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Yao Y, Song Q, Zhang J, Wen Y, Dou X. Retina-Brain Homology: The Correlation Between Ophthalmic or Retinal Artery Occlusion and Ischemic Stroke. Eye Brain 2024; 16:25-38. [PMID: 39156910 PMCID: PMC11328846 DOI: 10.2147/eb.s454977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/23/2024] [Indexed: 08/20/2024] Open
Abstract
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.
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Affiliation(s)
- Yufeng Yao
- Shantou University Medical College, Shantou, Guangdong Province, People’s Republic of China
- Department of Ophthalmology, Shenzhen Second People’s Hospital, the First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
| | - Qiyuan Song
- Department of Ophthalmology, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, People’s Republic of China
| | - Jingnan Zhang
- Department of Ophthalmology, Shenzhen Second People’s Hospital, the First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
- Shenzhen University Medical College, No.1066 Xueyuan Road, Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
| | - Yingying Wen
- Department of Ophthalmology, Shenzhen Second People’s Hospital, the First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
- Shenzhen University Medical College, No.1066 Xueyuan Road, Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
| | - Xiaoyan Dou
- Department of Ophthalmology, Shenzhen Second People’s Hospital, the First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong Province, People’s Republic of China
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Oh D, Mehra A, Echegaray J, Sobol W. Retinal Artery Reperfusion After Translumenal YAG Laser Embolysis in a Case of Branch Retinal Artery Occlusion. JOURNAL OF VITREORETINAL DISEASES 2024; 8:349-354. [PMID: 38770074 PMCID: PMC11102726 DOI: 10.1177/24741264241240325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
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.
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Affiliation(s)
- David Oh
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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3
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Kalaga SVP, Krishnan P, Krupa A L, Riyaz A, Vemula R. Thrombolysis in acute retinal ischemia treated with tenecteplase. Digit J Ophthalmol 2024; 30:33-37. [PMID: 38962669 PMCID: PMC11218839 DOI: 10.5693/djo.02.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
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.
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Affiliation(s)
| | - Pramod Krishnan
- Department of Neurology, Manipal Hospital, Bangalore, Karnataka, India
| | - Lakshmi Krupa A
- Department of Ophthalmology, Manipal Hospital, Bangalore, Karnataka, India
| | - Alfa Riyaz
- Department of Ophthalmology, Manipal Hospital, Bangalore, Karnataka, India
| | - Ramya Vemula
- Department of Ophthalmology, Manipal Hospital, Bangalore, Karnataka, India
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Stretz C, Paddock JE, Burton TM, Bakaeva T, Freeman M, Choudhury A, Yaghi S, Furie KL, Schrag M, MacGrory BC. IV Thrombolysis for central retinal artery occlusion - Real-world experience from a comprehensive stroke center. J Stroke Cerebrovasc Dis 2024; 33:107610. [PMID: 38301747 PMCID: PMC11145518 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Central retinal artery occlusion (CRAO) is a stroke of the retina potentially amenable to intravenous thrombolysis (IVT). We aimed to determine feasibility of an emergency treatment protocol and risk profile of IVT for CRAO in a comprehensive stroke center (CSC). METHODS We performed a retrospective, observational cohort study including patients with acute CRAO admitted to a CSC over 4 years. Patients are offered IVT if they present with acute vision loss of ≤ 20/200 in the affected eye, have no other cause of vision loss (incorporating a dilated ophthalmologic exam), and meet criteria akin to acute ischemic stroke. We collected socio-demographic data, triage data, time from onset to presentation, IVT candidacy, and rates of symptomatic intracranial hemorrhage (sICH)- or extracranial hemorrhage. RESULTS 36 patients presented within the study period, mean (standard deviation (SD)) age of 70.7 (10), 52 % female, and median time (Q1, Q3) to ED presentation of 13.5 (4.3, 18.8) h. Patients within 4.5 h from onset presented more commonly directly to our ED (66.6 % vs 37.1 %, p = 0.1). Nine patients (25 %) presented within the 4.5 h window. Of those eligible, 7 (77 %) received IVT. There were no events of intracranial or extracranial hemorrhage. CONCLUSIONS Our study confirmed that IVT for acute CRAO is feasible. We found a high rate of treatment with IVT of those eligible. However, because 75 % of patients presented outside the treatment window, continued educational efforts are needed to improve rapid triage to emergency departments to facilitate evaluation for possible candidacy with IVT.
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Affiliation(s)
- Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States.
