Acute Stroke Risk and Trends in Secondary Prevention after Retinal Artery Occlusion

To quantify the short-term risk of stroke and myocardial infarction (MI) following acute, ophthalmologist-confirmed non-arteritic retinal artery occlusion (RAO), and to assess patterns of secondary preventative care in a large community setting.

Retrospective self-controlled cohort study PARTICIPANTS: 1,380 adults with acute, embolic RAO (654 CRAO [central RAO], 726 BRAO [branch RAO]) who presented within 30 days of symptom onset to Kaiser Permanente Northern California (2015-2023).

Three fellowship-trained ophthalmologists independently verified each RAO diagnosis. Incident stroke and MI events were identified through diagnosis codes and were manually confirmed. Poisson regression was utilized to estimate vascular event risk across time intervals relative to a pre-RAO control period (181-365 days).

Incidence rate ratios (IRRs) of stroke and MI prior to, on the day of, within 30 days of, and within 1 year of RAO presentation. Rates of neuroimaging, carotid and cardiac evaluation and initiation of secondary preventive therapies within 30 days of presentation.

The risk of stroke peaked on the day of RAO presentation, particularly in the CRAO subgroup: all RAO (IRR: 5.67; 95% confidence interval (CI): [2.38, 13.5]; p<0.0001), CRAO (IRR: 8.67; 95% CI: [2.62, 28.6]; p=0.0004)). Elevated stroke risk persisted throughout the first 30 days following presentation for all subgroups: all RAO (IRR: 5.67; 95% CI: [2.38, 13.5]; p<0.0001), CRAO (IRR: 5.14; 95% CI: [2.29, 11.6]; p<0.0001), and BRAO (IRR: 6.67; 95% CI: [1.98, 22.4]; p=0.002). Beyond 30 days, stroke risk remained modestly elevated for up to 1 year. MI risk showed no statistically significant increase in any subgroup. Within 30 days, patients with CRAO were more likely than those with BRAO to undergo neuroimaging (68.0% vs 48.8%, p<0.0001), carotid imaging (85.6% vs 80.6%, p<0.05), and cardiac evaluation (77.1% vs 67.8%, p<0.0001). Adherence to guideline-recommended diagnostic testing and preventive therapy increased steadily over the study period.

Acute RAO is associated with a significantly higher short-term risk of acute stroke. Although rates of recommended evaluation and preventive measures have improved over time, opportunities remain to optimize vascular risk mitigation following RAO.