Prepapillary vascular loops – A new classification

Background: Prepapillary vascular loops are a type of congenital vascular anomaly seen on or around the optic disk. Patients with this condition are usually asymptomatic and are detected incidentally on routine fundus examinations. Differential diagnosis for this condition includes neovascularization of the disk and collaterals on the disk. Prepapillary capillary loops are not associated with any systemic condition. They are usually unilateral in presentation, but can rarely be bilateral. Purpose: To discuss the new proposed classification of prepapillary capillary loops. Synopsis: Prepapillary capillary loops are classified based on their location around the disk, loop characteristics such as elevation, shape, and covering, and presence of vitreoretinal traction. Highlights: The most common vascular loops are arterial in origin and rarely venous in origin. They can sometimes be associated with spontaneous and recurrent vitreous hemorrhage, branch retinal artery or vein occlusion, and subretinal hemorrhage. It is an important differential diagnosis in spontaneous vitreous hemorrhage. Treatment is symptomatic

Multiple small branch retinal arteriolar occlusions following coil embolization of an internal carotid artery aneurysm

A 41-year-old male was referred from the neurosurgery department with visual disturbance immediately following coil embolization of a distal internal carotid artery aneurysm. On initial fundus examination, diffuse retinal opacification sparing the papillomacular bundle area was observed in his right eye. Optical coherence tomography showed inner retinal edema, and fluorescein angiography showed delayed arterial filling and multiple small arteriolar obstructions in that eye. After 2 weeks, although the inner retinal edema and retinal opacification improved, small arteriolar occlusions were still present. The small arteriolar occlusion-related perfusion defect persisted until the 6-month follow-up. Neurosurgeons should be aware of the possibility of iatrogenic retinal artery occlusion when they perform coil embolization. Moreover, long-term follow-up may be necessary to detect any ischemic complications, as these postprocedural retinal artery occlusions tend to be poorly reperfused.

Branch retinal artery occlusion post-penetrating globe injury with intraocular foreign body

Intraocular foreign body (IOFB) in cases of penetrating eye injury accounts for an important indication of vitreoretinal intervention following ocular trauma. Vascular occlusion as a complication of IOFB is rare. Here we present a case of a 34-year-old male with post-traumatic cataract and an intraocular metallic foreign body (IOFB) lodged in the superficial layers of the retina inferotemporal to the disc, causing an inferotemporal branch retinal artery occlusion. The case was managed by lensectomy with pars plana vitrectomy and IOFB removal followed by a second procedure of secondary IOL implantation. Final best-corrected visual acuity improved to 6/24. This case highlights an unusual sequelae following penetrating ocular trauma.

Analysis of visual prognosis and correlative factors in branch retinal artery occlusion / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:Analysis of visual prognosis and correlative factors in patients with branch retinal artery occlusion(BRAO). <p>METHODS: Retrospective medical record review of 68 eyes of 68 patients with BRAO seen at Fushun Ophthalmology Hospital from June 2015 and June 2017. Demographic and clinical characteristics were recorded, including gender, age, race, eye involved, and best-corrected visual acuity(BCVA), spectral domain optical coherence tomography(SD-OCT)and optical coherence tomography angiography(OCTA, OptoVue). The OCTA retinal blood flow imaging scan mode was performed, the scanning region in the macular area were 3mm×3mm. the patients were followed up for 6mo.<p>RESULTS: On presentation, 69% of eyes with BRAO had BCVA of 0.5 or better, 24% of moderate visual impairment(0.1-0.4)and 7% of severe visual impairment(<0.1). At the 6-month visit, the percentage of eyes with slight, moderate and severe visual impairment was 75%, 19% and 6% respectively. The presenting BCVA(<i>r</i>=0.776, <i>P</i><0.001), the integrity of superficial foveal capillary arcade(<i>r</i>=-0.003, <i>P</i><0.001), the integrity of deep foveal capillary arcade(<i>r</i>=-0.003, <i>P</i><0.001), the density of superficial retinal capillary plexuses(<i>r</i>=-0.034, <i>P</i>=0.029)and the density of deep retinal capillary plexuses(<i>r</i>=-0.014, <i>P</i>=0.012)were found to be statistically significant with regard to visual outcome. Male, age, duration of symptoms, macular retinal thickness, area of macular involvement(superior or inferior)and presence or absence of emboli were not found to be statistically significant with regard to follow-up BCVA(<i>r</i>=0.273, 0.01, 0, 0.082, 0.41, 0.109, all <i>P</i>>0.05). <p>CONCLUSION: The integrity of foveal capillary arcade, the density of retinal capillary plexuses and the presenting BCVA are dosely associated with visual outcome of patients with branch retinal artery occlusion.

