Successful Intravenous Thrombolysis of Central Retinal Artery Occlusion in a Patient with Giant Cell Arteritis

Importance: Central retinal artery occlusion (CRAO) is an ophthalmologic emergency, most often from non-arteritic etiology, but occasionally due to arteritic causes, especially giant cell arteritis (GCA), an inflammatory vasculitis affecting large and medium sized arteries. While thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) has gathered interest in non-arteritic CRAO, its role in arteritic CRAO remains unexplored. We report a case of successful visual recovery following intravenous thrombolysis in a patient with GCA-associated CRAO, and compare this outcome with current literature. Observations: A patient presenting with acute monocular vision loss in her left eye was diagnosed with CRAO in the setting of active GCA and received IV tPA within 2.5 hours of symptom onset. Visual acuity, fundus findings, and safety outcomes were documented post-treatment. Following treatment, the patient demonstrated significant visual improvement, regaining functional acuity. This contrasts sharply with the typically poor visual prognosis in arteritic CRAO, despite corticosteroid therapy alone. In non-arteritic CRAO, IV tPA, when administered within 4.5 hours, has been shown to improve vision in 30–60% of cases, with an excellent safety profile and very low incidence of symptomatic intracranial hemorrhage. No previous studies however have reported successful thrombolysis in arteritic CRAO. Conclusion: This case presents new evidence that early intravenous thrombolysis, in conjunction with corticosteroid therapy, may preserve vision in GCA-related CRAO by targeting a superimposed thrombotic component. While current guidelines do not support thrombolysis for arteritic CRAO, our findings suggest that a dual anti-inflammatory and thrombolytic approach could be effective in select patients. Further research is warranted to characterize patient selection criteria, optimize timing, and assess safety in this unique population.