Central Retinal Artery Occlusion: Local Intra-arterial Fibrinolysis versus Conservative Treatment, a Multicenter Randomized Trial

Usefulness of ocular ultrasound for monitoring acute retinal arterial ischemia

INTRODUCTION

The ocular ultrasound spot sign negatively predicts the success of thrombolytic treatment in retinal arterial occlusions. We evaluated the presence of the spot sign in these patients.

MATERIAL AND METHODS

Retrospective study of patients with acute central retinal artery occlusion (CRAO) or its branches (BRAO). An ocular ultrasound was performed to assess the presence of spot sign.

RESULTS

Twenty patients were included, 13 CRAO and 7 BRAO. Carotid stenosis was the most common etiology, in 50%, 7 CRAO and 3 BRAO. A spot sign was observed in 9 patients (45%), 7 CRAO and 2 BRAO. We did not observe significant differences between patients with CRAO and BRAO. Patients with the spot sign were significantly older: 73 (±9) vs. 66 (±6) years (p=0.028).

CONCLUSIONS

Ocular ultrasound is very useful in the evaluation of patients with acute retinal ischemia. More than 50% of CRAOs and one in 4 with BRAOs have the spot sign and would not benefit from systemic thrombolysis.

Correlation of Structure With Function: Future Utilities for Optical Coherence Tomography Angiography in Neuro-Ophthalmology

Optical coherence tomography angiography is a burgeoning imaging modality in Ophthalmology. In this review, we outline the breadth of potential utility for optical coherence tomography angiography for diagnosis and prognostication in neuro-ophthalmology. Further mapping of the characteristics and natural history of the optic disc vascular network in neuro-ophthalmic conditions is necessary to increase the utility of this imaging modality for neuro-ophthalmic conditions, as the specificity and sensitivity of optical coherence tomography angiography are currently limited by the small pool of available observational data.

Early reperfusion in patients with acute retinal artery occlusion: A multicenter prospective study

BACKGROUND

The visual outcome after central retinal artery occlusion (CRAO) is poor, but its relationship with early reperfusion (ER) is poorly known. We evaluated the incidence of ER in acute CRAO or branch retinal artery occlusion (BRAO), and its association with clinical outcome.

METHODS

In this prospective observational multicenter study, we included patients with acute CRAO or macula-involving BRAO presenting within 24 hours from symptom onset. ER was evaluated within 24 hours after the initial clinical evaluation using indocyanine green angiography (ICGA). The primary outcome was the best-corrected visual acuity (BCVA) at 1 month.

RESULTS

In all, 70 patients were enrolled, of whom 63 (90%) had CRAO. Median age was 71 years (interquartile range: 67-77), 63% were male, median time from symptom onset to presentation was 5.3 hours (interquartile range: 3.1-15.1), and 17% received intravenous fibrinolysis. ER was identified in 34 patients (49%), of whom 21 (30%) achieved complete reperfusion (100% filling of the 55° ICGA field). Patients with ER were less likely to have hypertension and diabetes mellitus (p < 0.001 and p = 0.046, respectively). At the 1-month follow-up, BCVA was significantly better in ER patients (median BCVA 1.3 logMAR vs 1.7 logMAR, p = 0.001), with greater benefit with complete reperfusion (p for trend < 0.001). ER was also associated with improved visual field and quality of life at the 1-month follow-up (both p < 0.05).

CONCLUSION

ER occurred in almost 50% of the patients and was associated with improved visual outcomes and quality of life. Therapies that increase ER in CRAO will likely improve clinical outcomes.

CLINICAL TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov (identifier NCT03049514); https://classic.clinicaltrials.gov/ct2/show/NCT03049514.

Visual outcomes of central retinal artery occlusion: Exploring treatment strategies beyond the conventional time window

BACKGROUNDS/AIMS

Central retinal artery occlusion (CRAO) is a vision-devastating emergency. However, widely-acknowledged treatment consensus is lacking and prehospital delays commonly occur. Hence, we aimed to investigate the visual outcomes of conservative treatments (CT), local intra-arterial fibrinolysis (LIF) and hyperbaric oxygen (HBO) therapy for non-arteritic CRAO (NA-CRAO) patients beyond the conventional time window.

METHODS

This retrospective comparative study included 99 NA-CRAO patients followed up for over 6 months. The subjects were divided into three groups: the CT (50 patients), LIF (10 patients) and HBO group (39 patients). The primary endpoint was the best-corrected visual acuity (BCVA) change at 6 months compared to baseline. The secondary endpoint was the improvement in BCVA at 1 year and final visits.

RESULTS

No heterogeneity regarding demographics was identified. However, the HBO group had a more extended time-to-treatment period (median 6.0 days) and more advanced-stage CRAO cases (41 % stage III) than the CT (median 4.0 days, 14 % stage III) and LIF (median 0.6 days, 20 % stage III) groups. Despite this, the HBO group exhibited a significantly greater BCVA and a higher proportion of patients achieving significant vision improvement than those in the CT group at 6-, 12-month and final exams (51.3 % vs. 24.0 %, P < 0.05). The LIF appeared to improve outcomes more than CT over time without significance.

CONCLUSION

Our study provided a concurrent comparison across 3 approaches and demonstrated that HBO therapy beyond the time window remained more effective in improving vision than CT alone for NA-CRAO patients, which had not been proposed by prior studies.

Central Retinal Artery Occlusion Following Intralesional Triamcinolone Injection for IgG4-related Orbital Disease

The risk of blindness associated with periocular and facial injections is well documented. Previous cases describing vision loss following a recent periocular or facial injection have emphasized the importance of facial "danger zones." To date, the literature suggests that nearly half of all cases of central retinal artery occlusion in the setting of a recent periocular or facial injection involve an injection in or around the nose. Here, the authors report the second known case of central retinal artery occlusion following a triamcinolone injection to the lacrimal gland. A 30-year-old female with a diagnosis of IgG4-related disease underwent lacrimal gland debulking with an intralesional steroid injection. She noted OD vision loss immediately after surgery, with posterior segment examination demonstrating retinal whitening with a cherry-red spot and intra-arterial yellow-white plaques. This case serves as a reminder to clinicians regarding the risk of iatrogenic embolism following triamcinolone injections around the face with special attention drawn to the lacrimal gland.

Profile and outcomes of retinal artery occlusion: The underrealized need to expedite presentation

PURPOSE

To evaluate the clinical profile of retinal artery occlusion (RAO) and impact of presentation on visual outcomes.

DESIGN

A retrospective analysis of case files of 3070 patients with RAO was performed using electronic medical records.

METHODS

Demographic data were analyzed using descriptive statistics. The differential distribution of risk factors of RAO with age was studied. Time to presentation and treatment effects were assessed using multivariate regression. Interaction plots were drawn to assess the impact of risk factors on outcomes.

RESULTS

Central RAO was the most common type (n = 2443, 77.11%), followed by branch RAO (n = 500, 15.78%), while combined retinal vascular occlusion and cilio-RAO were rare. Most of the patients (71.40%) were male and had unilateral (96.81%) affliction. Almost half presented within the fifth (24.85%) and sixth (21.4%) decades of life. Hyperhomocysteinemia had a higher association (1.95, P = 0.0019) with younger patients (<40 years), while hypertension (3.64, P < 0.001), diabetes mellitus (DM; 4.18, P < 0.001), and coronary artery disease (CAD) (4.26, P = 0.002) were significantly commoner in older patients. CAD (5.1%) and cerebrovascular disease (0.6%) were detected after ocular presentation in some patients. Embolus, though detected rarely (1%), was associated (60%) with serious systemic disorders. Early presentation (<6 h) was associated with better visual outcomes (mean log of minimum angle of resolution 1.8 ± 1.3 vs. 2.1 ± 1.3, P = 0.032). Neovascular glaucoma (2.14% overall) was twice more common in DM (P < 0.0004) and led to further vision loss. Visual improvement occurred in 10% of patients over follow-up.

CONCLUSION

RAO occurs slightly earlier compared to coronary and cerebrovascular disorders and can precede their detection. Associated risk factors vary with the age of presentation. Presentation within 6 h needs facilitation for better outcomes and management.

