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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The vascular pathology of the retina&#44; as well as involvement of the optic nerve&#44; encompasses a wide range of aetiologies that can complicate diagnostic approach and management&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The vascular pathologies of the retina mainly involve arterial ischemic disease&#44; venous thrombosis disease&#44; optic nerve ischemic neuropathy&#44; and arteritic inflammatory disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The source of many of these pathologies is due to cardiovascular and&#47;or atherosclerosis involvement&#44; meaning a specialised cardiovascular risk consultation should perform an assessment and comprehensive approach to the main risk factors&#44; in addition to a broad study of less common pathologies according to the patient&#8217;s characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ophthalmologic assessment prior to the vascular risk &#40;VR&#41; consultation is very important as it must define in as much detail as possible the vascular situation of the retina&#44; regardless of whether it is purely vascular or if there is optic nerve involvement&#44; not to mention the possibility of arteritic inflammatory disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After ophthalmologic diagnosis&#44; patients should be referred to VR consultation where they should undergo two basic evaluations&#58; first&#44; an etiological study of the patient&#8217;s ocular vascular pathology and&#44; second&#44; an assessment of the patient&#8217;s global burden of atherosclerotic vascular disease &#40;AVD&#41;&#46; This global vascular assessment of the patient should include a comprehensive assessment of the vascular risk factors&#44; a search for subclinical atherosclerotic disease via ultrasound examination of other vascular territories with subclinical involvement and&#44; lastly&#44; an evaluation of prior presence of clinical AVD&#46; With this assessment we can establish an overall etiologic and vascular treatment for the patient to try to reduce the possibility of new ocular and systemic vascular events&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Rapid referral pathways should be set up between ophthalmology and VR units for early care for these patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Retinal artery occlusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The eye is an organ that is frequently affected by ischemic changes&#46; It tends to manifest clinically as one-sided&#44; persistent&#44; or temporary loss of vision that is sudden and non-painful&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In broad terms&#44; retinal artery ischemia could be included within conditions of the brain&#46; It could be considered as equivalent to a stroke&#44; both in terms of presentation and management and in terms of treatment&#44; because the retinal vasculature forms part of the cerebral arterial tree and shares similar risk factors to those that cause cerebrovascular accidents&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Even so&#44; the vascular anatomy and physiology of the retina differ from those of the brain&#44; so the strategy and diagnostic tests used to assess patients with ocular ischemia may vary compared to those used in brain ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In addition&#44; we know that retinal circulation ischemia can be a dial gauge of general vascular or cardiac pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Central retinal artery occlusion presents with an approximate incidence of 1&#8211;2&#47;100&#44;000&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The mean age of patients is 60&#8211;65 years&#44; and it is very uncommon in patients under the age of 40&#46; In addition&#44; it is more common in males and tends to be associated with HTN&#44; DM&#44; and smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Aetiology</span><p id="par0065" class="elsevierStylePara elsevierViewall">Retinal artery ischemia is considered to be equivalent to a stroke and therefore is a general marker of patient prognosis as it is related to an elevated incidence of vascular events in other territories&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Patient age can provide guidance on the different aetiologies&#46; Atherosclerosis of the carotid artery is the most common cause of central retinal artery occlusion&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but is uncommon in patients under 40&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In patients over the age of 70&#44; giant cell arteritis is more likely than in younger patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Determining the aetiology is important to preventing recurrence or other vascular events&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Below we describe the main aetiologies of retinal artery ischemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1&#46;</span> Embolic pathology&#58; Embolisms are more common than in situ thrombosis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Embolisms typically originate due to atherosclerotic disease of the internal carotid artery or aortic arch or are due to embolic cardiopathy&#46; Less frequently it is of an extravascular origin&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1&#46;1</span> Atherosclerotic