Detection of underdiagnosed concurrent branch retinal artery occlusion in a patient with central retinal vein occlusion using spectral domain optical coherence tomography

BMC Ophthalmology Detection of underdiagnosed concurrent branch retinal artery occlusion in a patient with central retinal vein occlusion using spectral domain optical coherence tomography Anushavan Karapetyan Pingbo Ouyang Luo Sheng Tang Jiexi Zeng 0 Michele Dominique Li Ying 0 0 Equal contributors Department of Ophthalmology, The Second Xiangya Hospital, Central South University , 139 Renmin Middle Road, Changsha 410011 , China Background: Combined branch retinal artery and central retinal vein occlusion is a rare condition that has been infrequently reported. This case report, aside from reporting the above-mentioned condition, highlights the importance of performing spectral domain optical coherence tomography in establishing a complete diagnosis, especially in uncertain and complicated cases. We also present spectral domain optical coherence tomography findings of a case of combined unilateral simultaneous central retinal vein and branch retinal artery occlusion. Case presentation: We present a single case of an initially missed, unilateral branch retinal artery occlusion combined with central retinal vein occlusion in a 51-year-old female Chinese patient without a significant past medical history, who experienced sudden, painless vision diminution in her right eye eleven days prior to presentation. She eventually recovered visual acuity to 0.60, despite having presented with poor vision. Conclusion: Combined unilateral central retinal vein and branch retinal artery occlusion may occur in patients with no medical history of arterial hypertension and diabetes mellitus and can achieve a relatively good visual outcome. This case reaffirms the significance of performing a spectral domain optical coherence tomography examination in patients suffering from central retinal vein occlusion with suspicion of unilateral simultaneous branch retinal artery occlusion to identify the affected pathological areas. Branch retinal artery occlusion; Central retinal vein occlusion; Spectral domain optical coherence tomography - Background Central retinal vein occlusion (CRVO) and branch retinal artery occlusion (BRAO) are two different types of retinal vascular occlusions. CRVO is a common retinal vascular disorder that arises from a blockage of the central retinal vein. As a consequence of the blockage, stagnant blood gradually leaks out through the vein walls and leads to blurred vision. BRAO refers to an obstruction or blockage of one or multiple branch retinal arteries resulting in a severe loss of vision, the area and degree of which is associated with the distribution of the occluded branch retinal artery. Histopathologically, acute BRAO results in ischemia in the corresponding retinal quadrant marked by inner retinal edema in the initial stages and atrophy in long-standing cases [1]. The combination of the two aforementioned diseases is rare, despite the fact that these two types of ocular vascular obstructions share many common underlying systemic conditions, such as cardiovascular atherosclerotic disease, arterial hypertension, diabetes mellitus, toxoplasmosis, sarcoidosis, Behet's disease [2], coagulopathies [3], systemic lupus erythematosus and anti-phospholipid syndrome [4], and homocysteinemia [5], which result in severe loss of vision and impairment of the patients quality of life. In this report, we describe a single case of combined unilateral CRVO and BRAO and emphasize the efficacy of spectral domain optical coherence tomography (SD-OCT) examination in this type of case. Case presentation A 51-year-old female Chinese patient without arterial hypertension, diabetes mellitus or significant past ophthalmic history presented to our hospital complaining of painless, suddenly impaired vision in her right eye for 11 days. Prior to that, she had been hospitalized at the local county hospital with visual acuity of 0.06 and 0.80 in the right and left eyes, respectively. Based on the results of ophthalmologic, fundus and fluorescein angiography (FA) examinations, clinical diagnosis of CRVO was established and traditional Chinese medicine was prescribed to activate blood circulation and decrease blood stasis. Upon presentation to our hospital, the anterior segment examination under a slit lamp biomicroscope (SLE) was unremarkable in both eyes, and visual acuity of 0.10 and 0.80 was revealed in the right and left eyes, respectively. Intraocular pressure was in the normal range. A dilated fundus evaluation demonstrated an edematous macula, tortuous and dilated retinal veins with radially patterned hemorrhages, blurred and elevated disc margins in her right eye, and retinal paleness in the upper region of the macula (Figure 1A). On the basis of these signs, combined with the results from FA performed at the local hospital, the diagnosis of CRVO was reconfirmed. The FA examination was repeated at our hospital, which showed signs suggestive of BRAO (Figure 1B) and the patient was recommended to undergo SD-OCT examination. SD-OCT showed macular edema with a shallowly detached fovea, an edematous retina in its all sections, subfoveal liquid, a detached peripapillary retina, intact inner segment-outer segment (IS-OS) line and a strong reflected signal from thickened inner layers of the superior retina (ILSR) in contrast to the inferior retina, suggesting the possibility of merging BRAO in this region (Figure 2A). A retrospective view of the fundus photographs showed that, in addition to radial hemorrhages in the fundus of the right eye, a clearly demarcated pale area at the superior region of the retina existed. Because of the obvious CRVO manifestation, this region had been neglected during the previous examinations. Subsequently, the complete clinical diagnosis of combined unilateral CRVO and BRAO was made. The patient had neither medical history nor signs and symptoms of cardiovascular, hematological, systemic and parasitic diseases. The instrumental examinations, such as chest X-ray and echocardiography, did not reveal any pathology and blood and urine laboratory test results, namely enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR), plasma and urine homocysteine quantitative tests, full blood count were within the normal range. The ELISA and PCR testes were used to screen for 2-glycoprotein 1 dependent anticardiolipin (ACA), immunoglobulin G antibodies and Toxoplasma gondii B1 gene. Owing to a late presentation (>24 hours), the only treatment offered was one periocular injection of triamcinolone acetonide (40 mg). One week later at the first follow-up visit, the patient had visual acuity of 0.40 and 0.80 in the right and left eyes, respectively. A SD-OCT examination showed decreased volume of the accumulated fluid in the sub-neuroepithelial space as well as weakened reflected signal from the ILSR and reduced retinal thickness (Figure 2B). Two weeks later at the second and last follow-up visit, SD-OCT examination showed a further decrease of the (...truncated)