TIME-COURSE RETINAL CIRCULATION CHANGES IN EYES WITH CENTRAL RETINAL ARTERY OCCLUSION USING LASER SPECKLE FLOWGRAPHY

PURPOSE

To evaluate retinal circulation in eyes with central retinal artery occlusion.

METHODS

The best-corrected visual acuity (BCVA), fluorescein angiography, and laser speckle flowgraphy values were measured at the first visit in 42 patients with central retinal artery occlusion (42 eyes; mean age, 66.0 ± 14.0 years). Laser speckle flowgraphy was performed at baseline, 1 week, and 1, 3, and 6 months; the difference between the mean blur rate vessel area and mean blur rate tissue area (MV-MT), reflecting the retinal vessel blood flow, was measured. Fluorescein angiography measured the arteriovenous passage time. Time-course changes in the MV-MT and BCVA, and the relationship between MV-MT and final BCVA were examined.

RESULTS

Mean blur rate vessel area and mean blur rate tissue area were significantly correlated with arteriovenous passage time ( P < 0.001). The MV-MT increased significantly after 1, 3, and 6 months ( P < 0.001). The visual acuity improved significantly until 1 month ( P < 0.01). Multivariate analysis showed a significant correlation between the baseline BCVA ( P < 0.001) and MV-MT at 1 month ( P = 0.01) and the final BCVA. Age and MV-MT significantly negatively correlated at 1 month ( P < 0.001).

CONCLUSION

The retinal circulation improved significantly within 1 month; younger patients had better retinal circulation improvement. The baseline BCVA and retinal circulation within 1 month correlated with the final BCVA.

Therapeutic Strategies for Retinal Artery Occlusion-A Literature Review

Retinal artery occlusion (RAO) is an emergency condition causing acute retinal ischemia and is considered an equivalent of ischemic stroke. The occurrence of an episode of RAO is associated with significant impairment of visual functions and correlates with an increased risk of future vascular events. Although RAO requires immediate diagnosis and treatment, there are currently no clear guidelines specifying optimal management. This review discusses current and future therapeutic strategies following an episode of RAO, including secondary prevention.

A comprehensive evaluation of efficacy of hyperbaric oxygen therapy in non-arteritic central retinal artery occlusion using enhanced depth imaging optical coherence tomography

This study aimed to assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with central retinal artery occlusion (CRAO) by analyzing changes in visual acuity (VA) and enhanced depth imaging optical coherence tomography (EDI-OCT) parameters. A comparative retrospective study was conducted by reviewing the medical records of all HBO-treated RAO patients in our department and comparing them with matched RAO patients who did not receive HBO treatment. All patients treated with HBO received treatment within 7 days of the onset of visual symptoms. Baseline characteristics were compared, and VA and OCT parameters were evaluated at baseline and follow-up visits. A total of 50 eyes from 50 patients were included, with 29 eyes in the HBOT group and 21 eyes in the control group. The mean BCVA of the HBOT group at the initial visit was 2.03 logMAR, which improved to 1.55 logMAR at 6 months, with the change being statistically significant (P < 0.01), while the control group's BCVA remained almost unchanged, from 2.1 to 2.11 logMAR (P = 0.762). The central choroidal thickness increased significantly in the HBOT group over the subsequent period. The central fovea, and outer retinal layer thickness in the HBOT group were significantly greater than those in the control group at the 6-month follow-up after treatment. HBOT appears to be effective in improving VA and inducing favorable changes in OCT parameters in patients with CRAO. It helps to preserve retinal layer thickness, especially in the outer retinal layer.

Plasma Proteomics to Identify Drug Targets and Potential Drugs for Retinal Artery Occlusion: An Integrated Analysis in the UK Biobank

Retinal artery occlusion (RAO), which is positively correlated with acute ischemic stroke (IS) and results in severe visual impairment, lacks effective intervention drugs. This study aims to perform integrated analysis using UK Biobank plasma proteome data of RAO and IS to identify potential targets and preventive drugs. A total of 7191 participants (22 RAO patients, 1457 IS patients, 8 individuals with both RAO and IS, and 5704 healthy age-gender-matched controls) were included in this study. Unique 1461 protein expression profiles of RAO, IS, and the combined data set, extracted from UK Biobank Plasma proteomics projects, were analyzed using both differential expression analysis and elastic network regression (Enet) methods to identify shared key proteins. Subsequent analyses, including single cell type expression assessment, pathway enrichment, and druggability analysis, were conducted for verifying shared key proteins and discovery of new drugs. Five proteins were found to be shared among the samples, with all of them showing upregulation. Notably, adhesion G-protein coupled receptor G1 (ADGRG1) exhibited high expression in glial cells of the brain and eye tissues. Gene set enrichment analysis revealed pathways associated with lipid metabolism and vascular regulation and inflammation. Druggability analysis unveiled 15 drug candidates targeting ADGRG1, which demonstrated protective effects against RAO, especially troglitazone (-8.5 kcal/mol). Our study identified novel risk proteins and therapeutic drugs associated with the rare disease RAO, providing valuable insights into potential intervention strategies.

Eye stroke protocol in in the emergency department

BACKGROUND

Visual outcomes of acute central and branch retinal artery occlusions (CRAO/BRAO) are poor and acute treatment options are limited by delayed diagnosis. In the hyper-acute setting, the ocular fundus may appear "normal", making recognition challenging, but is facilitated by retinal optical coherence tomography (OCT), which is seldom available in emergency departments (ED). We evaluated the use of non-mydriatic ocular fundus photographs (NMFP) combined with OCT to facilitate ultra-rapid remote diagnosis and stroke alert for patients with acute vision loss presenting to the ED.

METHODS

Prospective evaluation of all CRAO/BRAO between 06/06/2023-06/06/2024 who had NMFP-OCT in our general ED affiliated with a stroke center.

RESULTS

Over 1 year, 22 patients were diagnosed with CRAO, 4 with BRAO. Five patients presented within 4.5 hours of vision loss onset, 6 within 4.5 to ≤12 hours and 15 within >12 to 24 hours. On average, NMFP-OCT was performed within 141 minutes of presentation to the ED (range 27- 422 minutes). Diagnosis of acute RAO was made remotely with NMFP-OCT within 4.5 hours in 4 patients, 2 of whom received intravenous thrombolysis. Of the 9 patients with NMFP-OCT within 12 hours of symptom onset, 5 patients had subtle retinal whitening on color fundus photograph, but all had OCT inner retinal hyper-reflectivity/edema.

CONCLUSION

Implementation of NMFP-OCT in a general ED enables rapid remote diagnosis of CRAO/BRAO and facilitates initiation of an eye stroke protocol in acute patients. OCT complements color fundus photography and provides greater diagnostic accuracy in hyperacute cases with near-normal appearing ocular fundi.

Successful Treatment of Central Retinal Artery Occlusion With Tissue Plasminogen Activator Followed by Recurrent Retinal Ischemia

Purpose: To describe the use of intra-arterial tissue plasminogen activator (tPA) to treat central retinal artery occlusion (CRAO). Methods: A case and its findings were analyzed. Results: A 45-year-old man diagnosed with a CRAO and had cerebral angiography and treatment with intra-arterial tPA. After treatment, follow-up included optical coherence tomography (OCT), fundus photography, fluorescein angiography, and OCT angiography. The visual acuity (VA) improved from hand motions to 20/30 immediately after fibrinolysis. A vascular occlusion event the next day resulted in a decrease in VA to 20/400. After initiation of dual antiplatelet therapy, the patient's VA improved to 20/20. As the retina recovered, the evolution of retinal ischemic changes to a finding similar to paracentral acute middle maculopathy was seen on imaging. Conclusions: This is the first report describing a patient safely started on dual antiplatelet therapy that led to vision improvement after initial treatment with intra-arterial tPA for a CRAO resulted in recurrent vision loss.

