Treatment for Branch Retinal Artery Occlusion (BRAO)

Immediate Management

The American Academy of Ophthalmology recommends that branch retinal artery occlusion (BRAO) should be treated as an emergency requiring immediate triage to an emergency department or stroke center without delay for further outpatient evaluation 2, 4
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) 4, 5
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 3, 6
The stroke center evaluation should include funduscopic examination to confirm diagnosis and exclude alternative causes, brain MRI with diffusion-weighted imaging, vascular imaging, and clinical assessment for stroke risk factors 1, 4

The American Heart Association recommends that all patients with BRAO should undergo a systematic evaluation for carotid occlusive disease, cardiac valve disease, and thromboembolic disease 3
In younger patients (<50 years), a workup for vasculitis or hypercoagulability is recommended, while in older patients (>50 years), an embolic workup is recommended 3, 6

Regular monitoring for neovascularization is essential, as BRAO can lead to iris or retinal neovascularization, and panretinal photocoagulation (PRP) is recommended if neovascularization develops 3, 6
Follow-up examinations should include assessment of visual acuity and symptoms, slit-lamp biomicroscopy with iris examination, intraocular pressure measurement, and undilated gonioscopy to detect iris neovascularization 6, 7

Delay in treatment significantly reduces the chance of visual recovery, and the risk of subsequent stroke is highest within the first few days after onset of visual loss 1, 2, 4, 5
BRAO should be managed as part of the spectrum of acute retinal arterial ischemia, similar to how stroke is managed, and local networks between ophthalmologists, optometrists, and stroke neurologists should be established to facilitate rapid evaluation 2