ARTERIAL OCCLUSIVE DISEASE

Marco Angelo Liwan

 Capillary Retinal Arteriole Obstruction
(Cotton-Wool Spots)
Acute Obstruction
Radial Peripapillary
Capilary net

NFL infarct (Cotton

wool spot)

Impaired • Superficial
axoplasmic • White
transport in NFL
• One fourth optic disc in size
• Appears 5-7 weeks ( longer in DR)
• Retinal depression may appear
• Visual loss and field loss depend on
location related
Capillary Retinal Arteriole Obstruction
(Cotton-Wool Spots)
The most common cause of cotton-wool spots is diabetic
retinopathy, other causes:
• systemic arterial hypertension
• HIV-associated retinopathy
• anemia (severe)
• radiation retinopathy
• sickle cell retinopathy
• cardiac embolic disease
• carotid artery obstructive disease
• vasculitis
• collagen vascular disease
• Leukemia

If even 1 cotton-wool spot is discovered in the fundus in an

otherwise apparently healthy eye, the clinician SHOULD
initiate a workup for the most likely underlying etiologies.
 Branch Retinal Arterial Occlusion
• Although an acute BRAO may be subtle and
unapparent on initial ophthalmoscopic
examination, within hours to days, it can lead
to edematous opacification caused by
infarction of the inner retina in the distribution of
the affected vessel.
• In time, the occluded vessel recanalizes,
perfusion returns, and the edema resolves;
however, a permanent visual field defect
remains. A retinal arterial occlusion that occurs
outside of the posterior pole may be clinically
asymptomatic.
Occlusion at any site is caused by embolization or thrombosis of
the affected vessel. There are 3 main varieties of emboli:
1. Cholesterol emboli (Hollenhorst plaques) arising in the carotid
arteries
2. Platelet-fibrin emboli associated with large-vessel
arteriosclerosis
3. calcific emboli arising from diseased cardiac valves
In rare cases, emboli might be caused by cardiac myxoma,
long-bone fractures (fat emboli), infective endocarditis (septic
emboli), and intravenous drug use (talc emboli). Although
rare, migraine cancause ocular arterial occlusions in patients
younger than 30–40 years. Other possible causes of emboli
include
• arrhythmias
• mitral valve prolapse
• oral contraceptive use or pregnancy
• coagulation disorders
• trauma
• sickle cell disease
• inflammatory and infectious etiologies such as toxoplasmic
retinochoroiditis and syphilis
• connective tissue disorders, including GCA
 Management
• Determining the underlying systemic etiologic
factors.
• Retinal arterial occlusions should be referred
urgently to an emergency department for a
stroke workup
• Lowering IOP and applying intermittent
pressure on the globe (“ocular massage”)
may dislodge an embolus from a large
central vessel toward a more peripheral
location
 Cilioretinal Artery Occlusion

• Occlusion of the cilioretinal artery, which arises from the

short posterior ciliary vessels rather than the central
retinal artery. These vessels, which are present in about
18%–32% of eyes, usually contribute to some portion of
the macular circulation.
• Most commonly, their occlusion occurs in patients with
a central retinal vein occlusion; it is postulated that the
increased hydrostatic pressure associated with CRVO
can reduce blood flow in the cilioretinal artery to the
point of stagnation.
• When cilioretinal artery occlusion occurs in isolation,
GCA should be considered.
Paracentral Acute Middle Maculopathy
• Acute ischemic events that affect the deep
macular capillary layers. It is best visualized as
hyperreflective bands on SD-OCT. There are 2
variants:
• Type 1: affects the superficial capillary plexus in
the outer plexiform layer (OPL)/inner nuclear layer
(INL) region INL thinning
• Type 2: affects the deep capillary plexus in the
OPL/outer nuclear layer (ONL) region 
disturbance of the ellipsoid or inner segment and
outer segment line
CENTRAL RETINAL ARTERY OCCLUSION
• Sudden Occlusion of Central
Retinal Artery
• Complete
• Painless loss of vision
Retina become opaque
and edematous

OCT imaging reveals a normal

macular profile with diffuse Choroidal vasculatur
intact, giving orange reflex
hyperreflectivity and loss of
internal layer definitionOCT
imaging reveals a normal Cherry red spot
macular profile with diffuse
hyperreflectivity and loss of
internal layer definition
• Central retinal artery reopens or recanalizes and the retinal
edema clears; but the effect on visual acuity is usually
permanent because the inner retina has been infarcted.