Retina-Brain Homology: The Correlation Between Ophthalmic or Retinal Artery Occlusion and Ischemic Stroke

The retina's similar structure and function to the brain make it a unique visual "window" for studying cerebral disorders. Ophthalmic artery occlusion (OAO) or retinal artery occlusion (RAO) is a severe ophthalmic emergency that significantly affects visual acuity. Studies have demonstrated that patients with OAO or RAO face a notably higher risk of future acute ischemic stroke (AIS). However, ophthalmologists often overlook multidisciplinary approach involving the neurologist, to evaluate the risk of AIS and devise clinical treatment strategies for patients with OAO or RAO. Unlike the successful use of thrombolysis in AIS, the application of thrombolysis for OAO or RAO remains limited and controversial due to insufficient reliable evidence. In this review, we aim to summarize the anatomical and functional connections between the retina and the brain, and the clinical connection between OAO or RAO and AIS, compare and review recent advances in the effectiveness and safety of intravenous and intra-arterial thrombolysis therapy in patients with OAO or RAO, and discuss future research directions for OAO or RAO. Our goal is to advance the development of multidisciplinary diagnosis and treatment strategies for the disease, as well as to establish expedited pathways or thrombolysis guidelines for vascular intervention.

Central retinal artery occlusion: a stroke of the eye

Central retinal artery occlusion (CRAO), like a stroke in the brain, is a critical eye condition that requiring urgent medical attention. Patients with CRAO present with acute loss of vision and the visual prognosis is poor with low chance of spontaneous visual recovery. Moreover, the risk of developing ischaemic heart disease and cerebral stroke is increased due to the presence of underlying atherosclerotic risk factors. Currently, there is no officially recommended treatment for CRAO. This review will describe the anatomy, pathophysiology, clinical features of CRAO, as well as exploring existing and potential future approaches for managing the condition.

Early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION): Study protocol of a phase III trial

RATIONALE

Meta-analyses of case series of non-arteritic central retinal artery occlusion (CRAO) indicate beneficial effects of intravenous thrombolysis when initiated early after symptom onset. Randomized data are lacking to address this question.

AIMS

The REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION) investigates intravenous alteplase within 4.5 h of monocular vision loss due to acute CRAO.

METHODS

This study is the randomized (1:1), double-blind, placebo-controlled, multicenter adaptive phase III trial.

STUDY OUTCOMES

Primary outcome is functional recovery to normal or mildly impaired vision in the affected eye defined as best-corrected visual acuity of the Logarithm of the Minimum Angle of Resolution of 0.5 or less at 30 days (intention-to-treat analysis). Secondary efficacy outcomes include modified Rankin Score at 90 days and quality of life. Safety outcomes include symptomatic intracranial hemorrhage, major bleeding (International Society on Thrombosis and Haemostasis definition) and mortality. Exploratory analyses of optical coherence tomography/angiography, ultrasound and magnetic resonance imaging (MRI) biomarkers will be conducted.

SAMPLE SIZE

Using an adaptive design with interim analysis at 120 patients, up to 422 participants (211 per arm) would be needed for 80% power (one-sided alpha = 0.025) to detect a difference of 15%, assuming functional recovery rates of 10% in the placebo arm and 25% in the alteplase arm.

DISCUSSION

By enrolling patients within 4.5 h of CRAO onset, REVISION uses insights from meta-analyses of CRAO case series and randomized thrombolysis trials in acute ischemic stroke. Increased rates of early reperfusion and good neurological outcomes in stroke may translate to CRAO with its similar pathophysiology.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04965038; EU Trial Number: 2023-507388-21-00.

Update on central retinal artery occlusion

The medical condition referred to as "central retinal artery occlusion" (CRAO) was first documented by Albrecht von Graefe in 1859. Subsequently, CRAO has consistently been identified as a serious medical condition that leads to substantial visual impairment. Furthermore, it is correlated with vascular complications that have the potential to affect crucial organs such as the brain and heart. A considerable amount of research has been extensively published on the various aspects of this topic, which is marked by notable debates and misconceptions, especially regarding its management and outcomes. The primary aim of this review article is to analyze the latest developments in the understanding of CRAO, which includes its causes, techniques for retinal imaging, systemic evaluation, and therapeutic strategies, such as vitrectomy. This review article offers readers a comprehensive learning experience to gain knowledge on the fundamental principles and recent advancements in CRAO.

Efficacy and safety of hyperbaric oxygen therapy monitored by fluorescein angiography in patients with retinal artery occlusion

AIMS

To assess the efficacy and safety of a standardised hyperbaric oxygen therapy protocol (HBOT) monitored by fluorescein angiography (FA) in patients with retinal artery occlusion (RAO).

METHODS

It is a prospective, non-comparative, monocentric study conducted between July 2016 and March 2022. All consecutive patients diagnosed with RAO within 7 days underwent visual acuity measurement, FA, macular optical coherence tomography (OCT) and OCT-angiography. They received two daily HBOT sessions (2.5 atmosphere absolute, 90 min) until revascularisation assessed by FA. Complete ophthalmic follow-up was scheduled at day 14, day 21 and at 1 month. The main outcome measure was a best-corrected visual acuity (BCVA) improvement defined as a decrease ≥0.3 logMAR at 1 month.

RESULTS

Thirty-one patients were included and received a mean number of 33.9 (13-56) HBOT sessions. Retinal revascularisation was observed in 48.4% and 87.1% of patients at days 14 and 21, respectively. The mean BCVA on referral and at 1 month was 1.51 logMAR and 1.10 logMAR, respectively. Fifteen (48.4%) patients achieved the main outcome measure. Six (19.4%) patients experienced minor barotrauma that did not require HBOT discontinuation. The univariate analysis showed that antiplatelet-treated patients (p=0.044) and patients with a poor initial BCVA (p=0.008) were more likely to achieve a BCVA improvement. OCT-angiography was not sensitive enough to diagnose RAO or assess revascularisation.

CONCLUSION

In RAO patients monitored by FA until spontaneous revascularisation of the central retinal artery, HBOT was effective and safe.

Implementation of a retinal stroke-code protocol results in visual recovery in patients receiving reperfusion therapies

INTRODUCTION

Reperfusion therapies represent promising treatments for patients with Central Retinal Artery Occlusion (CRAO), but access is limited due to low incidence and lack of protocols. We aimed to describe the benefit of implementing a Retinal Stroke-Code protocol regarding access to reperfusion, visual acuity and aetiological assessment.

PATIENTS AND METHODS

Prospective cohort study performed at a Comprehensive Stroke Centre. Criteria for activation were sudden monocular, painless vision loss within 6 h from onset. Eligible patients received IAT when immediately available and IVT otherwise. All patients were followed by ophthalmologists to assess best-corrected visual acuity (BCVA) and visual complications, and by neurologists for aetiological workup. Visual amelioration was defined as improvement of at least one Early Treatment Diabetic Retinopathy Study (ETDRS) letter from baseline to 1 week.

RESULTS

Of 49 patients with CRAO, 15 (30.6%) received reperfusion therapies (12 IVT, 3 IAT). Presentation beyond 6 h was the main contraindication. Patients receiving reperfusion therapies had better rates of visual improvement (33.3% vs 5.9%, p = 0.022). There were no complications related to reperfusion therapies. Rates of neovascular glaucoma were non-significantly lower in patients receiving reperfusion therapies (13.3% vs 20.6%, p = 0.701). Similar rates of atherosclerotic, cardioembolic and undetermined aetiologies were observed, leading to 10 new diagnosed atrial fibrillation and five carotid revascularizations.

CONCLUSION

A comprehensive acute management of CRAO is feasible despite low incidence. In our study, reperfusion therapies were safe and associated with higher rates of visual recovery. A similar etiological workup than ischemic stroke led to of high proportion of underlying aetiologies.

A Remote Consult Retinal Artery Occlusion Diagnostic Protocol

PURPOSE

To report a novel protocol for diagnosis of retinal artery occlusions at the point of care using OCT and a remote consult model.

DESIGN

Retrospective case series and evaluation of a diagnostic test or technology.

PARTICIPANTS

Adult patients who presented with painless monocular vision loss and were diagnosed with a nonarteritic retinal artery occlusion.

