Detection of underdiagnosed concurrent branch retinal artery occlusion in a patient with central retinal vein occlusion using spectral domain optical coherence tomography
- Anushavan Karapetyan1,
- Pingbo Ouyang1,
- Luo Sheng Tang1Email author,
- Jiexi Zeng†1 and
- Michele Dominique Li Ying†1
© Karapetyan et al.; licensee BioMed Central Ltd. 2014
Received: 29 December 2013
Accepted: 8 July 2014
Published: 12 July 2014
Combined branch retinal artery and central retinal vein occlusion is a rare condition that has been infrequently reported. This case report, aside from reporting the above-mentioned condition, highlights the importance of performing spectral domain optical coherence tomography in establishing a complete diagnosis, especially in uncertain and complicated cases. We also present spectral domain optical coherence tomography findings of a case of combined unilateral simultaneous central retinal vein and branch retinal artery occlusion.
We present a single case of an initially missed, unilateral branch retinal artery occlusion combined with central retinal vein occlusion in a 51-year-old female Chinese patient without a significant past medical history, who experienced sudden, painless vision diminution in her right eye eleven days prior to presentation. She eventually recovered visual acuity to 0.60, despite having presented with poor vision.
Combined unilateral central retinal vein and branch retinal artery occlusion may occur in patients with no medical history of arterial hypertension and diabetes mellitus and can achieve a relatively good visual outcome. This case reaffirms the significance of performing a spectral domain optical coherence tomography examination in patients suffering from central retinal vein occlusion with suspicion of unilateral simultaneous branch retinal artery occlusion to identify the affected pathological areas.
KeywordsBranch retinal artery occlusion Central retinal vein occlusion Spectral domain optical coherence tomography
Central retinal vein occlusion (CRVO) and branch retinal artery occlusion (BRAO) are two different types of retinal vascular occlusions. CRVO is a common retinal vascular disorder that arises from a blockage of the central retinal vein. As a consequence of the blockage, stagnant blood gradually leaks out through the vein walls and leads to blurred vision. BRAO refers to an obstruction or blockage of one or multiple branch retinal arteries resulting in a severe loss of vision, the area and degree of which is associated with the distribution of the occluded branch retinal artery. Histopathologically, acute BRAO results in ischemia in the corresponding retinal quadrant marked by inner retinal edema in the initial stages and atrophy in long-standing cases . The combination of the two aforementioned diseases is rare, despite the fact that these two types of ocular vascular obstructions share many common underlying systemic conditions, such as cardiovascular atherosclerotic disease, arterial hypertension, diabetes mellitus, toxoplasmosis, sarcoidosis, Behçet's disease , coagulopathies , systemic lupus erythematosus and anti-phospholipid syndrome , and homocysteinemia , which result in severe loss of vision and impairment of the patient’s quality of life.
In this report, we describe a single case of combined unilateral CRVO and BRAO and emphasize the efficacy of spectral domain optical coherence tomography (SD-OCT) examination in this type of case.
hyperreflectivity and increased thickness of the nerve fiber and inner retinal layers in the superior ischemic retina compared to the inferior unaffected area near the BRAO retina;
decreased reflectivity of the outer retinal layers in the superior half, probably due to an optical shadowing effect;
macular edema and serous macular detachment typical for CRVO;
no cystoid macular edema was observed either on presentation or at follow-up visits;
a well-defined demarcation line between the affected and unaffected areas near the BRAO retina6. peripapillary retinal detachment (Figure 3)
Combined unilateral simultaneous CRVO and BRAO is a rare condition, which if incomplete, has been proposed to be deemed as one entity. In patients with a combined concurrent CRVO and BRAO, an embolic compound has not been found, suggestive of the secondary nature of BRAO due to compression of the artery because of the obviously swollen optic nerve and/or central retinal vein resulting from CRVO . This is the main distinction from an isolated BRAO, which often is caused by embolic events. The patients with combined BRAO and incomplete CRVO have better visual outcomes than do those suffering from other types of combination retinal artery and vein occlusions, and almost 80% of the patients recover final visual acuity greater than 0.50, as occurred in our case [1, 2].
In our case, we performed the assisting diagnostic procedure with SD-OCT in addition to FA, in order to establish the final diagnosis of combined unilateral CRVO and BRAO. This approach is optimal for patients with a questionable diagnosis of combined unilateral CRVO and BRAO. SD-OCT has quite recently been introduced to the medical world and has revolutionized the ocular imaging service. It is a cutting-edge technique using a significantly faster, non-mechanical technology providing non-invasive acquisition of detailed; i.e., up to 5 microns resolution, in-vivo histological changes in the retina [1, 7].
These anatomical changes are the result of the denaturation of intracellular proteins, with the accumulation of intracellular fluid and consequent cellular necrosis. We propose that the name ‘retinal edema’ should not be used for this clinical condition, as the extravascular fluid is found in the intracellular space, and we suggest that the term ‘acute ischemic retinopathy’ is more appropriate .
Preservation of the integrity of the IS-OS line and the external limiting membrane has been reported to have prognostic value in cystoid macular edema due to vascular occlusions . Presence of an intact IS-OS line at the fovea in our patient suggested the preservation of structural integrity of the photoreceptor layer at the fovea, contributing to the recovery of relatively good visual acuity.
Throughout the follow-up visits, atrophy of the superior retina was observed.
Combined unilateral CRVO and BRAO may occur in patients without a significant past medical history. SD-OCT is an efficient method for establishing a combined unilateral CRVO and BRAO diagnosis. Timely use of SD-OCT facilitates fast and precise diagnosis of the aforementioned condition, ensuring prompt treatment. In our case, although the patient presented with poor visual acuity, we can report the presence of an intact IS-OS line on SD-OCT, thanks to which a good visual outcome was attained.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Branch retinal artery occlusion
Central retinal vein occlusion
Spectral domain optical coherence tomography
Inner layers of superior retina
Inner segment-outer segment
Enzyme-linked immunosorbent assay
Polymerase chain reaction.
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