Barriers to timely diagnosis of central retinal arterial occlusions can create hurdles

Adult Emergency Department Monocular Vision Loss Algorithm

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

The key to successful treatment of central retinal arterial 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.

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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.

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

2. 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).