| | - John E Paddock
- Department of Ophthalmology, Weill Cornell Medicine, Cornell University, New York, NY, United States; Department of Neurology, Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Tina M Burton
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Tatiana Bakaeva
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States; Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Melissa Freeman
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Aparna Choudhury
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Brian C MacGrory
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States; Department of Ophthalmology, Duke University School of Medicine, Durham, NC, United States
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Alhayek N, Sobczak JM, Vanood A, O’Carroll CB, Demaerschalk BM, Chen J, Dumitrascu OM. Thrombolytic Therapy for Central Retinal Artery Occlusion in an Academic Multi-Site Stroke Centre. Neuroophthalmology 2024; 48:111-121. [PMID: 38487357 PMCID: PMC10936677 DOI: 10.1080/01658107.2023.2290536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/20/2023] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Nour Alhayek
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Jacob M. Sobczak
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Aimen Vanood
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Cumara B. O’Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Bart M. Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota, USA
| | - John Chen
- Department of Ophthalmology and Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Oana M. Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
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6
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Shahjouei S, Bavarsad Shahripour R, Dumitrascu OM. Thrombolysis for central retinal artery occlusion: An individual participant-level meta-analysis. Int J Stroke 2024; 19:29-39. [PMID: 37424312 DOI: 10.1177/17474930231189352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Whether thrombolysis improves outcomes in non-arteritic central retinal artery occlusion (naCRAO) is uncertain. We aimed to evaluate the rate of visual recovery after intra-venous thrombolysis (IVT) or intra-arterial thrombolysis (IAT) administration of tissue plasminogen activator (tPA) or urokinase among patients with naCRAO and explore the parameters affecting the final visual acuity (VA). AIM We systematically searched six databases. Logarithm of the minimum angle of resolution (logMAR) and VA of ⩾20/100 were used to quantify visual recovery. To explore the role of other factors on visual recovery, we defined two models for studies with aggregated data (designs 1 and 2) and 16 models for individual participant data (IPD, models 1-16). SUMMARY OF REVIEW We included data from 771 patients out of 72 publications in nine languages. Visual improvement for ⩾0.3 logMAR was reported in 74.3% of patients who received IVT-tPA within 4.5 h (CI: 60.9-86.0%; unadjusted rate: 73.2%) and 60.0% of those who received IAT-tPA within 24 h (CI: 49.1-70.5%; unadjusted rate: 59.6%). VA of ⩾20/100 was observed among 39.0% of patients after IVT-tPA within 4.5 h and 21.9% of those with IAT-tPA within 24 h. IPD models highlighted the association between improved visual outcomes and VA at presentation, at least 2 weeks follow-up before reporting the final VA, antiplatelet therapy, and shorter symptom onset to thrombolysis window. CONCLUSION Early thrombolytic therapy with tPA is associated with enhanced visual recovery in naCRAO. Future studies should refine the optimum time window for thrombolysis in naCRAO.
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Affiliation(s)
- Shima Shahjouei
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Neurology, Neurosurgery, and Translational Medicine, Barrow Neurological Institute, St. Joseph's Hospital, Phoenix, AZ, USA
| | - Reza Bavarsad Shahripour
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, CA, USA
- Department of Neurology, Stroke Center, Loma Linda University, Loma Linda, CA, USA
| | - Oana M Dumitrascu
- Division of Cerebrovascular Diseases, Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
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7
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Baumgartner P, Kook L, Altersberger VL, Gensicke H, Ardila-Jurado E, Kägi G, Salerno A, Michel P, Gopisingh KM, Nederkoorn PJ, Scheitz JF, Nolte CH, Heldner MR, Arnold M, Cordonnier C, Della Schiava L, Hametner C, Ringleb PA, Leker RR, Jubran H, Luft AR, Engelter ST, Wegener S. Safety and effectiveness of IV Thrombolysis in retinal artery occlusion: A multicenter retrospective cohort study. Eur Stroke J 2023; 8:966-973. [PMID: 37421135 PMCID: PMC10683723 DOI: 10.1177/23969873231185895] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/13/2023] [Indexed: 07/09/2023] Open
Abstract
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.
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Affiliation(s)
- Philipp Baumgartner
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lucas Kook
- Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Institute for Data Analysis and Process Design, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kiran M Gopisingh
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan F Scheitz
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Lucie Della Schiava
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | | | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hamza Jubran
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Andreas R Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Kozner P, Eichenmann L, Ceska Burdova M, Pavlikova M, Hlozanek M, Dotrelova D. Long-term outcomes of intravenous fibrinolysis in central retinal artery occlusion. Sci Rep 2023; 13:20505. [PMID: 37993533 PMCID: PMC10665428 DOI: 10.1038/s41598-023-47987-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023] Open
Abstract
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.
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Affiliation(s)
- Pavel Kozner
- Department of Ophthalmology, Second Faculty of Medicine Charles University and Motol University Hospital in Prague, V Uvalu 84, 150 06, Prague, Czech Republic.
| | - Libor Eichenmann
- Department of Ophthalmology, Second Faculty of Medicine Charles University and Motol University Hospital in Prague, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Marie Ceska Burdova
- Department of Ophthalmology, Second Faculty of Medicine Charles University and Motol University Hospital in Prague, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Marketa Pavlikova
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University in Prague, Prague, Czech Republic
| | - Martin Hlozanek
- Department of Ophthalmology, Second Faculty of Medicine Charles University and Motol University Hospital in Prague, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Dagmar Dotrelova
- Department of Ophthalmology, Second Faculty of Medicine Charles University and Motol University Hospital in Prague, V Uvalu 84, 150 06, Prague, Czech Republic
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9
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Liu W, Bai D, Kou L. Progress in central retinal artery occlusion: a narrative review. J Int Med Res 2023; 51:3000605231198388. [PMID: 37712755 PMCID: PMC10504844 DOI: 10.1177/03000605231198388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
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.
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Affiliation(s)
- Weishai Liu
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Dan Bai
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Lieling Kou
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
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10
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Webb Z. Intravenous Thrombolysis for Central Retinal Artery Occlusion: A Look at the Literature for the Emergency Medicine Physician. Cureus 2023; 15:e41878. [PMID: 37457612 PMCID: PMC10348395 DOI: 10.7759/cureus.41878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a subtype of ischemic stroke and true ocular emergency presenting with acute, painless, monocular vision loss. Typical findings include poor visual acuity (VA), impaired color vision, relative afferent pupillary defect, and on fundoscopic evaluation, retinal edema, cherry red spot, and occasionally visualization of retinal artery emboli. While there are no proven treatments for CRAO, options include orbital massage, hyperbaric oxygen therapy, and intra-arterial or intravenous thrombolysis (IVT). This study reviews the current literature on the efficacy of IVT for patients affected by acute, symptomatic CRAO and provides an up-to-date, evidence-based background for emergency physicians (EPs) who evaluate and manage these patients.