METHODS

OCT machines were placed in the stroke center or emergency department at 3 hospitals within our health system. Patients who presented with painless monocular vision loss were evaluated by the stroke neurology service and an OCT was acquired. The images were interpreted remotely by the retina service. An in-house ophthalmology consult was not required to make the final treatment decision. Eligible patients were treated with intra-arterial tissue plasminogen activator (IA-tPA). Patients were followed by ophthalmology during their admission when an in-house consultation service was available or otherwise evaluated immediately after discharge.

MAIN OUTCOME MEASURES

Visual acuity (VA) before and after treatment with IA-tPA; time from last known well (LKW) to treatment; and time from presentation to treatment.

RESULTS

In the first 18 months since the protocol went live, 59 patients were evaluated. Twenty-five patients (42%) had a confirmed retinal artery occlusion based on OCT and follow-up examination. Ten patients were eligible for treatment, and 9 patients received treatment with IA-tPA. There was a statistically significant improvement in mean VA from logarithm of the minimum angle of resolution (logMAR) 2.14 to logMAR 0.7 within 24 hours after treatment (P = 0.0001) and logMAR 1.04 after 4 weeks (P = 0.01). Clinically significant improvement was noted in 66% of patients within 24 hours and maintained through 1 month in 56% of all treated patients. The mean time to treatment from LKW was 543 minutes and from presentation at the stroke center was 146 minutes.

CONCLUSIONS

We report the successful implementation of a remote consult protocol using point-of-care automated OCT. This novel paradigm demonstrates the potential utility of remote consult services for the diagnosis of time-sensitive ophthalmic emergencies.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Comparison of vascular risk profile and clinical outcomes among patients with central (branch) retinal artery occlusion versus amaurosis fugax

BACKGROUND

Retinal artery occlusions lead to sudden, painless vision loss, affecting millions globally. Despite their significance, treatment strategies remain unestablished, contrasting with acute ischemic stroke (AIS), where IVT has proven efficacy. Similar to AIS, retinal artery occlusions demand urgent evaluation and treatment, reflecting the principle "time is retina". Even for patients with transient monocular vision loss, also known as amaurosis fugax (AF), pertinent guidelines meanwhile recommend immediate emergency assessment in a specialized facility. However, data on the clinical benefit and comparability with persistent occlusions are missing. This study aimed to compare the results of a comprehensive stroke-workup among patients with persistent retinal artery occlusions (RAO), including both central retinal (CRAO) and branch retinal artery occlusion (BRAO) and those with AF.

METHODS

Conducted at the University Hospital Giessen, Germany, this exploratory cross-sectional study enrolled patients with transient or permanent unilateral vision loss of non-arteritic origin. The primary outcome were differences between the two groups RAO and AF with regard to cardiovascular risk profiles and comorbidities, vascular and pharmacological interventions and clinical neurological and ophthalmological outcomes. Secondary outcome was a sub-group analysis of patients receiving IVT.

RESULTS

Out of 166 patients assessed, 76 with RAO and 40 with AF met the inclusion criteria. Both groups exhibited comparable age, gender distribution, and cardiovascular risk profiles. Notably, RAO patients did not show significantly more severe vascular comorbidities than AF patients. However, AF patients received vascular interventions more frequently. Pharmacological intervention rates were similar across groups. RAO patients had slightly worse neurological outcomes, and IVT did not yield favorable ophthalmological outcomes within any observed patients.

CONCLUSION

The study found similar vascular burden and risk factors in patients with RAO and AF, with implications for clinical workflows. IVT for RAO may only be effective in very early treatment windows. This emphasizes the need for public awareness and collaborative protocols between ophthalmologists and neurologists to improve outcomes.

Retinal Artery Reperfusion After Translumenal YAG Laser Embolysis in a Case of Branch Retinal Artery Occlusion

Purpose: To present a potential treatment for embolic branch retinal artery occlusion (BRAO). Methods: A case and its findings were analyzed. Results: A 75-year-old man with a 5-day history of an acute superior visual field defect in the right eye was found to have a BRAO secondary to a Hollenhorst plaque and was treated with translumenal YAG laser embolysis. Reperfusion of the retinal artery was observed on dislodging the Hollenhorst plaque, and improvements were seen in the patient's superior visual field defect. Conclusions: Translumenal YAG laser embolysis could potentially reverse ischemia secondary to embolic RAOs. This case report and the current literature cited suggest a rationale for treatment and supports further study of this technique.

Ophthalmic vascular manifestations in eosinophil-associated diseases: a comprehensive analysis of 57 patients from the CEREO and EESG networks and a literature review

Introduction

Eosinophils have widespread procoagulant effects. In daily practice, eosinophil-related cardiovascular toxicity consists of endomyocardial damage, eosinophilic vasculitis and arterial or venous thrombosis. Here we aim to report on the clinical features and treatment outcomes of patients with unexplained ophthalmic vascular manifestations and eosinophilia.

Methods

We conducted a retrospective, multicenter, observational study and a literature review of patients with eosinophilia (≥0.5 x109/L) and concomitant ophthalmic vascular manifestations independent of the underlying eosinophilic disease but with no alternative cause for ophthalmic manifestations.

Results

Fifty-seven patients were included (20 from the observational study and 37 from the literature review). Ophthalmic vascular features were the initial manifestation of eosinophil-related disease in 34 (59%) patients and consisted of 29 central retinal artery occlusions, six branch retinal artery occlusions, five central retinal vein occlusions, two branch retinal vein occlusions, seven retinal vasculitides, two retinal vasospasms, 12 Purtscher's retinopathies, 13 anterior ischemic optic neuropathies and two posterior ischemic optic neuropathies. The median [IQR] absolute eosinophil count at onset of ophthalmic vascular manifestations was 3.5 [1.7-7.8] x109/L. Underlying eosinophil-related diseases included eosinophilic granulomatosis with polyangiitis (n=32), clonal hypereosinophilic syndrome (HES) (n=1), idiopathic HES (n=13), lymphocytic HES (n=2), adverse drug reactions (n=3), parasitosis (n=2), polyarteritis nodosa (n=1), IgG4-related disease (n=1), eosinophilic fasciitis (n=1) and primary sclerosing cholangitis (n=1). Other extra-ophthalmologic arterial or venous thromboses related to eosinophilia were reported in four (7%) and nine (16%) patients, respectively. Visual prognosis was poor: only eight (10%) patients achieved full recovery of ophthalmologic symptoms. After a median follow-up of 10.5 [1-18] months, one patient (3%) had a recurrence of an ophthalmic vascular manifestation, and three patients (10%) had a recurrence of other vascular symptoms (deep vein thrombosis in two and pulmonary embolism in one patient). At the time of recurrence, absolute eosinophil counts were above 0.5 x109/L in all cases (n=4).

Discussion

This study broadens the spectrum of vascular manifestations associated with hypereosinophilia by adding ophthalmic vascular manifestations. In patients with ophthalmological vascular manifestations and hypereosinophilia, aggressive treatment of the underlying pathology (and normalization of blood count) should be implemented.

Thrombolysis in acute retinal ischemia treated with tenecteplase

Central retinal artery occlusion (CRAO), a type of acute retinal arterial ischemia, analogous to an ocular stroke, is a medical emergency that warrants immediate diagnosis and treatment. CRAO usually presents with sudden, painless, monocular vision loss. Ipsilateral carotid artery disease is an important associated finding in these patients. The primary limitation to effective treatment of CRAO is that patients are rarely seen in the acute stage. Moreover, there are no guidelines for effective treatment. We report a patient with right CRAO whose treatment with intravenous thrombolysis with tenecteplase and anterior chamber paracentesis with ocular massage resulted in a good clinical outcome.

Evaluation of Increase in Retinal Thickness as Diagnostic Marker in Central Artery Occlusion

PURPOSE

To evaluate the increase in retinal thickness as a marker in predicting the onset of central retinal artery occlusions.

METHODS

Retrospective clinical study conducted at one Swiss hospital. Electronic records were filtered for patients with artery occlusions. Optical coherence tomography data, including time between the imaging and ischemic event, were reviewed. Increase in relative retinal thickness was measured, defined as an increase in retinal thickness compared to the unaffected partner eye. This was correlated with the time from symptom onset. A cutoff value of relative increase of < 24.5% was applied, as suggested in previous studies. The results were compared to the time gathered from the electronic records, and sensitivity, specificity, positive predictive value as well as negative predictive value were calculated for predicting an ischemia time of < 4.5 h.

