Branch Retinal Artery Occlusion 

  • Author: Janice C Law, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 16, 2010
 

Background

The central retinal artery, a branch of the ophthalmic artery, enters the eye through the optic disc and divides into multiple branches to perfuse the inner layers of the retina. A branch retinal artery occlusion (BRAO) occurs when one of these branches of the arterial supply to the retina becomes occluded. Examples are shown in the images below.

Color fundus photo of right eye with inferior branColor fundus photo of right eye with inferior branch retinal artery occlusion from a platelet-fibrin embolus. Retinal whitening surrounding the occluded artery is noted. Red-free photograph (before injection of fluoresceRed-free photograph (before injection of fluorescein) of right eye with inferior branch retinal artery occlusion. The red-free photograph greatly accentuates the retinal whitening surrounding the occluded artery. Fluorescein angiogram of right eye with inferior bFluorescein angiogram of right eye with inferior branch retinal artery occlusion. Delayed filling of the artery (arrow heads) by the fluorescein is noted. Optical coherence tomography (OCT) of right eye wiOptical coherence tomography (OCT) of right eye with inferior branch retinal artery occlusion. Cross-section goes through inferior retina to superior retina, capturing the abnormally thickened retina associated with intracellular edema.
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Pathophysiology

Most commonly, a branch retinal artery occlusion occurs secondary to an embolus. Emboli typically originate within vessels upstream where they dislodge and travel within the circulatory system to ultimately become lodged downstream in a vessel with a smaller lumen. The most common include cholesterol emboli from aorto-carotid atheromatous plaques, platelet-fibrin emboli from thrombotic disease, and calcific emboli from cardiac valvular disease. Various other endogenous emboli as well as exogenous emboli and nonembolic causes have been reported.

Ischemia of the inner layers of the retina leads to intracellular edema as a result of cellular injury and necrosis. This intracellular edema has the ophthalmoscopic appearance of grayish whitening of the superficial retina. Primate studies have shown that complete occlusion of arterial supply to the retina results in reversible ischemic injury in up to 97 minutes. This may help explain why patients may give a history of transient loss of vision prior to an episode of branch retinal artery occlusion. Possibly, these episodes are secondary to emboli transiently becoming lodged, causing temporary occlusions and then reperfusing the retina as the emboli are released.

Branch retinal artery occlusion is most likely to occur at the bifurcation of an artery because bifurcation sites are associated with a narrowed lumen. In 90% of cases, branch retinal artery occlusion involve the temporal retinal vessels. Whether the temporal retinal vessels are affected more often or whether the nasal retinal vessels are undetected is more often uncertain.

Patients with branch retinal artery occlusion have a higher risk for morbidity and mortality secondary to cardiovascular and cerebrovascular disease. A thorough medical workup is indicated for all patients with branch retinal artery occlusion, and an etiology can be identified in as many as 90% of patients.

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Epidemiology

Frequency

United States

Central retinal artery occlusions (CRAOs) account for 58% of acute retinal artery obstructions, branch retinal artery occlusions account for 38%, and cilioretinal artery occlusions account for 5%.

Mortality/Morbidity

Multiple studies have shown increased mortality in patients with retinal arterial emboli. Increased mortality secondary to fatal stroke has been shown in studies, but the most common cause of death in this population is cardiovascular disease.

One study reported a 10-fold increase in the annual rate of stroke in patients with retinal emboli compared to controls after a follow-up period of 3.4 years.[1] Another study found a 3-fold higher risk of 8-year mortality from stroke in patients with documented retinal emboli at baseline compared with patients without emboli. A case series reported that 15% of patients with retinal emboli died within 1 year, and a mortality rate of 54% was shown within 7 years.

The incidence of neovascularization in all retinal artery obstructions is less than 5%. In branch retinal artery occlusion, the incidence is even more rare. Neovascularization, when it does occur, is more likely in persons with diabetes. Clinical cases have been reported in which neovascular glaucoma developed after branch retinal artery occlusion.

Race

One study compared retinal artery occlusions in black and white patients and found that both groups have the same risk factors for retinal arterial occlusive disease.[2] This study also suggested that whites were more likely to have identifiable carotid disease than blacks.

Sex

Among elderly patients, men are 2.5 times more likely than women to have retinal emboli. This correlates with the higher rate of stroke found in men.

Age

Typically, branch retinal artery occlusion presents in the seventh decade of life. Branch retinal artery occlusion due to embolic causes is rare in patients younger than 30 years. Less than 1 per 50,000 outpatient visits to the ophthalmologist are estimated to involve a person younger than 30 years with retinal arterial obstruction. These cases are more likely to be nonembolic causes of retinal arterial occlusions.

