Primary Care Management of Multiple Retinal Hemorrhages

Immediate Management

Patients with multiple retinal hemorrhages should be urgently referred to a stroke center or emergency department within 24 hours for comprehensive neurological evaluation, as these findings may represent an ocular stroke equivalent with high risk for concurrent cerebrovascular events, according to the American College of Cardiology 1
The American Heart Association recommends treating retinal hemorrhages as a potential medical emergency requiring prompt referral to an emergency department or stroke center, especially when multiple hemorrhages are present 2, 1
The American Academy of Ophthalmology suggests establishing communication with the ophthalmologist who made the finding to understand the specific type, location, and extent of the hemorrhages 3
Patients over 50 years old with multiple retinal hemorrhages should be evaluated for symptoms of giant cell arteritis (GCA), including headaches, scalp tenderness, jaw claudication, or temporal tenderness, as recommended by the American College of Rheumatology 1, 4

Brain imaging with MRI and diffusion-weighted imaging should be performed urgently, as up to 24% of patients with retinal vascular events have concurrent silent brain infarctions, according to the American Heart Association 3, 1
Vascular imaging to assess carotid artery status is essential, as clinically significant carotid stenosis is discovered in up to 70% of patients with symptomatic retinal vascular events, as recommended by the American College of Cardiology 3, 1
Inflammatory markers (ESR, CRP) and complete blood count with platelets should be ordered, especially if GCA is suspected, according to the American College of Rheumatology 3, 4
Evaluation for cardiovascular risk factors including hypertension, diabetes, and hyperlipidemia is crucial, as recommended by the American Heart Association 3, 1

Retinal hemorrhages may indicate retinal artery occlusion (central or branch), as suggested by the American Academy of Ophthalmology 2, 5
Retinal vein occlusion is another possible cause of retinal hemorrhages, according to the American Academy of Ophthalmology 6
Diabetic retinopathy and hypertensive retinopathy are also potential causes of retinal hemorrhages, as recommended by the American Diabetes Association and the American Heart Association 7, 3

Secondary stroke prevention with antiplatelet therapy should be implemented as recommended by neurology, according to the American Heart Association 1
Control of chronic systemic diseases (diabetes, hypertension, lipid disorders) should be optimized, as recommended by the American Diabetes Association and the American Heart Association 3, 1
Smoking cessation counseling should be provided if applicable, according to the American Heart Association 3
Regular ophthalmologic follow-up is necessary to monitor for neovascular complications, as recommended by the American Academy of Ophthalmology 6, 3

Development of iris or retinal neovascularization should be watched for, which may require panretinal photocoagulation (PRP) with or without anti-VEGF therapy, according to the American Academy of Ophthalmology 6, 3
Signs of neovascular glaucoma should be monitored for, which can result from new vessels growing on the iris and anterior chamber angle structures, as recommended by the American Academy of Ophthalmology 6, 7
Visual changes that could indicate progression or complications should be alerted for, according to the American Academy of Ophthalmology 3

The risk of stroke is highest within the first 7 days after retinal vascular events and remains elevated for 30 days, as suggested by the American Heart Association 3, 4
Retinal vascular events are considered stroke equivalents by the American Heart Association 5
Effective communication with the patient's ophthalmologist about the status of the retinal disease and its relation to systemic disease is essential, according to the American Academy of Ophthalmology 3

Patient should follow up with ophthalmology within 1-2 weeks of initial finding, as recommended by the American Academy of Ophthalmology 3
Primary care follow-up should be scheduled within 1 week to review results of neurological evaluation, according to the American College of Physicians 1
Care should be coordinated between neurology, ophthalmology, and primary care, as recommended by the American Heart Association 3, 1