👉 Bottom Line Up Top
Current evidence does not support the routine use of intravenous thrombolysis for acute central retinal artery occlusion (CRAO).
🤕 Case
A 71 year old woman with hypertension and atrial fibrillation presents 2.5 hours after the sudden onset of vision loss in her left eye. Examination demonstrates profound monocular vision loss, CTA is negative but bedside POCUS shows a retrobulbar spot sign, confirming the diagnosis of acute CRAO. Because she presents within the traditional 4.5 hour thrombolytic window, you consider whether intravenous thrombolysis should be administered.
🗣️ What Your Gut Says
CRAO is commonly referred to as an “eye stroke.” If thrombolytics improve outcomes in acute ischemic stroke, they should similarly be helpful in restoring vision in CRAO.
📈 What The Evidence Says
CRAO is an acute ischemic injury of the retina, most commonly caused by an embolic occlusion of the central retinal artery or one of its branches. Because the retinal and cerebral circulations share a common vascular origin, thrombolysis has long been considered a potential treatment strategy (Dumitrascu 2020; Mac Grory 2021). Important anatomical differences distinguish CRAO from cerebral stroke. The retina has minimal collateral circulation, resulting in rapid, irreversible ischemic injury. In addition, the small caliber of the retinal vasculature and the heterogeneous causes of CRAO may reduce the effectiveness of systemic thrombolysis (Hayreh 2011).
Early evidence supporting thrombolysis came primarily from observational studies and patient level meta analyses. This led to the 2021 American Heart Association Scientific Statement to recommend considering thrombolysis in carefully selected patients presenting within 4.5 hours while acknowledging the absence of randomized evidence (Mac Grory 2021; Schrag 2015).
More recently, two high quality randomized controlled trials have challenged this practice. In contrast to the earlier observational studies and patient level meta analyses, these trials reduce important sources of bias inherent to non-randomized designs including selection bias and confounding, and therefore provide the strongest evidence available to date. The THEIA trial found no improvement in visual recovery with intravenous alteplase compared with aspirin and demonstrated a trend toward more adverse events (Preterre 2025). Likewise, the TenCRAOS trial showed no significant difference in vision recovery between tenecteplase and aspirin while reporting one symptomatic intracranial hemorrhage in the thrombolysis group (Ryan 2026). Together, these studies suggest that the potential risks of thrombolysis outweigh any unproven benefit.
🚨 Clinical Bottom Line
Routine intravenous thrombolysis is not supported for patients with acute nonarteritic CRAO. Emergency physicians should instead prioritize rapid diagnosis, ophthalmology and neurology consultation, stroke evaluation, and secondary stroke prevention. Although CRAO remains a vascular emergency, current evidence suggests that thrombolytic therapy does not improve visual outcomes and may expose patients to unnecessary harm (Preterre 2025; Ryan 2026).
📚 References
- Dumitrascu, O. M., Newman, N. J., & Biousse, V. (2020).
Thrombolysis for central retinal artery occlusion in 2020: Time is vision! Journal of Neuro-Ophthalmology, 40(3), 333–345.
PMID: 32739995 - Hayreh, S. S. (2011).
Ocular vascular occlusive disorders: Natural history of visual outcome. Progress in Retinal and Eye Research, 30(5), 359–394.
PMID: 24769221 - Mac Grory, B., et al. (2021)
Management of central retinal artery occlusion: A scientific statement from the American Heart Association. Stroke.
PMID: 33677974 - Preterre, C., Gaultier, A., Obadia, M., et al. (2025).
Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4.5 hours of severe vision loss (THEIA): The Lancet Neurology.
PMID: 41109232 - Ryan, S. J. et al.
A randomized trial of tenecteplase in acute central retinal artery occlusion. New England Journal of Medicine, 394(5), 442–450.
PMID: 41604638 - Schrag, M., et al.
Intravenous fibrinolytic therapy in central retinal artery occlusion: A patient level meta analysis. JAMA Neurology, 72(10), 1148–1154.
PMID: 26258861
Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)
Authors