Graefes Arch Clin Exp Ophthalmol. 2026 Jun;264(6):1541-1558. doi: 10.1007/s00417-026-07145-z.
Summary
Meta-analysis: IV thrombolysis for non-arteritic CRAO improves visual recovery when administered within 4.5 hours of symptom onset, but doesn’t alter final VA. May increase the chance of earlier vision recovery.
Abstract
Objective: To evaluate the effectiveness and safety of intravenous thrombolysis (IVT) in patients with non-arteritic central retinal artery occlusion (NA-CRAO), using a GRADE-assessed meta-analysis. METHODS: A systematic search was conducted across PubMed, Web of Science, Scopus, and Cochrane CENTRAL up to March 2025. Studies eligible included randomized controlled trials (RCTs) and observational designs evaluating IVT (alteplase or tenecteplase) against any comparator in NA-CRAO patients. Visual acuity (VA), visual recovery (VR), and adverse events were analyzed. Meta-analysis was performed using RevMan 5.4, calculating mean differences (MD) and risk differences (RD) with 95% confidence intervals (CI), employing a random-effects model. Risk of bias was assessed using RoB 2.0 and NOS tools. GRADE criteria evaluated evidence certainty. RESULTS: Ten studies (3 RCTs, 7 cohorts) involving 579 patients (224 IVT, 355 control) were included. IVT did not significantly improve VA (MD: -0.16; 95% CI: -0.35 to 0.03; P = 0.1) but showed a significant VR benefit (RD: 0.17; number needed to treat (NNT) = 6; 95% CI: 0.09 to 0.25; P < 0.0001), especially with early administration (< 4.5 h; RD: 0.24; NNT = 4). No significant differences in adverse events were found, including symptomatic ICH (RD: 0.00; 95% CI: -0.03 to 0.03; P = 1). CONCLUSIONS: IVT significantly improves VR, particularly when administered within 4.5 h, while no significant improvement in VA was observed except at 1 week. Safety outcomes were comparable to controls. These findings suggest that while IVT does not alter final VA, it may increase the probability of achieving earlier functional recovery within a narrow therapeutic window.