disease&#58; this is due to the embolization of thrombi formed in situ by platelets or fibrin and previous breakage of embolization plaque&#44; mainly in the ipsilateral carotid artery&#46; It is the primary cause of retinal artery occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of carotid atherosclerotic plaque is predictive of a higher risk of stroke and other vascular events&#46; The presence of plaque is a more significant factor than the degree of carotid artery stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1&#46;2</span> Cardiac embolic diseases&#58; Atrial fibrillation is the most common cause of cardiac embolism&#44; but the origin should be ruled out in the presence of valvular calcification &#40;mitral stenosis is the valvular heart disease with the highest embolic risk and is related to the size of the atrium&#41;&#46; Other cardiac embolic pathologies include mitral prolapse&#44; endocarditis&#44; myxoma&#44; acute myocardial infarction with ventricular dysfunction or ventricular aneurysm&#44; prosthetic heart valves&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Cardiac embolisms are the most common cause of central retinal artery occlusion in patients under the age of 40&#44; so a cardiovascular examination should be emphasised in younger patients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Paradoxical embolism in the presence of right-left shunts in congenital heart disease or atrial septal defects are not common&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1&#46;3</span> Embolism of extravascular origin&#58; in the presence of intravascular devices&#44; fat embolism&#44; amniotic fluid&#8230; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">2&#46;</span> Carotid artery stenosis due to atherosclerosis&#58; The presence of atheromatous plaque in the carotid artery can also cause distant embolism&#44; stenosis with obstruction&#44; or reduced blood flow&#46; When hypoperfusion is severe&#44; it can result in the so-called ocular ischemic syndrome that reflects retinal or ciliary ischemia&#46; If it affects the retina&#44; it is linked to degeneration of microvascular circulation&#46; The age with the highest incidence is the 6th decade of life&#44; with the condition typically presenting in the early hours of the morning&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Ischemic involvement can also affect the optic nerve and produce anterior ischemic neuropathy&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">3&#46;</span> Other vascular diseases&#58; carotid artery dissection&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> fibromuscular dysplasia&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> radiation of the carotid artery or retinal arteries&#44; Moyamoya disease<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; Fabry disease&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">4</span>&#46; Vasculitis&#58; the type of vasculitis that most commonly affects the ocular territory is temporal arteritis or giant cell arteritis&#46; It essentially affects the posterior ciliary arteries&#46; It can cause vision loss in over 30&#37; of cases if not treated early&#46; It occurs due to anterior ischemic neuropathy in 90&#37; of cases and due to central retinal artery occlusion in the remaining 10&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Other types of vasculitis associated with these pathologies include lupus erythematosus&#44; sarcoidosis&#44; or eosinophilic granulomatosis with polyangiitis &#40;Churg-Strauss&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">5&#46;</span> Vasospasm&#58; association between migraine and temporary vision loss in young patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Resolution with nitro-glycerine or nifedipine suggests vasospasm of the retinal arteries&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">6&#46;</span> Blood diseases&#58; Sickle cell disease&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> hypercoagulable states&#44; leukaemia or lymphoma&#44; hyperviscosity syndrome&#8230; etc&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical</span><p id="par0165" class="elsevierStylePara elsevierViewall">The most common clinical expression of central retinal artery occlusion &#40;CRAO&#41; is painless&#44; unilateral sudden loss of vision&#46; Vision loss tends to be severe&#44; though amaurosis or no perception of light is rare&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In the case of branch retinal artery occlusion &#40;BRAO&#41;&#44; 3 out of 4 patients recover vision &#8805;20&#47;40&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the case of BRAO&#44; partial visual field defects occur&#44; which are typically altitudinal&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Sometimes patients have previously presented episodes of amaurosis fugax&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ophthalmological diagnosis</span><p id="par0180" class="elsevierStylePara elsevierViewall">The presence of a relative afferent pupillary defect from the start is characteristic&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In the fundus of the eye&#44; retinal whitening at the posterior pole can be observed in cases of CRAO&#44; as well as the characteristic &#8220;cherry-red spot&#8221;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">When it comes to BRAO&#44; the whitening occupies the area dependent on the occluded