Retrobulbar Spot Sign Predicts Thrombolytic Treatment Effects and Etiology in Central Retinal Artery Occlusion

Abstract

Background and Purpose— Transorbital sonography may help establish diagnosis of central retinal artery occlusion (CRAO). Next to Doppler sonographic proof of CRAO, an intra-arterial spot sign can be detected in some cases. We hypothesized that it reflects calcified components. It may be associated with embolization from atherosclerotic plaques and may negatively influence thrombolysis. Methods— Prospective monocenter study of 46 patients with ophthalmologically confirmed CRAO. Systemic tissue-type plasminogen activator thrombolysis was performed when appropriate. All patients received etiologic workup. Results— CRAO was confirmed by Doppler in all patients. Fifty-nine percent of patients with arterio-arterial embolization were spot sign–positive compared with 20% from cardiac source ( P <0.05) and none with vasculitis. Eleven patients underwent thrombolysis. Clinically relevant visual improvement was only found in absence of a spot sign ( P <0.05). Conclusions— Transbulbar ultrasound is valuable for initial diagnosis and diagnostic workup of CRAO. In the light of inconsistent results of previous thrombolysis trials, ultrasound may identify patients more likely to benefit from thrombolytic treatment.

Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions

“…Although further studies are needed, we recommend ocular POCUS in all patients presenting with acute and subacute monocular vision loss, including an evaluation for an RBSS (Figure ). For those presenting with acute monocular vision loss, the presence of an RBSS has so far been shown to be 100% specific for thromboembolic (nonarteritic) CRAO, and a neurology consultation is warranted for evaluating the source and future preventive therapy …”

Intravenous recombinant tissue-type plasminogen activator thrombolysis for acute central retinal artery occlusion: a meta-analysis

“…Yet another RCT concluded that 16 of 24 patients (66.7%) had exhibited significant visual improvement [10]. In general, the improvement rate of VA following intravenous rt-PA treatment ranged from 0% to 83.3% [6][7][8][9][10][11][12].…”

“…After exclusion of duplicate studies, a total of 118 articles were initially identified; however, 111 were rejected based on the exclusion criteria. A total of seven remaining full-text articles that met inclusion criteria were included in this meta-analysis [6][7][8][9][10][11][12]. Two of these studies were randomized trial [8,10], three were prospective study [7,9,12], one was a pilot study [6], and one was a retrospective study [11].…”

“…Patients received the low-dosedose of 50mg rt-PA in only one study [7] and the conventional dose of 0.9mg/kg (maximum, 90 mg) in the other six studies [6,[8][9][10][11][12]. There was heterogeneity in the time from the onset of symptoms to treatment in all studies.…”

“…Recently, intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) has been extensively applied in the treatment of CRAO with the proven advantages of feasibility, safety, and effectiveness [6][7][8][9][10][11][12]. As a thrombolytic agent, rt-PA acts by inducing fibrinolysis.…”