Visual Improvement after Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion Does Not Correlate with Time to Treatment

An Efficacy and Safety Study of Intra-arterial Recanalization of Occluded Ophthalmic Arteries in Patients with Monocular Blindness Caused by Injection of Hyaluronic Acid in Facial Tissues

PROPOSE

To evaluate the efficacy and safety of recanalizing hyaluronic acid-occluded retinal central artery by intra-arterially infusing hyaluronidase.

METHODS

Between December 2015 and December 2016, 30 patients with monocular blindness due to the injection of hyaluronic acid in facial tissue underwent ophthalmic artery recanalization. The outcome of the intra-arterial treatment was retrospectively reviewed. The fundus was examined 24 hours after the treatment to observe revisualization of the retinal arteries. The success rate of intra-arterial recanalization of the ophthalmic artery, procedure-related complications, visual acuity recovery, eyeball and eyelid movement restoration was followed up for up to 3 months.

RESULTS

The success rate of ophthalmic arterial catheterization was 100%. No interventional procedure-related adverse events were found. Twenty-six patients presented ptosis and 23 patients presented ocular motility disorders. The ptosis disappeared and 18 patients had normal eye movement after the intra-arterial therapy. Five of the 30 patients had visual improvement and four patients with complete vision loss gained some light perception. After the intra-arterial thrombolysis, digital subtraction angiographic imaging revealed enlarged and numerous branches of the ophthalmic artery and a clearer ring around the eye.

CONCLUSION

Intra-arterial infusion of hyaluronidase and mechanical recanalization is an effective and safe approach for recovering the visual acuity in the patients with monocular blindness caused by the migration of hyaluronic acid injected in the facial tissues.

LEVEL OF EVIDENCE IV

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Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion

Introduction

Central 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.

Methods

A 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.

Results

Twenty-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.

Conclusion

Current 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.

Acute retinal arterial ischemia

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.

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

Background and purpose

Acute central retinal artery occlusion (CRAO) is a serious ophthalmologic emergency that may result in monocular blindness. To date, studies evaluating intra-arterial thrombolysis (IAT) have not shown a definitive clinical benefit. We have conducted a systematic review with a meta-analysis to effectively evaluate this treatment option.

Methods

A systematic literature search was focused on studies containing five or more patients undergoing IAT that included a control group treated with standard therapy. Pooled meta-analysis was performed.

Results

Five retrospective controlled studies and one randomized clinical trial were identified satisfying all inclusion criteria resulting in the analysis of 236 patients treated with IAT and 255 patients treated with ST. A pooled fixed effects analysis resulted in an estimated odds ratio of 2.52, 95% CI (1.69, 3.77) (P < 0.0001) favoring IAT.

Conclusion

IAT is a promising therapeutic option for CRAO with great potential. Further randomized trials are needed to establish a significant benefit and ensure the safety of the intervention.