Intra-Arterial Thrombolysis for Acute Central Retinal Artery Occlusion: A Systematic Review and Meta-Analysis

Page, Paul S.; Khattar, Nicolas K; White, Andrew C.; Cambon, A.; Brock, Guy; Shesh, N.; James, Robert F.

doi:10.3389/fneur.2018.00076

Cited by 46 publications

(38 citation statements)

References 39 publications

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“…Therefore, most clinicians base their decision to use thrombolytics in acute retinal ischemia on established stroke protocols. Unfortunately, a reliable improvement in visual function has not been demonstrated in patients treated with thrombolytics following acute retinal ischemia (89,90); no significant improvement in visual function following administration of tPA was reported in a number of retrospective reviews and observational studies (91–93), however other observational studies, case reports, and retrospective reviews have suggested that visual function improved following administration of tPA (94–101). It is possible that the low rate of vision improvement reported in most studies is related to the time between onset of visual symptoms and the administration of thrombolytics (72,96,101–105); in most studies, thrombolytics were administered more than 12 hours after vision loss.…”

Section: Treatment Of Acute Retinal Ischemia (Crao or Brao)mentioning

confidence: 99%

Acute retinal arterial ischemia

Dattilo¹,

Newman²,

Biousse³

2018

Ann. Eye Sci

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Acute retinal arterial ischemia, which includes transient monocular vision loss (TMVL), branch retinal artery occlusion (BRAO), central retinal artery occlusion (CRAO) and ophthalmic artery occlusion (OAO), is most commonly the consequence of an embolic phenomenon from the ipsilateral carotid artery, heart or aortic arch, leading to partial or complete occlusion of the central retinal artery (CRA) or its branches. Acute retinal arterial ischemia is the ocular equivalent of acute cerebral ischemia and is an ophthalmic and medical emergency. Patients with acute retinal arterial ischemia are at a high risk of having further vascular events, such as subsequent strokes and myocardial infarctions (MIs). Therefore, prompt diagnosis and urgent referral to appropriate specialists and centers is necessary for further work-up (such as brain magnetic resonance imaging with diffusion weighted imaging, vascular imaging, and cardiac monitoring and imaging) and potential treatment of an urgent etiology (e.g., carotid dissection or critical carotid artery stenosis). Since there are no proven, effective treatments to improve visual outcome following permanent retinal arterial ischemia (central or branch retinal artery occlusion), treatment must focus on secondary prevention measures to decrease the likelihood of subsequent ischemic events.

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Section: Treatment Of Acute Retinal Ischemia (Crao or Brao)mentioning

confidence: 99%

Acute retinal arterial ischemia

Dattilo¹,

Newman²,

Biousse³

2018

Ann. Eye Sci

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“…Results have been mixed, with reported visual outcomes of no benefit to surpassing 50% of patients, and with adverse events ranging from minor (headache, pain or hematoma at the access site) to major (TIA, intracranial hemorrhage, and neurologic deficit). 8 , 9 …”

Section: Introductionmentioning

confidence: 99%

Intra-Arterial Tissue Plasminogen Activator for Central Retinal Artery Occlusion

Sobol¹,

Sakai²,

Wheelwright³

et al. 2021

OPTH

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Purpose To investigate the benefit of early intra-arterial tissue plasminogen activator (IAT) for treatment of central retinal artery occlusion (CRAO). Patients and Methods Fifteen eyes of 15 patients presenting with acute CRAO were included in this retrospective consecutive interventional case series. Patients were excluded if treatment with IAT was not initiated within 12 hours. The diagnosis was confirmed by an ophthalmologist. IAT was performed via a transfemoral arterial approach. Tissue plasminogen activator (tPA) was infused into the ophthalmic artery in aliquots up to 3mg to a maximum of 22mg. Paracentesis was done at the ophthalmologist’s discretion. The primary outcome measure was visual acuity after three weeks. Adverse events were recorded during treatment and follow-up visits. Results After treatment with IAT, there was a statistically significant improvement in visual acuity, with a mean change of −0.76 (SD 0.91; range −2.4 to 0.85) logMAR (p=0.006). Vision improved by 3 or more lines in 53%, and of these, the mean Snellen visual acuity improvement was >6 lines. Notably, 4 patients (27%) improved from CF or worse to 20/80 or better. The mean dose of tPA used was 17mg and the mean time to treatment was 8.83 hours (range: 5.5 to 12 hours). There were no statistically significant differences based on time to treatment, dose of tPA, or use of a paracentesis. No major adverse events were recorded. Conclusion IAT was safe and showed significant visual improvement in this small uncontrolled study. Larger studies and efforts to decrease time to treatment should be initiated to optimize outcomes.

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“…A meta-analysis by Beatty et al11 in 2007 of the available literature found that 34.9% (n = 87) of patients who underwent thrombolysis had obvious improvement in VA and the results of thrombolysis appeared better than the visual recovery with conservative measures or the natural history of the condition. Additionally, a meta-analysis by Page et al63 found a pooled odds ratio of 3.32 to 3.41 of the controlled studies which was reduced to 2.52–2.65 by the addition of the EAGLE study – still considerably in favour of IAT. However, different outcome measures were used to assess the effectiveness of IAT varying from descriptive improvement in VA from initial VA to quantitative analysis using logMAR.…”

Section: Discussionmentioning

confidence: 99%

<p>Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion</p>

Hakim¹,

Hakim²

2019

OPTH

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IntroductionCentral retinal artery occlusion is an ophthalmic emergency which typically causes acute, painless visual loss. Several conservative treatment options are practiced with little benefit. Thrombolysis as a therapeutic option has gathered interest as well as controversy. This paper aims at reviewing the relevant literature to assess the efficacy and safety of intra-arterial thrombolysis for acute central retinal artery occlusion.MethodsA review of the literature was conducted. Keywords included “intra-arterial thrombolysis” or “intra-arterial fibrinolysis” in combination with “central retinal artery occlusion” or “CRAO”. A Cochrane Database search was performed for randomised control trials, systematic reviews and meta-analyses using the same keywords.ResultsTwenty-eight studies were identified which included case reports, case series, case-control studies and 1 randomised control trial: the European Assessment Group for Lysis in the Eye Study. Improvement in vision was measured using different methods and at different time points. The findings of these studies generally favour an effect towards intra-arterial thrombolysis however there are many limitations. Additionally, the European Assessment Group for Lysis in the Eye Study showed lack of effect in intra-arterial thrombolysis vs conservative measures.ConclusionCurrent evidence is not sufficient to recommend intra-arterial thrombolysis due to the variability of visual improvement within retrospective studies, heterogeneity in treatment regimens between studies and adverse effects. Intra-arterial thrombolysis may have a role in patients presenting early, particularly if they have monocular vision, after discussion of the risks and benefits. Further high-quality trials assessing the clinical efficacy of intra-arterial thrombolysis may shed more light on this topic.

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Intra-Arterial Thrombolysis for Acute Central Retinal Artery Occlusion: A Systematic Review and Meta-Analysis

Cited by 46 publications

References 39 publications

Acute retinal arterial ischemia

Acute retinal arterial ischemia

Intra-Arterial Tissue Plasminogen Activator for Central Retinal Artery Occlusion

<p>Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion</p>

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