It is 4PM on a Friday afternoon. A 67 YO patient walks into your office with loss of vision. Two days earlier they noticed sudden, painless vision loss in their left eye. You find an acute central retinal artery occlusion. You see a small platelet-fibrin embolus just as the artery comes out of the optic nerve. You tell your front desk to refer the patient to your favorite retinal specialist the following week. That Sunday the patient can’t walk or speak and is admitted to the hospital with an acute stroke.
Question: Which of the following is true?
A. The stroke could possibly have been prevented.
B. The patient should have been sent emergently to the nearest stroke center that Friday evening.
C. You violated your professional standard of care.
D. You should sign a blank check and mail it directly to the patient’s malpractice attorney.
Answer: All are true!
If you answered these questions wrong, you are not alone. A recent survey reported that only 18% of retinal specialists compared to 73% of neurologists sent patients with acute CRAO to an emergency department for immediate evaluation.1
Following are key findings in the recent medical literature:
- TIAs are medical emergencies since they are a warning for an impending stroke: 10 to 15% will develop a stroke within 90 days, half of which occur within the first 48 hours.2
- The new tissue-based definition of TIA is “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”3 Acute retinal ischemia includes transient monocular vision loss (TMVL), branch retinal artery occlusion (BRAO) and central retinal artery occlusion (CRAO).
- Emergent diagnosis and treatment for the underlying cause of the TIA dramatically decreases the risk for subsequent stroke by 80%.4 This includes carotid endarterectomy which should be performed within 14 days of the ischemic event.5
- Acute asymptomatic brain infarcts on diffusion-weighted MRI scanning are surprisingly common in patients with acute retinal ischemia, occurring in up to 31% of patients with TMVL, 33% with BRAO, and 76% with CRAO.6,7
It seems that optometrists and ophthalmologists, the very doctors who see patients with TMVL, were the last specialties to become aware of something that cardiologists, neurologists and emergency medicine specialists have known for years. In 2018 the American Academy of Ophthalmology got the word out to its membership with the article, “Management of Acute Retinal Ischemia: Follow the Guidelines!”8 However, many optometrists are still not aware of these recommendations.
Once diagnosed, patients with acute vascular TMVL (classic amauroses fugax, not temporary vision loss from nonvascular causes such as migraines), BRAO or CRAO require immediate referral to a Joint Commission Accredited Stroke Center and a retinal referral within a week or so. The stroke center will perform all relevant testing, including bloodwork for giant cell arteritis, electrocardiography, MRI, carotid non-invasives, and cardiac echography. Emergent medical and surgical treatments are then coordinated by the stroke center.
Patients with non-acute symptoms (greater than several days) or an old retinal arterial occlusion do not need such an urgent workup and should be referred to their primary care doctor for systemic evaluation.
You can find your nearest center by clicking here.
Steven Bloom, MD
Inder Singal, MD
Anupa Mandava, MD
Janelle Adeniran, MD, PhD
Bennett & Bloom Eye Centers
1. Abel AS, Suresh S, Hussein HM, Carpenter AF, Montezuma SR, Lee MS. Practice Patterns After Acute Embolic Retinal Artery Occlusion. Asia Pac J Ophthalmol (Phila) 2017;6:37-9.
2. Okada Y. Transient ischemic attack as a medical emergency. Front Neurol Neurosci 2014;33:19-29.
3. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:227-76.
4. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432-42.
5. Gocan S, Bourgoin A, Blacquiere D, Shamloul R, Dowlatshahi D, Stotts G. Fast-Track Systems Improve Timely Carotid Endarterectomy in Stroke Prevention Outpatients. Can J Neurol Sci 2016;43:648-54.
6. Golsari A, Bittersohl D, Cheng B, et al. Silent Brain Infarctions and Leukoaraiosis in Patients With Retinal Ischemia: A Prospective Single-Center Observational Study. Stroke 2017;48:1392-6.
7. Helenius J, Arsava EM, Goldstein JN, et al. Concurrent acute brain infarcts in patients with monocular visual loss. Ann Neurol 2012;72:286-93.
8. Biousse V, Nahab F, Newman NJ. Management of Acute Retinal Ischemia: Follow the Guidelines! Ophthalmology 2018.
Thanks for this timely article. An RAO is indeed a stroke, with the embolus going to the eye rather than the brain. Stroke center first!