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RETINAL ARTERY OCCLUSIONS CRAO BRAO CLRAO

The document discusses the arterial supply and occlusions of the retina, focusing on central retinal artery occlusions (CRAO) and branch retinal artery occlusions (BRAO). It outlines the epidemiology, etiologies, clinical presentations, diagnostic methods, and management strategies for these conditions. Additionally, it highlights optometric practice patterns in the U.S. regarding the diagnosis and referral processes for patients experiencing acute vision loss due to retinal artery occlusions.

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BRAO, CRAO, CLRAO PRESENTOR : ASHISH NEUPANE BACHELOR OF OPTOMETRY NEPAL EYE HOSPITAL, NAMS
ARTERIAL SUPPLY OF THE RETINA
• Inner 6 layers - Central retinal artery • Outer 4 layers - Posterior ciliary arteries -Anterior to equator - long posterior ciliary arteries -Posterior to equator - short posterior ciliary arteries In some individuals, cilioretinal artery supplies the macular area.
RETINALARTERY OCCLUSIONS EPIDEMIOLOGY • Age : Mid 60’s • Gender : M>F • Medical conditions : Hypertension and other cardiovascular diseases • Laterality : Mostly U/L , 1-2% B/L
ETIOLOGY OF RAO 1. Emboli : • most common aetiology • three types of emboli associated with RAO Cholesterol emboli (Hollenhorst plaque) -arise from atheromas in the carotid artery Calcium emboli -arise from the cardiac valves Platelet fibrin -arise from atheromas in the carotid artery
2. Atherosclerosis-related thrombosis : 3. Retinal arteritis with obliteration : • Giant cell arteritis • Periarteritis : associated with polyarteritis nodusa, systemic lupus erythematosus, wegner’s granulomatosis and scleroderma 4. Angiospasm : - Rare - commonly associated with amaurosis
5. Raised IOP : 6. Thrombophilic disorders : 7. Other rare causes : retinal migraine, sickling haemoglobinopathies and hypercoagulation disorders such as oral contraceptives, polycythemia, and antiphospholipid syndrome
CLINICAL PRESENTATION • CRAO (60%) • BRAO (35%) • CLRAO (5%)
CRAO • Ocular Emergency • Occurs due to obstruction at the level of lamina cribrosa
SYMPTOMS • Sudden painless unilateral visual loss: occurs over seconds • Amaurosis fugax: in around 10% of patients • Past medical history: atherosclerotic disease or vasculitis • Symptoms of temporal/giant cell arteritis: headaches, temporal tenderness
SIGNS 1. VA : markedly reduced (<3/60 in 90% cases) except in few cases with cilioretinal artery. 2. Pupillary reflex : RAPD +ve
3. Fundus examination shows : • Markedly narrowing of retinal arteries • Retina becomes milky white due to ischaemic oedema • Cherry red spot is seen in the center of macula • Cattle truck appearance
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So, findings in ophthalmoscopy reveals : In acute phase In chronic stage • Cherry red spots (90%) • Post. pole retinal opacity or whitening (58%) • Box carring of retinal arteries and veins (20%) • Retinal artery attenuation (32%) • Optic disc edema (22%) • Optic nerve head pallor (39%) • Optic atrophy (91%) • Retinal arterial attenuation (58%) • Cilioretinal collaterals (18%) • Macular RPE changes (11%) • Cotton wool spots (3%)
INVESTIGATIONS : - CRAO is a clinical diagnosis, • OCT - edema of inner retina
FFA - delayed in arterial filling ( if cilioretinal artery is present , it will fill in early phase ), masking of choroidal vasculature due to retinal opacification.
• Autofluorescence imaging - reduced autofluorescence • ERG - more severe attenuation of b-wave than a-wave • Macular VF testing : Central scotoma is most common followed by paracentral scotoma.
