Case of Central Retinal Artery Occlusion from Paradoxical Embolism with Intra-Arterial Thrombolysis

Background Central retinal artery occlusion (CRAO) is most often seen in older patients with atherosclerotic or thromboembolic risk factors. In younger individuals, however, paradoxical embolism through right‐to‐left shunts such as patent foramen ovale (PFO) or pulmonary arteriovenous malformations (PAVMs) must be considered. Aberrant ophthalmic artery (OA) origin from the middle meningeal artery (MMA) is a rare anatomical variant, typically incidental, but may alter embolic flow dynamics. Case Presentation We report the case of a 33‐year‐old man with hereditary hemorrhagic telangiectasia (HHT), a large PAVM, and PFO who presented with acute, painless monocular vision loss. Ophthalmic examination revealed CRAO. Neuroimaging showed no cerebral ischemia. Angiography identified an aberrant origin of OA from the MMA. Intra‐arterial thrombolysis (IAT) via the MMA was performed, resulting in partial reperfusion and modest visual recovery. Importantly, the intervention also uncovered the aberrant anatomy, clarifying the pathogenesis as paradoxical embolism targeting the retinal circulation. Discussion To our knowledge, this represents the first reported case of CRAO in an aberrant OA origin due to paradoxical embolism. The case highlights the need to investigate systemic embolic sources such as PFO and PAVMs in young CRAO patients, and also the clinical importance of recognizing rare OA variants that may redirect emboli preferentially to the retina, along with the dual diagnostic and therapeutic role of IAT in such scenarios. Conclusion This report expands the spectrum of paradoxical embolic complications in HHT and emphasizes that aberrant OA origins, although rare, may critically shape the presentation and management of CRAO. Careful systemic evaluation and tailored vascular imaging are essential for accurate diagnosis and recurrence prevention image image