Central retinal artery occlusion (CRAO) is an ophthalmic emergency and the ocular analogue of cerebral stroke. Best evidence reflects that over three-quarters of patients suffer profound acute visual loss with a visual acuity of 20/400 or worse. This results in a reduced functional capacity and quality of life. There is also an increased risk of subsequent cerebral stroke and ischaemic heart disease. There are no current guideline-endorsed therapies, although the use of tissue plasminogen activator (tPA) has been investigated in two randomized controlled trials. This review will describe the pathophysiology, epidemiology, and clinical features of CRAO, and discuss current and future treatments, including the use of tPA in further clinical trials.

To assess the 10-year incidence of retinal vein occlusion (RVO) and its predictors in an older population.Methods: The Blue Mountains Eye Study examined 3654 residents aged 49 years and older (82.4% response) from 1992 to 1994, reexamined 2335 residents (75.1% of survivors) from 1997 to 1999, and reexamined 1952 residents (75.6% of survivors) from 2002 to 2004. Incident RVO was assessed from stereoscopic retinal photographs. Kaplan-Meier cumulative 10-year incidence was calculated.Results: After excluding 47 residents with RVO at baseline and 171 residents with no photographs at either followup examination, 2346 residents were considered at risk of developing RVO. The cumulative 10-year incidence of RVO was 1.6%. Age was significantly associated with the incidence of RVO (P=.03, Mantel-Haenszel 2 test for trend). Factors predictingtheincidenceofRVOincludedmeanarterialblood pressure (age-adjusted odds ratio [OR], 1.41 per 10-mm Hg increase),ocularperfusionpressure(OR,1.71per10-mmHg increase), obesity (OR, 2.16), and presence of retinal arteriolar wall signs (focal narrowing: OR, 3.37; arteriovenous nicking: OR, 4.09; and opacification: OR, 4.89).Conclusions: Older age (Ն70 years), increasing mean arterial blood pressure, and atherosclerotic retinal vessel signs were significant predictors of incident RVO.

Opinion statementCentral 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.