Treatment options for central retinal artery occlusion

Sudha Cugati, Daniel D Varma, Celia S Chen, Andrew W Lee, Sudha Cugati, Daniel D Varma, Celia S Chen, Andrew W Lee

Abstract

Central retinal artery occlusion (CRAO) is an ocular emergency and is the ocular analogue of cerebral stroke. It results in profound, usually monocular vision loss, and is associated with significant functional morbidity. The risk factors for CRAO are the same atherosclerotic risk factors as for stroke and heart disease. As such, individuals with CRAO may be at risk of ischemic end organ damage such as a cerebral stroke. Therefore, the management of CRAO is not only to restore vision, but at the same time to manage risk factors that may lead to other vascular conditions. There are a number of therapies that has been used in the treatment of CRAO in the past. These include carbogen inhalation, acetazolamide infusion, ocular massage and paracentesis, as well as various vasodilators such as intravenous glyceryl trinitrate. None of these "standard agents" have been shown to alter the natural history of disease definitively. There has been recent interest shown in the use of thrombolytic therapy, delivered either intravenously or intra-arterially by direct catheterisation of the ophthalmic artery. Whilst a number of observational series have shown that the recovery of vision can be quite dramatic, two recent randomised controlled trials have not demonstrated efficacy. On the contrary, intra-arterial delivery of thrombolytic may result in an increased risk of intracranial and systemic haemorrhage, while the intravenous use of tissue plasminogen activator (tPA) was not shown to be efficacious within 24 h of symptom onset. Nevertheless, both of these studies have shown one thing in common, and that is for treatment to be effective in CRAO, it must be deployed within a short time window, probably within 6 h of symptom onset. Therefore, while CRAO is a disease that does not have a treatment, nevertheless it needs to follow the same principles of treatment as any other vascular end organ ischaemic disease. That is, to attempt to reperfuse ischemic tissue as quickly as possible and to institute secondary prevention early.

Figures

Figure 1
Figure 1
Colour fundus photograph showing non-arteritic permanent central retinal artery occlusion in the right eye and a normal fundus in the left eye.
Figure 2
Figure 2
Colour fundus photograph and fundus fluorescein angiogram of the right eye showing non-arteritic CRAO with cilioretinal sparing.
Figure 3
Figure 3
Colour fundus photograph of the left eye showing arteritic central retinal artery occlusion; serial fundus fluorescein angiogram showing delayed arterial filling and choroidal ischaemia.
Figure 4
Figure 4
Colour fundus photograph and fundus fluorescein angiogram of the left eye showing neovascularisation of the disc where the new vessel result in leakage and bright hyper-fluorescence at the disc.

