Early intra-arterial tissue plasminogen activator (IAT) is safe and effective and associated with significant visual improvements in a small cohort of patients with central retinal artery occlusion (CRAO), according to research results published in Clinical Ophthalmology. 

Previous studies have demonstrated a degree of variability, and no standardized to evaluate visual outcomes for CRAO exists. Through a retrospective, consecutive, interventional case series study, researchers aimed to investigate the potential benefit of IAT for central retinal artery occlusion, while also determining if this intervention can be implemented safely in a large hospital system with endovascular capabilities. 

Fifteen eyes from 15 patients (11 right eyes, 4 left eyes) were included in the study cohort. Mean patient age was 60 years (range, 28 to 84 years) and 73% of participants were women. Six patients underwent ocular paracentesis, with a mean tissue plasminogen activator dose of 16.87± 7.19 mg used (range, 3 to 22 mg). Mean time from symptom onset to treatment initiation was 8.83 ± 2.37 hours (range, 5.5 to 12 hours). 


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Three weeks after IAT, final visual acuity improved by 3 or more Snellen lines in 8 eyes; 6 eyes remained stable or unchanged, and 6 eyes were worse. 

LogMAR visual acuity before treatment was an average of 2.18 (± 0.82; range, 0.6 to 3). Comparatively, at 3 weeks after IAT, logMAR visual acuity was 1.42 (± 0.99; range, 0.1 to 3), indicative of a statistically significant improvement of 0.76 ± 0.91 logMAR (range, -2.4 to 0.85; P =.0061). Among the 8 patients who experienced clinically significant improvement in visual acuity, an average improvement of 1.37 ± 0.72 logMAR visual acuity was observed (range, -2.4 to -0.42). An overall average of 3.43 ± 3.99 lines of Snellen visual acuity improvement was noted (range, -3 to 11). 

Average visual acuity before and 3 weeks post-treatment was correlated “in a linear fashion.” Average best-corrected visual acuity in patients who received IAT within less than 8 hours of symptom onset was -0.94 logMAR (95% CI, -1.42 to 0.21) vs -0.60 logMAR (95% CI, -1.74 to -0.13) in patients who received treatment between 8 and 12 hours after onset of symptoms. 

Of the patients who received treatment in less than 8 hours of symptom onset, 20% demonstrated clinically significant visual improvement and 4 demonstrated stable or worse visual acuity at follow-up. Results of a linear regression analysis of the degree of change did not demonstrate a statistically significant relationship between logMAR best corrected visual acuity and time to IAT. 

Study limitations include the lack of randomization due to patients being treated consecutively and reviewed retrospectively, the lack of availability of retinal imaging including optical coherence tomography and fluorescein angiography, and the small sample size. 

“Significant visual morbidity may be prevented by timely treatment for CRAO by IAT administered within the first 12 hours of symptom onset,” according to the researchers. “The safety profile reported in this cohort and past studies suggests a low risk of adverse events.” 

“Future efforts should focus on improving education of patients and clinicians about the emergent nature of CRAO while also streamlining the clinical evaluation of the patient to shorten the time to treatment,” the report adds. 

Disclosure: Several study authors declared affiliations with the biotech or pharmaceutical industries. Please see the original reference for a full list of authors’ disclosures.

Reference

Sobol EK, Sakai Y, Wheelwright D, et al. Intra-arterial tissue plasminogen activator for central retinal artery occlusion. Clin Ophthalmol. 2021;15:601-608. doi:10.2147/OPTH.S272126.