Updates in Central Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) is a vision-threatening neuro-ophthalmic emergency, analogous to acute ischemic stroke. Delayed presentation, limited therapeutic options, and lack of randomized prospective trials continue to restrict effective treatment.

This review summarizes current evidence on the emergent management and evolving treatment strategies for CRAO, based on recent observational studies, meta-analyses, and early randomized trials.

Conservative interventions, such as ocular massage, paracentesis, and vasodilator use, have shown no benefit and may be harmful. Limited data suggest that intravenous thrombolysis with recombinant t-PA (alteplase or tenecteplase [TNK]) within 4.5 hours of symptoms onset offers the strongest evidence for visual recovery, with a safety profile comparable to that of cerebral stroke treatment. TNK offers pharmacologic advantages but has not demonstrated clinical superiority over alteplase. Intra-arterial thrombolysis may extend the treatment window, although findings remain inconsistent. "Eye stroke" protocols incorporating teleophthalmology, nonmydriatic fundus photography, and artificial intelligence improved diagnostic efficiency. Hyperbaric oxygen therapy may serve as an adjunctive treatment when initiated early.

CRAO should be managed as an acute ischemic stroke of the eye. Thrombolysis within 4.5 hours offers the highest potential for visual recovery, but further prospective, randomized studies are needed to determine efficacy, safety, and optimal management strategies. Improving public awareness, implementing streamlined multidisciplinary protocols, and expanding access to specialized care are essential to enabling timely intervention.