Sudden Vision Loss as a Cardiovascular Red Flag
Sudden Vision Loss as a Cardiovascular Red Flag
Source: Medscape.Published June 24, 2025
Key Points Summary:
1. Vascular Causes of Vision Loss:
• Retinal artery or vein occlusion is a major cause of sudden, painless vision loss.
• These are ophthalmologic emergencies and often linked to systemic cardiovascular risk factors:
hypertension, diabetes, dyslipidemia, coronary and peripheral vascular disease.
2. Atrial Fibrillation (AF) and Vision Risk:
• AF is associated with central retinal artery occlusion, which can lead to irreversible vision loss.
• A Medicare study (1M+ patients ≥66 y/o) found a possible link between AF and retinal stroke.
• Cardiologists should actively screen for undiagnosed AF to mitigate thromboembolic risk.
3. Antithrombotic Therapy Considerations:
• Anticoagulants may be used in selected retinal vein occlusion cases but carry hemorrhagic risk.
• Antiplatelets show limited benefit in visual recovery.
4. Multimorbidity and Risk:
• Patients often have metabolic, renal, hepatic, hematologic, and other disorders (e.g., OSA, glaucoma).
• These comorbidities increase cardiovascular risk and impact visual prognosis.
5. Blood Pressure Control:
• Optimal BP control is crucial to preserve ocular health.
• Both high BP and excessive BP variability impair the blood-retina barrier and perfusion regulation.
• Contributes to other ocular conditions like glaucoma, cataracts, macular degeneration.
6. Semaglutide Safety Signal:
• Emerging concern about semaglutide use and nonarteritic anterior ischemic optic neuropathy (NAION).
• Risk noted in type 2 diabetics and obese patients; study limitations acknowledged, but vigilance advised.
Clinical Implications for Cardiologists:
• Be alert to complaints of vision changes — they may indicate vascular pathology.
• Collaborate closely with ophthalmologists.
• Control cardiovascular and metabolic comorbidities to prevent both ocular and systemic complications.
Management of Central Retinal Artery Occlusion (A Scientific Statement From the AHA 2021) :
Key Points (as listed in the statement):
1. CRAO is an ophthalmic emergency—equated with an acute ischemic stroke (“eye‑stroke”); immediate triage to a stroke-ready hospital is essential.
2. IV thrombolysis (tPA) can be considered if administered within 4.5 hours of symptom onset.
3. Implementation of “eye‑stroke” protocols across healthcare systems is recommended to reduce treatment delays and improve outcomes.
4. Increased awareness among the public and providers is critical: acute monocular vision loss should be treated with the same urgency as cerebral stroke or TIA.
5. Systemic evaluation of CRAO patients should include assessment for carotid stenosis, atrial fibrillation, hypertension, diabetes, dyslipidemia, and smoking.
The AHA/ASA guidance regarding antiplatelet therapy in CRAO, compiled from the scientific statement and expert reviews:
Antiplatelet Recommendations in CRAO (Secondary Prevention)
1. CRAO = Stroke Equivalent
• AHA considers CRAO analogous to acute cerebral ischemic events, warranting urgent stroke-focused evaluation and management .
2. Initiate Antiplatelet Therapy if No Anticoagulation Indication
• For patients without a cardioembolic source (e.g., atrial fibrillation) or surgical indication, antiplatelet therapy is reasonable .
3. Regimen: Dual → Single Antiplatelet
• If no contraindications, start an initial 21-day course of dual antiplatelet therapy (DAPT), typically:
• Aspirin 81 mg daily + Clopidogrel 75 mg daily, beginning within 24 hours of symptom onset .
• Thereafter, continue long-term single antiplatelet therapy (SAPT) with either:
• Aspirin 81 mg daily, or
• Clopidogrel 75 mg daily .
4. Implement Within 24 Hours
• The 21-day DAPT course should begin within the first day post-CRAO, mirroring TIA/stroke protocols
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