artery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">In some cases&#44; we can observe the embolism&#40;s&#41; along the course of the affected artery &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">Over the course of 4&#8211;6 months the symptoms tend to resolve&#44; observing certain arterial attenuation with a fully or partially paling of the papilla&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Special care must be taken when monitoring these patients due to the likelihood of onset of neovascularization of the iris &#40;Rubeosis iridis&#41;&#44; the retina and&#44; less frequently&#44; the optic nerve&#44; as a response to the ischemic process that the affected retina has undergone&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">While diagnosis is essentially clinical&#44; we can seek support from a series of complementary tests&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Optical coherence tomography &#40;OCT&#41; is very useful in that during the acute phase&#44; it provides an image of hyperreflectivity that affects the internal layers of the retina &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#59; meanwhile&#44; during patient monitoring or follow-up&#44; these layers atrophy and thinning of the retinal thickness can be observed&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">OCT angiography &#40;OCT-A&#41; may show decreased perfusion&#44; mainly of the superficial plexus of the retina&#44; as well as a whitish area in the characteristic &#8220;en face&#8221; projection &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; fluorescein angiography &#40;FA&#41; during the acute phase of the disease may reveal a delay in arterial filling&#46; It has shown to be very useful for detecting the presence of neovascularization&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Aetiological diagnosis</span><p id="par0230" class="elsevierStylePara elsevierViewall">In addition to ophthalmologic confirmation&#44; it is important to define the aetiology as precisely as possible in order to initiate measures during the acute phase&#44; if available&#44; or to consider preventive etiologic treatment to prevent new ocular vascular episodes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">A thorough medical history must be taken&#44; including&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Take note of the main cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">Imaging tests of the carotid artery&#58; initially Doppler of the supra-aortic trunks &#40;TSA&#41; then adding NMR or CT if necessary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">Exclusion of giant cell arteritis&#58; we must obtain ESR and CRP in individuals over the age of 50 in which retinal embolism are NOT observed&#44; primarily in cases with choroidal involvement&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Cardiovascular examination&#58; in patients for whom carotid artery disease has been ruled out&#46; Initially&#44; include baseline ECG&#44; echocardiogram and HOLTER-ECG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0260" class="elsevierStylePara elsevierViewall">Thrombophilia testing&#58; rule out antiphospholipid syndrome&#44; expand thrombophilia testing to young patients and&#47;or those with family history&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">The CVR workgroup proposes performing ocular vascular ultrasound since the appearance of the ocular &#8220;spot sign&#8221; is evidence of the presence of an ocular embolic pathology&#44; to guide etiological testing&#44; and it also helps determine which patients may or may not be candidates for fibrinolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">In certain cases of suspected vasculitis aetiology&#44; ultrasound enables us to guide testing&#58; on the one hand&#44; the retrobulbar &#8220;spot sign&#8221; will not be seen in the ultrasound&#44; and assessment of the short ciliary arteries may be affected in the case of vasculitis&#46; In addition&#44; an ultrasound assessment of the temporal and axillary arteries can be performed&#44; which help confirm the vasculitis aetiology&#46; &#40;Ultrasonido Doppler de arterias temporales en pacientes con arteritis de c&#233;lulas gigantes&#58; estado del arte y revisi&#243;n sistem&#225;tica de la literatura&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></li></ul></p><p id="par0275" class="elsevierStylePara elsevierViewall">Our work group also proposes evaluating the patient&#8217;s AVD burden&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">Via a medical history and thorough examination&#44; the presence of prior established AVD in the patient will be assessed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">A subclinical AVD assessment will be conducted via vascular ultrasound according to the VASUS protocol &#40;carotid&#44; abdominal aorta&#44; and femoral arteries&#41; and ABI&#44; particularly in patients with AVD of the carotid artery&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Acute phase&#46; Ophthalmological treatment</span><p id="par0290" class="elsevierStylePara elsevierViewall">The moment in which treatment is started is fundamental since ischemic damage can begin very quickly&#46; It is estimated that damage becomes irreversible 4&#8239;hours after onset&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> From the ophthalmological perspective&#44; various procedures can be performed based on the desired