Complications of Intra-Arterial tPA for Iatrogenic Branch Retinal Artery Occlusion: A Case Report through Multimodal Imaging and Literature Review

Abstract

Background and Objectives: To document, through multimodal imaging, the post-procedural clinical course and visual outcome of a patient who received intra-arterial tissue plasminogen activator (tPA) for acute iatrogenic branch retinal artery occlusion (BRAO), and to review the literature and guidelines regarding the use of tPA for retinal arterial occlusions. Methods: A 28-year-old female patient who sustained an iatrogenic BRAO and subsequently received intra-arterial tPA was followed through her post-interventional course of 3 months with serial exams and multimodal imaging, including color fundus photography, visual field testing, spectral domain optical coherence tomography (SD-OCT), and OCT angiography (OCT-A). Results: A patient with history of left internal cerebral artery (ICA) aneurysm and baseline visual acuity (VA) of 20/20 developed an acutely symptomatic BRAO after undergoing a neuroendovascular procedure and was acutely treated with tPA through the left ophthalmic artery. At two weeks follow-up, a central posterior pole hemorrhage was noted although VA was preserved. A superior altitudinal defect was shown on automated perimetry. VA dropped to 20/50 at 7 weeks follow-up and hyperreflective material deep to the attachment between the posterior hyaloid and the internal limiting membrane (ILM) consistent with hemorrhage was noted on SD-OCT. At 11 weeks follow-up, VA returned to 20/20, SD-OCT revealed a membrane bridging the foveal depression, OCT-A showed decreased vascularity in the inferior macula, and the visual field defect was stable by automated perimetry. Conclusions: Intraocular hemorrhage is a possible complication of intra-arterial tPA administration for BRAO, and a careful analysis of risks, benefits, and goals of this procedure must be considered by both provider and patient before such intervention.

Keywords: optical coherence tomography angiography; retinal artery occlusion; spectral domain optical coherence tomography; tPA.

Figure 1

Brain magnetic resonance angiography (MRA) immediately prior to ophthalmic examination shows anticipated changes from the recent revascularization procedure with persistent filling of the 2 mm supraclinoid segment aneurysm (arrowhead), without other abnormalities of the major intracranial vasculature.

Figure 2

Color fundus photograph of the left eye at presentation shows retinal whitening of the inferior fundus consistent with diagnosis of branch retinal artery occlusion. Note the yellow refractile body within the inferior arterial arcade at the disc margin (arrow) and attenuation of peripheral arterioles (arrowheads).

Figure 3

Color fundus photograph of the left eye at follow-up 2 weeks after administration of tissue plasminogen activator (tPA) shows new ellipsoid-shaped hemorrhage blocking the central macula and slightly improved inferior retinal whitening.

Figure 4

Color fundus photograph of the left eye at 7 weeks follow-up shows significant improvement of inferior retinal whitening and significant resorption of central macular hemorrhage. Note the yellowish superficial deposit over the fovea, consistent with residual dehemoglobinized blood.

Figure 5

Horizontal (A) and vertical (B) spectral domain OCT B-scans show hyperreflective material deep to the attachment between the posterior hyaloid and the internal limiting membrane (ILM) and filling the foveal depression suggestive of residual hemorrhage. Note the thinning of the inner retinal layers inferiorly from recent branch retinal artery occlusion (arrowhead).

Figure 6

Optical coherence tomography angiography (OCTA) en face images (A,B) and spectral domain OCT B-scans (C,D) of the left eye at 11 weeks follow-up. Decreased vessel density of the superficial (A) and deep (B) retinal capillary plexuses is noted inferiorly in the area of arterial occlusion. A contiguous membrane with mild residual hyper-reflective hemorrhage underneath traverses the foveal depression (C,D). Vertical (D) OCT shows significant thinning of inner retinal layers of the inferior macula (arrowhead).