This journal club reviews the TenCRAOS RCT, which asked whether IV tenecteplase (vs. oral aspirin) within 4.5 hours of symptom onset improves vision recovery at 30 days in adults with acute nonarteritic CRAO and severe vision loss (BCVA ≥1.0 logMAR).
No significant benefit: 20% (8/40) in the tenecteplase group vs. 24% (9/38) in the aspirin group achieved the primary vision recovery endpoint at 30 days (risk difference −3.7%; 95% CI −22.0 to 14.7). Adverse events were more common with tenecteplase, including one case of symptomatic intracranial hemorrhage.
- Very small sample (n=78); trial was likely underpowered to detect modest differences. - Single-arm safety signals (1 intracranial hemorrhage) are hard to interpret statistically at this size. - Findings apply only to nonarteritic CRAO within 4.5 hours; results may not generalize to other CRAO subtypes or longer time windows.
Current RCT evidence (TenCRAOS and THEIA) does not support routine IV thrombolysis for acute CRAO — it offers no vision benefit and carries real bleeding risk. Focus ED management on timely diagnosis, secondary stroke workup, and multidisciplinary care rather than thrombolytics.
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