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Contributor Information and Disclosures
Author

Janice C Law, MD  Clinical Instructor, Vanderbilt Eye Institute

Janice C Law, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Michigan Society of Eye Physicians & Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Gary W Abrams, MD  Professor and Chairman, Department of Ophthalmology, Wayne State University School of Medicine; Director, Kresge Eye Institute

Gary W Abrams, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Club Jules Gonin, International Society for Ophthalmic Ultrasound, Macula Society, Pan-American Association of Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Rubin W Kim, MD  Staff Physician, Department of Ophthalmology, Kresge Eye Institute

Rubin W Kim, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Dean Eliott, MD  Associate Professor, Department of Ophthalmology, Division of Vitreoretinal Surgery, Kresge Eye Institute, Wayne State University

Dean Eliott, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association

Disclosure: Nothing to disclose.

Enrique Garcia-Valenzuela, MD, PhD  Clinical Assistant Professor, Department of Ophthalmology, University of Illinois Eye and Ear Infirmary; Consulting Staff, Vitreo-Retinal Surgery, Midwest Retina Consultants, SC, Parkside Center

Enrique Garcia-Valenzuela, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Retina Society, and Society for Neuroscience

Disclosure: Nothing to disclose.

Specialty Editor Board

V Al Pakalnis, MD, PhD  Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Bruno A, Jones WL, Austin JK, Carter S, Qualls C. Vascular outcome in men with asymptomatic retinal cholesterol emboli. A cohort study. Ann Intern Med. Feb 15 1995;122(4):249-53. [Medline].

  2. Ahuja RM, Chaturvedi S, Eliott D, Joshi N, Puklin JE, Abrams GW. Mechanisms of retinal arterial occlusive disease in African American and Caucasian patients. Stroke. Aug 1999;30(8):1506-9. [Medline].

  3. Sharma S, Pater JL, Lam M, Cruess AF. Can different types of retinal emboli be reliably differentiated from one another? An inter- and intraobserver agreement study. Can J Ophthalmol. Apr 1998;33(3):144-8. [Medline].

  4. Arruga J, Sanders MD. Ophthalmologic findings in 70 patients with evidence of retinal embolism. Ophthalmology. Dec 1982;89(12):1336-47. [Medline].

  5. Doubal FN, Hokke PE, Wardlaw JM. Retinal microvascular abnormalities and stroke: a systematic review. J Neurol Neurosurg Psychiatry. Feb 2009;80(2):158-65. [Medline].

  6. Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. Vol. 2. WB Saunders; 1994:727-35.

  7. Blauth CI, Smith PL, Arnold JV, Jagoe JR, Wootton R, Taylor KM. Influence of oxygenator type on the prevalence and extent of microembolic retinal ischemia during cardiopulmonary bypass. Assessment by digital image analysis. J Thorac Cardiovasc Surg. Jan 1990;99(1):61-9. [Medline].

  8. Brown GC. Arterial obstruction disease and the eye. Int Ophthalmol Clin North Am. 1990;3:373-92.

  9. Brown GC, Magargal L, Augsburger JJ, Shields JA. Preretinal arterial loops and retinal arterial occlusion. Am J Ophthalmol. May 1979;87(5):646-51. [Medline].

  10. Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young adults. Ophthalmology. Jan 1981;88(1):18-25. [Medline].

  11. Brown GC, Magargal LE, Simeone FA, Goldberg RE, Federman JL, Benson WE. Arterial obstruction and ocular neovascularization. Ophthalmology. Feb 1982;89(2):139-46. [Medline].

  12. Brown GC, Reber R. An unusual presentation of branch retinal artery obstruction in association with ocular neovascularization. Can J Ophthalmol. Apr 1986;21(3):103-6. [Medline].

  13. Brown GC, Shields JA. Cilioretinal arteries and retinal arterial occlusion. Arch Ophthalmol. Jan 1979;97(1):84-92. [Medline].

  14. Chang M, Herbert WN. Retinal arteriolar occlusions following amniotic fluid embolism. Ophthalmology. Dec 1984;91(12):1634-7. [Medline].

  15. Chuang EL, Miller FS 3rd, Kalina RE. Retinal lesions following long bone fractures. Ophthalmology. Mar 1985;92(3):370-4. [Medline].

  16. Cohen SM, Davis JL, Gass DM. Branch retinal arterial occlusions in multifocal retinitis with optic nerve edema. Arch Ophthalmol. Oct 1995;113(10):1271-6. [Medline].

  17. Dhar-Munshi S, Ayliffe WH, Jayne D. Branch retinal arteriolar occlusion associated with familial factor V Leiden polymorphism and positive rheumatoid factor. Arch Ophthalmol. Jul 1999;117(7):971-3. [Medline].

