Alteplase Given Within 4.5 Hours via Telemedicine and in Person to Patients Presenting With a Central Retinal Artery Occlusion

Introduction: Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Studies on the efficacy of IV t-PA, treated patients up to 30 hours from symptom onset. There has only been one prospective study of early IV t-PA use. With the increasing use of telemedicine (TM), we evaluated the use of IV t-PA within 4.5 hours for CRAO/BRAO and assessed visual outcomes up to 90 days amongst patients evaluated via TM versus in-person. Methods: Data were retrospectively abstracted for CRAO/BRAO treated with IV t-PA within a large managed healthcare system. Visual outcomes abstracted at 24 hours were classified as Low Vision (light perception, hand motion, finger counting) and converted to mean LogMAR. Visual outcomes abstracted within 2 weeks and 3 months were classified as normal-mild impairment (LogMAR 0.4-0.5), moderate-severe impairment (LogMAR 0.6-1.3) and blind-low vision (LogMAR >1.3). Descriptive statistics were performed on all variables. Visual outcomes were analyzed using the sign test. Results: Between 2013-2019, 16 patients received IV t-PA within 4.5 hours of symptom onset. 11 were evaluated via TM and 5 in-person. All patients were accurately diagnosed with CRAO/BRAO. 24 hours post t-PA, 37.5% of TM vs 25% of in-person patients had at least a one-point improvement on the low vision scale. Within 2 weeks, 12.5% of TM vs 18.75% of in-person, and within 90 days, 13.33% of TM vs 20% of in-person patients improved from low vision to normal-mild impairment in vision. In all patients, at 24 hours post t-PA 56.25% (p= 0.04) had at least a one-point improvement on the low vision scale. Within 2 weeks, 31.25% (p= 0.03) and 90 days, 33.3% (p= 0.03) of patients continued to improve from low vision to normal-mild impairment in vision. Conclusions: All patients were correctly diagnosed with CRAO/BRAO irrespective of method of evaluation. More patients improved on the low vision scale at 24 hours via TM than in-person. More in-person diagnosed patients improved from low vision to normal-mild impairment in vision within 2 weeks and 90 days of IV t-PA. IV t-PA use within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days regardless of TM or in-person diagnosis. Our study was limited by small sample size and no control group.