The current case provided an unusual opportunity for treatment. The patient was a relatively healthy individual who came to the emergency department within a few hours of an acute CRAO without evidence of classical giant cell arteritis. A “stat” fluorescein angiogram performed before intervention confirmed the clinical diagnosis of acute CRAO and also revealed that the occlusion was incomplete. Hematological testing also confirmed that giant cell arteritis was unlikely (ie, normal ESR, no evidence of normochromic, normocytic anemia, no thrombocytosis).

TRADITIONAL THERAPIES: Current traditional therapies for embolic CRAO (ie, paracentesis, Carbogen, ocular massage, medication-induced IOP lowering) typically give poor results. Similarly, the natural untreated course has a poor prognosis.

EMERGING THERAPY: A growing European literature supports superselective arterial thrombolysis in early CRAO (less than 6 hours’ duration, possibly longer). This patient was offered traditional therapies, as well as superselective cerebral angiography with directed TPA infusion into the ophthalmic artery. The poor results of traditional therapies, as well as the additional risk of stroke (1% to 2%) or even death with cerebral angiography were openly discussed. The patient elected to undergo superselective angiography and TPA infusion after informed consent was obtained. A brief trial of ocular massage, as well as pharmacological intraocular pressure lowering was attempted without change in the visual acuity or examination.

CONCLUSION: This case suggests that aggressive therapy may be indicated in very early, well documented, selected cases of embolic CRAO. Certainly the additional risks must be carefully discussed, but the treatment may be offered in specialized facilities with appropriate staff, “stroke teams”, and ophthalmologic support. Inclusion or exclusion parameters need to be defined and will likely include length of arterial occlusion before intervention and possibly initial acuity level. It may be difficult to appropriately document the efficacy of this procedure with a randomized and masked controlled clinical trial, typically considered our “gold standard” measurement. However, more widespread awareness by the ophthalmologic, medical, as well as general community might result in earlier detection, diagnosis, and possibly effective treatment of CRAO through timely emergency referral to appropriately staffed treatment centers.