  18. Dori D, Beiran I, Gelfand Y, Lanir N, Scharf J, Miller B, et al. Multiple retinal arteriolar occlusions associated with coexisting primary antiphospholipid syndrome and factor V Leiden mutation. Am J Ophthalmol. Jan 2000;129(1):106-8. [Medline].

  19. Fineman MS, Savino PJ, Federman JL, Eagle RC Jr. Branch retinal artery occlusion as the initial sign of giant cell arteritis. Am J Ophthalmol. Sep 1996;122(3):428-30. [Medline].

  20. Friberg TR, Gragoudas ES, Regan CD. Talc emboli and macular ischemia in intravenous drug abuse. Arch Ophthalmol. Jun 1979;97(6):1089-91. [Medline].

  21. Gass JD. Stereoscopic Atlas of Macular Diseases. 3rd ed. Mosby-Year Book; 1987:340-60.

  22. Gass JD, Tiedeman J, Thomas MA. Idiopathic recurrent branch retinal arterial occlusion. Ophthalmology. Sep 1986;93(9):1148-57. [Medline].

  23. Gold D, Feiner L, Henkind P. Retinal arterial occlusive disease in systemic lupus erythematosus. Arch Ophthalmol. Sep 1977;95(9):1580-5. [Medline].

  24. Greven CM, Slusher MM, Weaver RG. Retinal arterial occlusions in young adults. Am J Ophthalmol. Dec 1995;120(6):776-83. [Medline].

  25. Greven CM, Weaver RG, Owen J, Slusher MM. Protein S deficiency and bilateral branch retinal artery occlusion. Ophthalmology. Jan 1991;98(1):33-4. [Medline].

  26. Guyer DR. Retina-Vitreous-Macula. Vol. 1. WB Saunders; 1999:271-85.

  27. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. Jan 1980;87(1):75-8. [Medline].

  28. Hayreh SS, Podhajsky P. Ocular neovascularization with retinal vascular occlusion. II. Occurrence in central and branch retinal artery occlusion. Arch Ophthalmol. Oct 1982;100(10):1585-96. [Medline].

  29. Ho AM, Ling E. Systemic air embolism after lung trauma. Anesthesiology. Feb 1999;90(2):564-75. [Medline].

  30. Hollenhorst RW. Vascular status of patients who have cholesterol emboli in the retina. Am J Ophthalmol. May 1966;61(5 Pt 2):1159-65. [Medline].

  31. Howard RS, Russell RW. Prognosis of patients with retinal embolism. J Neurol Neurosurg Psychiatry. Sep 1987;50(9):1142-7. [Medline].

  32. Jacob HS, Goldstein IM, Shapiro I, Craddock PR, Hammerschmidt DE, Weissmann G. Sudden blindness in acute pancreatitis. Possible role of complement-induced retinal leukoembolization. Arch Intern Med. Jan 1981;141(1):134-6. [Medline].

  33. Johnson MW, Thomley ML, Huang SS, Gass JD. Idiopathic recurrent branch retinal arterial occlusion. Natural history and laboratory evaluation. Ophthalmology. Mar 1994;101(3):480-9. [Medline].

  34. Karjalainen K. Occlusion of the central retinal artery and retinal branch arterioles. A clinical, tonographic and fluorescein angiographic study of 175 patients. Acta Ophthalmol Suppl. 1971;109:1-95. [Medline].

  35. Klein R, Klein BE, Jensen SC, Moss SE, Meuer SM. Retinal emboli and stroke: the Beaver Dam Eye Study. Arch Ophthalmol. Aug 1999;117(8):1063-8. [Medline].

  36. Kollarits CR, Lubow M, Hissong SL. Retinal strokes. I. Incidence of carotid atheromata. JAMA. Dec 4 1972;222(10):1273-5. [Medline].

  37. Kraushar MF, Brown GC. Retinal neovascularization after branch retinal arterial obstruction. Am J Ophthalmol. Sep 15 1987;104(3):294-6. [Medline].

  38. Malinowski SM, Pesin SR. Visual field loss caused by retinal vascular occlusion after vitrectomy surgery. Am J Ophthalmol. May 1997;123(5):707-8. [Medline].

  39. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology. May 1988;95(5):660-5. [Medline].

  40. Nelson ME, Talbot JF, Preston FE. Recurrent multiple-branch retinal arteriolar occlusions in a patient with protein C deficiency. Graefes Arch Clin Exp Ophthalmol. 1989;227(5):443-7. [Medline].

  41. Penner R, Font RL. Retinal embolism from calcified vegetations of aortic valve. Spontaneous complication of rheumatic heart disease. Arch Ophthalmol. Apr 1969;81(4):565-8. [Medline].

