BACKGROUND:Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency associated with poor visual recovery. There is a dilemma regarding the appropriate treatment, as formal guidelines are lacking. Despite being considered an ocular equivalent of cerebral infarction, the time window of intravenous (IV) thrombolysis administration for maximum efficacy and safety in CRAO remains uncertain. OBJECTIVE:To critically assess the current evidence regarding the safety and effectiveness of IV thrombolysis in the treatment of patients with CRAO. METHODS:The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, and content experts in the fields of vascular neurology and ophthalmology. RESULTS:A recent patient-level meta-analysis was selected for critical appraisal. The study compared the visual recovery rates after IV thrombolysis in CRAO against the natural history of this illness and conservative therapies (ocular massage, anterior chamber paracentesis, and/or hemodilution). Time to thrombolytic therapy administration had a significant impact on visual recovery in CRAO (P<0.001). IV thrombolysis within the first 4.5 hours after symptom onset resulted in recovery of vision in 50.0% of the patients [95% confidence interval (CI), 32.4%-67.6%]. The rate of visual recovery was nearly 3 times higher than in the natural history cohort [odds ratio, 4.7 (95% CI, 2.3-9.6); P<0.001], with a 32.3% absolute risk reduction and a number needed to treat of 4.0 (95% CI, 2.6-6.6). There was no significant difference in the recovery rate after thrombolysis compared with the natural history cohort for those patients treated after 4.5 hours. No major hemorrhages occurred after alteplase administration in this meta-analysis. CONCLUSIONS:IV thrombolysis in CRAO seems to be safe and effective within the first 4.5 hours of symptom onset. A clinical decision based on this meta-analysis alone cannot be made due to several limitations. A randomized controlled clinical trial of early IV alteplase administration in CRAO is necessary to provide evidence-based therapeutic guidance.

译文

背景:视网膜中央动脉阻塞(CRAO)是一种神经和眼科急症,伴有视力恢复不良。由于缺乏正式的指导方针,因此在适当的治疗上存在两难选择。尽管被认为是脑梗死的等效眼药,静脉溶栓治疗在CRAO中获得最大疗效和安全性的时间窗口仍然不确定。
目的:严格评估有关IV溶栓治疗CRAO患者的安全性和有效性的现有证据。
方法:通过制定一个严格评估的主题来解决该目标,该主题包括临床方案,结构化问题,文献检索策略,严格评估,结果评估,证据总结,评论和底线结论。参加者包括血管神经病学和眼科领域的顾问和住院神经病学家,医学馆员以及内容专家。
结果:选择了近期的患者水平荟萃分析进行严格评估。这项研究比较了CRAO静脉溶栓后的视力恢复率与该疾病的自然病史和保守治疗方法(眼部按摩,前房穿刺和/或血液稀释)。溶栓治疗的时间对CRAO的视力恢复有显着影响(P <0.001)。在症状发作后的最初4.5小时内进行静脉溶栓治疗可导致50.0%的患者恢复视力[95%置信区间(CI),32.4%-67.6%]。视觉恢复率比自然史队列高出近3倍[赔率,比率4.7(95%CI,2.3-9.6); P <0.001],绝对危险度降低32.3%,需要治疗的数字为4.0(95%CI,2.6-6.6)。对于4.5小时后接受治疗的患者,溶栓后的恢复率与自然史队列相比无显着差异。在这项荟萃分析中,服用阿替普酶后未发生大出血。
结论:CRAO中的IV溶栓似乎在症状发作的最初4.5小时内是安全有效的。由于一些限制,不能仅基于这种荟萃分析做出临床决定。在CRAO中早期静脉给予阿替普酶的随机对照临床试验对于提供循证治疗指导是必要的。

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