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"en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CRAO with whitening of the posterior pole and the cherry-red spot.</p>"
]
]
]
"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, as well as involvement of the optic nerve, encompasses a wide range of aetiologies that can complicate diagnostic approach and management.<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, venous thrombosis disease, optic nerve ischemic neuropathy, and arteritic inflammatory disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The source of many of these pathologies is due to cardiovascular and/or atherosclerosis involvement, meaning a specialised cardiovascular risk consultation should perform an assessment and comprehensive approach to the main risk factors, in addition to a broad study of less common pathologies according to the patient’s characteristics.<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 (VR) consultation is very important as it must define in as much detail as possible the vascular situation of the retina, regardless of whether it is purely vascular or if there is optic nerve involvement, not to mention the possibility of arteritic inflammatory disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After ophthalmologic diagnosis, patients should be referred to VR consultation where they should undergo two basic evaluations: first, an etiological study of the patient’s ocular vascular pathology and, second, an assessment of the patient’s global burden of atherosclerotic vascular disease (AVD). This global vascular assessment of the patient should include a comprehensive assessment of the vascular risk factors, a search for subclinical atherosclerotic disease via ultrasound examination of other vascular territories with subclinical involvement and, lastly, an evaluation of prior presence of clinical AVD. 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.</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.</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. It tends to manifest clinically as one-sided, persistent, or temporary loss of vision that is sudden and non-painful.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In broad terms, retinal artery ischemia could be included within conditions of the brain. It could be considered as equivalent to a stroke, both in terms of presentation and management and in terms of treatment, because the retinal vasculature forms part of the cerebral arterial tree and shares similar risk factors to those that cause cerebrovascular accidents.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Even so, the vascular anatomy and physiology of the retina differ from those of the brain, so the strategy and diagnostic tests used to assess patients with ocular ischemia may vary compared to those used in brain ischemia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In addition, we know that retinal circulation ischemia can be a dial gauge of general vascular or cardiac pathology.<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 1–2/100,000.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The mean age of patients is 60–65 years, and it is very uncommon in patients under the age of 40. In addition, it is more common in males and tends to be associated with HTN, DM, and smoking.<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.<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. Atherosclerosis of the carotid artery is the most common cause of central retinal artery occlusion,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but is uncommon in patients under 40.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In patients over the age of 70, giant cell arteritis is more likely than in younger patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Determining the aetiology is important to preventing recurrence or other vascular events.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Below we describe the main aetiologies of retinal artery ischemia (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>):</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1.</span> Embolic pathology: Embolisms are more common than in situ thrombosis.</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. Less frequently it is of an extravascular origin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1.1</span> Atherosclerotic disease: this is due to the embolization of thrombi formed in situ by platelets or fibrin and previous breakage of embolization plaque, mainly in the ipsilateral carotid artery. It is the primary cause of retinal artery occlusion.<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. The presence of plaque is a more significant factor than the degree of carotid artery stenosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1.2</span> Cardiac embolic diseases: Atrial fibrillation is the most common cause of cardiac embolism, but the origin should be ruled out in the presence of valvular calcification (mitral stenosis is the valvular heart disease with the highest embolic risk and is related to the size of the atrium). Other cardiac embolic pathologies include mitral prolapse, endocarditis, myxoma, acute myocardial infarction with ventricular dysfunction or ventricular aneurysm, prosthetic heart valves, etc.<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, so a cardiovascular examination should be emphasised in younger patients.<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.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">1.3</span> Embolism of extravascular origin: in the presence of intravascular devices, fat embolism, amniotic fluid… etc.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">2.</span> Carotid artery stenosis due to atherosclerosis: The presence of atheromatous plaque in the carotid artery can also cause distant embolism, stenosis with obstruction, or reduced blood flow. When hypoperfusion is severe, it can result in the so-called ocular ischemic syndrome that reflects retinal or ciliary ischemia. If it affects the retina, it is linked to degeneration of microvascular circulation. The age with the highest incidence is the 6th decade of life, with the condition typically presenting in the early hours of the morning.<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.