References

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

    1. Graefes AV. Ueber Embolie der Arteria centralis retinae als Ursache plotzlicher Erblindung. Arch Ophthalmol;5:136–157
    1. Leavitt JA, Larson TA, Hodge DO, Gullerud RE. The incidence of central retinal artery occlusion in Olmsted County, Minnesota. Am J Ophthalmol. 2011;152:820–823. doi: 10.1016/j.ajo.2011.05.005.
    1. Rumelt S, Brown GC. Update on treatment of retinal arterial occlusions. Curr Opin Ophthalmol. 2003;14:139–141. doi: 10.1097/00055735-200306000-00005.
    1. Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol. 2005;140:376–391. doi: 10.1016/j.ajo.2005.03.038.
    1. Lorentzen S. Incidence of cilioretinal arteries. Acta Ophthalmol. 1970;48:518–524.
    1. Hayreh S. Acute retinal arterial occlusive disorders. Progr Retin Eye Res. 2011;30:359–394. doi: 10.1016/j.preteyeres.2011.05.001.
    1. Hayreh S. A Study of the Central Artery of the Retina in Human Beings in its Intra-orbital and Intra-neural Course: Thesis for Master of Surgery, Panjab University, India, 1958. Back to cited text, 1958.
    1. Mangat HS. Retinal artery occlusion. Surv Ophthalmol. 1995;40:145–156. doi: 10.1016/S0039-6257(95)80004-2.
    1. Hayreh SS. Prevalent misconceptions about acute retinal vascular occlusive disorders. Progr Retin Eye Res. 2005;24:493–519. doi: 10.1016/j.preteyeres.2004.12.001.
    1. Hayreh S, Kolder H, Weingeist T. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. 1980;87:75.
    1. Chen CS, Lee AW. Management of acute central retinal artery occlusion. Nat Clin Pract Neurol. 2008;4:376–383. doi: 10.1038/ncpneuro0811.
    1. Rudkin A, Lee A, Chen C. Vascular risk factors for central retinal artery occlusion. Eye. 2009;24:678–681. doi: 10.1038/eye.2009.142.
    1. Schmidt DP, Schulte-Mönting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment. Am J Neuroradiol. 2002;23:1301–1307.
    1. Kline L. The natural history of patients with amaurosis fugax. Ophthalmol Clinics of N Am. 1996;9:351–358.
    1. Savino PJ, Glaser JS, Cassady J. Retinal stroke: is the patient at risk? Arch Ophthalmol. 1977;95:1185. doi: 10.1001/archopht.1977.04450070083005.
    1. Augsburger J, Magargal L. Visual prognosis following treatment of acute central retinal artery obstruction. Br J Ophthalmol. 1980;64:913–917. doi: 10.1136/bjo.64.12.913.
    1. Pfaffenbach D, Hollenhorst R. Morbidity and survivorship of patients with embolic cholesterol crystals in the ocular fundus. Trans Am Ophthalmol Soc. 1972;70:337.
    1. Ffytche T. A rationalization of treatment of central retinal artery occlusion. Trans Ophthalmol Soc U K. 1974;94:468–479.
    1. Wang FM, Henkind P. Visual system involvement in giant cell (temporal) arteritis. Surv Ophthalmol. 1979;23:264–271. doi: 10.1016/0039-6257(79)90051-1.
    1. McBrien D, Bradley R, Ashton N. The nature of retinal emboli in stenosis of the internal carotid artery. Lancet. 1963;281:697–699. doi: 10.1016/S0140-6736(63)91450-8.
    1. Cogan DG, Kuwabara T, Moser H. Fat emboli in the retina following angiography. Arch Ophthalmol. 1964;71:308–313. doi: 10.1001/archopht.1964.00970010324005.
    1. David NJ, Lintworth GK, Friedberg SJ, Dillon M. Fetal atheromatous cerebral embolism associated with bright plaques in the retinal arterioles. Report of a case. Neurology. 1963;13:708–713. doi: 10.1212/WNL.13.8.708.
    1. Greven CM, Slusher MM, Weaver RG. Retinal arterial occlusions in young adults. Am J Ophthalmol. 1995;120:776–783.
    1. Schmidt D, Hetzel A, Geibel-Zehender A, Schulte-Monting J. Systemic diseases in non-inflammatory branch and central retinal artery occlusion-an overview of 416 patients. Eur J Med Res. 2007;12:595–603.
    1. Hayreh SS, Piegors DJ, Heistad DD. Serotonin-induced constriction of ocular arteries in atherosclerotic monkeys: implications for ischemic disorders of the retina and optic nerve head. Arch Ophthalmol. 1997;115:220–228. doi: 10.1001/archopht.1997.01100150222012.
    1. Hjermann I, Velve BK, Holme I, Leren P. Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo Study Group of a randomised trial in healthy men. Lancet. 1981;2:1303–1310. doi: 10.1016/S0140-6736(81)91338-6.