Laboratory investigations • Relevant laboratory investigations include: • ESR and CRP: to exclude temporal/giant cell arteritis • Full blood count: to check for myeloproliferative disorders or anaemia • Coagulation studies : to screen for coagulation disorders
Other investigations If an embolic cause is suspected, other investigations to consider may include: • Carotid duplex ultrasound (doppler): to look for carotid artery stenosis • ECG: to look for atrial fibrillation • Echocardiogram: to look for mural thrombus • Ambulatory ECG monitoring: to look for paroxysmal atrial fibrillation
D/D Cherry red spot Sudden onset U/L painless visual loss • Trauma - blunt trauma, concussion • Neimann - pick disease • Gaucher disease • Tay sach disease • Sandhoff disease • Retinal detachment • Vitreous haemorrhage • Retinal vein occlusion • Acute optic neuritis
MANAGEMENT RETINAL ISCHEMIC TIME • 90 min - complete recovery can be done • 240 min - partial recovery • Irreversible after 4 hours
Principles of management of CRAO can be divided into : 1. Acute : Restore blood flow 2. Subacute : preventions of secondary complications 3. Secondary prevention : Systemic control and prevention of future vascular ischemic events. Taiwan J Ophthalmol. 2022 Jul-Sep; 12(3): 273–281. Published online 2022 Aug 18. doi: 10.4103/2211-5056.353126
1. Acute management : • Non-invasive therapies • Invasive therapies Non- invasive therapies: • Vasodilation of CRA : sublingual isosorbide dinitrate, inhaling carbogen, hyperbaric oxygen treatment (HBOT) • Reducing the intraocular pressure : Ocular massage, IV mannitol, or topical antiglaucoma drops • Reducing retinal edema : Taiwan J Ophthalmol. 2022 Jul-Sep; 12(3): 273–281. Published online 2022 Aug 18. doi: 10.4103/2211- 5056.353126
Invasive therapies : • Anterior chamber paracentesis • Transluminal ND -YAG laser • Pars plana vitrectomy • IV and intra-arterial (IA) tissue plasminogen activator (tPA) • Intravenous tissue plasminogen activator Taiwan J Ophthalmol. 2022 Jul-Sep; 12(3): 273–281. Published online 2022 Aug 18. doi: 10.4103/2211- 5056.353126
2. Sub-acute - preventing secondary ocular complication 3. Secondary prevention - systemic control and prevention of future vascular events Taiwan J Ophthalmol. 2022 Jul-Sep; 12(3): 273–281. Published online 2022 Aug 18. doi: 10.4103/2211- 5056.353126
BRAO • Represents 38% of all artery occlusion • RE (60%) > LE (40%) • Pt presents with monocular vision loss, which may be restricted to one part of VF Presenting VF defect includes : • Central scotoma(20%) • Central altitudinal (13%) • Sector defect (49%)
BRAO cont... • typically occurs at vessel bifurcation and 98% of time, temporal vessels are affected • due to nasal occlusion may be asymptomatic and undetected • emboli are visible in 62% of time
• In chronic stage, sectorial nerve fibre loss and arterial attenuation may be seen, • Rarely, iris neovascularization and posterior segment neovascularization particularly in DM patients • Artery to artery collaterals are pathognomic of BRAO • Risk factor for BRAO is similar to CRAO so similar evaluation is recommended • Good visual prognosis so, aggressive therapy is not performed unless foveal involvement is seen
D/D of BRAO • Artery Obstruction • Cotton–wool spot(s) • Central retinal artery obstruction • Cilioretinal artery obstruction • Retinal astrocytoma • Inflammatory or infectious retinitis
CLRAO • Accounts for 5% of retinal artery obstruction • On FA - they are seen 32 % of time and fill concomitantly with the choroidal circulation • When evaluating CLRAO, 3 distinct groups are found : • Isolated CLRAO • CLRAO associated with CRVO • CLRAO in conjunction with anterior ischemic optic neuropathy
Isolated CLRAO • Usually occur in young patients in setting of collagen vascular disorders. • Good visual prognosis CLRAO associated with CRVO • Behaves as non-ischemic CRVO with good central vision prognosis • Mechanism of association is unclear, • But hypothesized that some eyes harbor a primary optic disc vasculitis(papillophlebitis) that affects both arterial and venous circulation