RESULTS

Forty-two eyes from 41 patients with central artery occlusions were identified. Fourteen were female. Mean age was 66.4 ± 15.8 years. Initial corrected visual acuity was 2.41 ± 0.68 logMAR, and 2.13 ± 0.87 logMAR at the last follow-up (p > 0.05). Of eyes with a visual acuity of counting fingers (n = 38) or worse, 89.5% showed no improvement during follow-up, while eyes with logMAR 1 or better (n = 4) improved. Thirteen eyes (13 patients) presented within 4.5 h of the ischemic event. Four patients received i. v. thrombolysis, with visual recovery in one. In 12 eyes with an ischemia time of < 4.5 h, relative increase was below 24.5%. In the remaining 29 eyes with > 4.5 h, relative increase was below 24.5% in 4 eyes and above 24.5% in 25 eyes. This yielded a sensitivity of 92.3%, a specificity of 86.2%, with a positive predictive value of 75.0% and a negative predictive value of 96.2%.

CONCLUSION

Central retinal artery occlusion is associated with severe vision loss. There is no current established therapy. Parameters that objectify the presence of a therapeutic window for thrombolysis are gaining in importance as patient history is often imprecise. Relative retinal thickness increase proved a noninvasive imaging parameter demonstrating adequate performance in detecting patients within the therapeutic window of thrombolysis. Further investigation of this parameter in central retinal occlusion is warranted.

Aetiology, Diagnosis and Treatment of Arterial Occlusions of the Retina-A Narrative Review

Arterial occlusions of the retina are potentially sight-threatening diseases which often result in profound visual loss. The aim of this narrative review is to provide an overview of the aetiology, discuss major risk factors, describe the management and systemic assessments and evaluate existing therapies. For this review, an extensive literature search in PubMed was performed. Emboli from the heart or the carotid arteries can cause ophthalmic artery occlusion (OAO), central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO). Most patients with arterial occlusions have vascular risk factors such as arterial hypertension, hyperhomocysteinaemia, carotid stenosis and atrial fibrillation, which also increase the risk of cerebral stroke and myocardial infarction. Therapies such as ocular massage, thrombolysis and anterior chamber paracentesis have been suggested but are still equivocal. However, it is evident that retinal artery occlusion should be immediately treated and accompanied by interdisciplinary collaboration, since early diagnosis and the proper treatment of possible risk factors are important to reduce the risk of further damage, recurrences, other vascular diseases and mortality.

Improved visual outcomes of central retinal artery occlusion with local intra-arterial fibrinolysis beyond the conventional time window

Local intra-arterial fibrinolysis (LIF) is a promising therapeutic option for CRAO. However, the narrow time window of 6 h has greatly limited the application of LIF. In this study, we explored the efficacy of LIF beyond the conventional time windows and compared the result with conservative therapy. This prospective study included 179 CRAO patients with baseline visual acuity (VA) ≤ 20/400 treated at Renmin Hospital of Wuhan University. The mean time from vision loss to presentation was 5.5 days. 58 patients received conventional standard therapy (CST) alone.121 patients underwent LIF. Main outcome was VA improvement ≥ 0.3 logMAR. Secondary outcome was a favorable VA outcome of 20/200 or better. Logistic regressions were performed to identify predictors of visual improvement. 43% patients in the LIF group experienced VA improvement versus 19% with CST (P = 0.002). LIF was associated with 4.0-fold higher likelihood of visual improvement compared to CST (P = 0.001). Poor baseline VA (light perception or no light perception) and shortened prothrombin time (PT) were associated with greater chance of visual improvement with LIF. However, LIF showed no significant advantage over CST for favorable VA outcomes. No major complications occurred. LIF beyond the therapeutic time window improved vision in functionally blind CRAO patients and showed better efficacy when compared with CST. PT may be a potential predictor of visual outcome after LIF. Our findings could complement existing time-based treatment guidelines and potentially allow for personalized decisions on the use of LIF beyond time windows.

A Review of Current Literature on Central Retinal Artery Occlusion: Its Pathogenesis, Clinical Management, and Treatment

The ocular analogue of a cerebral stroke is central retinal artery occlusion (CRAO), a medical emergency concerning the eyes. Most patients experience substantial acute vision loss with a visual acuity of 20/400 or worse, resulting in decreased quality of life (QoL) and decreased functional ability. An impending cerebral stroke and ischemic heart disease are also more likely. The four distinct clinical entities that make up CRAO are non-arteritic CRAO, transitory non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, and arteritic CRAO. Depending on the CRAO type, clinical traits, visual results, and treatment all vary greatly. Contrary to current belief, there is a spontaneous improvement in the optical field and vision, mainly in the first week. The likelihood of instinctive development in optical acuity in the first seven days varies greatly. The pathogenesis, epidemiology, and medical features of CRAO will be described in this review, along with present and potential management future options.

Network Meta-Analysis of Different Thrombolytic Strategies for the Treatment of Central Retinal Artery Occlusion

PURPOSE

Intravenous and intra-arterial thrombolytic strategies have been used to treat central retinal artery occlusion (CRAO); however, previous meta-analyses evaluated the efficacy of these two thrombolytic strategies separately but did not compare them. This network meta-analysis aimed to evaluate the comparative efficacy and safety of different thrombolytic methods for treating CRAO.

METHODS

We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfangdata to identify relevant studies published before 1 January 2023. We used the "network" command in STATA 14.0 software to perform network meta-analysis. In addition, we calculated the surface under the cumulative ranking (SUCRA) to rank all currently available thrombolytic strategies.

RESULTS

We included 12 studies in the final data analysis. Results suggested that, compared with standard treatment (ST), intravenous tissue plasminogen activator (IVtPA) (OR, 5.78; 95% CI, 2.07 to 16.11) and intra-arterial urokinase (IAUK) (OR, 2.78; 95% CI, 1.10 to 7.02) and intra-arterial tPA (IAtPA) (OR, 2.45; 95% CI, 1.04 to 5.77) achieved better visual improvement. The differences in visual improvement among IVtPA, IAUK, and IAtPA are insignificant. Furthermore, compared with ST, administration of IVtPA within 4.5 hours of CRAO onset (OR, 8.87; 95% CI, 3.35 to 23.48) rather than administration after 4.5 hours of onset (OR, 3.09; 95% CI, 0.81 to 11.70) achieved better visual improvement. In addition, compared to ST, all available thrombolytic strategies we evaluated were associated with a higher risk of adverse events, but these strategies did not differ. Based on the results of SUCRA, IVtPA had the highest ranking probability in visual improvement (91.9%) but had a relatively lower ranking probability of adverse events (60.1%).

CONCLUSION

Both intravenous and intra-arterial thrombolytic strategies are effective for treating CRAO, but SUCRA results show that IVtPA may be the optimal strategy for treating CRAO. Furthermore, based on the results of subgroup analysis, we further speculate that IVtPA injection within 4.5 hours of the onset of CRAO should be the optimal thrombolytic option for treating CRAO. However, due to the limitations of all eligible studies, more studies are still required in the future to validate our findings.