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Affiliation(s)
- Zachary Webb
- Emergency Medicine, Huntington Hospital, Northwell Health, Huntington, USA
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11
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Raber FP, Gmeiner FV, Dreyhaupt J, Wolf A, Ludolph AC, Werner JU, Kassubek J, Althaus K. Thrombolysis in central retinal artery occlusion: a retrospective observational study. J Neurol 2023; 270:891-897. [PMID: 36305969 PMCID: PMC9886599 DOI: 10.1007/s00415-022-11439-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Florian Philipp Raber
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany
- Department of Ophthalmology, ViDia Christliche Kliniken, 76135, Karlsruhe, Germany
| | | | - Jens Dreyhaupt
- Institute for Epidemiology and Medical Biometry, Ulm University, 89075, Ulm, Germany
| | - Armin Wolf
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany
| | | | - Jens Ulrich Werner
- Department of Ophthalmology, University Hospital Ulm, 89075, Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, 89081, Ulm, Germany
| | - Katharina Althaus
- Department of Neurology, University Hospital Ulm, 89081, Ulm, Germany.
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12
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[Cardiovascular risk factors, haemostasis and antithrombotic treatment in retinal vessel occlusion]. DIE OPHTHALMOLOGIE 2022; 119:1129-1139. [PMID: 36344732 DOI: 10.1007/s00347-022-01751-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
Venous and arterial retinal vascular occlusions are age-related disorders, generally associated with classical cardiovascular risk factors, rather than an isolated ocular disease. As affected patients often also have an increased general risk for other vascular diseases, such as ischemic stroke, an interdisciplinary clarification of cardiovascular risk factors and systemic comorbidities is essential for all patients. Extended hemostaseological investigations may be recommended in those patients who do not match the typical risk profile. Patients at a young age by the time of manifestation, without conventional risk factors as well as patients with an increased risk of developing antiphospholipid syndrome may require a selective clinical investigation including testing for thrombophilic risk factors. Recent studies have clearly demonstrated an association between coagulation and lipid metabolism disorders and the development of both retinal vein and artery occlusions in specific subgroups of patients. Therapeutic approaches to treat retinal vascular occlusions or reduce the long-term risk of recurrences with anticoagulant or antiplatelet drugs have not gained widespread acceptance. However, intravenous thrombolysis may be a valuable treatment option for central retinal artery occlusions within a short time to treatment therapeutic window. For defined disorders of the coagulation system, the administration of antithrombotic drugs to reduce the general vascular risk can be a reasonable approach. This article provides an overview of cardiovascular risk factors, the general vascular risk and the current state of knowledge on ophthalmologically relevant disorders of coagulation and lipid metabolism in patients with venous and arterial retinal vascular occlusions.
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Retinal Infarction: A Pilot Study on the Efficacy and Safety of Intravenous Thrombolysis and Underlying Aetiologies. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081279. [PMID: 36013458 PMCID: PMC9409746 DOI: 10.3390/life12081279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/15/2022] [Accepted: 08/17/2022] [Indexed: 01/10/2023]
Abstract
Background: Treatment of non-arteritic central retinal artery occlusion is still inconsistent. Therefore, the current study aimed to evaluate the efficacy of intravenous thrombolysis (IVT) and describe the prevalence of co-occurring ischemic brain lesions in patients with acute visual loss due to ischemia. Methods: We analysed 38 consecutive patients with acute visual loss between January 2015 and June 2020. Patients presenting within 4.5 h of symptom onset without any contraindication were treated with IVT. Patients underwent neurologic and ophthalmologic examination and diagnostic workup for the underlying aetiology. Follow-up was performed after 3 and 12 months. Results: Patients treated with IVT had a significantly better functional outcome at discharge compared to patients treated conservatively. No additional ischemic brain lesions were detected (0 of 38). Three patients had extracranial carotid artery stenosis ≥50%. Atrial fibrillation was present in four patients, three of whom already received oral anticoagulation. In the remaining 31 patients no embolic source was detected. However, the number of plaques were rated mild to moderate. Within three months, one patient developed transient visual loss while another suffered a contralateral transient ischemic attack. Conclusions: IVT may represent a safe and effective treatment option in patients with isolated visual loss due to ischemia. The aetiology was atherosclerotic burden rather than embolism caused by carotid stenosis or atrial fibrillation, bringing the current diagnostic procedure and therapy into question. Randomized trials are necessary to evaluate the efficacy and safety of IV thrombolysis and clarify the aetiology of isolated visual loss due to ischemia.
