EDITORIAL
Urgent Evaluation of the Patient With Acute Central
Retinal Artery Occlusion
ANTHONY C. ARNOLD
T
HERE IS A FUNDAMENTAL DIFFERENCE IN POINT OF
view between the study by Lavin and associates1
and the commentary by Hayreh,2 but they agree
on one basic principle: patients with central retinal artery
occlusion (CRAO) require immediate evaluation for po-
tential causes of the vascular occlusion, including disease
of the carotid arteries and the heart, hyperlipidemia, hyper-
coagulability, and vasculitis. Hayreh suggests that an
outpatient evaluation performed by the ophthalmologist
is sufficient to identify the conditions that require therapy
to prevent further events and that urgent referral to a stroke
center or emergency department (ED) with neurologic
consultation is unnecessary in the absence of additional
neurologic findings. Lavin and associates indicate that
the risk of simultaneous or subsequent neurologic events,
including stroke, is too high to depend on nonexpert super-
vision of a potentially delayed outpatient evaluation, and
they provide evidence supporting urgent referral to the
ED or stroke team. What should the ophthalmologist faced
with this acute clinical scenario do?
In order to make sense of this question, we need to clarify
several issues. First, in the context of a required systemic
evaluation, is it important to distinguish between amau-
rosis, transient ischemic attack (TIA), and CRAO? For
our purposes, probably not. Despite Hayreh’s statement
that the guidelines put forth by the American Heart Asso-
ciation and others did not refer to CRAO and that TIA
refers to cerebral ischemia, these guidelines do now explic-
itly include retinal ischemia in their definition of TIA; this
is a distinct change from the prior definition, which
referred to cerebral ischemia.3 It would follow that the risks
for subsequent vascular events ascribed to TIA surely would
apply to permanent (CRAO) as well as transient retinal
ischemia. Lavin and associates’ study provides supporting
data for this risk.
Second, how great is the risk to patients with CRAO?
Data from the North American Symptomatic Carotid
See Accompanying Articles on pages 53 and 96.
Accepted for publication Aug 25, 2018.
From the UCLA Department of Ophthalmology, Stein Eye Institute,
Los Angeles, California, USA
Inquiries to Anthony C. Arnold, UCLA Department of
Ophthalmology, Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA
90095 USA; e-mail: arnolda@jsei.ucla.edu
xvi © 2018 ELSEVIER INC. ALL
Endarterectomy Trial suggested that the risk of stroke after
retinal TIA was less than that after cerebral TIA, but still
significant at up to 24.2% at 3 years. The combined
vascular risk was actually equivalent to cerebral TIA.4
Multiple studies of the more severe event of permanent
retinal ischemia (CRAO) confirm the subsequent
increased risk of stroke, myocardial infarction, and death.
This is not controversial, although the actual reported
estimates of combined risk vary significantly, depending
on definition, duration of follow-up, and other factors,
most in the range of 14%–20%,5,6 compared to the 32%
at 2 years documented by Lavin and associates.
Third, does it make a difference how quickly the evalu-
ation is performed? Hayreh confirms that the evaluation of
CRAO finds an increased frequency of carotid and heart
disease, but he suggests that since, in data from his own
studies, the risk of stroke after CRAO and branch retinal
artery occlusion is substantially less than that suggested
elsewhere in the literature, it is unnecessary overkill to refer
all of these patients for urgent formal stroke evaluation;
identifying these factors for subsequent treatment is suffi-
cient. It is possible that his patient population, derived as
it is from an outpatient ophthalmology clinic, may differ
from that seen in other studies, which may be biased toward
a population with more severe risk factors or even simulta-
neous neurologic findings. This certainly may be the case
with Lavin and associates’ study, coming as it does from
the ‘‘stroke belt’’ of the southern United States. But to focus
on the differences in population studied is to miss the point:
urgent evaluation is necessary in these cases to characterize
those differences and identify more severely involved
patients immediately, because they are at a greater risk
for new events within 24-72 hours.3,7
These patients are identified by the presence of docu-
mented simultaneous acute brain ischemia (diffusion-
weighted imaging [DWI] evidence on magnetic resonance
imaging [MRI], whether clinically evident or not), which is
present in a significant percentage of those presenting with
retinal TIA or CRAO (contrary to Hayreh’s assertion that
‘‘patients who have no neurological symptoms are unlikely
to have an abnormal brain MRI’’). Helenius and associates8
reported this finding with CRAO in 24%, and Lavin’s
current study documents 37.3%. Urgent referral either to
an ED capable of rapid MRI DWI imaging or to a stroke
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center is essential to identify these patients at high risk, as a
part of full evaluation and therapy per stroke protocol.
Why? Because there are now treatments in this acute phase
that can reduce the risk of subsequent stroke and cardiac
events, and they must be instituted immediately. Adminis-
tration of antiplatelet therapy and statins, along with
subsequent consideration of anticoagulation and carotid
revascularization, have been studied and found to be of
benefit in both the SOS-TIA and the EXPRESS studies.9,10
Lavin and associates document that the urgent stroke
evaluation resulted in detection of findings requiring
hospitalization in 79% and resulted in change in
management in over 90%.
Hayreh’s approach—which has been a standard for most
ophthalmologists in past years—while covering major risk
FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT FINANCIAL DISCLOSURES: THE AUTHOR HAS NO FINANCIAL DISCLO-
sures. The author attests that he meets the current ICMJE criteria for authorship.
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2. Hayreh SS. Do patients with retinal artery occlusion need ur-
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VOL. 196 EDITORIAL
factors for future vascular events, leaves some gaps unat-
tended: he does not specify how quickly has was able to
obtain results from his ‘‘immediate’’ evaluation, but delay
of several days to obtain carotid and cardiac evaluations
in an outpatient setting would not be unusual and
could very well result in missed opportunities to prevent
additional ischemic events. He does not describe blood
pressure evaluation, which revealed ‘‘hypertensive crisis’’
in 33% in Lavin and associates’ study. Most important,
he argues against the need for acute MRI DWI imaging,
which might identify those patients at risk for a subsequent
vascular event within 24-72 hours. The paradigm for
management of acute retinal ischemia, either transient or
permanent, has changed. Ophthalmologists who manage
these patients must recognize and institute the change.
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ment Group for Lysis in the Eye. Cardiovascular risk factors
in central retinal artery occlusion: results of a prospective
and standardized medical examination. Ophthalmology 2015;
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6. Chang YS, Jan RL, Weng SF, et al. Retinal artery occlusion
and the 3-year risk of stroke in Taiwan: a nationwide
population-based study. Am J Ophthalmol 2012;154(4):
645–652.
7. Johnston SC, Albers GW, Gorelick PB, et al. National Stroke
Association recommendations for systems of care for transient
ischemic attack. Ann Neurol 2011;69(5):872–877.
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brain infarcts in patients with monocular visual loss. Ann
Neurol 2012;72(2):286–293.
9. Lavallee PC, Meseguer E, Abboud H, et al. A transient ischae-
mic attack clinic with round-the-clock access (SOS-TIA):
feasibility and effects. Lancet Neurol 2007;6(11):953–960.
10. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of
urgent treatment of transient ischaemic attack and minor
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