Hurdles to timely diagnosis of central retinal arterial occlusions can create issues

Article

Bryce Buchowicz, MD, outlines roadblocks to timely diagnosis of central retinal artery occlusion and treatment with tissue plasminogen activator during a virtual presentation at ARVO.

Reviewed by Bryce Buchowicz, MD, Logan Vander Woude, DO, MPH, and Siva S. Iyer, MD

The key to successful treatment of central retinal arterial

Adult Emergency Department Monocular Vision Loss Algorithm

Adult Emergency Department Monocular Vision Loss Algorithm

occlusions (CRAOs) is timely recognition of both the symptoms and the systemic severity of the pathology by patients and emergency medical personnel, leading to appropriate treatment with tissue plasminogen activator (tPA).

“CRAOs are newly characterized as stroke equivalents1 and may benefit from tPA2; however, barriers to presentation and evaluation within the timeframe for tPA administration limit our ability to study potential treatments,” according to Bryce Buchowicz, MD, from the departments of Ophthalmology and Neurology at the University of Florida, Gainesville.

In light of this, she and her colleagues undertook an observational study to identify and quantify barriers to timely diagnosis of CRAOs.

Forty-one patients with newly diagnosed CRAO were included. They all had presented to the University of Florida Emergency Department (ED) or Ophthalmology Clinic between January 1, 2012, and March 23, 2020, and were identified using the International Classification of Diseases-9 and -10 codes for CRAO. The primary outcomes were the time to presentation after symptom onset and times from arrival to examinations by the ED physician, ophthalmology consultation, and ophthalmology examination.

The investigators reported that the average time to patient presentation at the ED after visual loss was 38.16 ± 54.43 hours. Only 11 of 41 of patients presented within 4 hours of the episode (average presentation, 148 ± 47.82 minutes); however, an ophthalmologist diagnosed only 4 of those patients within the window for tPA administration.

Of those presenting within 4 hours, the average times from arrival to examination by an ED physician, ophthalmology consultation, and ophthalmology examination were, respectively, 28 ± 20.85, 65 ± 26.2, and 108 ± 28.79 minutes. Among all patients, these times were 35 ± 45.69, 101 ± 26.0, and 127 ± 61.46 minutes, respectively.

The investigators concluded that timely diagnosis of CRAO was held up by late identification of symptoms and realization by patients and emergency medical services of the severity of the clinical picture. This was compounded by delays in triage and evaluation by ED and ophthalmology teams.

As a result, the investigators proposed a novel protocol (Figure) to hasten diagnosis, which has been adapted at the University of Florida Shands Emergency Department; further studies will be conducted using this protocol to examine its utility.

Bryce Buchowicz, MD

E: Bryce.Buchowicz@ufl.edu

This article is adapted from Dr. Buchowicz’s presentation at the Association for Research in Vision and Ophthalmology on May 2, 2021. She has no financial interest in this subject matter.

References

Biousse V, Nahab F, Newman NJ. Management of acute retinal ischemia: follow the guidelines! Ophthalmology 2018;125:1597-607.

Mohammed A, Bongiorno C, Logue C, et al. Guideline-based intravenous tPA for central retinal artery occlusion: a case series and systematic review. Neurology 2018; 90 (15 Supplement).

Newsletter

Join ophthalmologists across Europe—sign up for exclusive updates and innovations in surgical techniques and clinical care.

Recent Videos
Christine Curcio, PhD, of the University of Alabama at Birmingham Heersink School of Medicine, shares histology update and revised nomenclature for OCT with Sheryl Stevenson of the Eye Care Network and Ophthalmology Times
SriniVas R. Sadda, MD, FARVO, shares key points from his retina presentation at the International SPECTRALIS Symposium
Robert Sergott, MD, describes fluorescence lifetime imaging ophthalmoscopy (FLIO) and the International SPECTRALIS Symposium – And Beyond (ISS) in Heidelberg, Germany.
Rayaz Malik, MBChB, PhD, a professor of medicine at Weill Cornell Medicine - Qatar, spoke with Ophthalmology Times Europe about his presentation. It's titled "An eye on neurodegenerative diseases: Challenging the dogma" at the International SPECTRALIS Sympsoium. In conversation with Hattie Hayes, Ophthalmology Times Europe
Anat Loewenstein, MD, describes her presentation on remote imaging for age-related macular degeneration and geographic atrophy at the International SPECTRALIS Symposium, in conversation with Hattie Hayes of Ophthalmology Times Europe
Tyson Brunstetter, OD, PhD, a US Navy Aerospace Optometrist at the NASA Johnson Space Center in Houston, Texas, shares key takeaways from his keynote at the International SPECTRALIS Symposium (ISS)
Rayaz Malik, MBChB, PhD, shares his presentation, titled An eye on neurodegenerative diseases: Challenging the dogma, at this year's International SPECTRALIS Symposium
At the Retina World Congress, Siegfried Priglinger, MD, speaks about ensuring the best outcomes for preschool-aged patients
At the 2025 ASCRS meeting, Robert Ang, MD said small aperture IOLs can benefit all patients, especially those with complex corneas or who have undergone previous corneal refractive surgery
Viha Vig, MBChB graduate student at the University of Auckland, New Zealand, discusses her poster presentation on the relationship between mitochondiral disease, Alzheimer disease, and other types of dementia.
© 2025 MJH Life Sciences

All rights reserved.