: Systemic associations in Indian population. Indian J Ophthalmol. 2012 Mar. 60(2):95-100. [Medline].

  4. Biousse V, Calvetti O, Bruce BB, Newman NJ. Thrombolysis for central retinal artery occlusion. J Neuroophthalmol. 2007 Sep. 27(3):215-30. [Medline].

  5. Beiran I, Goldenberg I, Adir Y, Tamir A, Shupak A, Miller B. Early hyperbaric oxygen therapy for retinal artery occlusion. Eur J Ophthalmol. 2001 Oct-Dec. 11(4):345-50. [Medline].

  6. 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].

  7. Nowak RJ, Amin H, Robeson K, Schindler JL. Acute Central Retinal Artery Occlusion Treated with Intravenous Recombinant Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis. 2012 Feb 18. [Medline].

  8. Cohen JE, Moscovici S, Halpert M, Itshayek E. Selective thrombolysis performed through meningo-ophthalmic artery in central retinal artery occlusion. J Clin Neurosci. 2012 Mar. 19(3):462-4. [Medline].

  9. 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].

  10. Augsburger JJ, Magargal LE. Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol. 1980 Dec. 64(12):913-7. [Medline].

  11. Beiran I, Reissman P, Scharf J, et al. Hyperbaric oxygenation combined with nifedipine treatment for recent-onset retinal artery occlusion. Eur J Ophthalmol. 1993 Apr-Jun. 3(2):89-94. [Medline].

  12. Brown GC. Retinal artery obstructive disease. Ryan SJ, ed. Retina. St. Louis: Mosby; 1994. Vol 2: 1361-77.

  13. Brown GC, Magargal LE, Shields JA, et al. Retinal arterial obstruction in children and young adults. Ophthalmology. 1981 Jan. 88(1):18-25. [Medline].

  14. Butz B, Strotzer M, Manke C, et al. Selective intraarterial fibrinolysis of acute central retinal artery occlusion. Acta Radiol. 2003 Nov. 44(6):680-4. [Medline].

  15. Cella W, Avila M. Optical coherence tomography as a means of evaluating acute ischaemic retinopathy in branch retinal artery occlusion. Acta Ophthalmol Scand. 2007 Nov. 85(7):799-801. [Medline].

  16. Ffytche TJ, Bulpitt CJ, Kohner EM, et al. Effect of changes in intraocular pressure on the retinal microcirculation. Br J Ophthalmol. 1974 May. 58(5):514-22. [Medline].

  17. Fraser S, Siriwardena D. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane Database Syst Rev. 2002. CD001989. [Medline].

  18. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. 1980 Jan. 87(1):75-8. [Medline].

  19. Hertzog LM, Meyer GW, Carson S, et al. Central retinal artery occlusion treated with hyperbaric oxygen. J Hyperbaric Med. 1992. 7:33-42.

  20. 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].

  21. Lacy C, Armstrong LL, Ingram N, et al. Drug Information Handbook. 4th ed. Hudson, Cleveland: Lexi-Comp Inc; 1996.

  22. Magargal LE, Goldberg RE. Anterior chamber paracentesis in the management of acute nonarteritic central retinal artery occlusion. Surg Forum. 1977. 28:518-21. [Medline].

  23. Mangat HS. Retinal artery occlusion. Surv Ophthalmol. 1995 Sep-Oct. 40(2):145-56. [Medline].

  24. Mead GE, Lewis SC, Wardlaw JM, Dennis MS. Comparison of risk factors in patients with transient and prolonged eye and brain ischemic syndromes. Stroke. 2002 Oct. 33(10):2383-90. [Medline].

  25. Miyake Y, Horiguchi M, Matsuura M, et al. Hyperbaric oxygen therapy in 72 eyes with retinal arterial occlusion. 9th International Symposium on Underwater and Hyperbaric Physiology. 1987. 949-53.

  26. Rumelt S, Brown GC. Update on treatment of retinal arterial occlusions. Curr Opin Ophthalmol. 2003 Jun. 14(3):139-41. [Medline].

  27. 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].

  28. Schmidt DP, Schulte-Monting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment. AJNR Am J Neuroradiol. 2002 Sep. 23(8):1301-7. [Medline].

  29. Suri MF, Nasar A, Hussein HM, Divani AA, Qureshi AI. Intra-arterial thrombolysis for central retinal artery occlusion in United States: Nationwide In-patient Survey 2001-2003. J Neuroimaging. 2007 Oct. 17(4):339-43. [Medline].

  30. Wray SH. The management of acute visual failure. J Neurol Neurosurg Psychiatry. 1993 Mar. 56(3):234-40. [Medline].

 
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The cherry red spot of central retinal artery occlusion.
 
 
 
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