Successful recovery of vision following intravenous thrombolysis using low-dose alteplase in central retinal artery occlusion

Abstract

Central retinal artery occlusion (CRAO) is an ophthalmic emergency characterized by sudden loss of vision with a low chance of spontaneous recovery. This case report presents a 49-year-old female with sudden right eye visual loss, diagnosed as non-arteritic CRAO. Fundoscopic examination revealed retinal pallor, and optical coherence tomography demonstrated edema of the inner retinal layer, consistent with CRAO. Brain magnetic resonance imaging (MRI) showed an acute ischemic lesion in the right occipital subcortex. The patient received intravenous recombinant tissue plasminogen activator (IV rt-PA) at a lower-than-standard dose of 0.6 mg/kg within 4 h and 17 min of symptom onset, resulting in significant visual improvement. Extensive etiological investigation, including transesophageal echocardiography, uncovered a large, high-risk patent foramen ovale (PFO), leading to the diagnosis of PFO-associated CRAO and concomitant embolic stroke. This case suggests the effectiveness of low-dose IV rt-PA in treating CRAO, which might offer comparable efficacy to the standard dose while potentially minimizing bleeding risks. It also emphasizes the importance of considering cardiac comorbidities, particularly PFO, in younger CRAO patients, and underscores the need for a multidisciplinary approach and comprehensive stroke-etiology workups in CRAO management. This report contributes to the limited evidence on CRAO treatment in Japan, particularly in the context of lower tPA dosing and associated cardiac abnormalities. It underscores the importance of early diagnosis, treatment, and thorough etiological investigation in improving outcomes for CRAO patients.