    1. Pearson TA, Blair SN, Daniels SR, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation. 2002;106:388–391. doi: 10.1161/01.CIR.0000020190.45892.75.
    1. Sottilotta G, Oriana V, Latella C, et al. Role of hyperhomocystinemia in retinal vascular occlusive disease. Clin Appl Thromb Hemost. 2007;13:104–107. doi: 10.1177/1076029606296423.
    1. Hayreh SS, Zimmerman MB, Kimura A, Sanon A. Central retinal artery occlusion: retinal survival time. Exp Eye Res. 2004;78:723–736. doi: 10.1016/S0014-4835(03)00214-8.
    1. Chen CS, Lee AW, Campbell B, et al. Efficacy of intravenous tissue-type plasminogen activator in central retinal artery occlusion. Stroke. 2011;42:2229–2234. doi: 10.1161/STROKEAHA.111.613653.
    1. 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;146:700–706. doi: 10.1016/j.ajo.2008.06.016.
    1. Beatty S, Eong KGA. Local intra-arterial fibrinolysis for acute occlusion of the central retinal artery: a meta-analysis of the published data. Br J Ophthalmol. 2000;84:914–916. doi: 10.1136/bjo.84.8.914.
    1. Landa E, Rehany U, Rumelt S. Visual functions following recovery from non-arteritic central retinal artery occlusion. Ophthalmic Surg Laser Imag. 2004;35:103.
    1. Mueller AJ, Neubauer AS, Schaller U, Kampik A. Evaluation of minimally invasive therapies and rationale for a prospective randomized trial to evaluate selective intra-arterial lysis for clinically complete central retinal artery occlusion. Arch Ophthalmol. 2003;121:1377–1381. doi: 10.1001/archopht.121.10.1377.
    1. Incandela L, Cesarone M, Belcaro G, et al. Treatment of vascular retinal disease with pentoxifylline: a controlled, randomized trial. Angiology. 2002;53:31–34.
    1. Fraser SG, Adams W. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane Database Syst Rev 2009;1.
    1. Arend O, Harris A, Martin BJ, Holin M, Wolf S. Retinal blood velocities during carbogen breathing using scanning laser ophthalmoscopy. Acta Ophthalmol. 1994;72:332–336.
    1. Harino S, Grunwald JE, Petrig BJ, Riva CE. Rebreathing into a bag increases human retinal macular blood velocity. Br J Ophthalmol. 1995;79:380–383. doi: 10.1136/bjo.79.4.380.
    1. Deutsch TA, Read JS, Ernest JT, Goldstick TK. Effects of oxygen and carbon dioxide on the retinal vasculature in humans. Arch Ophthalmol. 1983;101:1278–1280. doi: 10.1001/archopht.1983.01040020280023.
    1. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating acute nonarteritic central retinal artery occlusion. Ophthalmology. 1995;102:2029–2034.
    1. Aisenbrey S, Krott R, Heller R, Krauss D, Rössler G, Heimann K. Hyperbaric oxygen therapy in retinal artery occlusion. Ophthalmologe: Zeitschrift der Deutschen Ophthalmologischen Gesellschaft. 2000;97:461–467. doi: 10.1007/s003470070075.
    1. Menzel-Severing J, Siekmann U, Weinberger A, Roessler G, Walter P, Mazinani B. Early hyperbaric oxygen treatment for nonarteritic central retinal artery obstruction. Am J Ophthalmol. 2012;153:454–459. doi: 10.1016/j.ajo.2011.08.009.
    1. Cope A, Eggert J, O'Brien E. Retinal artery occlusion: visual outcome after treatment with hyperbaric oxygen. Diving Hyperb Med. 2011;41:135–138.
    1. Hertzog L, Meyer G, Carson S, Strauss M, Hart G. C treated with hyperbaric oxygen. Undersea Hyperb Med. 1992.
    1. Weiss JN. Hyperbaric oxygen treatment of nonacute central retinal artery occlusion. Undersea Hyperb Med. 2010;37:167–172.
    1. Anderson B, Jr, Saltzman HA, Heyman A. The effects of hyperbaric oxygenation on retinal arterial occlusion. Arch Ophthalmol. 1965;73:315–319. doi: 10.1001/archopht.1965.00970030317004.
    1. Butler Jr F, Hagan C, Murphy-Lavoie H. Hyperbaric oxygen therapy and the eye. Undersea Hyperb Med. 2008:333–387
    1. Rumelt S, Dorenboim Y, Rehany U. Aggressive systematic treatment for central retinal artery occlusion. Am J Ophthalmol. 1999;128:733–738. doi: 10.1016/S0002-9394(99)00359-1.
    1. Beatty S, Eong KGA. Acute occlusion of the retinal arteries: current concepts and recent advances in diagnosis and management. Emerg Med J. 2000;17:324–329. doi: 10.1136/emj.17.5.324.
