Optometry case study: Branch retinal artery occlusion

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Figure 1. Fundus appearance of RE one hour after onset of symptoms. Inferior retinal pallor evident
Figure 1. Fundus appearance of RE one hour after onset of symptoms. Inferior retinal pallor evident

by Andrew Lovejoy, Specsavers Kawana, QLD

History

Px: 87-year-old man presented with an acute, painless vision loss from the right eye. He presented within an hour after the onset of his symptoms
POH: No previous transient visual obscuration
GH: No reported symptoms consistent with giant cell arteritis

Clinical Tests

Visual acuity: RE 6/7       LE 6/9
Fundus examination:
RE: Intraretinal oedema with inferior retinal pallor (Figure 1). Inferior retinal artery attenuation. RE ONH appearance normal. No retinal haemorrhages, cottonwool spots or emboli noted
LE: Normal
Visual field investigation: 30-2 Threshold field shows RE superior field loss (Figure 2)

Figure 2. Visual field showing complete superior field loss in RE at presentation

Diagnosis

Differential diagnosis:

  • Branch retinal artery occlusion
  • Giant cell arteritis
  • Vein occlusion
  • Retinal detachment
  • Acute optic neuritis

Diagnosis: Branch retinal artery occlusion involving the inferior hemi-retina of the right eye

Management

Ocular massage was initiated by firmly depressing the globe and releasing. This was administered in office for 20 minutes. Attempts to have the patient re-breathe into a bag in an effort to increase carbon dioxide intake were abandoned due to the patient’s shortness of breath. An urgent ophthalmologist appointment was arranged.

On presentation to the ophthalmologist, the patient’s visual field had returned to full by confrontation. There was no evidence of retinal pallor or retinal oedema. Retinal blood flow had been restored.

The patient was sent for haematological investigation and imaging of his carotids. He was found to have dense plaques at the right carotid bulb and internal carotid artery. He was treated accordingly to minimise future risk of carotid based emboli.

The patient has since been reviewed at the optometry clinic on several occasions. The acuity has been preserved at right 6/7 and left 6/9 with almost full visual fields (Figure 3). The retinal vasculature has remained intact, although small haemorrhages did develop below the right disc.

Figure 3. RE visual field several months after initial occlusion

Discussion

Vision loss from retinal artery occlusion often has a poor prognosis. Management includes treating the acute event in a timely manner as well as minimising the risk of systemic complications.

Should an acute artery occlusion present to your practice, attempts have to be made to restore retinal blood flow. Approaches to dislodging an embolic occlusion that optometrists can take include ocular massage, administering pressure lowering agents, and re-breathing techniques.

Management of this ocular emergency include the exclusion of other manifestations such as giant cell arteritis, vein occlusion, retinal detachment and acute optic neuritis.

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