Introduction:
Central retinal artery occlusion (CRAO) is a rare, but devastating disease that results in profound visual loss in a majority of cases. It has no proven treatment and a variety of management options used clinically all have dismal rates of success.

Description:
A 72-year-old male had undergone uncomplicated cataract surgery in his left eye. Post-operative check at 2.5 hours documented uncorrected vision of 20/60, intraocular pressure of 18 mmHg, trace corneal edema and a well-positioned intraocular lens. He returned an hour later, and his left eye vision had reduced to light perception. He had a brisk relative afferent pupillary defect (RAPD), but the retina and optic nerve appeared normal. Intravenous fluorescein angiography confirmed vascular attenuation and reduced flow. The patient underwent local intra-arterial thrombolysis (LIT) of his left ophthalmic artery 2.75 hours after the onset of his vision loss. Within one minute of injection, the patient noted improvement in his vision. By the next day, his vision had improved to 20/40 and by one week, his vision was 20/20 with no RAPD. CT angiography of his chest, neck and brain revealed a large plaque in the left subclavian artery that was the presumed source of his embolic CRAO.

Conclusions:
There are various potential treatment options for CRAO, however they lack strong evidence for their efficacy. While the EAGLE study concluded that there was no difference in visual outcome between observation and LIT, the mean interval between symptom onset and therapy was 13 hours. This case demonstrates that in cases of CRAO, the retina may initially appear normal –  even in the presence of an RAPD. Also, early administration of LIT can have profound effect on the final visual outcome. Working closely with experienced interventional neuro-radiologists can provide excellent outcomes for this rare, but visually significant condition.

Dramatic visual recovery in central retinal artery occlusion treated with local intra-arterial tissue plasminogen activator

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