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CRAO after tPA findings

  • 1.  CRAO after tPA findings

    Posted 05-11-2026 11:35
    If a patient with acute vision loss at age 37 is seen in an ER and given tPA given an hour after symptoms of presumed CRAO (no ophthalmology exam), with persistent very poor vision, APD, dense field cut, is it possible for there to be no retina finding at all two weeks later? No cherry red spot, NFL edema on OCT - nothing. A bit of optic nerve pallor maybe, that’s all. Color me very skeptical of the presumed diagnosis. (As kind of an aside unrelated to the question, this patient later had pain with eye movement developed a few days later with worsening of vision, the hospital’s MRI wa without contrast so getting one with contrast, probably optic neuritis actually).

    Mitch


  • 2.  RE: CRAO after tPA findings

    Posted 05-11-2026 11:53

    Mitch,

    If you are asking if the fundus findings of a central retina artery occlusion will disappear after successful treatment with TPA, then yes, you should not see any fundus findings of a central retina artery occlusion. However, if the fundus appears normal and the afferent examination is not normal then yes you are likely dealing with a different problem.

    Robert




  • 3.  RE: CRAO after tPA findings

    Posted 05-11-2026 12:04
    Thanks - the ultimate question is, since I have never seen a successful tPA rescue of a CRAO, can the CF vision, severe field loss, APD occur due to the minutes long periodof ischemia, via tPA (or good luck) restoring circulation, and while the vision loss has occurred and is likely to be permanent, the typical retinal edema and cherry red spot and OCT findings never had a chance to develop? Is this a reasonable scenario, especially for those of you who have seen a rescued CRAO with prompt restoration of circulation with severe persistent loss of vision but zero retina findings?

    I left out part of the history, she’s has a PFO which is obviously common, with R->L shunt on bubble study yes, but this is also common, and she is scheduled for PFO closure. I’m reluctant to be the person who says hold off unless it is theoretically possible for this situation to occur fwithr no retina findings after rescue from CRAO with tPA.

    Mitch


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  • 4.  RE: CRAO after tPA findings

    Posted 05-11-2026 12:06
    Robert, sorry I forgot to emphasize that the theoretical restoration of circulation after an hour of ischemia led to a visit two weeks where the findings of CRAO were absent. Of course, if it’s months and years later the retinal edema/cherry red spot goes away with resulting disk pallor and inner retinal thinning on OC. This one was two weeks later.

    Mitch


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  • 5.  RE: CRAO after tPA findings

    Posted 05-11-2026 14:19
    ERG should show signs of  retinal ischemia. If not I agree probably not CRAO
    Peter
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  • 6.  RE: CRAO after tPA findings

    Posted 05-11-2026 14:23
    The retinal edema subsides. The retinal can look pretty normal ( look carefully for retinal thinning) with disk pallor slowly developing. Oct can show inner retinal thinning w loss of the rnfl and gcl. Of course, it's a transition from thickening from the initial edema to thinning, so the thinning can be missed during that transition period.

    Russ Edwards




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  • 7.  RE: CRAO after tPA findings

    Posted 05-11-2026 14:37
    Thanks… Every case I’ve seen has obvious findings when fresh, and more subtle findings later, i.e. inner retinal thinning along with atrophy as things evolve. I suppose it’s possible to thread the needle and have the timing of restoration of circulation from TNK save the edema from happening but vision loss occurs. It’ll be interesting to see if the nerve lights up on MRI.

    Mitch


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  • 8.  RE: CRAO after tPA findings

    Posted 05-13-2026 04:07
    I saw cases of CRAO where retina looked completely normal 2 weeks after the incident with standard massage, induced hypotony, etc. No TPA. Disc changes came later

    Michael


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  • 9.  RE: CRAO after tPA findings

    Posted 05-13-2026 11:18
    Sounds like it’s possible to thread the timing needle and have enough ischemia to har the retina, but not long enough for edema - but as you say the optic atrophy comes later.

    However, in my case the MRI showed classic enhancement of optic neuritis. I was kind of expecting this because the APD wasn’t profound and extreme peripheral vision (on confrontation) was intact, plus the pain, which was atypical though in that it started many days after the loss of vision.

    Mitch


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  • 10.  RE: CRAO after tPA findings

    Posted 05-13-2026 11:39
    I don't think you can assume there never was retinal edema. It only takes 90 minutes of retinal artery blockage to kill the inner retinal; once circulation is reestablished, the edema can resolve. So it could easily have resolved 2 weeks after a crao. Optic atrophy evolves more slowly.

    Russ Edwards




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  • 11.  RE: CRAO after tPA findings

    Posted 05-13-2026 11:44
    I imagine the degree of vision/retina damage depends on duration of course but also percentage of occlusion, and other modifiers like BP and even hemoglobin level and local oxygen partial pressure, but I’ve never seen a CRAO younger than an hour.


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