SCIENTIFIC CORRESPONDENCE Local intra-arterial fibrinolysis for acute occlusion of the central retinal artery: a meta-analysis of the published data

Background/aim—Central retinal artery occlusion (CRAO) is typically associated with a poor visual outcome. Several favourable reports of local intra-arterial fibrinolysis (LIF), which involves the superselective administration of a thrombolytic agent directly into the ophthalmic artery, have appeared in the recent literature. The aim of this study was to critically appraise these studies in a collective fashion. Methods—A meta-analysis was performed of all the published literature germane to LIF in cases of CRAO. Results—Of the 16 studies identified, all were retrospective and non-randomised. After correction for data duplication, the results of LIF in 100 patients can be reported. A final acuity of 6/6 or better was seen in 14% of patients following LIF, and a visual result of 6/12 or better was seen in 27% of subjects. A poor final acuity of 3/60 or worse was seen in 60.6% of eyes treated with local intra-arterial fibrinolysis. These results compare favourably with conventional forms of therapy. Potentially serious complications were seen in four patients, but no patient suVered a permanent neurological deficit. Conclusion—The results of this study suggest that there may be a marginal visual benefit associated with LIF compared with conventional management of CRAO. However, the methodology of the cited studies was often unsatisfactory, and a randomised controlled trial of LIF in cases of CRAO is justified. Outside of a randomised clinical trial, the use of superselective fibrinolytic therapy for CRAO cannot be recommended on the basis of current evidence. (Br J Ophthalmol 2000;84:914–916) Central retinal artery occlusion (CRAO) is associated with a poor visual prognosis, and aggressive management with ocular massage, anterior chamber paracentesis, and carbogen therapy does not appear to improve the outcome. 2 These considerations have motivated the use of catheter administered, local intra-arterial fibrinolysis (LIF) for CRAO, of which there are several encouraging reports in the literature. We have performed a metaanalysis of the published data in order to investigate whether we should be oVering LIF to our patients presenting with acute occlusive events of the retinal arterial circulation. Methods Sixteen reports of intra-arterial fibrinolytic therapy for CRAO were identified in the published literature, (Table 1), and covert duplicate use of data was found in three of these papers 6 8 and acknowledged duplication in a further two papers, 10 a problem commonly encountered in meta-analyses. Therefore, only the most recent and complete series reported by these investigators were included Table 1 Studies and review articles relating to fibrinolytic therapy in central retinal artery occlusion Author, year Number of subjects Fibrinolytic agent Comment Richard et al, 1999 46 rt-PA Weill et al, 1998 7 Urokinase Wirostko et al, 1998 1 Urokinase Case report Weber et al, 1998 15 Urokinase Annonier et al, 1988 5 Urokinase Contains data also used in reference 10 Schumacher et al, 1993 23 Urokinase (n=18) rt-PA (n=5) Vulpius et al, 1996 9 rt-PA Annonier et al, 1984 2 Urokinase Contains data also used in reference 7 Mach et al, 1992 1 Urokinase Case report Coscas et al, 1970 1 Streptokinase Intravenous administration Ma et al, 1996 4 Urokinase InsuYcient data for comment Brassel et al, 1993 NA NA Review article Schmidt et al, 1992 14 Urokinase Contains data also used in reference 6 Van Cauwenberge, 1993 NA NA Review article Schumacher et al, 1991 6 Urokinase Contains data also used in reference 6 Turmer et al, 1993 NA NA Animal study Br J Ophthalmol 2000;84:914–916 914 Academic Department of Ophthalmology, Manchester Royal Eye Hospital