Introduction Central retinal artery occlusion (CRAO) is considered an ophthalmologic emergency. Neurointerventionalists commonly treat emergent large vessel occlusion stroke with endovascular reperfusion procedures and, therefore, are well positioned to provide emergent endovascular treatment of CRAO with intra-arterial thrombolysis (IAT). The clinical benefit of IAT therapy for CRAO remains controversial. The most recent systematic review and meta-analysis on the topic was published in 2000 that evaluated five studies totaling 100 patients. Since that time additional studies have been performed with hundreds more patients available including a randomized controlled trial. Here we performed a systematic review of the literature and an exploratory meta-analysis.
Methods A comprehensive literature search was conducted in MEDLINE (1946–January 2015) for the following medical keywords: intra-arterial thrombolysis; retinal artery occlusion; intra-arterial fibrinolysis; and retinal artery. Additional articles were identified by review of the reference sections of each article. Inclusion criteria consisted of articles written in English, microcatheter directed infusion of thrombolytic (tPA, urokinase, streptokinase), studies with control groups, and studies with more than five patients. An exploratory meta-analysis was conducted for studies of a similar level of evidence using the inverse variance method for weighting studies and the DerSimonian-Laird estimator for quantifying heterogeneity. A Forest plot was created using R (package meta) statistical software.
Results Six studies were identified that met the inclusion criteria.1–6 There were five controlled retrospective cohort studies consisting of 409 patients and one randomized controlled trial (RCT) consisting of 82 patients (EAGLE Study). Pooled analysis was not performed on the RCT due to it having a significantly different level of evidence. The estimated pooled odds ratio for fixed effects analysis of the remaining five studies was 3.11 (95% CI, 2.02 to 4.78; P < 0.0001) in favor of IAT therapy (Figure 1). The RCT did not show benefit of IAT therapy (P = 0.69).
Conclusion IAT therapy for CRAO remains controversial. Pooled analysis of the retrospective studies supports IAT therapy whereas a single RCT does not support intervention. Other authors have suggested significant methodological concerns for the EAGLE study calling into question its conclusions that conflict with favorable studies of presumably lower levels of evidence.7 Additional study, potentially with stricter IAT time to treatment criteria may be warranted.
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Disclosures P. Page: None. A. Cambon: None. R. James: 1; C; Microvention, Penumbra. 2; C; Pulsar, Covidien. 4; C; Remedy Pharmaceuticals.