Prognosis of Central Retinal Artery Occlusion: Local Intraarterial Fibrinolysis versus Conservative Treatment

Dieter P. Schmidt; Jürgen Schulte-Mönting; Martin Schumacher

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Fig 1.
Superselective angiography of the ophthalmic artery in a patient with acute blindness due to CRAO.
A, Before the administration of LIF.
B, After the administration of LIF, no significant changes were noted, except for slightly better choroidal-retinal perfusion (arrows).

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TABLE 1:

Results of conservative treatment of central retinal artery occlusion

Authors	No. of Patients	Medical Treatment	Final Results
Karjalainen, 1971 (19) (Patients with arteritis were included)	91	No comment	58%blind, 21%good or reduced visual acuity
Neubauer et al., 2000 (20)	65	Acetazolamide, acetylsalicylic acid, massage of the globe, Pentoxifyllin, beta-blocker, paracentesis	15%showed distinct improvement (at least three visual acuity gradations)
Schmidt et al., 1992 (18) (Control group of conservative treatment in comparison with small number of patients with LIF treatment)	41	Ocular massage, Pentoxifyllin, and anterior chamber paracentesis	Virtually no visual improvement; visual acuity improved to 20/50 in only one patient
Atebara et al., 1995 (8)	40	Paracentesis and Carbogen treatment	Nine (22.5%) patients, visual improvement
Augsburger and Magargal, 1980 (21)	34	Paracentesis, ocular massage, inhalational therapy (95%oxygen and 5%carbon dioxide), acetazolamide, and aspirin	Helpful in 12 (35%) patients (visual acuity ≥20/100)
Duker et al., 1991 (9)	33	Carbogen (95%oxygen and 5%carbon dioxide), ocular massage, anterior chamber paracentesis, topical timolol maleate, acetazolamide	29 patients, low vision (ie, counting fingers or hand movements); one patient, vision deteriorated from 20/40 to hand motions; two patients, final visual acuity of 20/40; one patient, 20/50; one patient, 20/20
Wolf et al., 1989 (10)	20	Hypervolemic or isovolemic hemodilution	10 patients, central vision improved
Magargal and Goldberg, 1977 (22)	20	Paracentesis	Five patients, significant improvement; five patients, moderate improvement
Lorentzen 1969 (23)	12	No comment	In no case was there any improvement, rather deterioration
	(10-year follow-up)
Rumelt et al., 1999 (14)	11	Ocular massage, sublingual isosorbide dinitrate, acetazolamide, mannitol or glycerol, paracentesis, methylprednisolone, streptokinase, and retrobulbar tolazoline	Eight patients, improvement
Gombos, 1970 (24)	7	Dextran (Rheomacrodex) with papaverine hydrochloride	Two patients, complete recovery; three patients, marked improvement
Perkins et al., 1987 (13)	5	Acetazolamide, inhalation of 5%carbon dioxide and 95%oxygen, aspirin	Three patients, spontaneous improvement to 20/50 or better; two patients, 20/80 or better after treatment
Beiran et al., 1993 (11)	4	Hyperbaric oxygenation combined with ocular massage, nifedipine, and glycerol	Three patients, treatment began <100 min, considerable improvement in vision; one patient, treatment began at 6 hr, no improvement

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TABLE 2:

Conservative treatment of 29 patients with incomplete central retinal artery occlusion

Pentoxifyllin	Hemodilution	Aspirin	Acetacolamid (Diamox)	Heparin
2^* (7.89%)	25^† (86.2%)	4 (13.79%)	3 (10.34%)	10 (34.48%)
Additional treatment or single treatment
Pentoxifyllin + additional treatment in one patient^*	Hemodilution + additional treatment in 12 patients^†			9 Heparin + 1 Marcumar)
Pentoxifyllin only in one (3.45%) patient	Hemodilution only in 11 (39.93%) patients	Aspirin only in one (3.45%) patient	Diamox only in one (3.45%) patient	Heparin only in one (3.45%) patient

Note.—In all patients, an immediate massage of the globe and treatment of high blood pressure were performed.
* Pentoxifyllin + hemodilution + aspirin, one (3.45%) patient.
† Hemodilution + heparin, nine (31.03%) patients; hemodilution + aspirin, two (6.89%) patients; hemodilution + Diamox, two (6.89%) patients.