    1. Hausmann N. High dose steroid bolus given for occlusion of central retinal artery: author’s reply. Br Med J. 1992;304:506–507. doi: 10.1136/bmj.304.6825.506-b.
    1. Pandit JC, Tiamiyu F. High dose steroid bolus given for occlusion of central retinal artery. BMJ: Br Med J. 1992;304:506–507. doi: 10.1136/bmj.304.6825.506-a.
    1. Biousse V, Calvetti O, Bruce BB, Newman NJ. Thrombolysis for central retinal artery occlusion. J Neuro Ophthalmol. 2007;27:215–230. doi: 10.1097/WNO.0b013e31814b1f66.
    1. Noble J, Weizblit N, Baerlocher M, Eng K. Intra-arterial thrombolysis for central retinal artery occlusion: a systematic review. Br J Ophthalmol. 2008;92:588–593. doi: 10.1136/bjo.2007.133488.
    1. Aldrich EM, Lee AW, Chen CS, et al. Local Intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion. Stroke. 2008;39:1746–1750. doi: 10.1161/STROKEAHA.107.505404.
    1. Zhang X, Ji X, Luo Y, et al. Intra-arterial thrombolysis for acute central retinal artery occlusion. Neurol Res. 2009;31:385–389. doi: 10.1179/174313209X444008.
    1. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 2010;117:1367–1375. e1361.This randomised multicentre study compares the treatment outcomes of conventional treatment versus intra-arterial tPA in patients with CRAO.
    1. Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006;37:922–928. doi: 10.1161/01.STR.0000202582.29510.6b.
    1. Arnold M, Koerner U, Remonda L, et al. Comparison of intra-arterial thrombolysis with conventional treatment in patients with acute central retinal artery occlusion. J Neurol Neurosurg Psychiatr. 2005;76:196–199. doi: 10.1136/jnnp.2004.037135.
    1. Biousse V. Thrombolysis for acute central retinal artery occlusion: is it time? Am J Ophthalmol. 2008;146:631. doi: 10.1016/j.ajo.2008.07.025.
    1. Feltgen N, Neubauer A, Jurklies B, et al. Multicenter study of the European Assessment Group for Lysis in the Eye (EAGLE) for the treatment of central retinal artery occlusion: design issues and implications. EAGLE Study report no. 1. Graefes Arch Clin Exp Ophthalmol. 2006;244:950–956. doi: 10.1007/s00417-005-0140-2.
    1. Genentech. (2011). Activase, Alteplase, a recombinant tissue plasminogen activator. Available: Last accessed 16/8/12.
    1. Derex L, Nighoghossian N. Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update. J Neurol Neurosurg Psychiatr. 2008;79:1093. doi: 10.1136/jnnp.2007.133371.
    1. PDR Staff . 2004 Red Book Pharmacy's Fundamental Reference. 2004. Montvale: Thomson Healthcare; 2004. p. p183.
    1. Fagan S, Morgenstern L, Petitta A, et al. Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. Neurology. 1998;50:883–890. doi: 10.1212/WNL.50.4.883.
    1. Demaerschalk BM, Hwang HM, Leung G. Cost analysis review of stroke centers, telestroke, and rt-PA. Am J Manag Care. 2010;16:537.
    1. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333:1581–1587.
    1. Demaerschalk BM, Yip TR. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke. 2005;36:2500–2503. doi: 10.1161/01.STR.0000185699.37843.14.
    1. Reynard M, Hanscom TA. Neodymium: yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol. 2004;137:196–198. doi: 10.1016/S0002-9394(03)00817-1.
    1. Haritoglou C, Wolf A, Ulbig MW. Laser embolectomy for central retinal artery occlusion. Ophthalmologe. 2010;107:465–467. doi: 10.1007/s00347-009-2078-y.
    1. Tang WM, Topping TM. Vitreous surgery for central retinal artery occlusion. Arch Ophthalmol. 2000;118:1586–1587. doi: 10.1001/archopht.118.1.138.
    1. Peyman GA, Gremillion CM. Surgical removal of a branch retinal artery embolus: a case report. Int Ophthalmol. 1990;14:295–298. doi: 10.1007/BF00159866.
    1. Garcia-Arumi J, Martinez-Castillo V, Boixadera A, Fonollosa A, Corcostegui B. Surgical embolus removal in retinal artery occlusion. Br J Ophthalmol. 2006;90:1252–1255. doi: 10.1136/bjo.2006.097642.
    1. Rudkin AK, Lee AW, Chen CS. Ocular neovascularization following central retinal artery occlusion: prevalence and timing of onset. Eur J Ophthalmol. 2010;20:1042–1046.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する