Immediate imaging expedites care of acute retinal ischemia

Key takeaways: Researchers tried ordering nonmydriatic fundus photography and OCT immediately for ED patients with vision complaints. Diagnosis time fell from 3 hours to 28 minutes for early-presenting patients. Care for acute retinal ischemia, an event comparable to a stroke in the eye, could be accelerated through immediate nonmydriatic fundus photography and OCT, according to a study. 'Similar to the brain, the retina has a very short tolerance to ischemia and a time-dependent 'penumbra' beyond which irreversible injury occurs,' Madhuri Akella, MD, of the department of ophthalmology at Emory University School of Medicine, and colleagues wrote in Frontiers in Neurology. 'Recent studies have shown that the implementation of nonmydriatic fundus photography and optical coherence tomography in general EDs enables ophthalmologists to remotely diagnose ocular emergencies, thereby accelerating care in the ED and facilitating the integration of acute retinal ischemia into established stroke pathways.' To evaluate this concept, Akella and colleagues studied the performance of Eye-Stroke, a protocol they developed that utilizes nonmydriatic fundus photography and optical coherence tomography (NMFP-OCT) on all patients presenting to the ED with vision complaints. 'For the subgroup of patients presenting within 6 hours of vision loss, an Eye-Stroke alert is triggered, paging both on-call ophthalmology and on-call stroke neurology teams,' the researchers wrote. 'NMFP-OCT is obtained immediately by ED staff, and ... an on-call ophthalmologist confirms the diagnosis of acute retinal ischemia following immediate remote interpretation of ocular imaging.' Akella and colleagues reviewed 100 eyes that had acute central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO) between June 2023 and April 2026. They compared their outcomes with data from 52 patients collected between 2010 to 2020, before the protocol was implemented. After implementing the protocol, there was a 'marked reduction' in the time taken to diagnose patients who presented within 4.5 hours of onset, the researchers wrote. From 2010 to 2020, the median time to diagnose these patients was 3 hours, falling to 28.5 minutes when the protocol was implemented. A total of 16% of eyes presented within the 4.5-hour window needed for off-label intravenous thrombolysis. Of those who were eligible, 43% received thrombolysis. A 'major cause' of the occlusion could be identified in 72% of patients. Five had giant cell arteritis. Of those who had brain MRI, 18% had concurrent silent cerebral infarctions. Almost all eyes (95.9%) seen at the ED between 4.5 and 24 hours from symptom onset were either transferred from other EDs (mostly due to lack of an ophthalmologist) or referred to the ED by eye care providers. 'These findings support the need for broader system-level solutions, including wide deployment of NMFP-OCT and ED-based Eye-Stroke protocols,' Akella and colleagues wrote. 'The remote diagnosis of acute CRAO/BRAO on ocular imaging eliminates the delays encountered when an ophthalmologic consultation is requested by the ED, in which case pharmacologic pupil dilation is always necessary for a bedside diagnosis of acute CRAO/BRAO.'