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Hoyer C, Winzer S, Matthé E, Heinle I, Sandikci V, Nabavi D, Platten M, Puetz V, Szabo K. Current diagnosis and treatment practice of central retinal artery occlusion: results from a survey among German stroke units. Neurol Res Pract 2022; 4:30. [PMID: 35909171 PMCID: PMC9341096 DOI: 10.1186/s42466-022-00193-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency whose optimal management is still under debate and due to the absence of definite guidelines, practice is expected to vary. We aimed to characterize early evaluation as well as acute treatment and diagnostic approaches in German hospitals with a stroke unit (SU). METHODS In 07/2021, all 335 certified German SUs were invited to participate in an anonymous online survey endorsed by the German Stroke Society on emergency department care organization, diagnostic procedures, and treatment of patients with unilateral vision loss (UVL) subsequently diagnosed with CRAO. RESULTS One hundred and sixty-three (48.6%) of the 335 eligible centers responded. Most (117/135; 86.7%) stated that UVL patients were treated as an emergency, in 62/138 (44.9%) hospitals according to specific guidelines. First-line evaluation was performed by neurologists in 85/136 (62.5%) hospitals, by ophthalmologists in 43/136 (31.6%) hospitals. Seventy of 135 (51.9%) respondents indicated a lack of on-site ophthalmological expertise. Seventy-four of 129 (57.4%) respondents performed thrombolysis in CRAO and 92/97 (94.8%) stated that patients with CRAO-if admitted to neurology-were treated on a SU. CONCLUSIONS Our findings reflect notable heterogeneity in early intrahospital care of CRAO in German SUs but demonstrate a preference for work-up and management as acute stroke by the involved neurologists. Streamlining interdisciplinary emergency evaluation is essential for ongoing and future prospective trials.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology and Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Simon Winzer
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Egbert Matthé
- Department of Ophthalmology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Ida Heinle
- Department of Neurology and Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Vesile Sandikci
- Department of Neurology and Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Michael Platten
- Department of Neurology and Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristina Szabo
- Department of Neurology and Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Pérez SMP, Ramirez DJ, Martínez CE, Cárdenas V. Bilateral central retinal artery occlusion: Endovenous and intra-arterial thrombolysis in a patient with a subsequent diagnosis of antiphospholipid antibody syndrome. Indian J Ophthalmol 2022; 70:2695-2697. [PMID: 35791210 PMCID: PMC9426057 DOI: 10.4103/ijo.ijo_406_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sara M P Pérez
- Department of Ophthalmology, Pontifical Xaverian University, Bogotá, Colombia
| | - Daniela J Ramirez
- Department of Ophthalmology, Pontifical Xaverian University, Bogotá, Colombia
| | - Camilo E Martínez
- Department of Ophthalmology, Pontifical Xaverian University, Bogotá, Colombia
| | - Valentina Cárdenas
- Department of Ophthalmology, Pontifical Xaverian University, Bogotá, Colombia
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Chen C, Madike R, Cugati S. A review of the management of central retinal artery occlusion. Taiwan J Ophthalmol 2022; 12:273-281. [PMID: 36248088 PMCID: PMC9558462 DOI: 10.4103/2211-5056.353126] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022] Open
Abstract
Central retinal artery occlusion (CRAO), the ocular analog of a cerebral stroke, is an ophthalmic emergency. The visual prognosis for overall spontaneous visual recovery in CRAO is low. Furthermore, the risk of future ischemic heart disease and cerebral stroke is increased due to the underlying atherosclerotic risk factors. There is currently no guideline-endorsed treatment for CRAO. This review will describe the anatomy, pathophysiology, epidemiology, and clinical features of CRAO, and investigate the current and future management strategies.
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Janská K, Bodnár R, Janský P, Vosko M. INTRAVENOUS THROMBOLYTIC THERAPY FOR ACUTE NONARTERITIC CENTRAL RETINAL ARTERY OCCLUSION. A REVIEW. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2022; 78:101-109. [PMID: 35760581 DOI: 10.31348/2021/32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke. It is a critical condition that often leads to severe visual loss or blindness and can be a harbinger of further cerebrovascular events. Due to the lack of scientific data, there are no effective evidence-based forms of therapy for this condition. None of the conservative therapies have proven effective. The results of some previously published studies suggest a benefit of intravenous thrombolytic therapy in the same regimen as in the treatment of ischemic stroke. This work aims to present an overview of published clinical studies focused on the use of intravenous thrombolysis for CRAO, evaluate its efficacy and safety, and propose an optimal diagnostic and therapeutic algorithm for acute management of CRAO. Summary statistics of patient data from relevant studies indicate that a significant visual acuity improvement was achieved by a total of 45 % of patients receiving alteplase within 4.5 hours of symptoms onset. The occurrence of adverse events in this time window was not significant. Intravenous thrombolytic therapy in CRAO thus appears to be effective and safe. However, we still lack data from adequate prospective randomized controlled trials to confirm this conclusion. To date, two randomized trials are being conducted. The intravenous thrombolysis administration, patient monitoring, etiologic workup, and setting of effective secondary prevention should be ensured at the centre of highly specialized cerebrovascular care. Urgent transport of the CRAO patient to the nearest centre is essential.
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Huang L, Wang Y, Zhang R. Intravenous thrombolysis in patients with central retinal artery occlusion: a systematic review and meta-analysis. J Neurol 2021; 269:1825-1833. [PMID: 34625849 DOI: 10.1007/s00415-021-10838-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the efficacy and safety of intravenous thrombolysis (IVT) with alteplase in patients with central retinal artery occlusion (CRAO). METHODS We searched the database of PubMed and EMBASE for potentially eligible studies that reported IVT in CRAO patients from their dates of inception to May 19, 2021. The rate and odds ratios (OR) of best-corrected visual acuity (BCVA) improvement, mean difference (MD) of BCVA with 95% confidence interval (CI) were pooled with random effects model. RESULTS We included 8 studies enrolling 316 CRAO patients, among them, 157 patients received IVT with alteplase while 159 patients did not. The rate of best BCVA improvement was 47% (95% CI 33-62%) in the CRAO patients treated with IVT, which was higher than that of 12% (95% CI 1-23%) in those without IVT (OR 5.97, 95% CI [2.77-12.86]). In the setting of similar baseline BCVA (MD [logMAR] 0.16, 95% CI [- 0.15 to 0.46]), compared with those who did not receive IVT, the CRAO patients who received IVT had better best BCVA (MD [logMAR] - 0.23, 95% CI [- 0.44 to - 0.02]), but had no significant better final BCVA (MD [logMAR] - 0.10, 95% CI [- 0.32 to 0.12]). Two CRAO patients had complicated symptomatic intracranial hemorrhage after IVT. CONCLUSIONS IVT treatment might be effective and safe for CRAO patients, but ocular-specific complications which were not associated with thrombolysis could affect final visual acuity.
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Affiliation(s)
- Lele Huang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjingbei Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Yujie Wang
- Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Ruijun Zhang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjingbei Street, Heping District, Shenyang, 110001, People's Republic of China.