</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">3.</span> Other vascular diseases: carotid artery dissection,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> fibromuscular dysplasia,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> radiation of the carotid artery or retinal arteries, Moyamoya disease<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>, Fabry disease.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">4</span>. Vasculitis: the type of vasculitis that most commonly affects the ocular territory is temporal arteritis or giant cell arteritis. It essentially affects the posterior ciliary arteries. It can cause vision loss in over 30% of cases if not treated early. It occurs due to anterior ischemic neuropathy in 90% of cases and due to central retinal artery occlusion in the remaining 10%.<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, sarcoidosis, or eosinophilic granulomatosis with polyangiitis (Churg-Strauss).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">5.</span> Vasospasm: association between migraine and temporary vision loss in young patients.<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.</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">6.</span> Blood diseases: Sickle cell disease,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> hypercoagulable states, leukaemia or lymphoma, hyperviscosity syndrome… etc.</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 (CRAO) is painless, unilateral sudden loss of vision. Vision loss tends to be severe, though amaurosis or no perception of light is rare.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In the case of branch retinal artery occlusion (BRAO), 3 out of 4 patients recover vision ≥20/40.</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the case of BRAO, partial visual field defects occur, which are typically altitudinal.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Sometimes patients have previously presented episodes of amaurosis fugax.<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.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In the fundus of the eye, retinal whitening at the posterior pole can be observed in cases of CRAO, as well as the characteristic “cherry-red spot”<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">When it comes to BRAO, the whitening occupies the area dependent on the occluded artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">In some cases, we can observe the embolism(s) along the course of the affected artery (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">Over the course of 4–6 months the symptoms tend to resolve, observing certain arterial attenuation with a fully or partially paling of the papilla.</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 (Rubeosis iridis), the retina and, less frequently, the optic nerve, as a response to the ischemic process that the affected retina has undergone.</p><p id="par0210" class="elsevierStylePara elsevierViewall">While diagnosis is essentially clinical, we can seek support from a series of complementary tests.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Optical coherence tomography (OCT) is very useful in that during the acute phase, it provides an image of hyperreflectivity that affects the internal layers of the retina (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A and B); meanwhile, during patient monitoring or follow-up, these layers atrophy and thinning of the retinal thickness can be observed.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">OCT angiography (OCT-A) may show decreased perfusion, mainly of the superficial plexus of the retina, as well as a whitish area in the characteristic “en face” projection (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<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, fluorescein angiography (FA) during the acute phase of the disease may reveal a delay in arterial filling. It has shown to be very useful for detecting the presence of neovascularization.</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, it is important to define the aetiology as precisely as possible in order to initiate measures during the acute phase, if available, or to consider preventive etiologic treatment to prevent new ocular vascular episodes.</p><p id="par0235" class="elsevierStylePara elsevierViewall">A thorough medical history must be taken, including:<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.<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: initially Doppler of the supra-aortic trunks (TSA) then adding NMR or CT if necessary.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">Exclusion of giant cell arteritis: we must obtain ESR and CRP in individuals over the age of 50 in which retinal embolism are NOT observed, primarily in cases with choroidal involvement.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Cardiovascular examination: in patients for whom carotid artery disease has been ruled out. Initially, include baseline ECG, echocardiogram and HOLTER-ECG.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0260" class="elsevierStylePara elsevierViewall">Thrombophilia testing: rule out antiphospholipid syndrome, expand thrombophilia testing to young patients and/or those with family history.</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 “spot sign” is evidence of the presence of an ocular embolic pathology, to guide etiological testing, and it also helps determine which patients may or may not be candidates for fibrinolysis.<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, ultrasound enables us to guide testing: on the one hand, the retrobulbar “spot sign” will not be seen in the ultrasound, and assessment of the short ciliary arteries may be affected in the case of vasculitis. In addition, an ultrasound assessment of the temporal and axillary arteries can be performed, which help confirm the vasculitis aetiology. (Ultrasonido Doppler de arterias temporales en pacientes con arteritis de células gigantes: estado del arte y revisión sistemática de la literatura.<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’s AVD burden.<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, the presence of prior established AVD in the patient will be assessed.