Thank you, Dr Cohen, for your interest in our article. We are extremely pleased for the opportunity to restate and clarify our opinion. Concerning the recommendations of the American Heart Association and American Stroke Association guidelines, we admit that the referenced journals provide insufficient information. However, according to the newly proposed definition by the American Heart Association (AHA), transient neurological dysfunctions caused by retinal ischemia are considered as a transient ischemic attack (TIA) and the guideline recommends undergoing similar processes of evaluation in patients with retinal ischemia as in those with focal brain ischemia. The AHA acute stroke guideline states that brain imaging is a required component of emergency assessments in patients with suspected cerebral ischemia. Even in patients with transient ischemic neurological symptoms, the guideline recommends performing neuroimaging within 24 hours of symptom onset. Regarding the aspect of etiologic evaluations, the AHA acute stroke guideline states that it is essential to establish the mechanism of ischemia as soon as possible to prevent subsequent episodes. In patients with TIA, the AHA TIA guideline recommends completing etiologic evaluations according to the AHA acute stroke guidelines. Based on these guidelines, we suggest proceeding with immediate brain imaging and etiologic evaluations in the patients with acute retinal artery occlusion (RAO). Moreover, recent studies showed that acute cerebral infarction co-occurred in a considerable proportion of patients with retinal artery occlusion and retinal TIA. Thus, evaluation and management of retinal ischemia should be performed following AHA TIA and acute stroke guidelines.
The survey referenced by our article states that 35% of ophthalmologists and 73% of neurologists reported to refer acute central retinal artery occlusion patients to an emergency room for immediate evaluation. We agree that “immediate evaluations” in the article may imply the evaluation for emergency thrombolysis, and not mainly for searching underlying etiology. However, it is true that only a small portion of acute RAO patients are being referred to emergency rooms. Also, although some differences may exist between studies, evaluations performed in the process of emergency thrombolysis usually include brain imaging and studies that could reveal the underlying etiology, including electrocardiogram and conventional angiography in cases of intra-arterial thrombolysis. Biousse, the author of the survey article, also referred to this article to demonstrate that the majority of acute RAO patients are not sent to the emergency room for immediate evaluations.