What is the immediate management for a case of reperfused Branch Retinal Artery Occlusion (BRAO)?

Immediate Management of Reperfused Branch Retinal Artery Occlusion (BRAO)

Patients with reperfused BRAO should be treated as medical emergencies requiring immediate referral to an emergency department or stroke center for neurological evaluation within 24 hours of symptom onset, as there is a high risk of concurrent cerebrovascular events. 1, 2

Urgent Evaluation and Referral

• Immediate referral to an emergency department or stroke center is critical, as up to 25% of BRAO patients have silent brain infarction on diffusion-weighted MRI 2
• Do not delay emergency department referral to obtain further outpatient evaluation or institute other treatments 1
• The risk of stroke is highest within the first 7 days after ocular stroke and remains elevated for 30 days 2, 1

Diagnostic Workup in Emergency Setting

• Brain MRI with diffusion-weighted imaging should be performed urgently (within 24 hours) to identify concurrent silent brain infarctions 1, 3
• Vascular imaging to assess carotid artery status is essential, as clinically significant carotid stenosis is discovered in up to 70% of patients with symptomatic retinal artery occlusions 2, 1
• Evaluate for signs of giant cell arteritis (GCA) in patients over 50 years of age, including temporal tenderness, jaw claudication, weight loss, proximal myalgia, or fever 2, 1
• Order C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR) tests, which are typically elevated in GCA 1
• Non-mydriatic ocular fundus photographs (NMFP) combined with optical coherence tomography (OCT) can facilitate ultra-rapid remote diagnosis 3

Acute Treatment Options

• For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be considered 1, 4
• Hyperbaric oxygen therapy (100% oxygen over 9 hours) has demonstrated efficacy over observation alone in several small randomized trials 2, 1
• For suspected arteritic BRAO (giant cell arteritis), immediate systemic corticosteroid therapy is indicated to prevent vision loss in the fellow eye 2, 1

Management of Complications

• Monitor for development of iris or retinal neovascularization; if present, consider panretinal photocoagulation (PRP) with or without anti-vascular endothelial growth factor (anti-VEGF) therapy 2
• In acute cases, intravitreal anti-VEGF agents may be used (off-label) to supplement or facilitate PRP treatment 2

Prognosis and Follow-up Care

• Visual prognosis for BRAO is generally better than for CRAO, with 80% of BRAO patients achieving final visual acuity of 0.5 or better 5
• Identify and optimize control of chronic systemic diseases (e.g., diabetes, hypertension, lipid disorders) 2
• Secondary stroke prevention with antiplatelet therapy is recommended 1
• Regular follow-up to monitor for neovascular complications is essential 1

Important Considerations and Pitfalls

• Do not assume that reperfusion eliminates the need for urgent evaluation - the risk of concurrent cerebrovascular events remains high 2
• Only one-third of ophthalmologists currently transfer patients with retinal artery occlusions to an emergency department for immediate evaluation, despite guidelines recommending this practice 2
• Even in cases where the ocular fundus appears relatively normal after reperfusion, OCT may reveal inner retinal hyper-reflectivity/edema, confirming the diagnosis 3
• Rare causes of BRAO should be considered in the absence of typical vascular risk factors, including severe iron deficiency anemia 6 and vascular tumors 7