Network Meta-Analysis of Different Thrombolytic Strategies for the Treatment of Central Retinal Artery Occlusion

Intravenous and intra-arterial thrombolytic strategies have been used to treat central retinal artery occlusion (CRAO); however, previous meta-analyses evaluated the efficacy of these two thrombolytic strategies separately but did not compare them. This network meta-analysis aimed to evaluate the comparative efficacy and safety of different thrombolytic methods for treating CRAO.

We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfangdata to identify relevant studies published before 1 January 2023. We used the "network" command in STATA 14.0 software to perform network meta-analysis. In addition, we calculated the surface under the cumulative ranking (SUCRA) to rank all currently available thrombolytic strategies.

We included 12 studies in the final data analysis. Results suggested that, compared with standard treatment (ST), intravenous tissue plasminogen activator (IVtPA) (OR, 5.78; 95% CI, 2.07 to 16.11) and intra-arterial urokinase (IAUK) (OR, 2.78; 95% CI, 1.10 to 7.02) and intra-arterial tPA (IAtPA) (OR, 2.45; 95% CI, 1.04 to 5.77) achieved better visual improvement. The differences in visual improvement among IVtPA, IAUK, and IAtPA are insignificant. Furthermore, compared with ST, administration of IVtPA within 4.5 hours of CRAO onset (OR, 8.87; 95% CI, 3.35 to 23.48) rather than administration after 4.5 hours of onset (OR, 3.09; 95% CI, 0.81 to 11.70) achieved better visual improvement. In addition, compared to ST, all available thrombolytic strategies we evaluated were associated with a higher risk of adverse events, but these strategies did not differ. Based on the results of SUCRA, IVtPA had the highest ranking probability in visual improvement (91.9%) but had a relatively lower ranking probability of adverse events (60.1%).

Both intravenous and intra-arterial thrombolytic strategies are effective for treating CRAO, but SUCRA results show that IVtPA may be the optimal strategy for treating CRAO. Furthermore, based on the results of subgroup analysis, we further speculate that IVtPA injection within 4.5 hours of the onset of CRAO should be the optimal thrombolytic option for treating CRAO. However, due to the limitations of all eligible studies, more studies are still required in the future to validate our findings.