BACKGROUND: Central retinal artery occlusion (CRAO) is an ophthalmological 
emergency, the retinal analog of a stroke. To date there is no consensus or 
national guidelines on how this disorder should be managed. As academic 
neurologists and ophthalmologists treat CRAO frequently, we set out to 
understand how these clinicians approach patients with CRAO with a national 
survey.
METHODS: We identified university-associated teaching hospitals offering 
vascular neurology, neuro-ophthalmology and/or retina fellowships in the US and 
asked the directors of the programs to respond to questions in an open response 
format to profile the acute management of CRAO at their institution.
RESULTS: We found remarkable heterogeneity in the approach to acute treatment of 
patients with CRAO among the 45 institutions that responded to the survey. Only 
20% had a formal policy, guideline or white paper to standardize the approach to 
treatment. The primary treating physician was an ophthalmologist, neurologist, 
or neuro-ophthalmologist 44, 27, and 4% of the time, respectively; 24% were 
co-managed acutely by neurology and ophthalmology. Intravenous fibrinolysis was 
offered to selected patients in 53% of institutions, and was the preferred 
initial treatment in 36%. When the acute treatment team involved a vascular 
neurologist, fibrinolysis was more likely to be considered a first-line 
treatment (p < 0.05). Anterior chamber paracentesis, ocular massage and 
hyperbaric oxygen therapy were offered 42, 66 and 7% of the time, respectively, 
while 9% of institutions offered no treatment. Anterior chamber paracentesis was 
more likely to be offered at programs where neurologists were not involved in 
treating CRAOs (p < 0.001). At 35% of institutions, patients with acute CRAO 
were not routinely referred to a general emergency room for initial evaluation 
and treatment. Carotid imaging was routinely obtained by 89% of programs, 
magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, 
laboratory screening for an inflammatory state by 27% and retinal angiography by 
30%. The thoroughness of vascular risk factors' screening was greater in 
programs that routinely referred acute CRAO cases to the emergency department.
CONCLUSIONS: This survey shows that there is significant variability in 
treatment practices for acute CRAO in the US. Because of the high 
cerebrovascular and cardiovascular risk reported in this population of patients, 
it is notable that the approach to risk factor screening is also highly variable 
and many programs do not routinely refer patients to an emergency department for 
urgent evaluation. Finally, there appears to be equipoise among treatment teams 
regarding the efficacy of systemic fibrinolysis, as 53% of programs report a 
willingness to treat at least some patients with this modality.