Abstract: Diagnostic Delays and Impediments in Managing CRAO for Better Outcomes: A Retrospective Cohort Study of Barriers to Thrombolysis Across a Regional Health System from 2018-2025.
Central retinal artery occlusion (CRAO) is an ophthalmic emergency analogous to acute ischemic stroke, presenting with sudden painless vision loss and carrying a poor visual prognosis. The use of thrombolysis in managing CRAO remains controversial; recent randomized trials have not demonstrated statistically significant improvement in visual outcomes, though authors acknowledge potential underpowering to detect a clinically meaningful effect, with larger trials ongoing. Observational data suggest time-dependent treatment effects within a 4.5-hour window. Regardless of treatment efficacy, rapid recognition and evaluation within this narrow therapeutic window are essential for time-sensitive intervention. This study evaluated CRAO incidence and barriers to timely diagnosis within a regional healthcare system.
Retrospective chart review of patients diagnosed with CRAO across Avera Health facilities (June 2018-September 2025). Cases were identified using ICD-10 codes and confirmed through medical record review. Thrombolysis rates were used as a process measure to identify workflow inefficiencies. Data included presentation site, referral pathways, time from symptom onset to presentation, and thrombolysis eligibility and administration.
Of 107 patients identified, 67 had complete documentation. Initial presentation occurred across multiple settings: 36 (53.7%) to the emergency department, 31 (46.3%) to ophthalmology/optometry/outpatient settings. Forty-three patients (64.2%) presented >4.5 hours after symptom onset. Among 24 presenting within the window, 7 (29%) received thrombolysis, 4 (16.7%) had contraindications to thrombolysis, and 13 (54.2%) either presented to or were referred to ophthalmology for evaluation, all of whom were diagnosed outside the treatment window.
Timely CRAO evaluation remains uncommon due to delayed presentation and diagnostic delays awaiting ophthalmologic consultation. Among patients presenting within the treatment window, just 45.8% received time-sensitive treatment options. Referral for ophthalmologic evaluation prior to emergency department diagnosis was the most common barrier (54.2%). Streamlined triage pathways, emergency department education, and remote retinal imaging may facilitate earlier diagnosis and preserve treatment opportunities.
Retrospective chart review of patients diagnosed with CRAO across Avera Health facilities (June 2018-September 2025). Cases were identified using ICD-10 codes and confirmed through medical record review. Thrombolysis rates were used as a process measure to identify workflow inefficiencies. Data included presentation site, referral pathways, time from symptom onset to presentation, and thrombolysis eligibility and administration.
Of 107 patients identified, 67 had complete documentation. Initial presentation occurred across multiple settings: 36 (53.7%) to the emergency department, 31 (46.3%) to ophthalmology/optometry/outpatient settings. Forty-three patients (64.2%) presented >4.5 hours after symptom onset. Among 24 presenting within the window, 7 (29%) received thrombolysis, 4 (16.7%) had contraindications to thrombolysis, and 13 (54.2%) either presented to or were referred to ophthalmology for evaluation, all of whom were diagnosed outside the treatment window.
Timely CRAO evaluation remains uncommon due to delayed presentation and diagnostic delays awaiting ophthalmologic consultation. Among patients presenting within the treatment window, just 45.8% received time-sensitive treatment options. Referral for ophthalmologic evaluation prior to emergency department diagnosis was the most common barrier (54.2%). Streamlined triage pathways, emergency department education, and remote retinal imaging may facilitate earlier diagnosis and preserve treatment opportunities.