Aggressive systematic treatment for central retinal artery occlusion

doi:10.1016/S0002-9394(99)00359-1

American Journal of Ophthalmology

Volume 128, Issue 6, December 1999, Pages 733-738

Data from this study were presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, Louisiana, November 1998.

https://doi.org/10.1016/S0002-9394(99)00359-1 Get rights and content

Abstract

PURPOSE:

To report the efficacy of an aggressive systematic regimen for the treatment of acute nonarteritic central retinal artery occlusion (CRAO).

METHODS:

Eleven patients who had unilateral CRAO with symptoms of fewer than 48 hours’ duration were treated with an aggressive stepwise systematic regimen until retinal circulation improved or until all the treatment steps were performed. Five patients with unilateral CRAO and symptoms of fewer than 48 hours’ duration were treated in the same institution in an arbitrary nonsystematic manner. The therapeutic steps of the aggressive treatment included ocular massage, sublingual isosorbide dinitrate, intravenous acetazolamide, intravenous mannitol or oral glycerol, anterior chamber paracentesis, intravenous methylprednisolone followed by streptokinase, and retrobulbar tolazoline. After each step, retinal flow was evaluated by three-mirror contact lens. The nonsystematic treatment was arbitrary and included one or several of the above. Visual acuity and complete eye examination data were recorded before and after treatment.

RESULTS:

Visual acuity and retinal arterial supply were improved in eight (73%) of the 11 patients treated in the stepwise systematic manner. All eight patients in whom visual acuity improved had symptoms for fewer than 12 hours, and the presumed cause was either platelet-derived or cholesterol embolus from atheroma or the patients had glaucoma. Patients in whom visual acuity did not improve had CRAO that was attributed to calcified emboli or primary antiphospholipid antibody syndrome and had symptoms more than 12 hours before treatment. Visual acuity did not improve in all five patients with the nonsystematic treatment regardless of the presumed cause or duration of the occlusion. The success of the treatment in the systematic treatment group was statistically significantly better compared with the outcome of the nonsystematic treated group (Fischer exact test, P = .01).

CONCLUSIONS:

In the treatment of CRAO, an aggressive systematic regimen including medical and mechanical means may reestablish retinal circulation and improve visual outcome. The cause of arterial occlusion, the nature of occlusive emboli, and the duration of retinal ischemia may determine the visual outcome, but a larger series is warranted to verify the effectiveness of the treatment and the prognostic factors.

Section snippets

Patients and methods

Central retinal artery occlusion was diagnosed based on abrupt visual loss accompanied by one or more of the following signs as observed by slit-lamp biomicroscopy with a +90 diopter or +78 diopter lens: (1) sluggish, thinned retinal artery flow; (2) fragmentation of the blood column in retinal arterioles; (3) retinal opacification combined with sluggish retinal blood flow; and (4) the presence of a cherry-red spot. These findings were compared with the fellow noncompromised eye. Visual acuity

Results

Improvement of the retinal blood flow observed by three-mirror contact lens at completion of treatment was invariably associated with improvement of visual acuity in our patients. After treatment, retinal circulation and visual acuity improved in eight (73%) of the 11 patients in the systematic treatment group. In only one of the eight patients in this group (Case 1), retinal circulation improved after ocular massage, sublingual isosorbide dinitrate, oral acetazolamide, and intravenous

Discussion

The incidence of CRAO in the population is unknown. Only one report estimated CRAO to occur in one per 10,000 outpatient visits.5 Because our facility is the only tertiary referral facility for a population of 200,000 and our outpatient clinic has approximately 15,000 visits per year, our estimate for acute CRAO (duration of fewer than 48 hours) is 0.85 per 100,000 per year or 1.13 per 10,000 outpatient visits.

Central retinal artery occlusion is an ocular emergency. Prolonged retinal ischemia

References (17)

H.S. Jenkins et al.
Central retinal artery occlusion
JACEP
(1979)
H.S. Mangat
Retinal artery occlusion
Surv Ophthalmol
(1995)
N.H. Atebara et al.
Efficacy of anterior chamber paracenteis and carbogen in treating acute nonarteritic central retinal artery occlusion
Ophthlamology
(1995)
D. Schmidt et al.
Microcatheter urokinase infusion in central retinal artery occlusion
Am J Ophthalomol
(1992)
S.S. Hayreh et al.
Central retinal artery occlusion and retinal tolerance time
Ophthalomolgy
(1980)
G.C. Brown et al.
Central retinal artery obstruction and visual acuity
Ophthalmology
(1982)
G.C. Brown et al.
Acute obstruction of the retinal and choroidal circulations
Ophthalmology
(1986)
C.E. Margo et al.
Therapeutic decisions involving disparate clinical outcomespatient preference survey for treatment of central retinal artery occlusion
Ophthalmology
(1996)

There are more references available in the full text version of this article.

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Aggressive systematic treatment for central retinal artery occlusion

Abstract

Section snippets

Patients and methods

Results

Discussion

JACEP

Surv Ophthalmol

Ophthlamology

Am J Ophthalomol

Ophthalomolgy

Ophthalmology

Ophthalmology

Ophthalmology