outcome&#44; with a combination of said procedures typically used during emergency situations&#46; In spite of this&#44; there are no consistent clinical trials that clearly demonstrate the benefit of these procedures&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Therefore&#44; actions can be taken with the goal of reducing intraocular pressure in an attempt to promote vascular blood flow&#58;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0300" class="elsevierStylePara elsevierViewall">Anterior chamber puncture<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0305" class="elsevierStylePara elsevierViewall">Ocular massage</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">Hypotensive eyedrops</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">Intravenous infusion of acetazolamide and&#47;or mannitol</p></li></ul></p><p id="par0320" class="elsevierStylePara elsevierViewall">Manoeuvres can be used to increase the flow of oxygen to the affected tissue&#44; either by causing vasodilatation or by increasing oxygen in the tissues&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">Auto-inhalation of exhaled air &#40;vasodilatation&#41;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">Hyperbaric oxygen chamber &#40;increase in partial pressure of oxygen&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li></ul></p><p id="par0335" class="elsevierStylePara elsevierViewall">And action can be taken against the embolus that causes the picture&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall">Nd&#58; YAG laser embolysis<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0345" class="elsevierStylePara elsevierViewall">Pars plana vitrectomy with embolus extraction<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall">Acute reperfusion therapies</p></li></ul></p><p id="par0355" class="elsevierStylePara elsevierViewall">As acute treatment&#44; retinal artery ischemia is a medical emergency&#46; Therefore&#44; once the suspicion of giant cell arteritis &#40;with ESR or CRP&#41; has been ruled out&#44; it should be determined whether the patient is a candidate for acute reperfusion therapy&#46; For this&#44; the time elapsed since the start of symptoms is of utmost importance&#44; as the window of intervention is very short&#46; Once any contraindications have been ruled out&#44; fibrinolysis therapy may be considered&#44; but this must be performed in a specialised unit by experienced physicians&#44; such as in the stroke unit or&#44; failing that&#44; in an ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Treatment should be undertaken within the first 4&#46;5&#8239;hours since the onset of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">This window of time may be extended to 6&#8239;hours for intra-arterial thrombolysis&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">In a study review&#44; it was observed that in some select patients&#44; early use of intravenous tPA &#40;alteplase&#41; improved long-term vision outcomes without significant adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">The use of intra-arterial tPA in ophthalmic circulation reduces the risk of intracranial and systemic haemorrhage but must be conducted in a highly specialised centre&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Further studies at this level are needed to develop an action protocol&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Etiological treatment and secondary prevention</span><p id="par0385" class="elsevierStylePara elsevierViewall">Other than purely ophthalmological treatments&#44; long-term treatments will be on an individual basis according to the aetiology of the process and the presence of VR factors and clinical and subclinical AVD risk factors&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">In the acute phase&#44; activation of the stroke code will be considered according to the protocol of each centre in case the patient is a candidate for fibrinolysis&#46; Currently it is only performed occasionally&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Patients with embolic cardiopathy often require chronic anticoagulation therapy and&#44; in select cases&#44; repair of their valvular pathology&#46; However&#44; patients with a high degree of carotid artery stenosis &#40;&#8805;70&#37;&#8211;99&#37; AI recommendation&#41; may benefit from carotid angioplasty or endarterectomy according to the most recent European guidelines from the Society for Vascular Surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Depending on the presence of VRF and the AVD burden&#44; patients will be added to an intensive vascular secondary prevention program&#44; based on the current VR guidelines&#44; which generally include the use of antihypertensive agents&#44; hypolipidemic agents and&#44; where appropriate&#44; anti-diabetic drugs&#44; with general aims of achieving blood pressure &#60;130&#47;80&#44; HbA1c&#8239;&#60;&#8239;7&#37;&#44; LDL&#8239;&#60;&#8239;70 &#40;55&#41; mg&#47;dL or a 50&#37; decrease in LDL&#44; with individualised secondary lipid goals &#40;such as non-HDL cholesterol or TG&#41;&#44; BMI&#8239;&#60;&#8239;30&#44; and diet and physical exercise adapted to each patient&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Antiplatelet therapy recommendations in retinal ischemia are parallel to the American Heart Association guidelines for TIAs or minor strokes&#46; In patients with contraindications&#44; it is reasonable to