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Schultheiss M, Spitzer MS, Hattenbach LO, Poli S. [Update on intravenous lysis treatment : The REVISION trial]. Ophthalmologe 2021; 118:1107-1112. [PMID: 34351478 DOI: 10.1007/s00347-021-01467-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND To date, no evidence-based treatment for acute non-arteritic central retinal artery occlusion (CRAO) exists. Considering the limited ischemia tolerance of the retina and the results of multiple case series, increasing expectations are directed towards an early intravenous thrombolysis within 4.5 h after CRAO onset. OBJECTIVE The current literature regards timely retinal reperfusion as the only potentially beneficial therapeutic option to treat non-arteritic CRAO. Available data on the efficacy and safety of thrombolysis in CRAO are presented and discussed. On the basis of these data, the prospective, randomized, double-blind, placebo-controlled REVISION trial (early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion) will shortly be initiated in 25 centers across Germany in order to investigate early intravenous thrombolysis in acute CRAO. The main inclusion criteria of the REVISION trial are outlined, which may help ophthalmologists to identify study candidates and facilitate rapid referral to a study center. CONCLUSION The efficacy of intravenous thrombolysis in acute ischemic stroke is critically time dependent. This may also be assumed in acute CRAO; however, definite evidence still needs to be provided. Until then, the motto "time is retina" should be applied and intravenous thrombolysis should be offered to CRAO patients as part of randomized trials (such as REVISION). According to the current literature, other acute treatment approaches (such as paracentesis) are not indicated.
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Affiliation(s)
- Maximilian Schultheiss
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Martin S Spitzer
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland
| | | | - Sven Poli
- Hertie-Institut für klinische Hirnforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
- Neurologie mit Schwerpunkt neurovaskuläre Erkrankungen, Universitätsklinikum Tübingen, Tübingen, Deutschland
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Tuuminen R, Achiron A, Kanclerz P. Controversies on the Recommended Treatment for Central Retinal Artery Occlusion. J Stroke Cerebrovasc Dis 2021; 30:105970. [PMID: 34274179 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Raimo Tuuminen
- Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Eye Centre, Kymenlaakso Central Hospital, Kotka, Finland
| | - Asaf Achiron
- University Hospitals Bristol NHS Foundation Trust UK
| | - Piotr Kanclerz
- Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Hygeia Clinic, Gdańsk, Poland.
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Abstract
BACKGROUND Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis and no proven effective therapies. Given advances in acute stroke care, thrombolysis in CRAO merits critical re-examination. We review the evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management. EVIDENCE ACQUISITION MEDLINE, Scopus, and Cochrane online databases were systematically searched from 1960 to present, for reports of acute IV or IA therapy with alteplase or tenecteplase in nonarteritic CRAO patients. English language case reports, case series, interventional studies, or randomized controlled trials were included. The study type, age and number of subjects, the regimen administered, the time since symptoms' onset, visual outcome, and safety reports were noted. RESULTS Use of IV thrombolysis with alteplase was reported in 7 articles encompassing 111 patients, with 54% of them receiving IV tPA within 4.5 hours of symptom onset, and none developing symptomatic intracranial or ocular hemorrhage. Six studies described IA alteplase administration, with only 18 of a total of 134 patients (13.4%) treated within the first 6 hours after visual loss. The reported adverse events were minimal. Visual outcomes post-IV and IA thrombolysis were heterogeneously reported; however, most studies demonstrated benefit of the respective reperfusion therapies when administered very early. We found no reports of tenecteplase administration in CRAO. CONCLUSIONS In 2020, nonarteritic CRAO patients should theoretically receive the same thrombolytic therapies, in the same time window, as patients with acute cerebral ischemia. Eye stroke and teleeye stroke code encounters must include an expert ophthalmologic evaluation to confirm the correct diagnosis and to evaluate for ocular signs that may help guide IV tPA administration or IA management. Future research should focus on developing feasible retinal penumbra imaging studies that, similar to cerebral tissue viability or perfusion imaging, can be incorporated into the thrombolysis decision-making algorithm.
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Ko SJ, Shin IC, Kim DW, Choi SS, Yang YS. Safety and Efficacy of Selective Intra-arterial Thrombolysis for Central Retinal Artery Occlusion. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:261-271. [PMID: 34162193 PMCID: PMC8357610 DOI: 10.3341/kjo.2020.0082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 05/18/2021] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The purpose of this study was to determine the efficacy and safety of selective intra-arterial thrombolysis in patients with central retinal artery occlusion (CRAO). METHODS Medical records for 44 eyes of 44 patients diagnosed with acute non-arteritic CRAO and thrombolysis between October 2010 and February 2019 were analyzed retrospectively. Based on visual acuity, fundoscopic findings, and fluorescein angiography, the patients were classified into three stages: incomplete, subtotal, and total. The perfusion state using the best-corrected visual acuity (BCVA), arm to retina time, and arteriovenous passage times, after 1 month, 6 months, and at the final visit after the procedure, were compared with baseline readings. RESULTS Improvement of visual acuity was confirmed in 31 out of 44 patients (70.45%). The mean BCVA of 44 patients changed from 1.65 ± 0.78 logarithmic minimum angle of resolution (logMAR) at the first visit to 1.18 ± 0.91 logMAR at the last visit (p = 0.114). The BCVA according to CRAO stage was 0.08 ± 0.11 logMAR for the incomplete stage at the first visit, 0.06 ± 0.05 logMAR (p = 0.933) 1 month after the procedure, and 0.05 ± 0.07 logMAR (p = 0.933) at the last visit. In the subtotal stage, the results were 1.81 ± 0.54 logMAR at the first visit, 1.63 ± 0.76 logMAR (p = 0.035) 1 month after the procedure, and 1.36 ± 0.85 logMAR (p = 0.014) at the last visit. For the total stage of BCVA, the result at the first visit was 2.36 ± 0.25 logMAR, and it was 2.30 ± 0.30 logMAR (p = 0.510) 1 month after the procedure, and 2.42 ± 0.30 logMAR (p = 0.642) at the last visit. Reperfusion was observed in 40 patients out of the 44 (90.91%). CONCLUSIONS Selective intra-arterial thrombolysis can be helpful in patients with subtotal CRAO in terms of visual improvement and retinal arterial reperfusion.
