Would you consider giving thrombolytic therapy for patients with acute vision loss concerning for CRAO based on history and within the window before any ophthalmological assessment and confirmation?

We have utilized a prior study to give tPA or tenecteplase within 4.5 hours of onset for CRAO. I would not do so, however, without an ophthalmology evaluation to confirm the likely diagnosis and to exclude an alternative diagnosis such as a retinal detachment.

This is a comment for the author of this question. The answer is a matter of general principles of medical practice: when a patient presents with a serious or life-threatening new neurological or other symptom in an ED, which has a differential diagnosis including at least 2 diagnoses that are treated completely differently, do you treat empirically for one of those diagnoses without a) confirming your suspicion with some objective evidence or b) at least excluding the mimics of the suspected diagnosis? Of course not! If a diabetic patient presents with acute hemiparesis, would you ever give tPA without a capillary blood sugar level to exclude hypoglycemia? Or a head CT? Well, the same applies to acute vision loss. There are several other s...

Vitreous and retinal hemorrhage and detachment (and other thrombolytic contraindications) should be excluded first because thrombolytics would end up causing harm in those situations. If ophthalmology is not available, ultrasound (available in the ED) can be used to detachment. Also, dilation of the eyes can be done in the ED by the ED physician or the neurologist to evaluate for hemorrhage with the ophthalmoscope, or if a pan optic is available, then this could potentially be done without eye dilation. The AHA scientific statement beautifully outlines a pathway for assessment for CRAO before administering thrombolytics:

Mac Grory et al., PMID 33677974