Thrombolytic Therapy for Central Retinal Artery Occlusion in an Academic Multi-Site Stroke Centre

Central retinal artery occlusion (CRAO) is a subtype of acute ischaemic stroke leading to severe visual loss. A recent American Heart Association scientific statement proposed time-windows for thrombolysis in CRAO similar to acute ischaemic cerebral strokes. We aimed to review our academic multi-site stroke centre experience with intravenous (IVT) and intra-arterial thrombolysis (IAT) in CRAO between 1997 and 2022. Demographic, clinical characteristics, thrombolysis timeline, concurrent therapies, complications, and 3-month follow-up visual acuity (VA) were collected. The thrombolysed cohort follow-up VA was compared with an age, gender and baseline VA matched cohort of CRAO patients that received conservative therapies. Thrombolytic therapy was administered to 3.55% (n = 20) of CRAO admissions; 13 IVT (mean age 68, 61.5% male, 12 alteplase and 1 tenecteplase, all embolic aetiology, 1 CRAO mimic) and 7 IAT (mean age 55, 85.7% male, 3 post-operative and 3 embolic). Additional conservative CRAO-targeting therapies was received by 60%. The median time from onset of visual loss to IVT was 158 minutes (range 67-260). Improvement by at least two Snellen lines was achieved by 25% with 12.5% improving to 20/100 or better. Intracranial haemorrhage post IVT occurred in 1/13 (7.6%). The median time from onset of visual loss to IAT was 335 minutes. Improvement by at least two Snellen lines was achieved by 42%. No difference in 3-month VA was noted between patients that received thrombolysis, either alone (n = 8) or combined with other therapies, and those that received conservative therapies. Our results suggest that the management of acute CRAO remains heterogeneous. The lack of obvious benefit of thrombolysis in our small series supports the need for randomizsd clinical trials comparing thrombolysis to placebo to guide hyperacute CRAO management.

Safety and effectiveness of IV Thrombolysis in retinal artery occlusion: A multicenter retrospective cohort study

BACKGROUND

Retinal artery occlusion (RAO) may lead to irreversible blindness. For acute RAO, intravenous thrombolysis (IVT) can be considered as treatment. However, due to the rarity of RAO, data about IVT safety and effectiveness is limited.

METHODS

From the multicenter database ThRombolysis for Ischemic Stroke Patients (TRISP), we retrospectively analyzed visual acuity (VA) at baseline and within 3 months in IVT and non-IVT treated RAO patients. Primary outcome was difference of VA between baseline and follow up (∆VA). Secondary outcomes were rates of visual recovery (defined as improvement of VA ⩾ 0.3 logMAR), and safety (symptomatic intracranial hemorrhage (sICH) according to ECASS II criteria, asymptomatic intracranial hemorrhage (ICH) and major extracranial bleeding). Statistical analysis was performed using parametric tests and a linear regression model adjusted for age, sex and baseline VA.

RESULTS

We screened 200 patients with acute RAO and included 47 IVT and 34 non-IVT patients with complete information about recovery of vision. Visual Acuity at follow up significantly improved compared to baseline in IVT patients (∆VA 0.5 ± 0.8, p < 0.001) and non-IVT patients (∆VA 0.40 ± 1.1, p < 0.05). No significant differences in ∆VA and visual recovery rate were found between groups at follow up. Two asymptomatic ICH (4%) and one (2%) major extracranial bleeding (intraocular bleeding) occurred in the IVT group, while no bleeding events were reported in the non-IVT group.

CONCLUSION

Our study provides real-life data from the largest cohort of IVT treated RAO patients published so far. While there is no evidence for superiority of IVT compared to conservative treatment, bleeding rates were low. A randomized controlled trial and standardized outcome assessments in RAO patients are justified to assess the net benefit of IVT in RAO.

Long-term outcomes of intravenous fibrinolysis in central retinal artery occlusion

Central retinal artery occlusion (CRAO) is an ophthalmologic emergency that can lead to irreversible loss of vision. Intravenous thrombolysis (IVT) has been used experimentally for its treatment. Our study aimed to evaluate the effect of emergency IVT on CRAO and its impact on visual acuity outcomes. We conducted a retrospective observational study of patients with CRAO. A total of 46 patients with CRAO were analysed; 16 patients received IVT treatment (IVT group) while 30 did not (no-IVT group). Seven patients from the IVT group received IVT early, within 4.5 hours (h) after the onset of symptoms (early-IVT), and 9 patients received it beyond this timeframe (late-IVT). The median time-to-hospital was 8.5 h: 3 h for the IVT group and 24 h for the no-IVT group. The median time-to-treatment was 5 h. The median outcome of visual acuity was 0.05 in the early-IVT, 0.025 in the late-IVT, and 0.01 in the no-IVT group. Among patients who received IVT early, 86% exhibited significant visual improvement. This improvement was four-fold greater compared to all other groups (p = 0.040), including the late-IVT (p = 0.011) and no-IVT groups (p = 0.023). No complications of the treatment were reported. Our study confirms that the administration of IVT treatment for CRAO within the 4.5-h time window is both safe and effective.

Presence of Embolic Source and Outcome in Central Retinal Artery Occlusion

OBJECTIVES

The etiology of central retinal artery occlusion (CRAO) is unclear in approximately 50% of patients, suggesting pathomechanical heterogeneity; moreover, little is known about outcomes according to etiology. This study investigated whether the presence of an embolic source affects outcome in CRAO.

METHODS

CRAO patients within 7 days of symptom onset were retrospectively enrolled. Clinical parameters, including initial and 1-month visual acuity, CRAO subtype, and brain images, were reviewed. CRAO etiology was categorized as CRAO with or without an embolic source (CRAO-E+ and CRAO-E-). Visual improvement was defined as a decrease in logarithm of the minimum angle of resolution ≥0.3 at 1 month.

RESULTS

A total of 114 patients with CRAO were included. Visual improvement was noted in 40.4% of patients. Embolic sources were identified in 55.3% of patients, and visual improvement group rather than no improvement group was more commonly associated with the presence of an embolic source. In multivariable logistic regression analysis, CRAO-E+ independently predicted visual improvement (odds ratio 3.00, 95% CI 1.15-7.81, p = 0.025).

DISCUSSION

CRAO-E+ was found to be associated with a better outcome. CRAO-E+ may be more prone to recanalization than that CRAO-E-.

Analysis of the Association between Retinal Artery Occlusion and Acute Ischaemic Stroke/ST-Elevation Myocardial Infarction and Risk Factors in Hungarian Patients

Background and Objectives: We aimed to analyse data on retinal artery occlusion (RAO) patients to explore correlations with acute ischaemic stroke (AIS), ST-elevation myocardial infarction (STEMI), and cardio/cerebrovascular comorbidities. Patients and Methods: Our retrospective cohort study included 169 RAO and 169 age- and gender-matched control patients. We examined the association of AIS, STEMI, and related comorbidities such as hypertension (HT), type 1 and type 2 diabetes (T1DM and T2DM, respectively), hyperlipidaemia, and ischaemic heart disease (IHD) with RAO. We also recorded atrial fibrillation in our RAO patients. Results: Our results demonstrated that RAO patients developed both AIS and STEMI at a significantly higher rate compared to controls (p < 0.001 for both). We also found that RAO patients had a significantly higher prevalence of HT and hyperlipidaemia (p1 = 0.005, p2 < 0.001) compared to controls. Multiple risk factors together significantly increased the odds of developing AIS and STEMI. Conclusions: Our results suggest that through identifying and treating the risk factors for RAO patients, we can reduce the risk of AIS, STEMI, and RAO of the fellow eye. Considering that ophthalmologists are often the first detectors of these cardiovascularly burdened patients, collaboration with colleagues from internal medicine, cardiology, and neurology is essential to achieve secondary prevention.

Visual Recovery in 2 Cases of Central Retinal Artery Occlusion Treated With Prompt Intra-ophthalmic Artery Fibrinolysis

BACKGROUND

Central retinal artery occlusion (CRAO) rapidly produces inner retinal ischemia and irreversible vision loss. Although many therapeutic interventions have been proposed, no interventions have proven effective in restoring vision in large randomized controlled trials and final visual outcome in most patients is very poor.

METHODS

Retrospective case series.

RESULTS

We describe 2 cases of CRAO occurring after uncomplicated cataract surgery under topical anesthesia and rapidly diagnosed. Both had very severe vision loss at presentation with dramatic improvement after intra-ophthalmic artery fibrinolysis administered 2.75 and 5.5 hours after symptom onset.

CONCLUSIONS

Sudden monocular vision loss is an ophthalmologic emergency as CRAO must be ruled out and if diagnosed, rapid intervention should be performed. Devastating vision loss can be prevented if interventional neuroradiology is trained and available on a 24-hour basis for administration of local intra-arterial thrombolysis.

