Detection of underdiagnosed concurrent branch retinal artery occlusion in a patient with central retinal vein occlusion using spectral domain optical coherence tomography

Simultaneous Branch Retinal Artery and Central Retinal Vein Occlusion Improved with No Ocular Therapy: A Case Report

A rarely described condition known as branch retinal artery occlusion (BRAO) with concurrent obstruction of the central retinal vein (CRVO) is characterized by diffuse retinal hemorrhages, dilated and tortuous retinal veins, macular and disc edema, cotton wool spots, and a generalized delay in arteriovenous transit on fluorescein angiography, together with a retinal whitening in the area of the affected retinal arterial branch. Although BRAO and CRVO may share underlying systemic risk factors, the pathogenesis of combined BRAO + CRVO is still unknown. We present a BRAO + CRVO case report concerning a 63-year-old white male who came to our observation complaining of sudden vision loss in his right eye. An increased risk for thrombotic event was revealed in this case, and the patient improved only with systemic anticoagulant therapy and in the absence of ocular therapy. We also explain all the clinical findings that are detectable using different diagnostic devices and analyze the scientific literature for other, similar clinical cases.

Combined Branch Retinal Artery and Central Retinal Vein Occlusion: A Systematic Review

We performed a systematic review and analyzed the current available data on branch retinal artery occlusion (BRAO) with simultaneous central retinal vein obstruction (CRVO), a rarely described occurrence. MEDLINE/PubMed and ISI Web of Sciences searches were performed according to MOOSE guidelines. Studies were considered eligible if they (1) described patients with simultaneous BRAO + CRVO and (2) had been published in peer-reviewed journals. We initially identified 239 records from databases. Ultimately, only 19 reports met the selection criteria. Twenty-nine patients (15 men, 14 women; mean age 43 ± 15 years) were analyzed. Seventeen (59%) patients presented vascular risk factors. Mean visual acuity at onset and final visual outcome were 20/83 and 20/45, respectively, an insignificant improvement. Vision improved in 48% of cases. A marked heterogeneity in treatment approach was found. Eight (28%) patients received no therapy, whereas for 21 (72%) a large variety of topical and/or systemic drugs was given. In the treated group, mean visual acuity at onset and final visual outcome were 20/90 and 20/44, respectively, a not statistically significant improvement. Results suggest that combined BRAO + CRVO occurs at a younger age than isolated BRAO or CRVO. At present, there is insufficient evidence to support any specific management to improve vision in simultaneous BRAO + CRVO.

Concurrent branch retinal artery occlusion in central retinal vein occlusion: 3 cases reports and literature review

Concurrent branch retinal artery occlusion (BRAO) and central retinal vein occlusion (CRVO) are the infrequently encountered clinical entities, with only a handful of cases elaborated in the literature. This case series describes three patients who presented with a dramatic fundus appearance that led to the diagnosis of unilateral BRAO and CRVO. Hypertension could be identified as a predisposing factor in only one patient. All three patients had relatively good visual acuity at presentation. The role of spectral-domain optical coherence tomography in confirming the simultaneous presence of BRAO is also illustrated.

Combined retinal vascular occlusion: Demography, clinical features, visual outcome, systemic co-morbidities, and literature review

Purpose:

To document the clinical features, systemic association, and treatment outcome of patients with a combined retinal vein and artery occlusion (CRVAO) and review of literature.

Methods:

A retrospective chart review of patients diagnosed with CRVAO at a tertiary eye care center. Patient's demographic details and associated ocular and systemic factors were recorded. Treatment included laser photocoagulation, anti-vascular endothelial growth factor (VEGF) intravitreal injection or transscleral cyclophotocoagulation (TSCPC), alone or in combination. At last, follow- up treatment response was measured in visual acuity status, regression of neovascularization, and control of intraocular pressure (IOP). All cases reported in the current decade were analyzed and compared with this study.

Results:

Seventeen eyes with CRVAO accounted for 0.3% of total vascular occlusion (total 5151 patients were seen in this period). The mean age was 48.12 ± 17.5 years (range: 12-87 years) and there were 9 females. Nine eyes had CRVO + CRAO; 6 eyes had BRVO + BRAO, and one patient each had CRVO + BRAO and CRAO + BRVO. Fluorescein angiography (FA) showed delayed 'arm to retina' time (>20 seconds) in all 10 eyes and delayed arteriovenous transit time in 9 out of 10 eyes. Optical coherence tomography (OCT) showed hypereflective inner retinal layers (16 eyes) and neurosensory detachment (7 eyes). The most common systemic associations were hypertension and dyslipidemia (n = 7 people; 41.18%) each. Four patients (23.5%) had a plaque in carotid arteries with normal 2D echocardiography. Ten (59%) eyes were treated with intravitreal bevacizumab + laser; four (23.5%) eyes were treated with laser only, and three (17.6%) eyes were treated with laser + anti-VEGF + TSCPC. At last follow up, vision improved in 9 (52.9%) eyes; stable in 3 (17.7%) eyes, and reduced to perception of light in 5 (29.4%) eyes.

Conclusion:

Combined CRVAO is a rare emergency leading to acute vision loss. Early diagnosis and treatment for ocular complications and systemic evaluation for cardiovascular risk factors are needed.

Combined branch retinal vein and branch retinal artery occlusion - clinical features, systemic associations, and outcomes

PURPOSE

Retinal vascular occlusions affecting both the arterial and venous systems are rare events. Combined branch retinal artery (BRAO) and vein (BRVO) occlusion are exceedingly rare and not well characterized.

METHODS

Six patients with combined BRAO and BRVO underwent a comprehensive eye examination, fundus fluorescein angiography, optical coherence tomography, and cardiovascular evaluation.

RESULTS

Mean age at presentation was 54 ± 7.8 years (range: 39-60), and five of the six were men. Patients had a combination of systemic comorbidities such as diabetes (5), hypertension (4), dyslipidemia (5), and hyperhomocysteinemia (1). All had unilateral combined occlusion characterized by narrowing and cattle tracking of blood in arteries and dilated tortuous veins in the involved quadrant. Fluorescein angiography demonstrated complete capillary drop out and a clear demarcation between the perfused and nonperfused retina. Presenting vision ranged from 6/9 to 1/60 Snellen's, and final vision depended on the macular perfusion status. All eyes were treated with angiography-guided sectoral laser photocoagulation, and three eyes required intravitreal bevacizumab due to macular edema or retinal neovascularization.

CONCLUSIONS

Combined BRAO and BRVO is rare, may have unique underlying pathogenetic mechanisms, is associated with multiple systemic comorbidities and can yield good visual outcome if macula remains well perfused.