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TABLE 3:

Conservative treatment of 83 patients with subtotal central retinal artery occlusion

Pentoxifyllin Infusions	Hemodilution	Aspirin	Acetacolamide (Diamox)	Rheomacrodex Infusions	Heparin	Eye Drops for Lowering Eye Pressure	Paracentesis
29 (34.9%)	46 (54.21%)	28 + 1 Plavix + 1 Tiklyd: 30 (36.14%)	9 (10.84%)	8 (9.64%)	16 (19.28%)	11 (13.25%)	13 (15.66%)
Additional treatment or single treatment
Pentoxifyllin + additional treatment^*: 21 patients (25.3%)	Pentoxifyllin + additional treatment^†: 36 (43.37%)	Aspirin + additional treatment^‡: 25 (30.12%)	Acetacolamide + additional treatment^§: nine (10.84%)	Rheomacrodex + additional treatment^§§: eight (9.64%)	Heparin + additional treatment: 14 (16.87%)	Eye drops + additional treatment: 11 (13.25%)	Paracentesis + additional treatment: 11 (13.25%)
Pentoxifyllin only: eight patients (9.64%)	Hemodilution only: 10 (12.05%)	Aspirin only: five (6.02%)	Acetacolamide only	Rheomacrodex only	Heparin only: two (2.41%)	Eye drops only	Paracentesis only: two (2.41%)

Note.—In all patients, immediate massage of the globe and treatment of high blood pressure were performed.
* Pentoxifyllin + aspirin, five (6.02%) patients; Pentoxifyllin + Diamox, one (1.2%) patient; Pentoxifyllin + aspirin + Diamox, one patient; Pentoxifyllin + Rheomacrodex, two (2.41%) patients; Pentoxifyllin + hemodilution, one patient; Pentoxifyllin + Paracentesis, three (3.61%) patients; Pentoxifyllin + hemodilution + aspirin + paracentesis, one patient; Pentoxifyllin + eye drops + paracentesis, two (2.41%) patients; Pentoxifyllin + hemodilution + eye drops + paracentesis, one patient; Pentoxifyllin + hemodilution + aspirin + heparin: one patient; Pentoxifyllin + Diamox + Rheomacrodex + paracentesis, one patient; Pentoxifyllin + hemodilution + eye drops, one patient; Pentoxifyllin + Diamox + paracentesis, one patient.
† Hemodilution + aspirin, 12 (14.45%) patients; hemodilution + eye drops, three (3.61%) patients; hemodilution + heparin, 10 (12.05%) patients; hemodilution + aspirin + heparin, one (1.2%) patient; hemodilution + aspirin + eye drops, one patient; hemodilution + Diamox + Rheomacrodex + paracentesis, one patient; hemodilution + aspirin + Diamox + heparin, one patient; hemodilution + eye drops + Diamox, one (1.2%) patient.
‡ Aspirin + Heparin, one patient; aspirin + Rheomacrodex, one patient.
§ Diamox + Rheomacrodex + eye drops, two patients.
§§ Rheomacrodex + paracentesis, one patient.

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TABLE 3a:
Conservative treatment of four patients with a total central retinal artery occlusion
Pentoxifyllin Infusions Hemodilution Aspirin Acetacolamide (Diamox) Rheomacrodex Infusions Heparin Eye Drops for Lowering Eye Pressure Paracentesis
One patient^* Two patients One patient One patient
Note.—In all patients, immediate massage of the globe and treatment of high blood pressure were performed.
* One patient was treated with Pentoxifyllin infusions + Diamox + paracentesis.

