Fovea Sparing Branch Retinal Artery Occlusions Imaged with Optical Coherence Tomography Angiography: Two Case Reports

Abstract

Introduction: Central retinal artery occlusions and branch retinal artery occlusions (BRAOs) are ophthalmic emergencies that require workups for systemic risk factors. In the acute setting, BRAOs present with retinal whitening in a sectoral pattern on exam as well as hyperreflectivity and thickening of the inner retinal layers on optical coherence tomography (OCT). In the subacute to chronic phase, the retinal whitening dissipates, which may confound the diagnosis of remote arterial occlusions if there is no clearly visible plaque.

Case presentations: A 66-year-old male presented with 20/25 visual acuity (VA) and an inferior visual field defect in the right eye, and a 69-year-old male presented with 20/60 VA and a superior visual field defect in the left eye. Exams of both patients showed ischemic retinal whitening with visible Hollenhorst plaques in the affected eyes. OCT demonstrated inner retinal edema. At follow-up, wide-field OCT angiography (OCTA) showed persistent capillary dropout following the same initial vascular distribution but sparing the fovea and papillomacular bundle. VAs at the most recent follow-up visits were 20/30 and 20/20, respectively.

Conclusion: These cases demonstrate the utility of wide-field OCTA in characterizing areas of capillary nonperfusion that can persist for years after the initial ischemic event. Additionally, patients with macula-involving BRAOs can have good VA outcomes if the fovea is spared.

Keywords: Branch retinal artery occlusion; Case report; Optical coherence tomography; Optical coherence tomography angiography.

Fig. 1.

Multimodal imaging for case 1. a Initial exam demonstrates a focal area of retinal whitening in a vascular distribution in the superior macula with a visible Hollenhorst plaque (white arrow). bEn face retinal thickness map overlay demonstrates thickening in the superior macula. c OCT vertical B-scan demonstrates marked inner and middle retinal hyperreflectivity and edema corresponding to the area of retinal whitening (white arrows). d At the 10-year follow-up visit, the retinal edema noted on exam has resolved. eEn face retinal thickness map overlay demonstrates thinning in the superior macula. f OCT vertical B-scan demonstrates diffuse inner retinal atrophy in areas of prior retinal edema (white arrows). g Visual field at the time of presentation demonstrates a partial inferior paracentral scotoma. hEn face OCT angiography is notable for an ongoing area of nonperfusion corresponding to the prior area of retinal ischemia (red dotted circle).

Fig. 2.

Multimodal imaging for case 2. a Initial exam demonstrates a focal area of retinal whitening in a vascular distribution in the inferior macula with a visible Hollenhorst plaque (white arrow). bEn face retinal thickness map overlay demonstrates thickening in the inferior macula. c OCT vertical B-scan demonstrates marked inner and middle retinal hyperreflectivity and edema corresponding to the area of retinal whitening (white arrows). d At 1-year follow-up, the retinal edema noted on exam has resolved with a persistent large plaque within the proximal vessel (white arrows). eEn face retinal thickness map overlay demonstrates thinning in the inferior macula. f OCT vertical B-scan demonstrates diffuse inner retinal atrophy in areas of prior retinal edema. gEn face OCT angiography is notable for an ongoing area of nonperfusion corresponding to the prior area of retinal ischemia (red dotted circle).