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Affiliation(s)
- Sang Jun Ko
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea
| | - In Choel Shin
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea
| | - Dae Won Kim
- Department of Neurosurgery, Wonkwang University College of Medicine, Iksan, Korea
| | - Si Sung Choi
- Department of Radiology, Wonkwang University College of Medicine, Iksan, Korea
| | - Yun Sik Yang
- Department of Ophthalmology, Wonkwang University College of Medicine, Iksan, Korea
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Intravenous Recombinant Tissue-Type Plasminogen Activator Thrombolysis for Acute Central Retinal Artery Occlusion. J Craniofac Surg 2021; 32:313-316. [PMID: 33156166 DOI: 10.1097/scs.0000000000007134] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Central retinal artery occlusion (CRAO), an ocular stroke, causes severe and permanent visual impairment. Thrombolytic therapy is currently the main treatment option for CRAO. Intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) has been extensively applied in the treatment of CRAO with the proven advantages of effectiveness and safety. This meta-analysis aimed to assess the efficacy of intravenous rt-PA thrombolysis for the management of CRAO by evaluating the pooled evidence. METHODS A comprehensive literature search of electronic databases including PubMed, OVID, and Cochrane Library was conducted up to and including March 2019. All studies reporting visual outcomes after CRAO with thrombolytic therapy were collected. Data on visual acuity and adverse events were recorded and assessed in this analysis. Data were inputted into the statistical software of STATA. The studies were weighed by the inverse of the variance and merged in a random-effects model. RESULTS The systematic review process yielded 7 eligible studies including 121 patients with CRAO who received the intravenous rt-PA treatment. Sixty-two patients showed improvement in visual acuity (52.0%; 95% CI, 34.0%-70.0%) following rt-PA intravenous thrombolytic therapy. The observed improvement rate in the intravenous rt-PA treatment group was significantly higher than the conservative treatment group (40.4% vs. 13.0%; OR = 5.16; 95% CI, 1.90-14.05). The incidence rate of complications was relatively low (11 out of the 121 patients). Hemorrhage (9/11) was the major reported complication. Mortality was zero. DISCUSSION This meta-analysis indicated that intravenous rt-PA thrombolysis could be an effective and safe strategy for the management of CRAO. However, a more detailed large-scale clinical trial is warranted to strengthen the evidence-based therapeutic guidance.
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Mac Grory B, Schrag M, Biousse V, Furie KL, Gerhard-Herman M, Lavin PJ, Sobrin L, Tjoumakaris SI, Weyand CM, Yaghi S. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e282-e294. [PMID: 33677974 DOI: 10.1161/str.0000000000000366] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that causes severe visual loss and is a harbinger of further cerebrovascular and cardiovascular events. There is a paucity of scientific information on the appropriate management of CRAO, with most strategies based on observational literature and expert opinion. In this scientific statement, we critically appraise the literature on CRAO and provide a framework within which to consider acute treatment and secondary prevention. METHODS We performed a literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, case reports, clinical guidelines, review articles, basic science articles, and editorials concerning the management of CRAO. We assembled a panel comprising experts in the fields of vascular neurology, neuro-ophthalmology, vitreo-retinal surgery, immunology, endovascular neurosurgery, and cardiology, and document sections were divided among the writing group members. Each member received an assignment to perform a literature review, synthesize the data, and offer considerations for practice. Multiple drafts were circulated among the group until consensus was achieved. RESULTS Acute CRAO is a medical emergency. Systems of care should evolve to prioritize early recognition and triage of CRAO to emergency medical attention. There is considerable variability in management patterns among practitioners, institutions, and subspecialty groups. The current literature suggests that treatment with intravenous tissue plasminogen activator may be effective. Patients should undergo urgent screening and treatment of vascular risk factors. There is a need for high-quality, randomized clinical trials in this field.
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Hoyer C, Kahlert C, Güney R, Schlichtenbrede F, Platten M, Szabo K. Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness. Eur J Neurol 2021; 28:2111-2114. [PMID: 33452753 DOI: 10.1111/ene.14735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency necessitating adequate and comprehensive diagnosis. Its optimal management and treatment, however, are still under debate. This study aimed at identifying respective areas for improvement. METHODS We retrospectively analysed the medical records of patients with CRAO treated in our stroke unit between January 2016 and August 2020. RESULTS During the observational period, 101 patients with CRAO were admitted. We observed an increase in the rate of patients primarily admitted to the stroke unit from 52.2% to 97.4%. In addition, the thrombolysis rate - with thrombolysis performed on an individual basis - rose from 0% to 14.1%, coinciding with the implementation of an in-hospital management guideline. Almost 60% of all patients presented outside of the 4.5-h time window for thrombolysis; by far the most common reason not to deliver intravenous thrombolysis in our cohort was a prehospital delay to presentation (58.8%), with 44.4% of patients having consulted a private-practice ophthalmologist first. A total of 25 (32.5%) of 77 patients who underwent magnetic resonance imaging (MRI) had accompanying acute ischaemic stroke lesions on diffusion-weighted MRI of the brain. A possible aetiology of CRAO was identified in 41.4% of patients. DISCUSSION Public awareness of sudden unilateral visual loss as a presenting sign for stroke should be raised, increasing the chances for timely recognition in a hospital with ophthalmological expertise and a stroke centre. This is essential for ongoing and future prospective trials on this subject.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Christian Kahlert
- Department of Ophthalmology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Resul Güney
- Department of Neuroradiology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Schlichtenbrede
- Department of Ophthalmology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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Scott IU, Campochiaro PA, Newman NJ, Biousse V. Retinal vascular occlusions. Lancet 2020; 396:1927-1940. [PMID: 33308475 PMCID: PMC9546635 DOI: 10.1016/s0140-6736(20)31559-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/29/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022]
Abstract
Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients' primary care providers is an important component of the management of these two disorders.
