Branch Retinal Artery Occlusion Workup

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

Laboratory Studies

  • Laboratory tests to consider in patients with suspected branch retinal artery obstruction (BRAO) include the following:
    • In patients older than 50 years, consider ordering an immediate erythrocyte sedimentation rate (ESR) to help rule out giant cell arteritis.
    • In patients younger than 50 years or in patients with the appropriate risk factors, consider the following tests to evaluate for coagulopathies: antitreponemal antibody, antiphospholipid antibody, antinuclear antibody, rheumatoid factor, serum protein electrophoresis, hemoglobin electrophoresis, prothrombin time/activated partial thromboplastin time (PT/aPTT), fibrinogen, protein C and S, antithrombin III, and factor V Leiden.
    • A CBC count is obtained to evaluate for anemia, polycythemia, and platelet disorders.
    • Fasting blood sugar, glycosylated hemoglobin, cholesterol, triglycerides, and lipid panel are obtained to evaluate for atherosclerotic disease.
    • Blood cultures are obtained to evaluate for bacterial endocarditis and septic emboli.
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Imaging Studies

  • Fluorescein angiography shows delayed filling of the affected artery and hypofluorescence in the surrounding area. Vessels distal to the site of obstruction may show retrograde filling from surrounding perfused capillaries. Late staining of the vessel walls may be seen. After resolution of the obstruction, flow may return to normal. However, narrowing or sclerosis of the affected artery can occur. Artery-to-artery collaterals may form in the retina and are highly suggestive of an old branch retinal artery obstruction.
  • Optical coherence tomography (OCT) has been used to demonstrate structural damage of the retinal layers after retinal artery occlusion.
    • One study showed diffuse thickening of the neurosensory retina where the artery occlusion occurred. Increased reflectivity was noted in the inner retinal layers with decreased reflectivity of the photoreceptors and retinal pigment epithelium, which supported the pathophysiology of increasing intracellular fluid of the inner retinal layer.
    • Another study used OCT to demonstrate the long-term structural result after arterial occlusion. One year after diagnosis of branch retinal artery obstruction, the authors found segmental inner retinal layer and peripapillary retinal nerve fiber layer thickness to be reduced. They correlated visual field deficits with OCT thickness and found that a worse functional outcome was associated with a more extensive thinning of the macula and retinal nerve fiber layer.
  • An electroretinogram (ERG) is of limited usefulness. Findings may be normal. In the case of a large branch retinal artery obstruction, it may show loss of oscillatory potential and transient depression of the B wave.
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Other Tests

  • Serial Humphrey visual field testing reveals any field deficits and can be used to monitor the stability or improvement of these deficits.
  • Other tests to help evaluate possible sources of emboli include the following:
    • Elderly patients and patients with high-risk characteristics for cardioembolic disease warrant medical workup involving either 2-dimensional or transesophageal echocardiography. High-risk characteristics include a history of rheumatic heart disease, mitral valve prolapse, prosthetic valve placement, history of subacute bacterial endocarditis, recent heart attack, intravenous (IV) drug abuse, any type of valvular heart disease (congenital or acquired), detectable heart murmurs, and ECG changes (eg, atrial fibrillation, changes indicating myocardial damage).
    • Carotid ultrasonography studies and magnetic resonance angiography are crucial tests to evaluate for atherosclerosis. Considering the higher incidence of fatal stroke in the elderly population, atherosclerotic disease should be evaluated if no other etiology is obvious.
    • ECG/Holter monitor is used to evaluate for atrial fibrillation.
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Procedures

  • Because prognosis for branch retinal artery occlusion is very good, no interventions usually are taken. In the event of involvement of the perifoveolar capillaries, treatment as for central retinal artery occlusion (CRAO) may be attempted (see Central Retinal Artery Occlusion).
  • Intra-arterial thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) via a guiding catheter inserted into the femoral artery, placed into the internal carotid artery, and advanced into the ophthalmic artery has been used for CRAO with varying success. This has also been applied to some patients with branch retinal artery occlusion (BRAO) with limited benefit compared to conventional forms of therapy or observation.
  • Another procedure that has been attempted for both branch retinal artery occlusion (BRAO) and CRAO is transluminal Nd:YAG laser embolysis or TYE. This method relies on the Nd:YAG laser to shatter the embolus, clear the arteriole lumen, and improve perfusion without harming the vessel wall. Potential risks include retina tears, vitreous and retinal hemorrhages, choroidal neovascularization, and epiretinal membrane formation. One study found visual improvement to occur immediately after the embolysis.
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Histologic Findings

  • Branch retinal artery occlusion causes ischemia to the inner layers of the retina, which causes inner and intracellular edema and a coagulative necrosis.
  • Eventually, loss of the inner retinal layers occurs, including the nerve fiber layer to the inner nuclear layer.
  • Because the glial cells have also been destroyed, usually no gliosis is noted.
  • Histologic evidence of emboli or other etiology may be present.
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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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