Branch retinal artery occlusion in a young healthy patient: Embolism as a rare cause

Jyoti Jain; Shashank Banait; Tanvi Banait

doi:10.4103/jmgims.jmgims_70_19

CASE REPORT

Year : 2020 | Volume : 25 | Issue : 2 | Page : 110-112

Branch retinal artery occlusion in a young healthy patient: Embolism as a rare cause

Jyoti Jain¹, Shashank Banait², Tanvi Banait²
¹ Department of Medicine, MGIMS, Sevagram, Maharashtra, India
² Department of Ophthalmology, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India

Date of Submission	30-Nov-2019
Date of Acceptance	12-Jun-2020
Date of Web Publication	15-Dec-2020

Correspondence Address:
Dr. Shashank Banait
Jawaharlal Nehru Medical College, Sawangi, Wardha - 442 102, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jmgims.jmgims_70_19

Abstract

Branch retinal artery occlusion (BRAO) is an acute, painless, vision threatening, ocular emergency among people older than 60 years having cardiovascular disease. Here, we present a case of BRAO which occurred due to embolism as a rare etiology in an otherwise healthy young Asian male without any systemic or ocular disorders. The patient was treated as an ocular emergency with improved vision and retinal perfusion. The patient did not complain of recurrence of symptoms in the 3 months after the treatment.

Keywords: Atherosclerosis, branch retinal artery occlusion, central retinal artery occlusion, embolism

How to cite this article:
Jain J, Banait S, Banait T. Branch retinal artery occlusion in a young healthy patient: Embolism as a rare cause. J Mahatma Gandhi Inst Med Sci 2020;25:110-2

How to cite this URL:
Jain J, Banait S, Banait T. Branch retinal artery occlusion in a young healthy patient: Embolism as a rare cause. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2022 Aug 16];25:110-2. Available from: https://www.jmgims.co.in/text.asp?2020/25/2/110/303426

Introduction

In branch retinal artery occlusion (BRAO), patients present with acute, painless loss of monocular vision. It is a vision-threatening ocular emergency, commonly affecting people older than 60 years having cardiovascular disease.

Case Report

A 26-year-old normotensive, non-diabetic male presented to the hospital 4 hours after sudden-onset diminution of vision in the right eye (OD). There was no history of fever, rash, breathlessness, chest pain, palpitations, migraine, trauma, bleeding tendencies, ocular or systemic surgery, and drug abuse. The patient did not have any similar episode or any other ocular complaint in the past. He did not have personal and family history, suggestive of sickle cell anemia and tuberculosis. He was a non-smoker and a teetotaller.

Visual acuity (VA) in the OD was finger counting close to the face. The pupil was sluggish in reaction. On slit-lamp examination, the anterior segment was unremarkable and the intraocular pressure (IOP) was 14 mmHg on applanation tonometry. On fundus examination, an embolus was situated 4–5 disc diopter away from the disc in the inferotemporal branch of the artery [Figure 1]a. The inferior retina including the lower half of macula corresponding to the area of supply was pale and edematous. The distal retinal arterioles along the affected vessel were attenuated and under spasm. The left eye examination was unremarkable. The systemic examination was normal.

Figure 1: Fundus photograph of the OD showing (a) pale and ischemic inferior retina with macular involvement (double arrow).White embolus (arrow) seen in the inferotemporal branch retinal arteriole about four disc diameters away from the optic disc. (b) Partly restored perfusion of the inferior retina (double arrow). The embolus (arrow) seen moved away peripherally from the original site

Click here to view

The patient was treated as an ocular emergency and was given intensive intermittent digital ocular massage approximately for 10 min, oral acetazolamide 500 mg stat, rapid intravenous, infusion of 20% mannitol 200 ml, and topical 0.5% timolol maleate instilled twice. Anterior-chamber paracentesis under aseptic precautions was done to further reduce the IOP. The eye became soft digitally, after paracentesis. Amyl nitrate or any other vasodilator was not given due to non-availability. After about 10 min, the embolus was shifted toward the peripheral retina [Figure 1]b. The VA recorded was 3/60 and the retinal color changed to pink after several minutes. Posttreatment IOP was 5 mmHg on applanation tonometry [Figure 2]. With treatment, over a period of next 24 h, the patient's vision and retinal perfusion improved significantly with a VA of 6/60.

Figure 2: Fundus photograph of the OD showing normally perfused inferior retina (double arrow). The embolus has completely disappeared (arrow). The macula of OD showing pigmentary changes (block arrow)

Click here to view

Pertinent investigations including complete blood count, erythrocyte sedimentation rate, fasting blood sugar, prothrombin time, lipid profile, hemoglobin electrophoresis, kidney and liver function tests, ELISA for HIV, Mantoux test, homocysteine level, rheumatoid factor, antinuclear antibody, double-stranded DNA, antithrombin III, protein S and C, chest X-ray, echocardiography, and carotid Doppler study were normal.

