Branch Retinal Artery Occlusion (BRAO)

Tyler Miles                                                                                           September 12, 2002

 

Text Box: Patient B.W., a 74 year old Caucasian male presented with no visual complaint. His last eye exam had been 3 years prior at which time a BRAO was noted OS. B.W. takes Cozaar, Furosemide, Diltiazem, Coreg, and Hydrochlorothiazide to treat his hypertension (first diagnosed in 1948). He sees his cardiologist monthly, and keeps a log of his medications. DVA cc OD: 20/25-1 OS: 20/30+2 (No improvement through refraction) Pupils: PERRL –APD OU Blood Pressure: 190/105 RAS (further questioning revealed he had not taken his medications this morning.) SLE: WNL, Incipient cortical cataracts, NS grade 1. Tonometry (Applanation) OD:14 OS:14 @11:15 AM Ophthalmoscopy: C/D OD: .65h x .60v OS: .45h x .50v ONH: Distinct margins, rim tissue WNL OU. *OD: infero-nasal to macula- hard exudates, retinal thickening, and some dot hemorrhages. VF: 30-2 sitafast. OD: superior-temporal defect (not present in last VF), OS: Inferior field defect (noted on last VF.)

 

Discussion

BRAO is associated with hypertension, smoking, diabetes mellitus, hypercholesterolemia, and cardiac valvular disease.

 

Pathogenesis

·        Blockage in branch retinal artery may be caused by:

  1. Cholesterol (hollenhorst plaque- most common)
  2. Platelet-fibrin (from Carotid or Cardiac thrombosis)
  3. Calcific emboli (from heart valves)
  4. Other (vasculitis, neoplasm, talc, etc.)

·        Ischemia to inner retinal layers results in intracellular edema, and eventually necrosis.  The edema causes the affected area of retina to appear thickened and white.

           

Symptoms

·        Sudden, Painless loss of part of visual field.

·        50% have intact central acuity

 

Signs

·        APD

·        Retinal Emboli (noted in 2/3 of cases) seen at bifurcations.

·        Whitening (Edema) of Retinal area

·        Boxcarring

·        Cotton-wool spots

·        Visual Field defect

 

Differential Dx

·        Cotton-wool spot(s)

·        Central retinal artery occlusion

·        Ophthalmic artery occlusion

·        Cilioretinal artery obstruction

·        Retinal astrocytoma

·        Inflammatory or infectious retinitis.

           

Workup

·        Complete Exam with attention to pupils, and ophthalmoscopy (non-contact, BIO)

·        Check Blood Pressure

·        Check Visual Fields

           

Treatment

·        No treatment has been shown to have significant benefit.  Schedule follow-up in 1 month to reevaluate.

·        Refer to physician to treat any underlying condition (DM, HTN, etc.)  There is an increased mortality among BRAO patients reflecting the underlying risk factors (carotid vascular disease, heart disease, HTN, etc.)

 

Prognosis

·        80% of eyes recover to 20/40 or better

·        Small percentage may develop neovascularization.