</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 (carotid, abdominal aorta, and femoral arteries) and ABI, particularly in patients with AVD of the carotid artery.<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. 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. It is estimated that damage becomes irreversible 4 hours after onset.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> From the ophthalmological perspective, various procedures can be performed based on the desired outcome, with a combination of said procedures typically used during emergency situations. In spite of this, there are no consistent clinical trials that clearly demonstrate the benefit of these procedures.</p><p id="par0295" class="elsevierStylePara elsevierViewall">Therefore, actions can be taken with the goal of reducing intraocular pressure in an attempt to promote vascular blood flow:<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/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, either by causing vasodilatation or by increasing oxygen in the tissues:<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 (vasodilatation)</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">Hyperbaric oxygen chamber (increase in partial pressure of oxygen)<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:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall">Nd: 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, retinal artery ischemia is a medical emergency. Therefore, once the suspicion of giant cell arteritis (with ESR or CRP) has been ruled out, it should be determined whether the patient is a candidate for acute reperfusion therapy. For this, the time elapsed since the start of symptoms is of utmost importance, as the window of intervention is very short. Once any contraindications have been ruled out, fibrinolysis therapy may be considered, but this must be performed in a specialised unit by experienced physicians, such as in the stroke unit or, failing that, in an ICU.<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 4.5 hours since the onset of symptoms.<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 hours for intra-arterial thrombolysis.</p><p id="par0370" class="elsevierStylePara elsevierViewall">In a study review, it was observed that in some select patients, early use of intravenous tPA (alteplase) improved long-term vision outcomes without significant adverse events.<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.<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.</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, 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.</p><p id="par0390" class="elsevierStylePara elsevierViewall">In the acute phase, activation of the stroke code will be considered according to the protocol of each centre in case the patient is a candidate for fibrinolysis. Currently it is only performed occasionally.</p><p id="par0395" class="elsevierStylePara elsevierViewall">Patients with embolic cardiopathy often require chronic anticoagulation therapy and, in select cases, repair of their valvular pathology. However, patients with a high degree of carotid artery stenosis (≥70%–99% AI recommendation) may benefit from carotid angioplasty or endarterectomy according to the most recent European guidelines from the Society for Vascular Surgery.<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, patients will be added to an intensive vascular secondary prevention program, based on the current VR guidelines, which generally include the use of antihypertensive agents, hypolipidemic agents and, where appropriate, anti-diabetic drugs, with general aims of achieving blood pressure <130/80, HbA1c < 7%, LDL < 70 (55) mg/dL or a 50% decrease in LDL, with individualised secondary lipid goals (such as non-HDL cholesterol or TG), BMI < 30, and diet and physical exercise adapted to each patient.<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. In patients with contraindications, 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, typically 81 mg aspirin per day or 75 mg clopidogrel per day, as recommended by the current guidelines.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">In addition, based on the THALES trial (Acute Stroke or Transient Ischaemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death) and SOCRATES studies (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or <span class="elsevierStyleItalic">Ticagrelor</span> and Patient Outcomes) ticagrelor alone or in combination with aspirin could also be a therapeutic option.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,41</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.<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, the prognosis depends on the location of the arterial occlusion. Most patients with BRAO have a good prognosis, while spontaneous clinical improvement of CRAO is rare. Visual acuity at the moment of onset tends to predict the final visual acuity of patients with CRAO. Advanced patient age is also a marker of worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">Patients with retinal artery occlusion, particularly CRAO, are at a higher risk of experiencing cardiovascular and cerebrovascular events. However, it is uncommon for patients with retinal artery ischemia to present contralateral involvement.<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.<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. However, due to its association with classic cardiovascular risk factors, these patients require thorough examination of the possible associated aetiology via specialized consultations, as well as treatment and long-term follow-up for these risk factors.<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, and bearing in mind that it is currently considered a type of stroke, these patients are considered to be at high risk for new cardiovascular and cerebrovascular events and death, so identifying and intensively treating said risk factors is essential.<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 (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a> and <a class="elsevierStyleCrossRef" href="#tbl0001">Table 2</a>).</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.</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.</p></span></span>"
"textoCompletoSecciones" => array:1 [
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1 => array:2 [