• In one study, 66% of eyes had visual acuity worse than

20/400, and 18% of eyes had 20/40 or better. Most cases of
20/40 or better visual acuity occur in the presence of a
patent cilioretinal artery

• Studies in nonhuman primates have suggested that

irreversible damage to the sensory retina occurs after 90
minutes of complete CRAO.

• Nevertheless, clinical return of vision can occur in some

instances even if the obstruction has persisted for many
hours.
Causes:
• Embolization or atherosclerosis-related thrombosis
occurring at the level of the lamina cribrosa.
• Hemorrhage under an atherosclerotic plaque,
thrombosis, trauma, spasm, and a dissecting
aneurysm within the central retinal artery (Less
common)
• The leading cause of death in patients with retinal
arterial obstruction is cardiovascular disease with an
elevated risk of myocardial infarction within the first
7 days following onset of the obstruction.

Immediate referral for brain imaging in a stroke

center is indicated, along with evaluation of the
carotid arteries via Doppler ultrasound or computed
tomography angiography (CTA) and of the cardiac
valves via transesophageal echocardiography.
• In cases of CRAO in which emboli are not readily visible, 
The erythrocyte sedimentation rate (ESR), C-reactive protein
level, and fibrinogen levels—markers of inflammation—are
usually elevated and should be checked. A complete blood
countmay detect an elevated platelet count, which is also
suggestive of GCA; the blood count also aids in the
interpretation of the ESR.
• If GCA is suspected as a cause, corticosteroid therapy
should be instituted promptly because the second eye can
become involved by ischemia within hours to days after the
first.
• In addition, a temporal artery biopsy should be performed
shortly thereafter to confrm the diagnosis and justify the
need for prolonged corticosteroid treatment.
 TREATMENT

• Reducing IOP by administering IOP-lowering

medications and performing ocular massage,
are not without benefit.
• Anterior chamber paracentesis and carbogen
(a mixture of 95% oxygen and 5% carbon
dioxide) vasodilatory inhalation therapy have
shown inconsistent success, as have
hyperbaric oxygen therapy, catheterization of
the ophthalmic artery with tPA infusion, and
transvitrealNd:YAG embolysis.
• Initial management should also include an
evaluation directed toward determining the
underlying systemic etiologic factors, and an
urgent referral to an emergency department for a
stroke workup should be undertaken.
• Iris neovascularization develops in approximately
18% of eyes within 1–12 weeks after acute CRAO,
with a mean time interval of approximately 4–5
weeks. Full-scatter PRP results in regression
ofanterior segment neovascularization in
approximately two-thirds of cases. Anti-VEGF
therapy in conjunction with PRP has been reported
to have value as well.
• Ophthalmic artery occlusion is very rare. Clinically,
the disorder typically produces vision loss to the
level of light perception or no light perception
because simultaneous nonperfusion of the choroid
and retina results in ischemia of all retinal layers. A
cherry-red spot may not be present; both the inner
retina and outer retina become opacified from the
infarction, resulting in an absence of contrast
difference between foveal and perifoveal retina that
would produce such a spot.
Ophthalmic artery occlusion may be caused by
dissection of the internal carotid artery, orbital
mucormycosis, or embolization. An increasing
number of ophthalmic artery occlusions caused by
various cosmetic facial-filler injections, particularly
into the periocular and brow area, have been
reported, as popularity for such procedures has
increased
THANKS