Progressive Susac syndrome with bilateral visual loss and disability.

Susac syndrome (SS) is a rare retinal‑cochlear‑cerebral disease with an unclear etiology. A 35‑year‑old man presented with sudden painless vision loss in the right eye and 2 months later in the left eye with hemiparesis, behavioral changes, and hearing loss. Ophthalmic examinations revealed multiple branch retinal artery occlusions (BRAOs) in both eyes. Brain magnetic resonance imaging showed inflammatory changes with multiple “punched‑out” lesions in the corpus callosum which confirmed the diagnosis of SS. Despite intravenous and oral corticosteroid therapy, the disease progressed with the development of new BRAOs, low vision in both eyes, and disability. Prompt diagnosis and early treatment may save the vision and even patient’s life.

A Case of Branch Retinal Artery Occlusion Associated with Takayasu's Arteritis

PURPOSE: Takayasu's arteritis generally involves the aorta and its main branch. Various ocular manifestations associated with Takayasu's arteritis have been reported, but branch retinal artery occlusion (BRAO) is very rare. We report a case of BRAO associated with Takayasu's arteritis. CASE SUMMARY: 53-year-old female patient visited out emergency room for an inferior visual field defect of the right eye that had presented 2 hours earlier. Visual acuity was 1.0 in both eyes. There were no abnormalities of the anterior segment or pupil reflex. On fundus examination, superior retinal whitening was observed in her right eye. Through ancillary study including optical coherence tomography and fluorescein angiography, she was diagnosed with BRAO and underwent conservative treatments. She had received previous treatment and had been followed-up for Takayasu's arteritis for 20 years. She complained of general weakness, and body temperature was 38.7℃. On blood analysis, erythrocyte sedimentation rate and C-reactive protein were increased compared to previous levels. She was medically treated on the assumption of relapse of Takayasu's arteritis. After 3 months, the retinal whitening in her right eye was resolved, but the visual field defect remained similar to that at the initial visit. CONCLUSIONS: We report this rare case of BRAO associated with Takayasu's arteritis, indicating the need to consider an association between the two diseases.

Combined occlusion of branch retinal artery and vein secondary to prepapillary arterial loops.

A middle‑aged diabetic and hypertensive man presented with diminished vision in the left eye. Fundus examination revealed prepapillary arterial loops, but with features of venous rather than arterial occlusion. Fluorescein angiography and optical coherence tomography confirmed the presence of a branch retinal vein occlusion along with two branch retinal artery occlusions. The resultant macular edema responded well to intravitreal triamcinolone and laser photocoagulation though the visual improvement was moderate.

A Case of Idiopathic Pediatric Acute Branch Retinal Artery Occlusion Involving the Macular Area

PURPOSE: We report a case of branch retinal artery occlusion (BRAO) interconnected with the perifoveal capillaries in a healthy young female. CASE SUMMARY: A 16-year-old female presented with sudden loss of vision in her left eye. Upon initial examination, her left visual acuity was 0.02 and intraocular pressure was 31 mm Hg. Fundus examination revealed pallid retinal edema of the inferior posterior pole and retinal hemorrhage below optic disc. Ocular massage followed by anterior chamber paracentesis was performed for 30 minutes within 4 hours after the onset of vision loss. Fluorescein angiography (FAG) showed a very slow blood flow in the superotemporal and inferotemporal retinal arteries and a delay in retinal arteriovenous transit time. We performed hemodynamic tests such as blood pressure, echocardiography, and the hematologic test for thrombogenicity and all tests were normal. At three weeks after treatment, vision in the left eye was 0.7 and FAG revealed normal retinal arterial circulation and venous drainage time. CONCLUSIONS: This is the first report regarding acute BRAO in a healthy Korean child without any detectable systemic disorder. Prompt treatment can prevent permanent visual loss in BRAO involving the macular area.

