Treatment of Ocular Stroke

Immediate Management

Patients with suspected ocular stroke should be treated as medical emergencies requiring immediate referral to an emergency department or stroke center within 24 hours of symptom onset, as recommended by the American Academy of Ophthalmology 1, 3
Immediate triage to an emergency department should not be delayed to obtain further outpatient evaluation or institute other treatments, according to the American Heart Association 4
Eye care providers should establish relationships with certified stroke centers to create efficient pathways for rapid evaluation of patients with suspected vascular visual loss, as suggested by the American Academy of Ophthalmology 2, 5

For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be considered, with a standard dose of alteplase 0.9 mg/kg, as recommended by the American Heart Association 4, 6
Hyperbaric oxygen therapy (100% oxygen over 9 hours) has demonstrated efficacy over observation alone in several small randomized trials, according to the American Academy of Ophthalmology 3
For suspected arteritic CRAO (giant cell arteritis), immediate steroid therapy is indicated to preserve vision in the contralateral eye, as recommended by the American College of Rheumatology 4, 6

Immediate ophthalmological examination in parallel with structured neurological assessment is recommended, according to the American Heart Association 4, 6
Brain imaging (CT scan without contrast) should be performed, as suggested by the American College of Radiology 4
Screening for giant cell arteritis (consider ESR, CRP) is recommended, according to the American College of Rheumatology 4
Vascular imaging to assess carotid artery status should be performed, as suggested by the American Heart Association 3
MRI with diffusion-weighted imaging to identify concurrent silent brain infarctions (present in 19-25% of patients) is recommended, according to the American Academy of Neurology 3

Panretinal photocoagulation (PRP) with or without anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended for patients who develop iris or retinal neovascularization, as suggested by the American Academy of Ophthalmology 3
In acute cases, intravitreal anti-VEGF agents may be used (off-label) to supplement or facilitate PRP treatment, according to the American Academy of Ophthalmology 3

Secondary stroke prevention with antiplatelet therapy is recommended, as suggested by the American Heart Association 2, 7
Identification and management of vascular risk factors (hypertension, diabetes, lipid disorders) is recommended, according to the American Heart Association 3
Smoking cessation counseling is recommended, as suggested by the American Cancer Society 3
Regular follow-up to monitor for neovascular complications is recommended, according to the American Academy of Ophthalmology 3

The risk of stroke is highest within the first 7 days after ocular stroke and remains elevated for 30 days, as reported by the American Heart Association 3
Up to 24% of patients with acute retinal artery occlusion have concurrent cerebrovascular accident on diffusion-weighted MRI, according to the American Academy of Neurology 3
A new significant systemic cardiovascular condition (typically clinically significant carotid stenosis) is discovered in up to 70% of patients with symptomatic CRAO, as reported by the American Heart Association 3