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Affiliation(s)
- Ingrid U Scott
- Department of Ophthalmology and Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Peter A Campochiaro
- Department of Ophthalmology and Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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27
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Re: Flaxel et al.: Retinal and ophthalmic artery occlusions Preferred Practice Pattern® (Ophthalmology. 2020;127:P259–P287). Ophthalmology 2020; 127:e59-e60. [DOI: 10.1016/j.ophtha.2020.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/16/2020] [Indexed: 11/20/2022] Open
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28
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Mac Grory B, Nackenoff A, Poli S, Spitzer MS, Nedelmann M, Guillon B, Preterre C, Chen CS, Lee AW, Yaghi S, Stretz C, Azher I, Paddock J, Bakaeva T, Greer DM, Shulman JG, Kowalski RG, Lavin P, Mistry E, Espaillat K, Furie K, Kirshner H, Schrag M. Intravenous Fibrinolysis for Central Retinal Artery Occlusion: A Cohort Study and Updated Patient-Level Meta-Analysis. Stroke 2020; 51:2018-2025. [PMID: 32568646 DOI: 10.1161/strokeaha.119.028743] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Central retinal artery occlusion results in sudden, painless, usually permanent loss of vision in the affected eye. There is no proven, effective treatment to salvage visual acuity and a clear, unmet need for an effective therapy. In this work, we evaluated the efficacy of intravenous tissue-type plasminogen activator (IV alteplase) in a prospective cohort study and an updated systematic review and meta-analysis. METHODS We enrolled consecutive patients with acute central retinal artery occlusion within 48 hours of symptoms onset and with a visual acuity of <20/200 from January 2009 until May 2019. The primary outcomes were safety and functional visual acuity recovery. We compared rates of visual recovery between those treated with alteplase within 4.5 hours of symptom onset to those who did not receive alteplase (including an analysis restricted to untreated patients presenting within the window for treatment). We incorporated these results into an updated systematic review and patient-level meta-analysis. RESULTS We enrolled 112 patients, of whom 25 (22.3% of the cohort) were treated with IV alteplase. One patient had an asymptomatic intracerebral hemorrhage after IV alteplase treatment. Forty-four percent of alteplase-treated patients had recovery of visual acuity when treated within 4.5 hours versus 13.1% of those not treated with alteplase (P=0.003) and 11.6% of those presenting within 4 hours who did not receive alteplase (P=0.03). Our updated patient-level meta-analysis of 238 patients included 67 patients treated with alteplase within 4.5 hours since time last known well with a recovery rate of 37.3%. This favorably compares with a 17.7% recovery rate in those without treatment. In linear regression, earlier treatment correlated with a higher rate of visual recovery (P=0.01). CONCLUSIONS This study showed that the administration of intravenous alteplase within 4.5 hours of symptom onset is associated with a higher likelihood of a favorable visual outcome for acute central retinal artery occlusion. Our results strongly support proceeding to a randomized, placebo-controlled clinical trial.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Alex Nackenoff
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Sven Poli
- Department of Neurology with Focus on Neurovascular Diseases, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Germany (S.P.)
| | - Martin S Spitzer
- Eye Clinic, University Hospital Hamburg-Eppendorf, Germany (M.S.S.)
| | - Max Nedelmann
- Department of Neurology, Sana Regio Klinikum, Pinneberg, Germany (M.N.)
| | - Benoit Guillon
- Department of Neurology, CHU de Nantes - Laennec Nantes, France (B.G., C.P.)
| | - Cécile Preterre
- Department of Neurology, CHU de Nantes - Laennec Nantes, France (B.G., C.P.)
| | - Celia S Chen
- Department of Ophthalmology, Flinders Medical Center and Flinders University, Adelaide, Australia (C.S.C.)
| | - Andrew W Lee
- Department of Neurology, Flinders University and the Calvary Wakefield Hospital, Adelaide, Australia (A.W.L.)
| | - Shadi Yaghi
- Department of Neurology, New York University School of Medicine (S.Y.)
| | - Christoph Stretz
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Idrees Azher
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - John Paddock
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Tatiana Bakaeva
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI.,Division of Ophthalmology, Department of Surgery (T.B.), Warren Alpert Medical School of Brown University, Providence, RI.,Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston (T.B.)
