Efficacy and safety of intra-arterial thrombolysis for retinal artery occlusion based on the green channel for eye stroke_Chinese Journal of Ocular Fundus Diseases

Authors：

Liang Anyi ¹ , Niu Yongyi ¹ , Wu Qiaowei ¹ , Chen Daiyu ¹ , Lin Hongbin ² , Tan Mingkui ² , Hu Yijun ¹ ,  Yu Honghua ¹

1. Guangdong Eye Institute, Department of Ophthalmology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China;
2. School of Software Engineering, South China University of Technology, Guangzhou 510006, China;

Corresponding author：

Yu Honghua, Email: yuhonghua@gdph.org.cn

Keywords：

Retinal artery occlusion; Intra-arterial thrombolysis; Green channel; Efficacy; Safety

DOI：

10.3760/cma.j.cn511434-20230404-00145

Video：

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Objective To explore the short-term efficacy and safety of intra-arterial thrombolysis (IAT) in the treatment of retinal artery occlusion (RAO) with the assistance of the rescue green channel in the eye stroke center. Methods A prospective, interventional, single-center study. Thirty-eight eyes from 38 RAO patients who received IAT treatment in Guangdong Provincial People’s Hospital were enrolled. All the patients were rescued via the green channel in our eye stroke center. Data from comprehensive ocular examinations including best-corrected visual acuity (BCVA) and optical coherence tomography angiography (OCTA) were collected. BCVA was measured with Snellen chart and converted to the logarithmic minimum angle of resolution (logMAR) unit for statistical analysis. RTVue XR OCTA was used to measure vascular densities (VD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and radial peripapillary capillary (RPC), and central retinal thickness (CRT). All RAO eyes attempted IAT treatment and 34 eyes were successful. Four eyes failed to complete IAT because of the occlusion of internal or common carotid arteries on the same side with the RAO eyes. Ocular examinations in post-operative 1-3 days were performed with the same devices and methods as those before surgery. Parameters measured before and after surgery include BCVA, VD of SCP, DCP, RPC, and CRT. Data of the green channel collected include the time intervals from onset of RAO to first presentation in local hospitals, and from onset of RAO to our eye stroke center. Comparisons of VD and CRT between the RAO eyes and contralateral healthy eyes were performed with independent samples Mann-Whitney U test; comparisons of VD and CRT in RAO eyes before and after IAT surgery were performed with paired samples Wilcoxon Rank Sum test. Results Among the 34 RAO patients who had successful IAT surgery, 18 (52.9%, 18/34) were males and 16 (47.1%, 16/34) were females; the mean age was (51.0±12.9) years old. There were 30 and 4 eyes diagnosed as central RAO and branch RAO respectively. The logMAR BCVA before and after IAT surgery was 2.52±0.61 and 2.18±0.85 respectively, and the difference was statistically significant (Z=－3.453, P=0.002). Before surgery, VD of SCP, DCP and RPC were significantly decreased and CRT was significantly increased in the affected eye compared with the contralateral healthy eyes, with the statistical significance (P＜0.001). Compared with those before surgery, the VD of SCP and DCP were significantly improved after surgery (Z=－2.523, －2.427; P=0.010, 0.014), while there was no difference in VD of RPC and CRT (Z=－1.448, －1.454; P=0.150, 0.159). The time interval between onset of RAO and first visit to the hospital was (6.56±6.73) hours; the time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early post-operative period and no cerebrocardiovascular events were observed later. he time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early post-operative period and no cerebrocardiovascular events were observed later. Conclusions The short-term efficacy and safety of IAT in the treatment of RAO were satisfactory. The rescue time window might be prolonged.

Citation： Liang Anyi, Niu Yongyi, Wu Qiaowei, Chen Daiyu, Lin Hongbin, Tan Mingkui, Hu Yijun, Yu Honghua. Efficacy and safety of intra-arterial thrombolysis for retinal artery occlusion based on the green channel for eye stroke. Chinese Journal of Ocular Fundus Diseases, 2023, 39(6): 444-450. doi: 10.3760/cma.j.cn511434-20230404-00145 Copy

