Central retinal artery occlusion (CRAO) is an ophthalmic emergency caused by the blockage of the central retinal artery, leading to sudden, painless and profound vision loss. Ischemia of the inner retinal layers results in retinal infarction and poor visual recovery. Fewer than 20% of affected patients regain functional visual acuity.^{Reference Schrag, Youn, Schindler, Kirshner and Greer1,Reference Hayreh and Zimmerman2} CRAO is considered the ocular analog of a cerebral stroke. At present, no established treatment exists for CRAO, and management focuses on identifying the potential cause of CRAO and preventing future vascular events, particularly cerebral stroke.

A report by Quinn et al. published in the journal describes a retrospective cohort of 76 patients with CRAO seen over 4 years in a large Canadian academic institution. From the acute treatment perspective, 28.9% presented within the 4.5-hour, intravenous thrombolysis treatment window, but none received intravenous thrombolysis. Among non-arteritic CRAO (70 of 76, ∼92%), 25.7% had symptomatic carotid stenosis, while 10.5% had a cardioembolic source. Among patients over 50 years, giant cell arteritis was diagnosed in 8.1%. Functional visual recovery was seen in only 10.5% of patients. Stroke in the first 4 weeks of CRAO occurred in 3.2%. The use of dual antiplatelet therapy after CRAO was 45.3%, and most patients with symptomatic carotid stenosis (∼77%) underwent urgent carotid revascularization.

Findings are largely consistent with published observations and confirmed in a large Canadian cohort. An important limitation of the study is its retrospective design and limited follow-up data. Only 44 of the 76 patients had follow-up of at least 1 week, leaving long-term visual outcomes poorly studied. The report also lacks details on the subclassification of CRAO, which can have very different visual outcomes,^{Reference Hayreh and Zimmerman3} especially CRAO with cilioretinal artery sparing that carries a more favorable prognosis. The authors report timely workup for most patients; however, referral to the Stroke Prevention Clinic was notably low, with only 48 of 70 patients with non-arteritic CRAO referred. This is an important area for improvement, as cerebral stroke is the most feared vascular outcome after CRAO. Moreover, the stroke risk is front-loaded, highest in the first 1–2 weeks following CRAO.^{Reference Park, Choi and Yang4,Reference Chodnicki, Tanke and Pulido5} Also, the excellent access to urgent opthalmological consultation (∼96%) at the authors’ institution, which is crucial for early diagnosis/treatment, is unlikely to reflect real-world experiences at many community-based hospitals/clinics, where many of these patients might initially present. A concerted pan-Canadian and international effort is needed to urgently address acute treatment of CRAO, establish/standardize treatment pathways and streamline secondary prevention approaches.