Retinal Artery Occlusion (RAO) Treatment & Management

Updated: Jun 06, 2019
  • Author: Benjamin Feldman, MD; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Treatment

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

There are 2 phases of care for patients with RAO. The first phase occurs in the ED and 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 with varying success. Nonetheless, recent data suggest that these therapies may not be beneficial. [3, 4] In fact, Schrag et al (2015) suggest that classic treatments such as ocular massage and paracentesis may be harmful. [4]

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.

Hyperbaric oxygen (HBO) therapy may be beneficial if initiated within 2-12 hours of symptom onset. 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.

Thrombolytics may be useful, but they may not be much help if the embolus is cholesterol, talc, or calcific. While some evidence suggests intra-arterial thrombolytics may be helpful, a 2015 meta-analysis suggests that systemic thrombolytics may be beneficial if given within 4.5 hours of onset. [4] Research is evaluating the role of thrombolytics in RAO.

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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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Prevention

Patients should keep their blood pressure under control, lower their cholesterol, avoid IV drugs, and take their medication.

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Long-Term Monitoring

Patients should have serial evaluation of visual acuity by an ophthalmologist.

An ophthalmologist should perform evaluation for subsequent neovascularization of the iris or retina.

If HBO is to be used, several treatments may be necessary.

Patients require urgent follow up for carotid and cardiac evaluation to preclude further central retinal artery occlusion (CRAO) or stroke.

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Further Inpatient Care

Further inpatient care is indicated only if comorbid disease is present.

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Transfer

Transfer to a hyperbaric facility is necessary if hyperbaric oxygen is to be administered.

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