1.	Mac GB, Schrag M, Biousse V, et al. Management of central retinal artery occlusion: a scientific statement from the American Heart Association[J]. Stroke, 2021, 52(6): 282-294. DOI: 10.1161/STR.0000000000000366.
2.	Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome[J]. Am J Ophthalmol, 2005, 140(3): 376-391. DOI: 10.1016/j.ajo.2005.03.038.
3.	Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial[J]. Ophthalmology, 2010, 117(7): 1367-1375. DOI: 10.1016/j.ophtha.2010.03.061.
4.	Schrag M, Youn T, Schindler J, et al. Intravenous fibrinolytic therapy in central retinal artery occlusion: a patient-level meta-analysis[J]. JAMA Neurol, 2015, 72(10): 1148-1154. DOI: 10.1001/jamaneurol.2015.1578.
5.	Helenius J, Arsava EM, Goldstein JN, et al. Concurrent acute brain infarcts in patients with monocular visual loss[J]. Ann Neurol, 2012, 72(2): 286-293. DOI: 10.1002/ana.23597.
6.	Benavente O, Eliasziw M, Streifler JY, et al. Prognosis after transient monocular blindness associated with carotid-artery stenosis[J]. N Engl J Med, 2001, 345(15): 1084-1090. DOI: 10.1056/NEJMoa002994.
7.	Schorr EM, Rossi KC, Stein LK, et al. Characteristics and outcomes of retinal artery occlusion: nationally representative data[J]. Stroke, 2020, 51(3): 800-807. DOI: 10.1161/STROKEAHA.119.027034.
8.	Hakim N, Hakim J. Intra-arterial thrombolysis for central retinal artery occlusion[J]. Clin Ophthalmol, 2019, 13: 2489-2509. DOI: 10.2147/OPTH.S232560.
9.	Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2013, 44(7): 2064-2089. DOI: 10.1161/STR.0b013e318296aeca.
10.	Johnston SC, Albers GW, Gorelick PB, et al. National Stroke Association recommendations for systems of care for transient ischemic attack[J]. Ann Neurol, 2011, 69(5): 872-877. DOI: 10.1002/ana.22332.
11.	Biousse V. Acute retinal arterial ischemia: an emergency often ignored[J]. Am J Ophthalmol, 2014, 157(6): 1119-1121. DOI: 10.1016/j.ajo.2014.02.018.
12.	Streifler JY, Eliasziw M, Benavente OR, et al. The risk of stroke in patients with first-ever retinal vs hemispheric transient ischemic attacks and high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial[J]. Arch Neurol, 1995, 52(3): 246-249. DOI: 10.1001/archneur.1995.00540270034016.
13.	Jetty P, Husereau D, Kubelik D, et al. Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention[J]. J Vasc Surg, 2012, 56(3): 661-667. DOI: 10.1016/j.jvs.2012.03.001.
14.	Kishore K, Chan VW, Neekhra A. Comment on Chan W, Flowers AM, Meyer BI, et al. acute central retinal artery occlusion seen within 24 hours at a tertiary institution. J Stroke Cerebrovasc Dis 2021; 30: 105988[J]. J Stroke Cerebrovasc Dis, 2022, 31(5): 106392. DOI: 10.1016/j.jstrokecerebrovasdis.2022.106392.
15.	Hoyer C, Kahlert C, Guney R, et al. Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness[J]. Eur J Neurol, 2021, 28(6): 2111-2114. DOI: 10.1111/ene.14735.
16.	Rudkin AK, Lee AW, Chen CS. Central retinal artery occlusion: timing and mode of presentation[J]. Eur J Neurol, 2009, 16(6): 674-677. DOI: 10.1111/j.1468-1331.2009.02616.x.
17.	Flaxel CJ, Adelman RA, Bailey ST, et al. Retinal and ophthalmic artery occlusions preferred practice pattern(R)[J]. Ophthalmology, 2020, 127(2): P259-P287. DOI: 10.1016/j.ophtha.2019.09.028.
