SPARK IMAGEWISE 37

OCT Features Of Branch Retinal Artery Occlusion

Dr. Shashank Somani, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A male, 62 years of age, came with chief complaint of blurring of vision in the left eye (LE) since 3 days, which was sudden in onset, painless and non progressive in nature. He was known case of diabetes mellitus and systemic hypertension since 3 years. On Ophthalmic examination, his best corrected visual acuity (BCVA) was 6/6, N6 in right eye (RE) and 6/18, N18 in LE. Anterior segment examination showed psuedophakia in both eyes (BE). His intraocular pressure was 18 mmHg in the RE and 15 mmHg in the LE.

Figure 1a shows colour fundus photograph of RE with clear media, circular disc with VCDR of 0.5:1 normal blood vessels and macula. 
Figure 1b shows colour fundus photograph of LE with clear media, circular disc with VCDR of 0.5:1, infero-temporal arteriolar attenuation (green arrow). Retinal whitening and retinal edema along the IT arcade can be seen (red arrow). A cilio-retinal artery was seen in BE. (white arrow)
Figure 2 shows SD OCT vertical line scan through fovea of left eye with presence of hyper reflectivity of the inner retinal layers (blue arrow) in the inferior half as compared to superior half of normal appearing inner retinal layers. Reduced reflectivity (green arrow) of the outer retinal layers is also seen, probably due to optical shadowing. A horizontally oval structure in the inner retina with hyper-reflective borders  and a hypo-reflective lumen (yellow box) is seen suggestive of an empty vessel. A normal blood vessel can be seen as a vertically oval structure in a vertical section with two hyper reflective points at vertical ends suggestive of vessel wall and a less hyper reflective lumen suggesting blood in the lumen (Blue box). Shadowing effect of the vessel can be seen below the blood vessel. The foveal contour was normal, photoreceptor layer and retinal pigment epithelium beneath the fovea was noted to be intact. 
Figure 3a shows a horizontal line scan passing across the length of the occluded  vessel which shows a hyper-reflective border with a hypo-reflective lumen  suggestive of a vascular lumen lacking characteristic appearance of a  vessel with normal flow. (cyan arrow)
Figure 3b shows a horizontal line scan passing through a normal vessel of an age matched control. It shows a normal vessel with hyper-reflective borders suggestive of vessel wall and a less hyper-reflective lumen suggesting blood in the lumen with normal vascular flow. (Yellow arrow) 

Ocular massage was given to the patient but it did not improve the perfusion. The patient was asked to consult a cardiologist to rule out any systemic involvement and advised to come back for a follow up. 

Discussion 

This is a case of branch retinal artery occlusion in which the vision of the patient reduced to 6/18. A small cilio-retinal artery can be seen in fig 1b but it cannot be traced till fovea. SDOCT shows characteristic retinal hyperreflectivity in the area supplied by the occluded artery (fig 2). This is specially true for the inner retinal  layers. The occluded arteriole in the infero-temporal quadrant is seen with abnormal vascular flow characteristics as described in fig 2 and the difference can be very well appreciated in the comparative photograph of the normal vessels (shown in inset). Figure 3a shows the same vessel in a longitudinal section which appears to be devoid of normal appearing blood column as it is seen in the scan of an age matched control patient. (Fig 3 b)

This case highlights the pathological changes seen in retinal layers and vessels which are typically seen in a case of retinal artery occlusion. 

Retinal artery occlusion is a condition which should be treated without any delay as chances of restoring the vision and retinal perfusion are higher if the treatment is given within 6 hours of occurrence of the disease. Modalities of treatment include carbogen inhalation, ocular massage, anterior chamber paracentesis. Some other modalities have also been tried which include Sublingual isosorbide dinitrate, IV or intra-arterial recombinant tissue plasminogen activator (rt-PA), Nd:YAG laser embolectomy.  These are of  variable benefit and the best modality of treatment remains rather uncertain in a particular patient due to relatively  poor outcomes with the available  treatment options.

ReadWise

  1. Karacorlu M, Ozdemir H, Arf Karacorlu S. Optical coherence tomography findings in branch retinal artery occlusion. Eur J Ophthalmol. 2006 Mar-Apr;16(2):352-3. doi: 10.1177/112067210601600228. PMID: 16703561.
  1. Shah VA, Wallace B, Sabates NR. Spectral domain optical coherence tomography findings of acute branch retinal artery occlusion from calcific embolus. Indian J Ophthalmol. 2010 Nov-Dec;58(6):523-4. doi: 10.4103/0301-4738.71703. PMID: 20952838; PMCID: PMC2993984.

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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