CLRAO with ischemic optic neuropathy • Grim visual prognosis • Strong association with temporal arteritis
Optometric Practice Patterns for Acute Central and Branch Retinal Artery Occlusion • Abstract • Background: Optometrists are often the first providers to evaluate patients with acute vision loss and are often the first to diagnose a central retinal artery occlusion (CRAO). How quickly these patients present to the optometrist, are diagnosed, and referred for evaluation are major factors influencing the possibility of acute therapeutic intervention. Our aim was to survey the U.S. optometric community to determine current optometric practice patterns for management of CRAO. • Methods: An anonymous seven-question survey was emailed in 2020 to the 5,101 members of the American Academy of Optometry and the 26,502 members of the American Optometric Association. Mileski, Kelsey M. OD; Biousse, Valérie MD; Newman, Nancy J. MD; Flowers, Alexis M. MD; Chan, Wesley MD; Dattilo, Michael MD, PhD Journal of Neuro-Ophthalmology ():10.1097/WNO.0000000000001915, September 21, 2023. | DOI: 10.1097/WNO.0000000000001915
• Results: Of 31,603 optometrists who were sent the survey, 1,926 responded (6.1%). Most respondents (1,392/1,919, 72.5%) worked in an optometry- predominant outpatient clinic and were less than 30 minutes from a certified stroke center (1,481/1,923, 77.0%). Ninety-eight percent (1,884/1,922) of respondents had diagnosed less than 5 CRAOs in the previous year, and 1,000/1,922 (52.0%) had not diagnosed a CRAO in the prior year. Of the optometrists who diagnosed at least one CRAO in the previous year, 661/922 (71.7%) evaluated these patients more than 4 hours after the onset of vision loss. Optometrists who diagnosed a CRAO or branch retinal artery occlusion referred patients to an emergency department (ED) affiliated with a certified stroke center (844/1,917, 44.0%), an outpatient ophthalmology clinic (764/1,917, 39.9%), an ED without a stroke center (250/1,917, 13.0%), an outpatient neurology clinic (20/1,917, 1.0%), or other (39/1,917, 2.0%); most (22/39, 56.4%) who responded "other" would refer to a primary care physician. J Neuroophthalmol. 2023 Sep 21. doi: 10.1097/WNO.0000000000001915 Mileski, Kelsey M. OD; Biousse, Valérie MD; Newman, Nancy J. MD; Flowers, Alexis M. MD; Chan, Wesley MD; Dattilo, Michael MD, PhD
• Conclusions: Optometrists are likely the first providers to evaluate patients with acute vision loss, including from a retinal artery occlusion. However, only 6.1% of optometrists responded to our survey despite 2 reminder emails, likely reflecting the lack of exposure to acute retinal artery occlusions, and a potential lack of interest of optometrists in participating in research. Of the optometrists who reported evaluating a CRAO in the previous year, less than 29% saw the patient within 4 hours of vision loss. In addition, a large portion of optometrists are referring acute CRAO patients to outpatient ophthalmology clinics, delaying appropriate acute management. Therefore, it is imperative that optometrists and ophthalmologists are educated to view acute retinal arterial ischemia as an acute stroke and urgently refer these patients to an ED affiliated with a stroke center. The delay in patient presentation and these referral patterns make future clinical trials for acute CRAO challenging. J Neuroophthalmol 2023 Sep 21. doi: 10.1097/WNO.0000000000001915. Mileski, Kelsey M. OD; Biousse, Valérie MD; Newman, Nancy J. MD; Flowers, Alexis M. MD; Chan, Wesley MD; Dattilo, Michael MD, PhD
REFERENCES • Clinical ophthalmology - Jack J Kanski • Comprehensive ophthalmology - AK Khurana • Ophthalmology 5th edition -Myron Yanoff and JAY S. Duker • American academy of ophthalmology
RETINAL ARTERY OCCLUSIONS CRAO BRAO CLRAO