Low-dose intravenous alteplase for acute retinal artery occlusion: A multicentre retrospective study.

BACKGROUND: Central retinal artery occlusion (CRAO) is an ophthalmic emergency with poor visual prognosis. Although intravenous thrombolysis (IVT) within 4.5 h may be beneficial, the effectiveness and safety of low-dose alteplase remain uncertain. METHODS: We conducted a retrospective study at three centres in Japan, enrolling patients who presented within 24 h of onset with CRAO or macula-involving branch retinal artery occlusion (BRAO) between June 2021 and September 2024. Patients were analysed if they had baseline best-corrected visual acuity (BCVA) < 20/400, clearly defined symptom onset, absence of proliferative retinopathy or other retinal vascular diseases, and 30-day visual outcome data. Patients were grouped by treatment with IVT using alteplase at 0.6 mg/kg within 4.5 h or non-IVT management. The primary outcome was 30-day BCVA ≥ 20/100; secondary outcome included change in BCVA (logarithm of the minimum angle of resolution [logMAR]); and safety outcomes included intracranial hemorrhage (ICH). RESULTS: Sixteen of 41 registered patients were analysed (70.1 ± 12.6 years; 4 women; 13 had CRAO; 9 received IVT). The primary outcome was achieved in 22.2% (2/9) of the IVT group versus 0% (0/7) of the non-IVT group (p = 0.475). Improvement in logMAR was greater in the IVT than the non-IVT group (median difference 0.45 [95% confidence interval, 0.18-1.20]; p = 0.023). No symptomatic ICH occurred; one IVT-treated patient had asymptomatic ICH. CONCLUSION: IVT using low-dose alteplase within 4.5 h of CRAO (or macula-involving BRAO) onset may be associated with greater visual improvement without apparent safety concerns, although this requires confirmation by larger prospective studies.