We read with dismay the editorial by Valerie Biousse regarding management of patients with central or branch retinal artery occlusion (RAO). Dr Biousse states that patients with RAO should undergo an emergent stroke work-up, and implies that American ophthalmologists are remiss in failing to follow guidelines from national associations since we often manage RAO as a nonemergent event and perform an outpatient evaluation.
Dr Biousse’s editorial accompanies an article by Lee and associates on the co-occurrence of acute ischemic stroke and RAO. First, it should be emphasized that only patients with funduscopic evidence of retinal ischemia were included in this study. These findings do not apply to a patient with amaurosis fugax but no objective evidence of retinal ischemia or nonperfusion at the time of examination.
Second, in this retrospective consecutive case series we are not told how many patients first presented to the university outpatient ophthalmology clinic with new neurological deficits and vision loss. Some potentially were identified after stroke admission and inpatient ophthalmology consultation; this is unclear. However, of 28 patients without neurological symptoms, only 3 (11%) had positive brain magnetic resonance imaging (MRI) findings (1 with valvular calcification, 1 after surgery for aortic dissection, 1 not described). Further, 16% of patients with a normal brain MRI had either large vessel atherosclerosis or cardioembolic disease. Thus, a patient with RAO and no other symptoms is unlikely to have an abnormal brain MRI, and a normal brain MRI is no guarantee that a treatable embolic locus is absent. What use, then, the MRI?
Third, for patients with non–cardioembolic stroke or transient ischemic attack, antiplatelet agents are the uniform therapy for reducing the risk of subsequent stroke. This includes patients with intracranial stenosis and coagulopathies. The American Heart Association recommends aspirin monotherapy; aspirin with dipyridamole; or clopidogrel (Plavix) monotherapy. Combined aspirin and clopidogrel may be considered in patients presenting less than 24 hours after symptom onset. For patients already taking an antiplatelet medication, there is no evidence that adding or changing agents reduces the risk of subsequent stroke.
We agree with Dr Biousse that RAO is part of the stroke continuum and is worthy of evaluation. In patients with funduscopic evidence of RAO and no other neurological symptoms, measurement of vital signs and initiating or ensuring maintenance of antiplatelet agent(s) can be performed in the ophthalmology clinic. In most regions, an outpatient echocardiogram (the first priority), carotid ultrasound, and electrocardiogram or Holter monitor can be obtained within a week and the ophthalmologist can order them. Many patients have known vasculopathic risk factors, but those who have not undergone recent laboratory testing can be referred to a primary care provider for evaluation.
By initiating a prompt outpatient work-up combined with antiplatelet medication, we are reducing health care costs to the patient and the system as a whole without increasing the risk of subsequent stroke through delay in treatment.