start an initial cycle of 21 days of dual antiplatelet therapy followed by long-term treatment with a single antiplatelet agent&#44; typically 81&#8239;mg aspirin per day or 75&#8239;mg clopidogrel per day&#44; as recommended by the current guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">In addition&#44; based on the THALES trial &#40;Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death&#41; and SOCRATES studies &#40;Acute Stroke or Transient Ischemic Attack Treated With Aspirin or <span class="elsevierStyleItalic">Ticagrelor</span> and Patient Outcomes&#41; ticagrelor alone or in combination with aspirin could also be a therapeutic option&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Patients with elevated suspicion for giant cell arteritis should be considered a medical emergency and high dose corticosteroids should be started to prevent permanent vision loss&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Prognosis</span><p id="par0420" class="elsevierStylePara elsevierViewall">In terms of vision&#44; the prognosis depends on the location of the arterial occlusion&#46; Most patients with BRAO have a good prognosis&#44; while spontaneous clinical improvement of CRAO is rare&#46; Visual acuity at the moment of onset tends to predict the final visual acuity of patients with CRAO&#46; Advanced patient age is also a marker of worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">Patients with retinal artery occlusion&#44; particularly CRAO&#44; are at a higher risk of experiencing cardiovascular and cerebrovascular events&#46; However&#44; it is uncommon for patients with retinal artery ischemia to present contralateral involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">Multiple studies have demonstrated an increase in stroke in the first and second week following a central retinal artery occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">The initial diagnosis and treatment should be performed in an Ophthalmology department&#46; However&#44; due to its association with classic cardiovascular risk factors&#44; these patients require thorough examination of the possible associated aetiology via specialized consultations&#44; as well as treatment and long-term follow-up for these risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">In terms of the vascular prognosis of these patients&#44; and bearing in mind that it is currently considered a type of stroke&#44; these patients are considered to be at high risk for new cardiovascular and cerebrovascular events and death&#44; so identifying and intensively treating said risk factors is essential&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">Below we propose an action protocol for retinal artery occlusion and subsequent assessment and follow-up with said specialised cardiovascular risk consultations &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a> and <a class="elsevierStyleCrossRef" href="#tbl0001">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0001"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0450" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0455" class="elsevierStylePara elsevierViewall">There were no conflicts of interest when drafting this paper&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The retina is an organ frequently affected by ischemic changes&#46; Retinal arterial occlusion can be considered the equivalent of stroke&#44; in terms of presentation&#44; management and treatment&#46; In addition to a specific ophthalmological treatment systemic management is essential with an appropriate study and control of cardiovascular risk factors considering these patients of a very high cardiovascular risk&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">In this consensus document we aim to provide an update on this relatively frequent pathology in our practices&#44; considering the importance of an early and systematic action&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La retina es un &#243;rgano frecuentemente afectado por alteraciones isqu&#233;micas&#46; La oclusi&#243;n arterial de la retina puede considerarse como un equivalente a un ictus&#44; tanto en presentaci&#243;n como en manejo y tratamiento&#46; Adem&#225;s de un tratamiento oftalmol&#243;gico espec&#237;fico&#44; es fundamental el manejo sist&#233;mico&#44; con un adecuado estudio y control de los factores de riesgo cardiovascular&#44; considerando a estos pacientes de muy alto riesgo cardiovascular&#46; En este documento de consenso pretendemos realizar una actualizaci&#243;n sobre esta patolog&#237;a relativamente frecuente en nuestras consultas&#44; considerando la importancia de una actuaci&#243;n precoz y sistem&#225;tica&#46;</p></span>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Causes of retinal artery occlusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">EMBOLISM</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ARTERIAL ORIGIN&#58; ATHEROSCLEROSIS IN PROXIMAL ARTERIAL TERRITORY Embolization plaque in aortic arch&#44; carotid plaques &#40;most common cause&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">CARDIAC ORIGIN&#58; <span class="elsevierStyleHsp" style=""></span>ATRIAL FIBRILLATION<span class="elsevierStyleHsp" style=""></span>VALVE DISEASE&#58; Valve calcification&#44; MITRAL V&#46; &#40;stenosis&#44; prolapse&#41; and aortic &#40;stenosis&#41;&#44; PROSTHETIC VALVES&#44; ENDOCARDITIS<span class="elsevierStyleHsp" style=""></span>LV MURAL THROMBUS &#40;AMI OR LV ANEURYSM&#41; <span class="elsevierStyleHsp" style=""></span>DILATED CARDIOMYOPATHY OR HYPERTROPHY <span class="elsevierStyleHsp" style=""></span>MYXOMAS AND OTHER TUMOURS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">PARADOXICAL EMBOLISM ASD&#44; foramen ovale&#44;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EXOGENOUS ORIGIN&#58; amniotic fluid fat embolism&#44; vascular instrumentation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">PATHOLOGY OF THE ARTERY WALL</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">ATHEROSCLEROSIS&#58; Carotid artery stenosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">VASOSPASM&#58; associated with migraine&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">OTHER VASCULAR DISEASES&#58; Carotid dissection&#44; fibromuscular dysplasia&#44; radiation of the carotid artery or arteries of the retina&#44; Fabry disease&#44; Moyamoya disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">VASCULITIS</span><span class="elsevierStyleHsp" style=""></span>GIANT CELL ARTERITIS<span class="elsevierStyleHsp" style=""></span>SLE&#44; PAN&#44; SARCOIDOSIS&#44;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">HAEMATOLOGICAL CAUSES</span><span class="elsevierStyleHsp" style=""></span>SICKLE CELL DISEASE <span class="elsevierStyleHsp" style=""></span>HYPERCOAGULABLE STATES &#40;mainly antiphospholipid syndrome&#41; leukaemia or lymphoma with hypercoagulability or hyperviscosity syndrome&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">INFECTIONS&#58;</span> with secondary vasculitis due to fungi &#40;mucormycosis&#41;&#44; virus &#40;varicella&#41;&#44; cat-scratch disease and toxoplasmosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">RARE&#58;</span> Altitude-induced gas embolism&#44; intravitreal injections&#44; radiation therapy&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PROTOCOL FOR ACTION IN RETINAL ARTERY OCCLUSION CVR CONSULTATION&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1<span class="elsevierStyleSup">st</span> visit</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Reason for consultation&#58; RETINAL ARTERY OCCLUSION&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">BP&#44; WEIGHT&#44; BMI&#44; abdominal perimeter&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">ABI</span> in patients over 50 years of age and&#47;or presence of CVRF&#46; Mainly in the presence of carotid atherosclerosis&#46;Medical history&#58; HTN&#44; DM&#44; LBP&#44; smoking&#44; obesity&#44; sedentary lifestyle&#44; familial hypercholesterolemia&#44; previous cardiovascular history &#40;ischemic heart disease&#44; stroke&#44; peripheral arterial disease&#44; aortic aneurysm&#44; atrial fibrillation&#8230;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Echocardioscopy</span> and complete with <span class="elsevierStyleBold">clinical ultrasound VASUS protocol</span> &#40;carotid&#44; abdominal aorta&#44; femoral&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Drugs</span> &#40;previous antithrombotic treatment&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Depending on the patient&#39;s profile&#58;</span><span class="elsevierStyleHsp" style=""></span>HOLTER-ECGMAP &#40;if poor BP control&#41;<span class="elsevierStyleHsp" style=""></span>Doppler TSA &#40;TSA MRI&#47;CT&#41;<span class="elsevierStyleHsp" style=""></span>Analysis&#58; lipid profile&#44; Lp&#40;a&#41; Hb A1c&#44; hypercoagulability study&#44; autoimmunity&#44; ESR&#44; CRP&#44; ACE&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Suspected arteritic pathology &#40;clinical&#44; ESR&#44; PCR&#44; temporal artery study&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Etiological treatment and secondary prevention AVD</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">FOLLOW-UP IN CONSULTATION</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">BP&#44; WEIGHT&#44; BMI&#44; Abdominal Perimeter - Vision evolution - Has vision improved&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">CVF CONTROL AFTER TREATMENT OPTIMIZATION &#40;Lipid profile&#44; HbA1c&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">- Optimize-intensify etiological treatment and secondary prevention AVD</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Record cardiovascular events &#47; death</span>&nbsp;\t\t\t\t\t\t\n
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                  "host" => array:1 [
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                      "doi" => "10.1016/j.ophtha.2018.03.054"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                          "etal" => false
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                            1 => "T&#46;A&#46; Larson"
                            2 => "D&#46;O&#46; Hodge"
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                      "doi" => "10.1016/j.ajo.2011.05.005"
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                    0 => array:2 [
                      "titulo" => "Systemic diseases in non-inflammatory branch and central retinal artery occlusion-an overview of 416 patients"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Schmidt"
                            1 => "A&#46; Hetzel"
                            2 => "A&#46; Geibel-Zehender"
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                      "Revista" => array:6 [
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