18.	Dumitrascu OM, Newman NJ, Biousse V. Thrombolysis for central retinal artery occlusion in 2020: time is vision![J]. J Neuroophthalmol, 2020, 40(3): 333-345. DOI: 10.1097/WNO.0000000000001027.
19.	Mercier J, Kastler A, Jean B, et al. Interest of local intra-arterial fibrinolysis in acute central retinal artery occlusion: Clinical experience in 16 patients[J]. J Neuroradiol, 2015, 42(4): 229-235. DOI: 10.1016/j.neurad.2014.02.007.
20.	Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience[J]. Stroke, 2008, 39(6): 1746-1750. DOI: 10.1161/STROKEAHA.107.505404.
21.	Pettersen JA, Hill MD, Demchuk AM, et al. Intra-arterial thrombolysis for retinal artery occlusion: the Calgary experience[J]. Can J Neurol Sci, 2005, 32(4): 507-511. DOI: 10.1017/S0317167100004522.
22.	Richard G, Lerche RC, Knospe V, et al. Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator[J]. Ophthalmology, 1999, 106(4): 768-773. DOI: 10.1016/S0161-6420(99)90165-3.
23.	雷涛, 王润生, 李娟, 等. 尿激酶溶栓治疗面部微注射玻尿酸并发眼动脉和视网膜动脉阻塞及自发性视网膜动脉阻塞的疗效对比观察[J]. 中华眼底病杂志, 2019, 35(6): 593-598. DOI: 10.3760/cma.j.issn.1005-1015.2019.06.015.Lei T, Wang RS, Li J, et al. Effect of urokinase thrombolytic therapy for optic artery and retinal artery occlusion caused by facial microinjection with hyaluronic acid and spontaneous retinal artery occlusion[J]. Chin J Ocul Fundus Dis, 2019, 35(6): 593-598. DOI: 10.3760/cma.j.issn.1005-1015.2019.06.015.
24.	雷涛, 王润生, 李豫, 等. 经滑车上动脉逆行或颈外动脉顺行介入溶栓治疗视网膜中央动脉阻塞伴同侧颈内动脉闭塞的疗效观察[J]. 中华眼底病杂志, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.Lei T, Wang RS, Li Y, et al. The effect of interventional thrombolytic therapy for central retinal artery occlusion with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely[J]. Chin J Ocul Fundus Dis, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.
25.	姜金利, 李宝民, 马志忠, 等. 局部动脉内溶栓治疗视网膜中央动脉阻塞26例报告[J]. 解放军医学杂志, 2004, 29(4): 356-357. DOI: 10.3321/j.issn:0577-7402.2004.04.024.Jiang JL, Li BM, Ma ZZ, et al. Selective intra-arterial thrombolytic therapy for central retinal artery occlusion: 26 cases report[J]. Med J Chin PLA, 2004, 29(4): 356-357. DOI: 10.3321/j.issn:0577-7402.2004.04.024.
26.	吴晓云, 李国培, 何耀强, 等. 超选择眼动脉插管溶栓治疗视网膜中央动脉阻塞[J]. 现代诊断与治疗, 2016, 27(14): 2572-2573.Wu XY, Li GP, He YQ, et al. Observation of the effect of super selective ophthalmic artery catheterization in the treatment of central retinal artery occlusion[J]. Mod Diagn Treat, 2016, 27(14): 2572-2573.
27.	陈曦, 李珊珊, 赵露, 等. 动脉溶栓治疗视网膜中央动脉阻塞meta分析[J]. 山东大学耳鼻喉眼学报, 2020, 34(4): 28-34. DOI: 10.6040/j.issn:1673-3770.1.2020.057.Chen X, Li SS, Zhao L, et al. Intra-arterial thrombolysis for central retinal artery occlusion: a meta-analysis[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2020, 34(4): 28-34. DOI: 10.6040/j.issn:1673-3770.1.2020.057.
28.	Hayreh SS. Central retinal artery occlusion[J]. Indian J Ophthalmol, 2018, 66(12): 1684-1694. DOI: 10.4103/ijo.IJO_1446_18.
29.	Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after transient central retinal artery occlusion: an experimental study in rhesus monkeys[J]. Am J Ophthalmol, 2000, 129(6): 786-795. DOI: 10.1016/s0002-9394(00)00384-6.
30.	Bonini FM, Adhi M, de Carlo TE, et al. Optical coherence tomography angiography in retinal artery occlusion[J]. Retina, 2015, 35(11): 2339-2346. DOI: 10.1097/IAE.0000000000000850.

