Retinal microvascular changes on retinal photographs for predicting stroke recurrence: a systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Changes in retinal microvasculature have been associated with the stroke severity and incident stroke risk. However, its role in predicting stroke recurrence, which results in higher mortality and poorer functional recovery, remains uncertain. This study aims to determine the association of retinal microvascular changes with recurrent ischemic stroke. SUBJECTS/METHODS: We conducted a systematic search of the PubMed and Embase databases up to June 2026. Prospective studies that investigated the use of retinal biomarkers as predictors of recurrent stroke risk were included. The hazard ratio (HR), mean difference (MD) and odds ratio (OR) of various retinal biomarkers were then pooled using a random-effect model. RESULTS: Seven studies evaluating retinal microvasculature in 2938 stroke patients with or without recurrence were included. Our analysis revealed higher mean arterial branching angle (OR = 0.80; 95% CI: 0.71-0.90; p = 0.0002) and retinopathy consisting of only retinal haemorrhages (OR = 0.59, 95% CI: 0.41-0.87, p = 0.0069) to be significantly associated with lower stroke recurrence. Additionally, mean venous branching angle was found to be significantly lower in patients with stroke recurrence compared to stroke patients with no recurrence (MD = -0.44; 95% CI: -0.85--0.02; p = 0.0395). CONCLUSIONS: Our study identifies features of retinal microvasculopathy that may be able to identify patients at a higher risk of recurrent stroke. Given the accessibility of retinal imaging, our findings reinforce retinal microvasculature as a promising biomarker for risk stratification and monitoring of stroke recurrence.