Diagnosis of acute retinal artery occlusion in the Emergency Department (ED): Time for change!

Theme: Neuro-ophthalmology
What: Neuro-ophthalmology
Part of: Neuro-ophthalmology II / Neuro-ophtalmolgie II
When: 6/1/2024, 02:00 PM - 03:30 PM
Where: Room | Salle 714 B

Abstract

Purpose

Acute central and branch retinal artery occlusions (CRAO/BRAO) are similar to cerebral ischemic strokes and are associated with a risk of recurrent vascular events best prevented by immediate specialized Stroke Center care. Visual outcome is poor and acute treatment options are limited by often-delayed diagnosis.

In the hyper-acute setting (<4.5hrs), the fundus may appear “normal”, making the diagnosis challenging. Macular OCT demonstrates early inner retinal hyper-reflectivity, aiding the diagnosis of acute CRAO. However, OCT is seldom available in the ED, and ophthalmology is rarely on-site to immediately confirm the diagnosis. We evaluated the use of a nonmydriatic ocular fundus camera (NMFP) combined with OCT to facilitate ultra-rapid remote diagnosis and stroke alert for patients with acute visual loss presenting to the ED.

Study Design

Prospective evaluation of all CRAO/BRAO between 06/06/2023 to 10/01/2023 who had NMFP-OCT in our general ED affiliated with a comprehensive stroke center.  

Methods

Descriptive statistics were used to summarize demographic data, time between CRAO and presentation, time between CRAO and NMFP-OCT acquisition, time between NMFP-OCT acquisition and interpretation, number of patients undergoing thrombolysis treatment and OCT changes.

Results

Over 17 weeks, 11 patients were diagnosed with CRAO and 3 with BRAO. Two presented within 4.5hrs, 4 within 4.5-12hrs, 8 >12 hrs. On average, NMFP-OCT was performed within 2 hrs 34 min of presentation (30 min to 7 hrs 22 min) and remote interpretation occurred on average within 39 min (0 min to 2 hrs and 33 min). Diagnosis of acute RAO was made remotely with NMFP-OCT within 4.5 hrs in 2 patients (2 hrs 30 min and 3 hrs 55 min from symptom onset to imaging). One patient received intravenous thrombolysis with their visual acuity improving from Count Fingers to 20/200. Of the 6 patients with NMFP-OCT imaging within 12 hours of symptom onset, 4 patients had subtle retinal whitening on color fundus photograph, but all had OCT inner retinal hyper-reflectivity/edema.

Conclusion

Implementation of NMFP-OCT in the ED enables remote diagnosis of CRAO/BRAO and facilitates initiation of an Eye Stroke protocol in acute patients. OCT complements fundus photography and provides greater diagnostic accuracy in hyperacute cases which may have a near-normal appearing fundus. These positive preliminary results suggest that implementation of NMFP-OCT in the ED changes the approach to acute CRAO and accelerates the diagnosis of acute vision loss, potentially improving patient outcomes. Results of an additional 6 months will be presented at the conference.

Presenter(s)

Presenting Author: Etienne Benard-Seguin

Additional Author(s):

Andrew M. Pendley, Emory University

David W Wright, Emory University

Fadi Nahab, Emory University

Nancy Newman, Emory University

Valerie Biousse, Emory University

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