Progress in central retinal artery occlusion: a narrative review

Central retinal artery occlusion (CRAO) is a catastrophic ophthalmic emergency that severely impairs a patient's visual function, often reducing visual acuity to counting fingers or worse. Progress in CRAO research has provided new information regarding its epidemiological characteristics and led to useful assessments through various ophthalmic examinations. Additional insights about CRAO have been gained through studies of its pathophysiological mechanisms, improving intervention timing and enhancing patient prognosis. Treatment for CRAO has evolved, particularly with assistance from surgical instruments and surgical robots. Although surgical treatment is now possible, this option is not widely recognized by ophthalmologists. Conservative therapies have limited benefits compared with the natural course of disease. Recently, pars plana vitrectomy plus endovascular surgery has received considerable interest among ophthalmologists because of its potential efficacy in the treatment of CRAO. Considering the inconsistencies in rationale and efficacy of CRAO treatment modalities, it is important to distinguish between treatment effects and the natural courses of various CRAO subclasses. This narrative review explores progress in CRAO epidemiology, pathophysiology, ophthalmic examination, and treatment.

An Ocular Emergency Often Ignored

Branch retinal artery occlusion (BRAO) is a relatively rare vascular disorder characterized by the occlusion of one or more branches of the central retinal artery, with an incidence of around 5 per 100,000 persons per year. Its ability to cause permanent vision loss in a specific visual field makes it a significant clinical obstacle that requires careful management. We describe a case of a 77-year-old male patient, a known hypertensive (on medication and whose hypertension was under control), presented with sudden painless loss of vision in the superior field of his right eye. Timely and accurate diagnosis is crucial to initiate appropriate management. Patients with hypertension should be routinely screened for its various micro- and macrovascular complications, and prophylactic therapy/management should be started wherever warranted.

Intra-arterial Thrombolysis for Acute Retinal Ischemia: A Retrospective, Observational, Cohort Study

BACKGROUND

To determine whether intra-arterial thrombolysis (IAT) within 16 hours after the onset of symptoms is feasible and associated with better visual outcomes in patients with acute retinal ischemia (ARI).

METHODS

The retrospective cohort study was performed from January 2014 to December 2021 in the Xuanwu Hospital of Capital Medical University. Patients with ARI who initially presented visual acuity of 20/100 or worse were screened in the study. Visual end points were evaluated at one week and at final visit after treatment. Serious adverse events were recorded during operation and within 1 week after IAT treatment.

RESULTS

The amount of clinically significant visual improvement (≥0.3 logarithm of the minimum angle of resolution) in the IAT group was significantly higher than that in the conservative treatment group at one week after the treatment (47.8% vs 16.7%; P = 0.014) and at final visit (52.2% vs 20%; P = 0.014). After controlling confounding factors, ARI treatment was the only factor significantly associated with the amount of clinically significant visual improvement (OR, 4.364; 95 CI, 1.298-14.667; P = 0.017). A patient (4.3%) experienced retinal hemorrhage without symptom within 1 week after IAT treatment. No patients experienced new symptomatic cerebral infarction, intracranial hemorrhage, TIA, artery dissection, vascular perforation, and distal embolization during operation and within 1 week after IAT treatment.

CONCLUSIONS

IAT may be associated with better visual improvement within 16 hours after the onset of symptoms. Besides, IAT is feasible and associated with a low risk of periprocedural complications for ARI. This study will aid in feasibility testing and sample size calculations in advance of future, fully-powered efficacy studies for ARI.

Neuroprotection for Nonarteritic Central Retinal Artery Occlusion: Lessons from Acute Ischemic Stroke

Nonarteritic central retinal artery occlusion (NA-CRAO) is a variant of acute ischemic stroke (AIS) and is a cause of sudden severe loss of vision. There are guidelines by the American Heart Association and the American Stroke Association for the care of CRAO patients. This review explores the basis of retinal neuroprotection for CRAO and its potential for improving the outcome of NA-CRAO. Recently, there have been significant advances in research into the use of neuroprotection to treat retinal diseases, including retinal detachment, age-related macular degeneration, and inherited retinal diseases. Also, neuroprotective research in AIS has been extensive, and newer drugs tested, including Uric acid, Nerinetide, and Otaplimastat, with promising results. Progress in cerebral neuroprotection after AIS offers hope for retinal neuroprotection after CRAO; and a possibility of extrapolating research findings from AIS into CRAO. Combining neuroprotection and thrombolysis can extend the therapeutic window for NA-CRAO treatment and potentially improve outcomes. Experimented neuroprotection for CRAO includes Angiopoietin (Comp Ang1), KUS 121, Gene therapy (XIAP), and hypothermia. Efforts in the field of neuroprotection for NA-CRAO should focus on better imaging to delineate the penumbra after an acute episode of NA-CRAO (using a combination of high-definition optical coherence angiography and electrophysiology). Also, research should explore details of pathophysiologic mechanisms involved in NA-CRAO, allowing for further neuroprotective intervention, and closing the gap between preclinical and clinical neuroprotection.

Effects of Resveratrol on Vascular Function in Retinal Ischemia-Reperfusion Injury

Ischemia-reperfusion (I/R) events are involved in the development of various ocular pathologies, e.g., retinal artery or vein occlusion. We tested the hypothesis that resveratrol is protective against I/R injury in the murine retina. Intraocular pressure (IOP) was elevated in anaesthetized mice to 110 mm Hg for 45 min via a micropipette placed in the anterior chamber to induce ocular ischemia. In the fellow eye, which served as control, IOP was kept at a physiological level. One group received resveratrol (30 mg/kg/day p.o. once daily) starting one day before the I/R event, whereas the other group of mice received vehicle solution only. On day eight after the I/R event, mice were sacrificed and retinal wholemounts were prepared and immuno-stained using a Brn3a antibody to quantify retinal ganglion cells. Reactivity of retinal arterioles was measured in retinal vascular preparations using video microscopy. Reactive oxygen species (ROS) and nitrogen species (RNS) were quantified in ocular cryosections by dihydroethidium and anti-3-nitrotyrosine staining, respectively. Moreover, hypoxic, redox and nitric oxide synthase gene expression was quantified in retinal explants by PCR. I/R significantly diminished retinal ganglion cell number in vehicle-treated mice. Conversely, only a negligible reduction in retinal ganglion cell number was observed in resveratrol-treated mice following I/R. Endothelial function and autoregulation were markedly reduced, which was accompanied by increased ROS and RNS in retinal blood vessels of vehicle-exposed mice following I/R, whereas resveratrol preserved vascular endothelial function and autoregulation and blunted ROS and RNS formation. Moreover, resveratrol reduced I/R-induced mRNA expression for the prooxidant enzyme, nicotinamide adenine dinucleotide phosphate oxidase 2 (NOX2). Our data provide evidence that resveratrol protects from I/R-induced retinal ganglion cell loss and endothelial dysfunction in the murine retina by reducing nitro-oxidative stress possibly via suppression of NOX2 upregulation.

Retinal Vascular Occlusion Risks in High Blood Pressure and the Benefits of Blood Pressure Control

PURPOSE

This study aimed to evaluate the association of retinal vascular occlusion, including retinal vein occlusion (RVO) and retinal artery occlusion (RAO), with stages of hypertension.

DESIGN

Nationwide, population-based retrospective cohort study.

METHODS

Based on baseline blood pressure (BP) as defined by the 2017 American College of Cardiology/American Heart Association guideline, participants were categorized into 4 BP groups. For the BP change measurement, BP groups were defined based on the combination of baseline and follow-up BP categories. The composite retinal vascular occlusion events and hazard ratios (HRs) of retinal vascular occlusion according to BP groups were estimated.

RESULTS

With normal BP as the reference, multivariate-adjusted HRs for retinal vascular occlusion were significantly higher than in other BP groups, showing much higher HRs in stage 2 hypertension than in stage 1 (HR, 1.10 for elevated BP; 1.07 for stage 1 hypertension; and 1.32 for stage 2 hypertension). Individual disease analysis showed consistent statistical significance in RVO, whereas RAO showed nonsignificant results. Lowering BP significantly decreased the HRs of retinal vascular occlusion in both stage 1 and stage 2 hypertension (HR, 0.88 and 0.73, respectively). However, once hypertension was diagnosed, the risk of retinal vascular occlusion was higher compared to that in the normal BP groups.