1. Mac GB, Schrag M, Biousse V, et al. Management of central retinal artery occlusion: a scientific statement from the American Heart Association[J]. Stroke, 2021, 52(6): 282-294. DOI: 10.1161/STR.0000000000000366.
2. Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome[J]. Am J Ophthalmol, 2005, 140(3): 376-391. DOI: 10.1016/j.ajo.2005.03.038.
3. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial[J]. Ophthalmology, 2010, 117(7): 1367-1375. DOI: 10.1016/j.ophtha.2010.03.061.
4. Schrag M, Youn T, Schindler J, et al. Intravenous fibrinolytic therapy in central retinal artery occlusion: a patient-level meta-analysis[J]. JAMA Neurol, 2015, 72(10): 1148-1154. DOI: 10.1001/jamaneurol.2015.1578.
5. Helenius J, Arsava EM, Goldstein JN, et al. Concurrent acute brain infarcts in patients with monocular visual loss[J]. Ann Neurol, 2012, 72(2): 286-293. DOI: 10.1002/ana.23597.
6. Benavente O, Eliasziw M, Streifler JY, et al. Prognosis after transient monocular blindness associated with carotid-artery stenosis[J]. N Engl J Med, 2001, 345(15): 1084-1090. DOI: 10.1056/NEJMoa002994.
7. Schorr EM, Rossi KC, Stein LK, et al. Characteristics and outcomes of retinal artery occlusion: nationally representative data[J]. Stroke, 2020, 51(3): 800-807. DOI: 10.1161/STROKEAHA.119.027034.
8. Hakim N, Hakim J. Intra-arterial thrombolysis for central retinal artery occlusion[J]. Clin Ophthalmol, 2019, 13: 2489-2509. DOI: 10.2147/OPTH.S232560.
9. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2013, 44(7): 2064-2089. DOI: 10.1161/STR.0b013e318296aeca.
10. Johnston SC, Albers GW, Gorelick PB, et al. National Stroke Association recommendations for systems of care for transient ischemic attack[J]. Ann Neurol, 2011, 69(5): 872-877. DOI: 10.1002/ana.22332.
11. Biousse V. Acute retinal arterial ischemia: an emergency often ignored[J]. Am J Ophthalmol, 2014, 157(6): 1119-1121. DOI: 10.1016/j.ajo.2014.02.018.
12. Streifler JY, Eliasziw M, Benavente OR, et al. The risk of stroke in patients with first-ever retinal vs hemispheric transient ischemic attacks and high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial[J]. Arch Neurol, 1995, 52(3): 246-249. DOI: 10.1001/archneur.1995.00540270034016.
13. Jetty P, Husereau D, Kubelik D, et al. Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention[J]. J Vasc Surg, 2012, 56(3): 661-667. DOI: 10.1016/j.jvs.2012.03.001.
14. Kishore K, Chan VW, Neekhra A. Comment on Chan W, Flowers AM, Meyer BI, et al. acute central retinal artery occlusion seen within 24 hours at a tertiary institution. J Stroke Cerebrovasc Dis 2021; 30: 105988[J]. J Stroke Cerebrovasc Dis, 2022, 31(5): 106392. DOI: 10.1016/j.jstrokecerebrovasdis.2022.106392.
15. Hoyer C, Kahlert C, Guney R, et al. Central retinal artery occlusion as a neuro-ophthalmological emergency: the need to raise public awareness[J]. Eur J Neurol, 2021, 28(6): 2111-2114. DOI: 10.1111/ene.14735.
16. Rudkin AK, Lee AW, Chen CS. Central retinal artery occlusion: timing and mode of presentation[J]. Eur J Neurol, 2009, 16(6): 674-677. DOI: 10.1111/j.1468-1331.2009.02616.x.
17. Flaxel CJ, Adelman RA, Bailey ST, et al. Retinal and ophthalmic artery occlusions preferred practice pattern(R)[J]. Ophthalmology, 2020, 127(2): P259-P287. DOI: 10.1016/j.ophtha.2019.09.028.
18. Dumitrascu OM, Newman NJ, Biousse V. Thrombolysis for central retinal artery occlusion in 2020: time is vision![J]. J Neuroophthalmol, 2020, 40(3): 333-345. DOI: 10.1097/WNO.0000000000001027.
