Clinical Scorecard: Remote OCT Protocol to Speed Diagnosis and Treatment of CRAO

At a Glance

Key Highlights

• Remote consult protocol using macular OCT enables rapid diagnosis of CRAO without in-person ophthalmology consults
• Treatment with intravenous or intra-arterial tPA within 4.5 hours of last known well improves visual outcomes
• Implementation reduced door-to-treatment time by over 2 hours and resulted in significant visual acuity improvement in treated patients

Guideline-Based Recommendations

Diagnosis

• Activate stroke code for patients with acute painless monocular vision loss
• Perform focused history and physical exam by stroke neurology
• Acquire macular OCT scans of both eyes to identify inner retinal hyperreflectivity, thickening, loss of layer distinction, and foveal glow
• Transfer OCT images remotely to ophthalmology team for confirmation of CRAO

Management

• Administer intravenous tPA if within 4.5 hours of last known well
• Consider cerebral angiography with intra-arterial tPA injection into ophthalmic artery in eligible patients
• Intra-arterial tPA dosing: 2 mg increments every 5 minutes until visual improvement, choroidal blush restoration, or max 22 mg
• Admit all patients for stroke evaluation regardless of treatment

Monitoring & Follow-up

• Monitor visual acuity improvements within 24 hours and at 1 month post-treatment
• Observe for reocclusion and persistent vision loss
• Monitor for systemic complications including intracranial hemorrhage

Risks

• Potential for reocclusion causing persistent vision loss
• No intracranial hemorrhages or systemic complications observed in initial study

Patient & Prescribing Data

Patients presenting with acute painless monocular vision loss diagnosed with CRAO

Of patients meeting treatment criteria, 90% received intra-arterial tPA with mean dose 16 mg; 66% improved from worse than 20/200 to 20/100 or better within 24 hours; 44% improved to 20/40 or better

Clinical Best Practices

• Ensure collaboration and buy-in across ophthalmology, emergency, and stroke services
• Place OCT machines in accessible locations near stroke and emergency facilities
• Use user-friendly OCT devices operable by non-experts
• Eliminate unnecessary diagnostic testing to streamline workflow
• Establish redundant communication systems to ensure timely ophthalmology response

References

• Incidence and presentation of CRAO
• Diagnostic features of CRAO
• Stroke risk and management in CRAO
• Remote OCT protocol study and outcomes