  42. Pfaffenbach DD, Hollenhorst RW. Morbidity and survivorship of patients with embolic cholesterol crystals in the ocular fundus. Am J Ophthalmol. Jan 1973;75(1):66-72. [Medline].

  43. Reese LT, Shafer D. Retinal embolization from endocarditis. Ann Ophthalmol. Dec; 1978;10(12):1655-7. [Medline].

  44. Reichel E, Duker JS, Puliafito CA, Hedges TR 3rd, Caplan L. Branch retinal arterial occlusion caused by a preretinal arterial loop. Neurology. Jun 1994;44(6):1181-3. [Medline].

  45. Ros MA, Magargal LE, Uram M. Branch retinal-artery obstruction: a review of 201 eyes. Ann Ophthalmol. Mar 1989;21(3):103-7. [Medline].

  46. Rush JA, Kearns TP, Danielson GK. Cloth-particle retinal emboli from artificial cardiac valves. Am J Ophthalmol. Jun 1980;89(6):845-50. [Medline].

  47. Savino PJ, Glaser JS, Cassady J. Retinal stroke. Is the patient at risk?. Arch Ophthalmol. Jul 1977;95(7):1185-9. [Medline].

  48. Schatz H, Drake M. Self-injected retinal emboli. Ophthalmology. Mar 1979;86(3):468-83. [Medline].

  49. Shapiro I, Jacob HS. Leukoembolization in ocular vascular occlusion. Ann Ophthalmol. Jan 1982;14(1):60-2. [Medline].

  50. Sharma S, Sharma SM, Cruess AF, Brown GC. Transthoracic echocardiography in young patients with acute retinal arterial obstruction. RECO Study Group. Retinal Emboli of Cardiac Origin Group. Can J Ophthalmol. Feb 1997;32(1):38-41. [Medline].

  51. Soong HK, Newman SA, Kumar AA. Branch artery occlusion. An unusual complication of external carotid embolization. Arch Ophthalmol. Dec 1982;100(12):1909-11. [Medline].

  52. Spencer WH. Ophthalmic Pathology: An Atlas and Textbook. Vol. 2. American Academy of Ophthalmology; 1985:655-709.

  53. Tayyanipour R, Pulido JS, Postel EA, Lipkowitz JL, Pisciotta A, Braza E. Arterial vascular occlusion associated with factor V Leiden gene mutation. Retina. 1998;18(4):376-7. [Medline].

  54. Vine AK, Samama MM. The role of abnormalities in the anticoagulant and fibrinolytic systems in retinal vascular occlusions. Surv Ophthalmol. Jan-Feb 1993;37(4):283-92. [Medline].

  55. Wang MY, Arnold AC, Vinters HV, Glasgow BJ. Bilateral blindness and lumbosacral myelopathy associated with high-dose carmustine and cisplatin therapy. Am J Ophthalmol. Sep 2000;130(3):367-8. [Medline].

  56. Whiteman DW, Rosen DA, Pinkerton RM. Retinal and choroidal microvascular embolism after intranasal corticosteroid injection. Am J Ophthalmol. Jun 1980;89(6):851-3. [Medline].

  57. Wilkinson WS, Morgan CM, Baruh E, Gitter KA. Retinal and choroidal vascular occlusion secondary to corticosteroid embolisation. Br J Ophthalmol. Jan 1989;73(1):32-4. [Medline].

  58. Williamson TH, Meyer PA. Branch retinal artery occlusion in toxoplasma retinochoroiditis. Br J Ophthalmol. Apr 1991;75(4):253. [Medline].

  59. Yasuma F, Tsuzuki M, Yasuma T. Retinal embolism from left atrial myxoma. Jpn Heart J. Jul 1989;30(4):527-32. [Medline].

  60. Younge BR. The significance of retinal emboli. J Clin Neuroophthalmol. Sep 1989;9(3):190-4. [Medline].

  61. Zamora RL, Adelberg DA, Berger AS, Huettner P, Kaplan HJ. Branch retinal artery occlusion caused by a mitral valve papillary fibroelastoma. Am J Ophthalmol. Mar 1995;119(3):325-9. [Medline].

 
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Color fundus photo of right eye with inferior branch retinal artery occlusion from a platelet-fibrin embolus. Retinal whitening surrounding the occluded artery is noted.
Red-free photograph (before injection of fluorescein) of right eye with inferior branch retinal artery occlusion. The red-free photograph greatly accentuates the retinal whitening surrounding the occluded artery.
Fluorescein angiogram of right eye with inferior branch retinal artery occlusion. Delayed filling of the artery (arrow heads) by the fluorescein is noted.
Optical coherence tomography (OCT) of right eye with inferior branch retinal artery occlusion. Cross-section goes through inferior retina to superior retina, capturing the abnormally thickened retina associated with intracellular edema.
 
 
 
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