19. Mercier J, Kastler A, Jean B, et al. Interest of local intra-arterial fibrinolysis in acute central retinal artery occlusion: Clinical experience in 16 patients[J]. J Neuroradiol, 2015, 42(4): 229-235. DOI: 10.1016/j.neurad.2014.02.007.
20. Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience[J]. Stroke, 2008, 39(6): 1746-1750. DOI: 10.1161/STROKEAHA.107.505404.
21. Pettersen JA, Hill MD, Demchuk AM, et al. Intra-arterial thrombolysis for retinal artery occlusion: the Calgary experience[J]. Can J Neurol Sci, 2005, 32(4): 507-511. DOI: 10.1017/S0317167100004522.
22. Richard G, Lerche RC, Knospe V, et al. Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator[J]. Ophthalmology, 1999, 106(4): 768-773. DOI: 10.1016/S0161-6420(99)90165-3.
23. 雷涛, 王润生, 李娟, 等. 尿激酶溶栓治疗面部微注射玻尿酸并发眼动脉和视网膜动脉阻塞及自发性视网膜动脉阻塞的疗效对比观察[J]. 中华眼底病杂志, 2019, 35(6): 593-598. DOI: 10.3760/cma.j.issn.1005-1015.2019.06.015.Lei T, Wang RS, Li J, et al. Effect of urokinase thrombolytic therapy for optic artery and retinal artery occlusion caused by facial microinjection with hyaluronic acid and spontaneous retinal artery occlusion[J]. Chin J Ocul Fundus Dis, 2019, 35(6): 593-598. DOI: 10.3760/cma.j.issn.1005-1015.2019.06.015.
24. 雷涛, 王润生, 李豫, 等. 经滑车上动脉逆行或颈外动脉顺行介入溶栓治疗视网膜中央动脉阻塞伴同侧颈内动脉闭塞的疗效观察[J]. 中华眼底病杂志, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.Lei T, Wang RS, Li Y, et al. The effect of interventional thrombolytic therapy for central retinal artery occlusion with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely[J]. Chin J Ocul Fundus Dis, 2018, 34(3): 228-232. DOI: 10.3760/cma.j.issn.1005-1015.2018.03.005.
25. 姜金利, 李宝民, 马志忠, 等. 局部动脉内溶栓治疗视网膜中央动脉阻塞26例报告[J]. 解放军医学杂志, 2004, 29(4): 356-357. DOI: 10.3321/j.issn:0577-7402.2004.04.024.Jiang JL, Li BM, Ma ZZ, et al. Selective intra-arterial thrombolytic therapy for central retinal artery occlusion: 26 cases report[J]. Med J Chin PLA, 2004, 29(4): 356-357. DOI: 10.3321/j.issn:0577-7402.2004.04.024.
26. 吴晓云, 李国培, 何耀强, 等. 超选择眼动脉插管溶栓治疗视网膜中央动脉阻塞[J]. 现代诊断与治疗, 2016, 27(14): 2572-2573.Wu XY, Li GP, He YQ, et al. Observation of the effect of super selective ophthalmic artery catheterization in the treatment of central retinal artery occlusion[J]. Mod Diagn Treat, 2016, 27(14): 2572-2573.
27. 陈曦, 李珊珊, 赵露, 等. 动脉溶栓治疗视网膜中央动脉阻塞meta分析[J]. 山东大学耳鼻喉眼学报, 2020, 34(4): 28-34. DOI: 10.6040/j.issn:1673-3770.1.2020.057.Chen X, Li SS, Zhao L, et al. Intra-arterial thrombolysis for central retinal artery occlusion: a meta-analysis[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2020, 34(4): 28-34. DOI: 10.6040/j.issn:1673-3770.1.2020.057.
28. Hayreh SS. Central retinal artery occlusion[J]. Indian J Ophthalmol, 2018, 66(12): 1684-1694. DOI: 10.4103/ijo.IJO_1446_18.
29. Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after transient central retinal artery occlusion: an experimental study in rhesus monkeys[J]. Am J Ophthalmol, 2000, 129(6): 786-795. DOI: 10.1016/s0002-9394(00)00384-6.
30. Bonini FM, Adhi M, de Carlo TE, et al. Optical coherence tomography angiography in retinal artery occlusion[J]. Retina, 2015, 35(11): 2339-2346. DOI: 10.1097/IAE.0000000000000850.

Chinese Journal of Ocular Fundus Diseases

Efficacy and safety of intra-arterial thrombolysis for retinal artery occlusion based on the green channel for eye stroke

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