Branch Retinal Artery Occlusion Workup

  • Author: Niraj R Nathan, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Apr 06, 2016
 

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

Two-dimensional or transesophageal echocardiography

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

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

ECG/Holter monitor is used to evaluate for atrial fibrillation.

MRI

In cases of suspected Susac syndrome, MRI may be helpful to look for classic findings in the corpus callosum. Any concern for concurrent stroke symptoms would warrant the appropriate brain imaging and workup, usually guided by neurologic consultation.

Fluorescein angiography

Delayed filling of the affected artery and hypofluorescence in the surrounding retina will be visible immediately after onset of the occlusion. 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.

Red-free photograph (before injection of fluoresce 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 b 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

Optical coherence tomography (OCT) has been used to demonstrate structural damage of the retinal layers after retinal artery occlusion.[21]

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.

Another study suggested that spectral domain OCT may be a useful adjunct in the acute phase in characterizing retinal artery emboli, including perfusion characteristics (eg, extent of luminal occlusion) and emboli characteristics and embolus structure (eg, more crystalline in appearance or softer and more conforming to the shape of the vessel lumen).[22]

Optical coherence tomography (OCT) of right eye wi 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.
Optical coherence tomography (OCT) over time of a Optical coherence tomography (OCT) over time of a branch retinal artery occlusion. Taken 24 hours after symptom onset, A shows an unaffected portion of the macula, while B shows swelling of the inner retina in the area affected by the branch retinal artery occlusion (BRAO). Two weeks later, this swelling/increased thickness is beginning to resolve (C). Two months later, the inner retina has thinned notably, and the inner plexiform layer, inner nuclear layer, and outer plexiform layer are difficult to distinguish from one another. Courtesy of British Journal of Ophthalmology.
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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.

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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Procedures

Because the prognosis for branch retinal artery occlusion (BRAO) 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 BRAO with limited benefit compared to conventional forms of therapy or observation.

Another procedure that has been attempted for both 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

Niraj R Nathan, MD Resident Physician, Department of Ophthalmology, Vanderbilt University School of Medicine

Niraj R Nathan, MD is a member of the following medical societies: Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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, Association for Research in Vision and Ophthalmology, American Society of Retina Specialists, Retina Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Dean Eliott, MD Associate Director, Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School

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

Disclosure: Nothing to disclose.

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, Association for Research in Vision and Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Pan-American Association of Ophthalmology, Societas Internationalis Pro Diagnostica Ultrasonica in Ophthalmologia, Club Jules Gonin

Disclosure: Nothing to disclose.

Janice C Law, MD Assistant Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, 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, Phi Beta Kappa, Michigan Society of Eye Physicians & Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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Fluorescein angiogram of right eye with inferior branch retinal artery occlusion. Delayed filling of the artery (arrow heads) by the fluorescein 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.
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.
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.
Optical coherence tomography (OCT) over time of a branch retinal artery occlusion. Taken 24 hours after symptom onset, A shows an unaffected portion of the macula, while B shows swelling of the inner retina in the area affected by the branch retinal artery occlusion (BRAO). Two weeks later, this swelling/increased thickness is beginning to resolve (C). Two months later, the inner retina has thinned notably, and the inner plexiform layer, inner nuclear layer, and outer plexiform layer are difficult to distinguish from one another. Courtesy of British Journal of Ophthalmology.
Color fundus photo of left eye with branch retinal artery occlusion caused by embolization of ethylene vinyl alcohol copolymer (Onyx), a liquid embolic agent used in the treatment of saccular aneurysms, into the retinal circulation. Courtesy of Vanderbilt Eye Institute.
Color fundus photo of right eye with inferior branch retinal artery occlusion. Courtesy of Vanderbilt Eye Institute.
Color fundus photo of right eye with superior branch retinal artery occlusion. Courtesy of Vanderbilt Eye Institute.
 
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