Etiology and Prevention Influence Visual Outcomes in Acute Retinal Ischemia

INTRODUCTION Central retinal artery occlusion (CRAO) is a vision‐threatening emergency and a marker of systemic vascular disease, associated with increased risk of stroke and myocardial infarction. Although early treatment may preserve vision, most patients present too late for intervention due to delayed recognition and systemic barriers. As a result, longitudinal follow‐up is crucial to monitor both visual recovery and vascular risk, yet follow‐up practices vary widely and may influence outcomes. Methods This retrospective cohort study analyzed 74 patients evaluated for CRAO from January 1, 2015, to December 31, 2024, at a comprehensive stroke center. Related conditions—branch retinal artery occlusion (BRAO), amaurosis fugax, and giant cell arteritis—were included to ensure comprehensive case capture. Patient demographics, presentation details, treatments, and follow‐up data were reviewed. RESULTS The cohort was 51.6% male and racially diverse: 49.5% non‐Hispanic White, 20.9% African American, 16.5% Hispanic, 6.6% Asian, and 6.6% other. Follow‐up patterns were weak predictors of visual outcomes. Neither general follow‐up nor ophthalmology visits were significantly associated with visual improvement or worsening. In CRAO/BRAO patients, ophthalmology follow‐up was significantly associated with worsening vision (OR 1.45, p < 0.01), likely due to referral bias, but not with improvement. Patient‐reported visual outcomes mirrored this trend, with no statistically significant associations between follow‐up specialty and reported vision changes. Most visual improvement occurred during hospitalization and was unrelated to outpatient follow‐up or ophthalmology consultation. In contrast, stroke etiology and preventive strategies were strong predictors of outcomes. Etiology and secondary prevention were significantly associated with both improvement (OR 1.65, p < 0.01) and worsening (OR 1.52, p < 0.01). Inflammatory causes, such as giant cell arteritis or vasculitis, were linked to better visual recovery, while ischemic etiologies—embolic or atherosclerotic—were associated with poorer outcomes. Preventive therapies (aspirin, anticoagulation, or dual antiplatelet therapy) similarly influenced prognosis, though no single regimen was superior (all p > 0.10). CONCLUSION In this retrospective cohort study, visual prognosis after CRAO and BRAO is primarily influenced by underlying etiology and preventive strategies, not follow‐up patterns. Ophthalmology follow‐up was not predictive of improvement and may reflect selection bias. Effective prevention, regardless of specific therapy, was key to better outcomes. These findings emphasize the importance of acute care and vascular risk management, with primary care follow‐up offering a viable approach in settings with limited specialty access.