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, MA (D.M.G., J.G.S.)
| | - Julie G Shulman
- Department of Neurology, Boston University School of Medicine, MA (D.M.G., J.G.S.)
| | | | - Patrick Lavin
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Ophthalmology and Visual Sciences (P.L.), Vanderbilt University School of Medicine, Nashville, TN
| | - Eva Mistry
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kiersten Espaillat
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Karen Furie
- Department of Neurology (B.M.G., C.S., I.A., J.P., T.B., K.F.), Warren Alpert Medical School of Brown University, Providence, RI
| | - Howard Kirshner
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- Department of Neurology (A.N., P.L., E.M., K.E., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
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29
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Mac Grory B, Lavin P, Kirshner H, Schrag M. Thrombolytic Therapy for Acute Central Retinal Artery Occlusion. Stroke 2020; 51:687-695. [DOI: 10.1161/strokeaha.119.027478] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Brian Mac Grory
- From the Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island (B.M.G.)
| | - Patrick Lavin
- Department of Ophthalmology and Visual Sciences (P.L.), Vanderbilt University School of Medicine, Nashville, TN
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Howard Kirshner
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- Department of Neurology (P.L., H.K., M.S.), Vanderbilt University School of Medicine, Nashville, TN
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Abstract
PURPOSE OF REVIEW To review recent advances in the management of acute ocular ischemic events, including: transient monocular vision loss, central and branch retinal artery occlusions, and nonarteritic anterior ischemic optic neuropathy. RECENT FINDINGS Transient monocular vision loss and acute retinal arterial occlusions require immediate diagnosis and management, with recognition of these events as transient ischemic attack or stroke equivalents, respectively. Patients should undergo an immediate stroke workup in a stroke center, similar to patients with acute cerebral ischemia. The treatment of central retinal artery occlusions remains limited despite the growing use of thrombolytic treatments. The indication for these treatments remains under debate. No quality evidence exists to support any therapy, including corticosteroids, in the treatment of nonarteritic anterior ischemic optic neuropathy. The highest priority in management is to rule-out giant cell arteritis. SUMMARY Effective therapies for the treatment of ischemic events of the retina and optic nerve remain elusive. Clinicians should focus on the prompt recognition of these events as ocular emergencies and immediately refer patients with vascular transient visual loss and acute central and branch retinal arterial occlusions to the nearest stroke center.
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31
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Chronopoulos A, Schutz JS. Central retinal artery occlusion-A new, provisional treatment approach. Surv Ophthalmol 2019; 64:443-451. [PMID: 30707925 DOI: 10.1016/j.survophthal.2019.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
The retinal ganglion cells infarcted in central retinal artery occlusion (CRAO) are the somata of the optic nerve axons, part of the central nervous system. Consequently, CRAO with inner retinal infarction is a small vessel stroke, usually with the devastating consequence of severe visual loss in the affected eye. At present, there is no generally accepted, evidence-based therapy of nonarteritic CRAO in contrast to ischemic cerebral stroke that has well-accepted treatment protocols. Widely divergent and controversial therapeutic options for CRAO reflect the desperation of treating physicians and disparate conflicting studies. We examine reasons why treatment of nonarteritic CRAO remains problematic and then suggest a provisional new approach to treatment based on updated understanding of CRAO pathophysiology and analysis of current therapeutic options and their rationales.
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Affiliation(s)
- Argyrios Chronopoulos
- Department of Ophthalmology, Hospital of Ludwigshafen, Teaching Hospital of the University of Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland.
| | - James S Schutz
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
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32
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Dattilo M, Biousse V, Landau K, Newman NJ. Treatment of Central Retinal Artery Occlusion. Neuroophthalmology 2019. [DOI: 10.1007/978-3-319-98455-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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33
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Abstract
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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Affiliation(s)
- Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurologic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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34
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Schultheiss M, Härtig F, Spitzer MS, Feltgen N, Spitzer B, Hüsing J, Rupp A, Ziemann U, Bartz-Schmidt KU, Poli S. Intravenous thrombolysis in acute central retinal artery occlusion - A prospective interventional case series. PLoS One 2018; 13:e0198114. [PMID: 29813111 PMCID: PMC5973600 DOI: 10.1371/journal.pone.0198114] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 05/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND No evidence-based therapy exists for non-arteritic central retinal artery occlusion (NA-CRAO). Retinal ischemic tolerance is low; irreversible damage occurs within four hours of experimental NA-CRAO. In previous randomized trials evaluating intra-arterial or intravenous thrombolysis (IVT) in NA-CRAO, only one patient was treated this early. In December 2013, the Departments of Neurology & Stroke and Ophthalmology at University Hospital Tuebingen, Germany, decided to treat patients using IVT within 4.5 hours of NA-CRAO, the therapeutic window established for ischemic stroke. MATERIALS AND METHODS Consecutive NA-CRAO patients with severe visual loss received IVT after exclusion of intracranial hemorrhage. Follow-up was conducted at day 5 (d5) and day 30 (d30). Visual outcomes were compared to the conservative standard treatment (CST) arm of the EAGLE-trial. RESULTS Until August 2016, 20 patients received IVT within 4.5 hours after NA-CRAO with a median onset-to-treatment time of 210 minutes (IQR 120-240). Visual acuity improved from baseline mean logarithm of the minimum angle of resolution 2.46±0.33 (SD) (light perception) to 1.52±1.09 (Snellen equivalent: 6/200) at d5 (p = 0.002) and 1.60±1.08 (Snellen equivalent: 6/240) at d30. Compared to the EAGLE CST-arm, functional recovery to reading ability occurred more frequently after IVT: 6/20 (30%) versus 1/39 (3%) at d5 (p = 0.005) and at d30 5/20 (25%) versus 2/37 (5%) (p = 0.045). Two patients experienced serious adverse events (one angioedema and one bleeding from an abdominal aortic aneurysm) but recovered without sequelae. CONCLUSIONS IVT within 4.5 hours after symptom onset may represent an effective treatment of NA-CRAO. Randomized trials are warranted to evaluate efficacy and safety of early IVT in acute NA-CRAO.
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Affiliation(s)
- Maximilian Schultheiss
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- University Eye Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Martin S. Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- University Eye Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Nicolas Feltgen
- Department of Ophthalmology, University Medical Center Goettingen, Goettingen, Germany
| | - Bernhard Spitzer
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Johannes Hüsing
- Coordination Center for Clinical Trials, University Hospital Heidelberg, Heidelberg, Germany
| | - André Rupp
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | | | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
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