Intra-Arterial Fibrinolysis Not Recommended for Central Retinal Artery Occlusion Central Retinal Artery Occlusion: Local Intra-Arterial Fibrinolysis Versus Conservative Treatment, A Multicenter Randomized Trial

Objective: To evaluate the safety and efficacy of local intra-arterial fibrinolysis with tissue plasminogen activator (tPA) in the management of patients with central retinal artery occlusion. Design: Prospective randomized multicenter clinical trial (the European Assessment Group for Lysis in the Eye study). Methods: 9 centers in Austria and Germany recruited 84 patients with central retinal artery occlusion to participate in this clinical trial over a 5-year period. All patients had onset of symptoms of ≤20 hours, and were randomized to receive standard conservative therapy according to the traditional regimen used in this region, or local intra-arterial fibrinolysis. All patients received heparin, and conservative therapy included hemodilution and administration of intraocular pressure-reducing medications. Local intra-arterial fibrinolysis was performed using a super-selective catheter placed in the ophthalmic artery, through which tPA was injected until fibrinolysis was observed. A maximum dose of 50 mg of tPA was given. One-month visual outcomes were used as the primary outcome measure. Secondary outcome measures included safety of each form of therapy. Results: A significant improvement in visual acuity was seen in both groups. However, there was no significant difference in the preor post-treatment visual acuity between groups. In total, 60% of patients in each group developed improvement in visual acuity of at least 0.3 logMAR units. In contrast, complications were significantly more common in the intra-arterial fibrinolysis group, with 37% compared to 4% having a major or minor adverse event. Conclusions: Based on similar visual outcomes and a higher rate of complications associated with intraarterial fibrinolysis, this therapy is not recommended for acute central retinal artery occlusion. Reviewer's Comments: Although intra-arterial fibrinolysis has been used for years to manage patients following acute cerebrovascular occlusion, complications and lack of efficacy appear to make it unsuitable for the management of patients with central retinal artery occlusion. (Reviewer-Scott D. Smith, MD, MPH).