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4 => array:2 [
"identificador" => "sec0005"
"titulo" => "Introduction"
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5 => array:2 [
"identificador" => "sec0010"
"titulo" => "Retinal artery occlusion"
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6 => array:2 [
"identificador" => "sec0015"
"titulo" => "Aetiology"
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7 => array:2 [
"identificador" => "sec0020"
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8 => array:3 [
"identificador" => "sec0025"
"titulo" => "Diagnosis"
"secciones" => array:2 [
0 => array:2 [
"identificador" => "sec0030"
"titulo" => "Ophthalmological diagnosis"
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1 => array:2 [
"identificador" => "sec0035"
"titulo" => "Aetiological diagnosis"
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9 => array:3 [
"identificador" => "sec0040"
"titulo" => "Treatment"
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0 => array:2 [
"identificador" => "sec0045"
"titulo" => "Acute phase. Ophthalmological treatment"
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1 => array:2 [
"identificador" => "sec0050"
"titulo" => "Etiological treatment and secondary prevention"
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10 => array:2 [
"identificador" => "sec0055"
"titulo" => "Prognosis"
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11 => array:2 [
"identificador" => "sec0060"
"titulo" => "Funding"
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12 => array:2 [
"identificador" => "sec0065"
"titulo" => "Conflicts of interest"
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13 => array:1 [
"titulo" => "References"
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"pdfFichero" => "main.pdf"
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"fechaRecibido" => "2024-06-19"
"fechaAceptado" => "2024-06-25"
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0 => array:4 [
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0 => "Occlusion"
1 => "Artery"
2 => "Retina"
3 => "Vascular risk"
]
]
]
"es" => array:1 [
0 => array:4 [
"clase" => "keyword"
"titulo" => "Palabras clave"
"identificador" => "xpalclavsec1904866"
"palabras" => array:4 [
0 => "Oclusión"
1 => "Arteria"
2 => "Retina"
3 => "Riesgo vascular"
]
]
]
]
"tieneResumen" => true
"resumen" => array:2 [
"en" => array:2 [
"titulo" => "Abstract"
"resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The retina is an organ frequently affected by ischemic changes. Retinal arterial occlusion can be considered the equivalent of stroke, in terms of presentation, management and treatment. 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.</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, considering the importance of an early and systematic action.</p></span>"
]
"es" => array:2 [
"titulo" => "Resumen"
"resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La retina es un órgano frecuentemente afectado por alteraciones isquémicas. La oclusión arterial de la retina puede considerarse como un equivalente a un ictus, tanto en presentación como en manejo y tratamiento. Además de un tratamiento oftalmológico específico, es fundamental el manejo sistémico, con un adecuado estudio y control de los factores de riesgo cardiovascular, considerando a estos pacientes de muy alto riesgo cardiovascular. En este documento de consenso pretendemos realizar una actualización sobre esta patología relativamente frecuente en nuestras consultas, considerando la importancia de una actuación precoz y sistemática.</p></span>"
]
]
"NotaPie" => array:1 [
0 => array:2 [
"etiqueta" => "⋆"
"nota" => "<p class="elsevierStyleNotepara" id="npar0005">Sociedad Española de Medicina Interna (SEMI) (grupos de trabajo de Riesgo Vascular y de Enfermedad Tromboembólica Venosa) y Sociedad Española de Retina y Vitreo (SERV).</p>"
]
]
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0 => array:8 [
"identificador" => "fig0005"
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"en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CRAO with whitening of the posterior pole and the cherry-red spot.</p>"
]
]
1 => array:8 [
"identificador" => "fig0010"
"etiqueta" => "Figure 2"
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0 => array:3 [
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"en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BRAO with superior whitening of the posterior pole. The presence of an embolism is seen in the lumen of the affected vessel.</p>"
]
]
2 => array:8 [
"identificador" => "fig0015"
"etiqueta" => "Figure 3"
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"figura" => array:1 [
0 => array:4 [
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0 => array:3 [
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"en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Inferior temporal IO BRAO with inferior whitening (A). The presence of an embolism is seen in the lumen of the vessel (green circle) at the exit of the papilla (B).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p>"
]
]
3 => array:8 [
"identificador" => "fig0020"
"etiqueta" => "Figure 4"
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"mostrarFloat" => true
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"figura" => array:1 [
0 => array:4 [
"imagen" => "gr4.jpeg"
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0 => array:3 [
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"descripcion" => array:1 [
"en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Patient from <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> with CRAO, in which the slice of the OCT shows hyperreflectivity of the internal layers of the retina. (B) Patient from <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> with BRAO, in which the slice of the OCT shows hyperreflectivity of the internal layers of the retina, in this case, in the superior retina.</p>"
]
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4 => array:8 [
"identificador" => "fig0025"
"etiqueta" => "Figure 5"
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"en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Patient from <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> with BRAO, in which the OCT-A shows lower vascular density; (B) and in the “en face” projection the hyperreflectivity of the affected area.</p>"