The Intima Media Thickness (IMT) as Measured by Carotid Ultrasonography in Patients with Retinal Vascular Diseases

PURPOSE: To evaluate the findings of carotid ultrasonography performed on patients with retinal vascular disease and to determine the risk of cardiovascular disease and association of retinal vascular disease and cardiovascular disease. METHODS: From December 2009 to May 2012, patients diagnosed with central retinal artery occlusion (CRAO, n = 18), central retinal vein occlusion (CRVO, n = 23), and branch retinal vein occlusion (BRVO, n = 68) underwent carotid ultrasonography. We evaluated the intima-media thickness (IMT) of the common carotid artery (CCA) and the internal carotid artery (ICA), stenosis and the number of plaques, and then compared these results with those of a healthy control group (n = 221). RESULTS: The mean CCA-IMT and ICA-IMT were significantly higher in the CRAO and BRVO groups compared with the control group. On the contralateral side, CCA-IMT was increased in the CRAO, BRVO, and CRVO groups and ICA-IMT was increased in the CRAO and BRVO groups compared with the control group. Contralateral CCA stenosis was higher in the CRVO group (9.1%) and ipsilateral ICA stenosis in CRAO group (21.7%) was significantly higher than that of the control group. Plaque was observed better in all groups compared with the control group. The proportion of patients risk for cardiovascular disease, i.e. those who had IMT thickenesses more than 1.0 mm, was higher in the CRAO and BRVO groups compared with the control group. CONCLUSIONS: The carotid ultrasound findings of patients with retinal vascular diseases showed increased IMT and plaque. The group of patient at risk for cardiovascular disease, which was defined with carotid artery IMT, was higher in patients with retinal vascular disease. Therefore, in patients with retinal vascular disease, carotid artery ultrasonography and the overall management and treatment of cardiovascular disease are necessary.

Neovascular Glaucoma Due to Branch Retinal Vein Occlusion Combined with Branch Retinal Artery Occlusion

Branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO) rarely cause neovascular glaucoma (NVG). A 58-year-old woman with hypertension and type 2 diabetic mellitus complained of progressive visual loss in her right eye for the previous 3 months. At initial examination, visual acuity was 20 / 63 in the right eye. Angle neovascularization was observed and the intraocular pressure (IOP) was 30 mmHg in her right eye. Fundus examination and fluorescein angiography showed BRAO combined with BRVO. We immediately injected intravitreal and intracameral bevacizumab in her right eye. The next day, we performed scatter photocoagulation in the nonperfusion area. One month later, visual acuity was 20 / 20 in her right eye and the IOP was 17 mmHg with one topical antiglaucoma agent. The neovascularization had regressed completely. We report a case of unilateral NVG which was caused by BRAO with concomitant BRVO and advise close ophthalmic examination of the iris and angle in BRVO with BRAO.

Dynamic focal retinal arteriolar vasospasm in migraine.

A 48-year-old man presented following an episode of sudden onset simultaneous inferior altitudinal visual loss in his left eye and visual obscuration with shimmering in the inferonasal quadrant of the right eye. Clinical examination demonstrated left superior hemiretinal artery occlusion and an area of focal dynamic spasm along the right superior temporal branch retinal artery, the arteriolar spastic cycle was about 2 sec in duration. Hematological (including complete blood count, thrombophilia screen, vasculitic screen and serum magnesium), carotid, and cardiac investigations were normal. He was given acetazolamide 500 mg orally, timolol maleate 0.5% eye drops once daily and sublingual amyl-nitrate 0.8 mg, and maintained on felodipine 10 mg/day and aspirin 100 mg/day. The area of focal arteriolar spasm in the right eye resolved over two months. To our knowledge there are no prior reports of photographically documented dynamic focal retinal vascular spasm on a MEDLINE and PUBMED search.

Recurrent Bilateral Branch Retinal Artery Occlusion with Hearing Loss and Encephalopathy: The First Case Report of Susac Syndrome in Korea

We report the first case of Susac syndrome in Koreans, in a 23-yr-old female patient who presented with sudden visual loss and associated neurological symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, which tended to recur in both eyes. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum and left fornix, and audiometry showed low-frequency sensory hearing loss, compatible with Susac syndrome. She received immunosuppressive therapy with oral steroid and azathioprine. Three months later all the symptoms disappeared but obstructive vasculitis have been relapsing. This patient demonstrated the entire clinical triad of Susac syndrome, which tends to occur in young females. Although this disorder has rarely been reported in Asian populations, a high index of suspicion is warranted for early diagnosis and timely treatment.

