Abstract
Purpose :
Central retinal artery occlusions (CRAOs) are newly characterized as stroke equivalents and may benefit from tissue plasminogen activator (tPA); however, barriers to presentation and evaluation in the timeframe for tPA administration limit our ability to study potential treatments. We performed an observational study to identify and quantify barriers to timely diagnosis of CRAOs.
Methods :
This study included 41 newly diagnosed CRAO patients who presented to the University of Florida Emergency Department (ED) or Ophthalmology Clinic between 1/1/2012 and 3/23/2020 as identified using the ICD-9 and ICD-10 codes for “CRAO”. Patients were excluded if they presented with concurrent stroke symptoms, had a clearly identified surgical or traumatic etiology, or had decreased mental capacity affecting the accuracy of reported symptoms. Primary outcomes measured were time to presentation after symptom onset, and times from arrival to exam by ED physician, ophthalmology consult, and ophthalmology exam. Statistical analysis included the mean and standard deviation of these outcomes, including further stratification at the 4-hour mark (the requirement for possible tPA administration).
Results :
The average time to presentation after onset of vision loss was 38.16 ± 54.43 hours. 11 of 41 of patients presented within 4 hours with an average presentation time of 148 ± 47.82 minutes; however, only 4 of those patients were diagnosed by an ophthalmologist within the window for tPA administration. Of those presenting within 4 hours, the average time from arrival to exam by ED physician, ophthalmology consult, and ophthalmology exam were 28 ± 20.85, 65 ± 26.2, and 108 ± 28.79 minutes, respectively. Among all patients, these times were 35 ± 45.69, 101 ± 26.0, and 127 ± 61.46 minutes, respectively.
Conclusions :
The barriers to timely diagnosis of CRAO include early identification of symptoms and realization of systemic severity by patients and emergency medical services. In addition, there are delays in triage and evaluation by ED and ophthalmology teams, for which we propose a novel protocol to hasten diagnosis (Figure 1). This protocol has been adapted at the University of Florida Shands Emergency Department; further studies will be conducted using this protocol to examine its utility.
This is a 2021 ARVO Annual Meeting abstract.