]
]
5 => array:8 [
"identificador" => "fig0030"
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"en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Action protocol in the event of loss of vision/diminished visual acuity.</p>"
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6 => array:8 [
"identificador" => "tbl0005"
"etiqueta" => "Table 1"
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0 => """
<table border="0" frame="\n
\t\t\t\t\tvoid\n
\t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
\t\t\t\t\ttable-head\n
\t\t\t\t " align="left" valign="\n
\t\t\t\t\ttop\n
\t\t\t\t" scope="col" style="border-bottom: 2px solid black">Causes of retinal artery occlusion \t\t\t\t\t\t\n
\t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">EMBOLISM</span> \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">ARTERIAL ORIGIN: ATHEROSCLEROSIS IN PROXIMAL ARTERIAL TERRITORY Embolization plaque in aortic arch, carotid plaques (most common cause) \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">CARDIAC ORIGIN: <span class="elsevierStyleHsp" style=""></span>ATRIAL FIBRILLATION<span class="elsevierStyleHsp" style=""></span>VALVE DISEASE: Valve calcification, MITRAL V. (stenosis, prolapse) and aortic (stenosis), PROSTHETIC VALVES, ENDOCARDITIS<span class="elsevierStyleHsp" style=""></span>LV MURAL THROMBUS (AMI OR LV ANEURYSM) <span class="elsevierStyleHsp" style=""></span>DILATED CARDIOMYOPATHY OR HYPERTROPHY <span class="elsevierStyleHsp" style=""></span>MYXOMAS AND OTHER TUMOURS \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">PARADOXICAL EMBOLISM ASD, foramen ovale, \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: amniotic fluid fat embolism, vascular instrumentation \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">PATHOLOGY OF THE ARTERY WALL</span> \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">ATHEROSCLEROSIS: Carotid artery stenosis \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">VASOSPASM: associated with migraine \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">OTHER VASCULAR DISEASES: Carotid dissection, fibromuscular dysplasia, radiation of the carotid artery or arteries of the retina, Fabry disease, Moyamoya disease \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">VASCULITIS</span><span class="elsevierStyleHsp" style=""></span>GIANT CELL ARTERITIS<span class="elsevierStyleHsp" style=""></span>SLE, PAN, SARCOIDOSIS, \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">HAEMATOLOGICAL CAUSES</span><span class="elsevierStyleHsp" style=""></span>SICKLE CELL DISEASE <span class="elsevierStyleHsp" style=""></span>HYPERCOAGULABLE STATES (mainly antiphospholipid syndrome) leukaemia or lymphoma with hypercoagulability or hyperviscosity syndrome) \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:</span> with secondary vasculitis due to fungi (mucormycosis), virus (varicella), cat-scratch disease and toxoplasmosis \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">RARE:</span> Altitude-induced gas embolism, intravitreal injections, radiation therapy \t\t\t\t\t\t\n
\t\t\t\t</td></tr></tbody></table>
"""
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"descripcion" => array:1 [
"en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Causes of retinal artery pathology</p>"
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7 => array:8 [
"identificador" => "tbl0001"
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0 => """
<table border="0" frame="\n
\t\t\t\t\tvoid\n
\t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
\t\t\t\t\ttable-head\n
\t\t\t\t " align="left" valign="\n
\t\t\t\t\ttop\n
\t\t\t\t" scope="col" style="border-bottom: 2px solid black">PROTOCOL FOR ACTION IN RETINAL ARTERY OCCLUSION CVR CONSULTATION \t\t\t\t\t\t\n
\t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">1<span class="elsevierStyleSup">st</span> visit</span> \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">Reason for consultation: RETINAL ARTERY OCCLUSION \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">BP, WEIGHT, BMI, abdominal perimeter \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="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">ABI</span> in patients over 50 years of age and/or presence of CVRF. Mainly in the presence of carotid atherosclerosis.Medical history: HTN, DM, LBP, smoking, obesity, sedentary lifestyle, familial hypercholesterolemia, previous cardiovascular history (ischemic heart disease, stroke, peripheral arterial disease, aortic aneurysm, atrial fibrillation…). \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">Echocardioscopy</span> and complete with <span class="elsevierStyleBold">clinical ultrasound VASUS protocol</span> (carotid, abdominal aorta, femoral) \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">Drugs</span> (previous antithrombotic treatment) \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">Depending on the patient's profile:</span><span class="elsevierStyleHsp" style=""></span>HOLTER-ECGMAP (if poor BP control)<span class="elsevierStyleHsp" style=""></span>Doppler TSA (TSA MRI/CT)<span class="elsevierStyleHsp" style=""></span>Analysis: lipid profile, Lp(a) Hb A1c, hypercoagulability study, autoimmunity, ESR, CRP, ACE… \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">Suspected arteritic pathology (clinical, ESR, PCR, temporal artery study) \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">Etiological treatment and secondary prevention AVD</span> \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="elsevierStyleVsp" style="height:0.5px"></span> \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">FOLLOW-UP IN CONSULTATION</span> \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">BP, WEIGHT, BMI, Abdominal Perimeter - Vision evolution - Has vision improved? \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">CVF CONTROL AFTER TREATMENT OPTIMIZATION (Lipid profile, HbA1c…) \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">- Optimize-intensify etiological treatment and secondary prevention AVD</span> \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">Record cardiovascular events / death</span> \t\t\t\t\t\t\n
\t\t\t\t</td></tr></tbody></table>
"""
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