At the end of one month. the patient's best-corrected vision was 6/9, the pupil was brisk, the retina showed normal translucent color with mild attenuation of inferotemporal arteriole, and the macula showed pigmentary changes. At the end of 3 months, there was no neovascularization of the retina or angles and the IOP was normal. Visual fields on automated perimetry showed central and superonasal defects corresponding to the affected retina [Figure 3].

Figure 3: Automated perimetry OD showing relative scotoma in the superonasal visual field and the macular area corresponding to the retina that suffered ischemia due to arteriolar occlusion

Click here to view

Discussion

Retinal artery occlusion is rare in people younger than 30 years. It typically presents in the sixth or seventh decade of life, and the most common cause is an embolus from various sources.^[1],[2],[3] Ratra and Dhupper published in their study that among acute retinal artery occlusions, the magnitude of central retinal artery occlusion (CRAO) was 80%, BRAO was 8.6%, and 5.7% each for cilioretinal and hemiretinal artery occlusion.^[4] A reported increase in the annual rate of stroke in patients with retinal emboli compared to controls after a follow-up period of 3.4 years was 10-fold.^[5]

Various risk factors for retinal artery occlusion include atherosclerosis, vascular spasm as in migraines, smoking, hypertension, hypercholesterolemia, diabetes, coronary artery disease, history of stroke, and glaucoma.^[1] However, in younger patients, other diverse etiologies are non-embolic conditions such as thrombosis secondary to inflammation, cocaine or sildenafil abuse, sickle cell disease, Hodgkin's disease, pregnancy, anemia, platelet and clotting factor abnormalities, hypercoagulable states, antiphospholipid syndrome, preretinal arterial loops, vitrectomy surgery, and trauma.^[6],[7] A case of CRAO was reported in an otherwise healthy pregnant female with increased factor VIII without additional hypercoagulable conditions.^[8] As atheromatous disease is a rare cause in this age group, therefore, routine carotid angiography is not recommended.

Newer surgical treatment modalities such as intraocular endovascular therapy might be used as standard treatment.^[9] Another recent management approach, vitrectomy along with adventitious tissue removal from arterio- venous crossing with or without internal limiting membrane (ILM) peeling has shown good results.^[10] Visual prognosis is usually similar to older patients.

This is a rare case of BRAO with embolism as an unusual etiology in an otherwise healthy young Asian male without any systemic or ocular disorders (even on extensive evaluation). We re-emphasize the need for thorough systemic workup and treatment to prevent cardiovascular and cerebrovascular morbidity and mortality in such cases. Such patients should be explained about the risk of recurrence in same eye or other eye. They may be demonstrated Amsler grid monitoring periodically for both eyes. Any symptoms related to transient ischemic attacks should be explained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Babikian V, Wijman CA, Koleini B, Malik SN, Goyal N, Matjucha IC. Retinal ischemia and embolism. Etiologies and outcomes based on a prospective study. Cerebrovasc Dis 2001;12:108-13.
2.	Himori N, Kunikata H, Otomo T, Fuse N, Nishida K. Central retinal artery occlusion following severe blow-out fracture in young adult. Clin Ophthalmol 2009;3:325-8.
3.	Trojet S, El Afrit MA, Mazlout H, Sdiri N, Kraiem A. Inferior branch retinal artery occlusion in a young adult revealing rheumatismal valvular disease. J Fr Ophtalmol 2002;25:818-21.
4.	Ratra D, Dhupper M. Retinal arterial occlusions in the young: Systemic associations in Indian population. Indian J Ophthalmol 2012;60:95-100. [PUBMED] [Full text]
5.	Bruno A, Jones WL, Austin JK, Carter S, Qualls C. Vascular outcome in men with asymptomatic retinal cholesterol emboli. A cohort study. Ann Intern Med 1995;122:249-53.
6.	Chan KC, Wu DJ, Ueng KC, Lin CS, Tsai CF, Chen KS, et al. Branch retinal artery occlusion after diagnostic cardiac catheterization. Jpn Heart J 2002;43:193-6.
7.	Imai E, Kunikata H, Udono T, Nakagawa Y, Abe T, Tamai M. Branch retinal artery occlusion: A complication of iron-deficiency anemia in a young adult with a rectal carcinoid. Tohoku J Exp Med 2004;203:141-4.
8.	Tang WM, Han DP. A study of surgical approaches to retinal vascular occlusions. Arch Ophthalmol 2000;118:138-43.
9.	Chung YR, Kim JB, Lee K, Lew HM. Retinal artery occlusion in a healthy pregnant patient. Korean J Ophthalmol 2008;22:70-1.
10.	Lin CJ, Su CW, Chen HS, Chen WL, Lin JM, Tsai YY. Rescue vitrectomy with blocked artery massage and bloodletting for branch retinal artery occlusion. Indian J Ophthalmol 2017;65:323-5. [PUBMED] [Full text]