Successful Treatment of Central Retinal Artery Occlusion With Tissue Plasminogen Activator Followed by Recurrent Retinal Ischemia

Abstract

Purpose: To describe the use of intra-arterial tissue plasminogen activator (tPA) to treat central retinal artery occlusion (CRAO). Methods: A case and its findings were analyzed. Results: A 45-year-old man diagnosed with a CRAO and had cerebral angiography and treatment with intra-arterial tPA. After treatment, follow-up included optical coherence tomography (OCT), fundus photography, fluorescein angiography, and OCT angiography. The visual acuity (VA) improved from hand motions to 20/30 immediately after fibrinolysis. A vascular occlusion event the next day resulted in a decrease in VA to 20/400. After initiation of dual antiplatelet therapy, the patient's VA improved to 20/20. As the retina recovered, the evolution of retinal ischemic changes to a finding similar to paracentral acute middle maculopathy was seen on imaging. Conclusions: This is the first report describing a patient safely started on dual antiplatelet therapy that led to vision improvement after initial treatment with intra-arterial tPA for a CRAO resulted in recurrent vision loss.

Keywords: central retinal artery occlusion (CRAO); eye stroke; fibrinolysis; paracentral acute middle maculopathy (PAMM); tissue plasminogen activator (tPA).

Figure 1.

(A) Fluorescein angiography of the right eye on initial presentation to the outpatient retina specialist shows incomplete filling after 1 minute. (B) Initial outpatient optical coherence tomography of the right eye shows subtle loss of differentiation of inner retinal layers.

Figure 2.

(A) Initial Amsler grid of the right eye, drawn by the patient during recurrence of right eye vision loss, which the patient described as a large, diffuse, irregular central scotoma with intervening areas of relative clarity, indicated by small circles within area of involvement. (B) Amsler grid of the right eye, drawn the next day by the patient after subjective vision improvement with visual acuity of 20/20, shows a radial spoke-like central scotoma that is smaller than on the previous day.

Figure 3.

(A) Point-of-care OCT of the right eye within 90 minutes of recurrence of symptoms, at which point the VA was 20/400. (B) OCT after improvement of VA to 20/20 the next day, with consolidation of focal ischemic areas. Abbreviations: OCT, optical coherence tomography; VA, visual acuity.

Figure 4.

(A) Fundus photograph on day 3 shows mild venous dilation and a scant midperipheral dot blot hemorrhage. (B) Fluorescein angiography with a delayed arterial filling time of 30 seconds for complete filling.

Figure 5.

(A) Optical coherence tomography (OCT) and OCT angiography of the right eye from day 3 shows perifoveal changes on en face imaging corresponding to lesions similar to paracentral acute middle maculopathy primarily affecting the inner nuclear and outer plexiform layers with a prominent middle limiting layer. Serial OCTs on follow-up after initial presentation at (B) 2 weeks, (C) 6 weeks, (D) 3 months, and (E) 1.5 years show areas of residual retinal atrophy.