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Clinical Question

CRAO: thrombolysis or supportive care?

Synthesises 2 trialscentral retinal artery occlusion. Narrow ischemia window, first IV alteplase RCT plus the older intra-arterial trial

Clinical Synthesis

No therapy has been proven to restore vision after non-arteritic CRAO; the THEIA trial of IV alteplase within 4.5 hours was underpowered and missed its primary endpoint, and current practice is to treat CRAO as a TIA-equivalent and pursue urgent stroke workup rather than to deliver acute reperfusion.

Bottom line

There is no proven acute therapy for non-arteritic CRAO. Treat as a stroke-equivalent: admit (or expedited stroke-pathway workup), vessel and cardiac imaging, ECG monitoring, secondary-prevention initiation, and ophthalmology follow-up. Rule out giant cell arteritis with ESR/CRP and start empirical high-dose steroids if suspicion is meaningful.

Sources

Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4·5 h of severe vision loss (THEIA)· 2025Acute CRAO management· 2020EAGLE· 2010

Trials in this question· 2

EAGLE2010
IA tPA for CRAO causes harm (37% adverse events incl. ICH) with no visual benefit.
Harm−2.9% visual benefit
THEIA2025
First phase 3 RCT of IV alteplase vs aspirin for CRAO within 4.5h; directional but underpowered; safety reassuring.
No benefit66% vs 48%, p=0.95

Related questions

When can I give tPA?

0–3 h classic window through imaging-selected extended window

Tenecteplase or alteplase?

head-to-head IVT comparisons across geographies, dose, and time-window extensions

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