Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator

Objective: Retinal arterial occlusion is one of the most dramatic problems faced by ophthalmologists because of its sudden onset and the severe conseq uences it may have on the visual system. In this study, local intra-arteria l fibrinolysis (LIF) using recombinant tissue plasminogen activator (rTPA) as a new technique for the treatment of retinal arterial occlusion was inve stigated. Design: Retrospective, noncomparative case series. Participants: Strict inclusion and exclusion criteria were used to select p atients for treatment. Fifty-three patients with central retinal artery occ lusion (n = 46) or branch retinal arterial occlusion (n = 7) were enrolled. Intervention: For a maximum of 3 hours, 10- to 20-mg rTPA per hour in 50-ml sodium chloride was infused transfemorally by catheterization of the ophth almic artery with a variable stiffness microcatheter. Main Outcome Measurer The best-corrected visual acuity for distance by an 1 8-line logarithmic table was measured on admission, at 24 hours, and at 3 m onths after intervention. Results: At 3 months, visual acuity had improved in 35 (66%) of 53 patients . Twenty-five (47.2%) patients showed an improvement of more than 2 lines, and in 10 (18.8%) patients, improvements of 1 to 2 lines were observed. No change in visual acuity occurred in 12 (22.6%) patients, and in 6 (11.3%) p atients, the visual acuity deteriorated. The mean occlusion time was 14 hou rs (range, 3-50 hours). No statistically significant correlation was found between occlusion time and visual outcome (P > 0.22), in two patients, a te mporary slight hemiplegia was observed during catheterization, and in one p atient, a hypertensive crisis after LIF treatment was observed. Conclusions: The high success rate of LIF using rTPA in patients suffering from retinal arterial occlusion is supposedly due to a causal effect of rTP A on primary platelet-fibrin emboli and secondary thrombi. The local fibrin olytic therapy with rTPA involves little risk for patients selected by stri ct inclusion and exclusion criteria. it may be used for the treatment of re tinal arterial occlusion even later than 8 hours after the acute visual los s. However, a successful outcome of the therapy depends on the prompt refer ral by well-informed ophthalmologists; a speedy execution of all internal, neurologic, and ophthalmologic diagnostic measures; and a prompt therapy.