Abstract
Background Acute central retinal artery occlusion (CRAO) is a rare neuro-ophthalmic emergency with poor visual outcomes. Unfortunately, there is a paucity of strong evidence-based guidelines for acute CRAO management, although current treatment paradigms include intravenous thrombolysis and hyperbaric oxygen therapy. We report the first case of acute bilateral CRAO managed by thrombolysis after dabigatran reversal, followed by hyperbaric oxygen.
Case Description A 68-year-old man presented to hospital 1.5-hours after the acute onset of painless rapidly sequential bilateral visual loss. His other significant medical issues included hypertrophic cardiomyopathy and atrial fibrillation on dabigatran. On initial assessment, the patient had no perception of light bilaterally, and a pale retina with attenuated retinal vessels and cherry red spots bilaterally, without other focal neurological signs. Urgent CT stroke series and blood tests were normal. The patient was diagnosed with bilateral CRAO. Given the severity of his total vision loss, he was treated emergently. This consisted of thrombolysis with IV alteplase at 4-hours from symptom onset after reversal of dabigatran with idarucizumab, followed by anterior chamber paracentesis, and three sessions of hyperbaric oxygen treatment starting within the first 18 hours. The patient had some functional improvement in vision, to counting fingers bilaterally at 3 months. Extensive investigations revealed multiple tiny embolic infarcts on MRI brain, no features of systemic inflammatory conditions or pro-thrombotic factors.
Conclusion Emergent treatment for acute bilateral CRAOs, including intravenous thrombolysis, anterior chamber paracentesis and hyperbaric oxygen, may improve vision. There is a need for high-quality clinical trials in this field.