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TABLE 4:

Five groups of visual impairment

0	Blindness, no light perception
I (high degree of visual loss)	Perception of light, finger counting, recognition of hand motions
II (pronounced degree of visual loss)	1/50–1/15
III (distinct degree of visual loss)	0.1–0.3
IV (minor degree of visual loss)	0.4–1.0

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TABLE 5:
178 Patients with central retinal artery occlusion
Stage of Occlusion No. of Patients
Subtotal 130 (73.0%)
Incomplete 39 (21.9%)
Total 9 (5.1%)

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TABLE 6:

Influence of treatment on 178 patients with central retinal artery occlusion: results of ordinal logistic regression for visual acuity after treatment

Effect	No. of Patients		Wald’s χ²	P
Treatment	Conservative	116 (65.17%)
	LIF	62 (34.3%)	9.38	b
				0.0022
Gender	Male	125 (70.2%)		b
	Female	54 (30.3%)	0.17	0.6834
				e
Occlusion	Subtotal	130 (73.0%)		b
	Incomplete	39 (21.9%)	26.49	0.0001
	Complete	9 (5.1%)	4.53	0.0332
Age	18–89 years		8.71	0.0032
Latency	1–312 hr		3.97	0.0459
Initial visual acuity	0–5		43.31	0.0001

Note.—LIF indicates local intra-arterial fibrinolysis; b, baseline (reference) class; e, removed by backward elimination; (given P values are probability to remove values).

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TABLE 7:

Results for ordinal logistic regression for change of visual acuity under treatment: subpopulation of subtotal occlusions

Effect	Classes/Range	Wald’s χ²		P
Treatment	Conservative,	5.70			b
	83 (63.8%)	b		0.0169
	LIF, 47 (36.15%)
	(36.15%)
Gender	Male 93	0.01			b
	(71.5%)			0.9061	e
	Female, 37 (28.5%)
	(28.5%)
Age	18–89 years	8.85		0.0029
Latency	1–312 hr	3.60	e	0.0579	e
Initial visual acuity	1–3	4.28		0.0385

Note.—LIF indicates local intra-arterial fibrinolysis; b, baseline (reference) class; e, removed by backward elimination.

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TABLE 8:

Visual improvement after intra-arterial fibrinolysis: three different stages in 62 patients

Stage of CRAO	Group with Distinct Visual Improvement n = 10 patients (16.13%)	Group with Partial Visual Improvement n = 26 patients (41.93%)	Group without Visual Improvement n = 26 patients (41.93%)
Stage I (incomplete)	5 (50%)	3 (30%)	2 (20%)
Stage II (subtotal)	5 (10.64%)	19 (40.43%)	23 (48.94%)
Stage III (total) (no light perception)	0	4 (80%)	1 (20%)

Treatment of 62 patients with intra-arterial fibrinolysis: time interval of treatment after blindness
	Treatment <6 hr after Visual Loss (n = 10)	Treatment ≥6–14 hr after Visual Loss (n = 26)	Treatment >14 hr after Visual Loss (n = 26)
Distinct improvement	4 (30.77%)	5 (13.16%)	1 (9.09%)
Partial improvement	6 (46.15%)	15 (39.47%)	5 (45.45%)
No improvement	3 (23.08%)	18 (47.37%)	5 (45.45%)

Note.—CRAO indicates central retinal artery occlusion.

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TABLE 9:

Visual improvement after conservative treatment: three different stages in 116 patients

Stage of CRAO	Group with Distinct Visual Improvement n = 7 patients (6.5%)	Group with Partial Visual Improvement n = 27 patients (23.28%)	Group without Visual Improvement or with Deterioration n = 82 patients (70.69%)
Stage I (incomplete)	5 (17.24%)	14 (48.28%)	10 (34.48%)
Stage II (subtotal)	2 (2.41%)	13 (15.66%)	68 (81.93%)
Stage III (total) (no light perception)	0	0	4 (100%)

Conservative treatment of 116 patients: time interval of treatment after blindness
	Treatment <6 hr after Visual Loss n = 31 (26.72%)	Treatment: ≥6 to 14 hr after Visual Loss n = 44 (37.93%)	Treatment: ≥14 hr after Visual Loss n = 41 (35.34%)
Distinct improvement	1 (3.23%)	3 (6.82%)	3 (7.32%)
Partial improvement	7 (22.58%)	11 (25.00%)	9 (21.95%)
No improvement	23 (74.19%)	30 (68.18%)	29 (70.73%)