Central Retinal Artery Occlusion (CRAO), Hyperbaric Oxygen Therapy (HBOT) for CRAO, Thrombolysis for CRAO

This month JC will be reviewing the assessment and management of central retinal artery occlusion (CRAO). CRAO is a devastating disease that generally has a poor outcome with only 17% of patients having any significant restoration of visual acuity. Non-ischemic causes of CRAO represent only 5% of cases of CRAO and most etiologies are stroke-like in origin. Interestingly, the loss of vision associated with CRAO leads to long term disability and is associated with an increased likelihood of falls and functional dependence in patients with CRAO. Also of note, a survey of adults with normal vision evaluating patients’ preference for the treatment of CRAO showed that 39% of surveyed adults would accept some risk of stroke and 37% would accept some risk even of death to triple the chances of recovering 20/100 visual acuity. A recent AHA 2021 Position Statement on CRAO  states “Intravenous tissue plasminogen activator (TPA) is an evidence-based therapy for acute ischemic stroke. In patients presenting within 4.5 hours with no evidence of intracranial or systemic hemorrhage, it improves long-term functional outcomes”. TPA is currently administered in only 5.8% of patients admitted with CRAO in the USA. Unfortunately, robust evidence-based data regarding effective management of CRAO is lacking and consequently, there is no strong consensus on best practices for management. We will look some data regarding the management of CRAO utilizing adjunctive hyperbaric medicine as well as a meta-analysis regarding the use of thrombolytics in CRAO. Is it time to consider treating these patients with the same urgency as our “stroke-alert” patients? Should make for some interesting discussion. Hope to see you there! Charlie

Rozenberg A, et al., Hyperbaric oxygen treatment for non-arteritic central retinal artery occlusion retrospective comparative analysis from two tertiary medical centres. Eye (Lond). 2022 Jun;36(6):1261-1265. Appraisal

Wu X, et al., Oxygen therapy in patients with retinal artery occlusion: A meta-analysis. PLoS One. 2018 Aug 29;13(8) Appraisal

 Huang L, et al, Efficacy and safety of intra-arterial thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2023 Jan;261(1):103-113. Appraisal

Mac Grory B, et al., American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; and Council on Peripheral Vascular Disease. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke. 2021 Jun;52(6):e282-e294