What is the treatment for retinal artery branch occlusion?

Treatment for Branch Retinal Artery Occlusion (BRAO)

Branch retinal artery occlusion (BRAO) requires immediate referral to the nearest stroke center for evaluation and possible intervention, as it represents an ocular and systemic emergency with high risk for subsequent stroke and cardiovascular events. 1

Immediate Management

• BRAO should be treated as an emergency requiring immediate triage to an emergency department or stroke center without delay for further outpatient evaluation 1
• For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be considered (0.9 mg/kg with 10% given over 1 minute and remainder over 59 minutes) 1
• In patients over 50 years of age, giant cell arteritis (GCA) must be ruled out and urgent systemic corticosteroid therapy should be initiated if GCA is diagnosed or highly suspected 1
• The stroke center evaluation should include:
  • Funduscopic examination to confirm diagnosis and exclude alternative causes 1
  • Brain MRI with diffusion-weighted imaging 1
  • Vascular imaging 1
  • Clinical assessment for stroke risk factors 1

Secondary Prevention

• All patients with BRAO should undergo a systematic evaluation for:
  • Carotid occlusive disease 1, 2
  • Cardiac valve disease 1
  • Thromboembolic disease 1
  • In younger patients (<50 years): workup for vasculitis or hypercoagulability 1
  • In older patients (>50 years): embolic workup 1
• Long-term management typically includes:
  • Antiplatelet therapy 2
  • Statin therapy 2
  • For symptomatic carotid disease with >70% stenosis, carotid endarterectomy may be indicated 2

Alternative Treatments

• Currently, there are no proven treatments to reverse vision loss caused by BRAO 1
• Some experimental approaches have been reported with limited evidence:
  • Transluminal Nd:YAG laser embolysis/embolectomy for visible emboli (case series showed improved visual acuity in 89% of patients) 3, 4
  • Hyperbaric oxygen therapy as adjunctive treatment 4
  • Intravenous tenecteplase (TNK) has been used in case reports with functional visual recovery in BRAO 5
  • Aggressive systematic treatment including ocular massage, vasodilators, anterior chamber paracentesis, and other interventions has shown some benefit in small studies 6

Follow-up Care

• Regular monitoring for neovascularization is essential, as BRAO can lead to iris or retinal neovascularization 1
• Panretinal photocoagulation (PRP) is recommended if neovascularization develops 1
• Follow-up examinations should include 2:
  • Assessment of visual acuity and symptoms
  • Slit-lamp biomicroscopy with iris examination
  • Intraocular pressure measurement
  • Undilated gonioscopy to detect iris neovascularization, especially with elevated intraocular pressure

Prognosis

• Visual prognosis is generally better for BRAO than for central retinal artery occlusion 1
• Patients with a patent cilioretinal artery may have better preservation of central vision 7
• The presence of visible platelet-fibrin emboli (versus calcific emboli) and shorter duration of symptoms (<12 hours) are associated with better treatment response 6

Important Caveats

• Delay in treatment significantly reduces the chance of visual recovery 1
• The risk of subsequent stroke is highest within the first few days after onset of visual loss 1
• BRAO should be managed as part of the spectrum of acute retinal arterial ischemia, similar to how stroke is managed 1
• Local networks between ophthalmologists, optometrists, and stroke neurologists should be established to facilitate rapid evaluation 1