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Show Letters to the Editor Should Patients With Acute Central Retinal Artery Occlusion Be Treated With Intraarterial t-PA?: Comment difference in visual outcome between the two groups in the EAGLE trial. Neil R. Miller, MD, FACS Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland I n their Point-Counterpoint article on whether to treat patients with acute central retinal artery occlusion (CRAO) with local intra-arterial fibrinolysis (LIF), both Dr Egan and Dr Van Stavern (1) appropriately reference the prospectively performed European Assessment Group for Lysis of the Eye (EAGLE) trial in which 84 subjects received either LIF (44 subjects) or "conservative" therapy (40 subjects). This trial found no difference in the degree of improvement in best-corrected visual acuity between the 2 groups (2). What neither author discusses in their otherwise excellent article is that all subjects in the EAGLE trial received 5 days of intravenous heparin in addition to either LIF or conservative treatment. In general, treatment with intravenous heparin for that period of time in patients with acute CRAO is not the standard of care in the United States. Indeed, it was not used in the study that we reported from Johns Hopkins (3) nor in several other studies from other countries that reported that patients with CRAO treated with LIF have better visual outcomes than patients treated conservatively (4,5). I am not suggesting that patients with acute CRAOs be treated with LIF nor that the results reported in the EAGLE Trial were invalid; however, I do wonder if 5 days (or more) of anticoagulation might have been the reason that there was no Should Patients With Acute Central Retinal Artery Occlusion Be Treated With Intraarterial t-PA?: Response W e thank Dr Miller for his comments and question about our Point-Counterpoint article. We agree that the use of intravenous anticoagulation may have played a role in the outcomes. However, time to treatment likely represents the larger factor in the lack of a statistical benefit between the 2 groups. Again extrapolating from acute stroke trial data, the International Stroke Trial failed to demonstrate a benefit of intravenous heparin started within 48 hours of onset over aspirin therapy when the increased risk of anticoagulationrelated hemorrhage was taken into account (1). Looking purely at recurrent ischemic stroke as a surrogate for clinical outcome in that trial, the benefit of intravenous heparin was 0.9% at 14 days. The 2015 Cochrane sys444 The author reports no conflicts of interest. REFERENCES 1. Egan RA, Van Stavern R. Should patients with acute central retinal artery occlusion be treated with intra-arterial t-PA? J Neuroophthalmol. 2015;35:205-209. 2. Schumacher M, Schmidt D, Jurklies B, Algal C, Wanke I, Schmoor C, Maier-Lenz H, Solymosi L, Brueckmann H, Neubauer AS, Wolf A, Feltgen N; EAGLE-Study Group. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology. 2010;117:1367-1375. 3. Aldrich EM, Lee AW, Chen CS, Gottesman RF, Bahouth MN, Gailloud P, Murphy K, Wityk R, Miller NR. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion. The Johns Hopkins Hospital experience. Stroke. 2008;39:1746-1750. 4. Weber J, Remonda L, Mattle HP, Koerner U, Baumgartner RW, Sturzenegger M, Ozdoba C, Koerner F, Schroth G. Selective intraarterial fibrinolysis of acute central retinal artery occlusion. Stroke. 1998;29:2076-2079. 5. Richard G, Lerche RC, Knospe V, Zeumer H. Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator. Ophthalmology. 1999;106:768-773. tematic review of early anticoagulant therapy in acute ischemic stroke revealed no benefit (2). Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism, but these reductions were offset by increased bleeding risk. When considering at time as an important factor, an open label, single center, randomized controlled trial of intravenous heparin (goal partial thromboplastin time 2-2.5 times greater than control for 5 d) vs placebo in 418 points treated within 3 hours of nonlacunar hemispheric stroke revealed somewhat similar outcomes when compared with the original NINDS trial (3,4). Only one of the studies included in the Cochrane review included patients who had been enrolled fewer than 12 hours from stroke onset. Renee B. Van Stavern, MD Stroke and General Neurology Sections, Washington University in St. Louis School of Medicine, St. Louis, Missouri Letters to the Editor: J Neuro-Ophthalmol 2015; 35: 444-446 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