CONCLUSIONS

Elevated BP, stage 1 hypertension, and stage 2 hypertension were all associated with higher retinal vascular occlusion risks than was normal BP. Controlling hypertension appears to reduce the risk of subsequent retinal vascular occlusion; however, the incidence rate was still be significantly higher than that in persons who maintained a normal BP.

Thrombolysis in central retinal artery occlusion: a retrospective observational study

BACKGROUND

There is no evidence-based therapy for non-arteritic central retinal artery occlusion (NA-CRAO). Intravenous thrombolysis (IVT) with alteplase in a time window < 4.5 h may lead to a favorable outcome. Purpose of this study was to investigate the feasibility, efficacy and safety of IVT in patients classified as functionally blind.

METHODS

We conducted a retrospective observational study of NA-CRAO-patients. All patients underwent an ophthalmological and neurological examination including cerebral magnetic resonance imaging (MRI) for assessment of additional stroke lesions. Patients were treated either conservatively or with IVT within 4.5 h. Visual acuity (VA) was evaluated in logMAR and a categorical analysis was performed.

RESULTS

Thirty-seven patients were included in the study, 21 patients in the conservative treatment group (CTG) and 16 patients in the IVT group. The median logMAR visual acuity at admission and discharge was similar in both groups. The medium symptom to treatment time in the IVT group was 158.0 min. 3 patients (19%) of the IVT group showed a favorable outcome, all CTG patients remained at the level of functional blindness. No serious adverse events were observed after IVT. MRI showed additional acute stroke in over one-third of the patients (n = 14).

CONCLUSIONS

Early intravenous thrombolysis therapy according to the current stroke protocol n a time window up to 4.5 h after the onset of symptoms was feasible and might be a potential treatment option for NA-CRAO. Patients with NA-CRAO are at very high risk of ischemic stroke and MRI should be done in all patients for optimized treatment and secondary stroke prevention. A prospective randomized study is required.

Interventions for acute non-arteritic central retinal artery occlusion

BACKGROUND

Acute non-arteritic central retinal artery occlusion (CRAO) occurs as a sudden interruption of the blood supply to the retina and typically results in severe loss of vision in the affected eye. Although many therapeutic interventions have been proposed, there is no generally agreed upon treatment regimen.

OBJECTIVES

To assess the effects of treatments for acute non-arteritic CRAO.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 February 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing any interventions with another treatment in participants with acute non-arteritic CRAO in one or both eyes.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology and graded the certainty of the body of evidence for primary (mean change in best-corrected visual acuity [BCVA]) and secondary (quality of life and adverse events) outcomes using the GRADE classification.

MAIN RESULTS

We included six RCTs with 223 total participants with acute non-arteritic CRAO; the studies ranged in size from 10 to 84 participants. The included studies varied geographically: one in Australia, one in Austria and Germany, two in China, one in Germany, and one in Italy. We were unable to conduct any meta-analyses due to study heterogeneity. None of the included studies compared the same pair of interventions: 1) tissue plasminogen activator (t-PA) versus intravenous saline; 2) t-PA versus isovolemic hemodilution, eyeball massage, intraocular pressure reduction, and anticoagulation; 3) nitroglycerin, methazolamide, mecobalamin tablets, vitamin B1 and B12 injections, puerarin and compound anisodine (also known as 654-2) along with oxygen inhalation, eyeball massage, tube expansion, and anticoagulation compared with and without intravenous recombinant tissue plasminogen activator (rt-PA); 4) transcorneal electrical stimulation (TES) with 0 mA versus with 66% of the participant's individual electrical phosphene threshold (EPT) at 20 Hz (66%) versus with 150% of the participant's individual EPT (150%) at 20 Hz; 5) ophthalmic artery branch retrograde thrombolysis versus superselective ophthalmic artery thrombolysis; and 6) pentoxifylline versus placebo. There was no evidence of an important difference in visual acuity between participants treated with t-PA versus intravenous saline (mean difference [MD] at 1 month -0.15 logMAR, 95% confidence interval [CI] -0.48 to 0.18; 1 study, 16 participants; low certainty evidence); t-PA versus isovolemic hemodilution, eyeball massage, intraocular pressure reduction, and anticoagulation (MD at 1 month -0.00 logMAR, 95% CI -0.24 to 0.23; 1 study, 82 participants; low certainty evidence); and TES with 0 mA versus TES with 66% of EPT at 20 Hz versus TES with 150% of EPT at 20 Hz. Participants treated with t-PA experienced higher rates of serious adverse effects. The other three comparisons did not report statistically significant differences. Other studies reported no data on secondary outcomes (quality of life or adverse events).  AUTHORS' CONCLUSIONS: The current research suggests that proposed interventions for acute non-arteritic CRAO may not be better than observation or treatments of any kind such as eyeball massage, oxygen inhalation, tube expansion, and anticoagulation, but the evidence is uncertain. Large, well-designed RCTs are necessary to determine the most effective treatment for acute non-arteritic CRAO.

Efficacy and safety of intra-arterial thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis

PURPOSE

To investigate the efficacy and safety of intra-arterial thrombolysis (IAT) in patients with central retinal artery occlusion (CRAO).

METHODS

PubMed and EMBASE were searched for potentially eligible studies that reported IAT in CRAO patients from inception to Nov 8, 2021. Standard mean difference (SMD) was pooled to compare visual acuity (VA) at baseline with final in IAT patients. The rates and odds ratios (OR) were meta-analyzed to compare VA improvement in IAT with non-IAT patients, stratified to different times from onset to procedure, different definitions of VA improvement, and three CRAO stages. Adverse effects were recorded.

RESULTS

Fifteen studies were included, enrolling 507 CRAO patients who received IAT and 296 CRAO patients who did not. VA was significantly improved from baseline to final VA in IAT patients (SMD [LogMAR] 0.70, 95% CI [0.51, 0.90]). VA improvement rate was higher in IAT patients than that in non-IAT (56% vs 32%, OR 3.55, 95%CI [1.74, 7.24]), with greater OR in IAT within 6 h from onset to procedure (OR 4.60, 95%CI [1.24, 16.99]) than that beyond 6 h (OR 3.36, 95%CI [1.43, 7.85]). The benefit remained consistent when VA improvement was defined as ≥ 3 lines on the Snellen chart (OR 4.68, 95%CI [2.10, 10.41]) and was even greater when CRAO was incomplete. Five patients had a symptomatic intracranial hemorrhage and 21 patients had ischemic stroke or transient ischemic attack after IAT.

CONCLUSIONS

IAT treatment has certain potential in ameliorating VA in CRAO patients, which should be balanced against cerebral complications.

Management of ocular arterial ischemic diseases: a review

PURPOSE

To summarize the existing treatment options regarding central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), arteritic anterior ischemic optic neuropathy (AAION), non-arteritic anterior ischemic optic neuropathy (NAION), and ocular ischemic syndrome (OIS), proposing an approach to manage and treat these patients.

METHODS

A systematic literature search of articles published since 1st January 2010 until 31st December 2020 was conducted using MEDLINE (PubMed), Scopus, and Web of Science. Exclusion criteria included case reports, non-English references, articles not conducted in humans, and articles not including diagnostic or therapeutic options. Further references were gathered through citation tracking, by hand search of the reference lists of included studies, as well as topic-related European society guidelines.

RESULTS

Acute ocular ischemia, with consequent visual loss, has a variety of causes and clinical presentations, with prognosis depending on an accurate diagnosis and timely therapeutic implementation. Unfortunately, most of the addressed entities do not have a standardized management, especially regarding their treatment, which often lacks good quality evidence on whether it should or not be used to treat patients.

CONCLUSION

Ophthalmologic signs and symptoms may be a warning sign of cardiovascular or cerebrovascular events, namely stroke. Most causes of acute ocular ischemia do not have a standardized management, especially regarding their treatment. Timely intervention is essential to improve the visual, and possibly vital, prognosis. Awareness must be raised among non-ophthalmologist clinicians that might encounter these patients. Further research should focus on assessing the benefit of the management strategies already being employed .