Alteplase Plus Nimodipine Improves Acuity in Central Retinal Artery Occlusion

Alteplase plus nimodipine may improve best-corrected visual acuity (BCVA) for patients with central retinal artery occlusion (CRAO), according to results of a study published in Clinical Ophthalmology. The selective intraophthalmic arterial combination can improve BCVA in 1 month for patients with nonarteritic CRAO who present within 24 hours of onset, the study says.

Fewer than 20% of individuals affected by CRAO regain functional visual acuity (VA). As there is an established unmet need for improving visual outcomes post-CRAO, this nonrandomized prospective trial (VISION) was conducted at Ramathibodi Hospital in Thailand between 2020 and 2022.

Patients (N=9) who presented with acute nonarteritic CRAO, with vision no worse than 20/60, and who received treatment within 24 hours after onset were recruited for this study. Patients received 0.13 mg/mL nimodipine via microcatheter into the affected eye with a maximum dose of 5 mg. Nimodipine was stopped if the patient reported visual improvement. After nimodipine infusion, patients underwent an ophthalmologic examination then received up to 3 doses of 15 mg alteplase via microcatheter into the ophthalmic artery. Alteplase infusion was also stopped if the patient reported visual improvement. The primary outcome was the change in BCVA from baseline.

The patients were aged mean 54.7 (SD, 19.23) years, 55.6% were men, 66.7% had right laterality CRAO, 77.8% had hypertension, and 77.8% dyslipidemia.

The patients had a VA of 1.86 (SD, 0.47) logMAR at baseline, they received treatment 13.1 (SD, 4.5) hours after onset, and 66.7% were graded as having stage one CRAO.

During treatment, BCVA improved by -0.71 logMAR (P =.003) from baseline after alteplase infusion but no improvement was observed immediately after nimodipine infusion (mean difference, -0.23; 95% CI, -0.69 to 0.23 logMAR; P =.34).

At one month, BCVA had improved by -0.78 (P =.001) logMAR from baseline. Most patients (77.8%) had 0.3 logMAR or greater improvement in visual angle at the follow-up.

Most patients (55.6%) reported a headache during nimodipine infusion, which was reduced after the infusion rate was slowed. All patients presented with mild conjunctivital injection with minimal chemosis after nimodipine infusion, which improved without treatment. After alteplase infusion, 3 patients had delayed hemorrhage and 2 patients had scattered lacunar infarctions.

The major limitation of this study was the small sample size.

This study found that BCVA improved with alteplase plus nimodipine infusions among patients with non-arteritic CRAO. The study authors report, “The use of nimodipine combined with alteplase potentially has an added positive effect compared with alteplase alone. Though mostly minor and asymptomatic, the potential for adverse reactions resulting from the procedure should be considered prior to this treatment.”