Retinal artery occlusion associated with increased risk of death and vascular events

Pirthvi Mruthyunjaya, MD

Image source: Stanford University

New research reports that patients with retinal artery occlusion (RAO) have an increased risk of short- and long-term death, stroke and myocardial infarction compared with controls diagnosed with cataracts.¹

Researchers led by Pirthvi Mruthyunjaya, MD, of Stanford University’s Byers Eye Institute, found that the overall absolute risk in the short term remained relatively low, lower than previously reported evidence, although they noted some methodological differences compared with historical study designs. difference.

However, the risk of vascular events overall remains increased in the long term, underscoring the importance of cardiovascular workup and comprehensive monitoring in patients with RAO.

“This study confirms an increased risk of death, stroke, and myocardial infarction after RAO compared with a control population matched for age, sex, race, and systemic comorbidities,” the researchers wrote.

Given the association between RAO and stroke, the American Academy of Ophthalmology (AAO) guidelines recommend immediate referral to an emergency department or stroke center for all patients with RAO.³ There are currently no proven treatments for RAO-related vision loss; instead, the goals of treatment are to prevent future complications related to retinal ischemia and to prevent future secondary vascular events.

Mruthyunjaya and colleagues evaluated the risk of death and vascular ischemic events (including stroke and myocardial infarction) after RAO compared with a matched control population using the large aggregated TriNetX electronic health record network.¹ The retrospective cohort was selected from aggregation of de-identified data from more than 111 million patients between January 2003 and April 2023.

All included RAO patients had ≥1 year of follow-up after the RAO event. A control population was created that included patients diagnosed with cataract. Patients were excluded from the analysis if they had had a stroke or myocardial infarction within 2 years before the RAO event.

Propensity score matching was performed between the two cohorts to control for age, sex, race, and systemic comorbidities. The primary outcome of the analysis was stroke, myocardial infarction, or mortality at 2 weeks, 30 days, 1 year, 5 years, and 10 years after RAO compared with matched controls. Overall, there were 34,874 patients in the RAO cohort who were followed for ≥1 year, with a mean age at RAO event of 66 years.

After analysis, the mortality rate after RAO diagnosis was higher than that after cataract diagnosis at all time points. The researchers noted that the RR for death was approximately twice that of the control group, and the overall risk difference was relatively small at all time points:

• _{2 weeks: 0.14% vs. 0.06% (relative risk (RR), 2.45; 95% CI, 1.46 to 4.12; ask <.001)}
• _{30 days: 0.29% vs. 0.14% (RR, 2.10; 95% CI, 1.49 to 2.97; ask <.001)}
• _{1 year: 3.51% vs. 1.99% (RR, 1.78; 95% CI, 1.61 to 1.94; ask <.001)}
• _{5 years: 22.74% vs. 17.82% (RR, 1.28; 95% CI, 1.23 to 1.33; ask <.001)}
• _{10 years: 57.86% vs. 55.38% (RR, 1.05; 95% CI, 1.02 to 1.07; ask <.001)}

Additionally, the risk of stroke was higher in the RAO group than in the control group. Compared with controls, the relative risk of stroke in patients diagnosed with RAO was approximately 21 times within the first 2 weeks, approximately 14 times within 30 days, and approximately 5 times within 1 year:

• _{2 weeks: 1.72% vs. 0.08% (RR, 21.43; 95% CI, 14.67 to 31.29; ask <.001)}
• _{30 days: 2.48% vs. 0.18% (RR, 14.18; 95% CI, 10.94 to 18.48; ask <.001)}
• _{1 year: 5.89% vs. 1.13% (RR, 5.20; 95% CI, 4.67 to 5.79; ask <.001)}
• _{5 years: 10.85% vs. 4.86% (RR, 2.24; 95% CI, 2.09 to 2.40; ask <.001)}
• _{10 years: 14.59% vs. 9.18% (RR, 1.59; 95% CI, 1.48 to 1.70; ask <.001).}

Meanwhile, in the RAO cohort, the relative risk of myocardial infarction was 3-fold higher within the first 2 weeks, 2.6-fold higher within 30 days, and 1.7-fold higher within 1 year. However, the overall risk difference at all time points was relatively small.

• _{2 weeks: 0.16% vs. 0.06% (RR, 3.00; 95% CI, 1.79 to 5.04; ask <.001)}
• _{30 days: 0.27% vs. 0.10% (RR, 2.61; 95% CI, 1.78 to 3.83; ask <.001}
• _{1 year: 1.66% vs. 0.97% (RR, 1.72; 95% CI, 1.51 to 1.97; ask <.001)}
• _{5 years: 6.06% vs. 5.00% (RR, 1.21; 95% CI, 1.12 to 1.31; ask <.001)}
• _{10 years: 10.55% vs. 9.43% (RR, 1.12; 95% CI, 1.04 to 1.21; ask =.003)}

Mruthyunjaya and colleagues noted that more research is needed to determine the best way to classify patients after RAO, and that multidisciplinary evaluation and long-term follow-up after RAO may be needed.

“Further research is needed to evaluate the optimal method of triaging patients with RAO to determine whether urgent inpatient assessment versus rapid outpatient examination is best for managing patients with acute RAO,” they wrote.

refer to

1. _{Wai KM, Knapp A, Ludwig CA, et al. Risk of stroke, myocardial infarction, and death after retinal artery occlusion. JAMA Ophthalmology. Published online on October 26, 2023. doi:10.1001/jamao Phutmol.2023.4716}
2. _{Vestergaard N, Torp-Pedersen C, Vorum H, Aasbjerg K. Risk of stroke, myocardial infarction, and death in patients with retinal artery occlusion and the effect of antithrombotic therapy. Transform visible science and technology. 2021;10(11):2. doi:10.1167/tvst.10.11.2}
3. _{Olson TW, Pulido JS, Falk JC, Hyman L, Fraxell CJ, Adelman RA. Retinal and ophthalmic artery occlusions are the preferred practice modes. ophthalmology. 2017;124(2):120-P143. doi:10.1016/j.ophtha.2016.09.024}