A case of unusual presentation of Takayasu's arteritis.

Takayasu's arteritis is a chronic inflammatory disease of the large and medium-sized arteries. It commonly involves the aorta with its branches and the pulmonary arteries. The retinal hemodynamics suggest that the carotid artery involvement causes diminished retinal blood flow. This is the pathogenetic mechanism of Takayasu's retinopathy with characteristic features of microaneurysms, arterio-venous anastomosis and non-perfused retinal areas. Our case presented as branch retinal artery occlusion with collaterals and iris neovascularization. The branch retinal artery, a small retinal artery occlusion in our case is an unusual presenting feature of Takayasu's aorto-arteritis.

Treatment of Branch Retinal Artery Occlusion With Transluminal Nd:YAG Laser Embolysis

The purpose of this paper was to report a successful treatment of transluminal Nd:YAG laser embolysis (NYE) for branch retinal artery occlusion (BRAO) with visible emboli. Two patients with acute, severe vision loss secondary to a branch retinal artery occlusion with visible emboli in one eye underwent NYE. A complete ocular examination was performed which included biomicroscopy of the posterior pole of the retina, intraocular pressure measurement, fundus color photographs, and fluorescein angiography (FA). After the NYE, the two patients showed dramatic improvements in best-corrected visual acuity, as well as, immediate and dramatic restorations in flow past the obstructed arteriole in FA. NYE is a treatment modality to be considered in patients with BRAO who present acutely with severe vision loss and a visible embolus.

Prepapillary Vascular Loops associated with Branch Retinal Artery Occlusion and Vitreous Hemorrhage

PURPOSE: To report a case of prepapillary loops (PPLs) associated with branch retinal artery occlusion (BRAO) and vitreous hemorrhage in a patient with IgA nephropathy. METHODS: A 26-year-old woman presented with sudden loss of vision in her right eye. One year prior, she had been diagnosed as having IgA nephropathy. Examination of the right fundus revealed vitreous hemorrhage that appeared to be extending from the optic disc and a pale and edematous superior retina that was compatible with BRAO. Subretinal and intraretinal hemorrhage extending from the optic disc were also present. Laboratory tests of the factors associated with coagulation were normal. RESULTS: After spontaneous resolution of the vitreous hemorrhage and retinal edema, arterial PPLs and a venous PPL were detected at the superior portion of the optic disc. Fluorescein angiogram demonstrated slow filling of the superior branch of the retinal veins and the venous PPL. The filling of the arterial PPLs was normal and there was no delayed perfusion in the superior retina. These PPLs did not show any fluorescein leakage in the late phase of the angiogram. At the last follow-up visit, 18 months after the onset of symptoms, the vitreous hemorrhage and subretinal hemorrhage had been completely absorbed and no other ocular complications hd developed. CONCLUSIONS: PPL is usually asymptomatic; however, complications such as BRAO and vitreous hemorrhage can develop in some cases with causative factors.

A Case of Ocular Ischemic Syndrome Associated with Multiple Branch Retinal Artery Occlusion and Neovascular Glaucoma

The ocular ischemic syndrome includes the ocular symptoms and signs secondary to severe carotid artery obstruction. Recently, authors have experienced a case of ocular ischemic syndrome in a 55 years old man, who has multipl cilioretinal artery occlusions and neovascular glaucoma associated with ipsilateral internal carotid artery obstruction.

A Clinical Study of 36 Cases of Retinal Artery Occlusion

Blockage of the retinal artery system may occur in the form of central retinal arterial obstruction, branch retinal arterial obstruction, or combination of aforementioned. It may be related to known pre-existing systemic disease or it may be the initial manifestation of a previous undiagnosed systemic abnormality. The authors evaluatea the clinical course of 35 cases of retinal artery occlusion at Department of Ophthalmology, Pusan Paik Hospital Inje Mgdical College from September, 1979 to June, 1988.