Young Eyes, Old Problems – Unforeseen Cause of Branch Retinal Artery Occlusion in a Young Female

CASE DETAILS A 23-year-old female complained of a superior field defect in the right eye for 12 hours. Her vision in her right eye (OD) was 6/36, and that in her left eye (OS) was 6/6. The relative afferent pupillary defect was noted in OD. Fundus OD showed retinal edema along the inferior branch retinal artery (BRA) with a cherry red spot in the macula [Figure 1a]. Humphrey visual field analyser HFA 30-2 showed a superior field defect [Figure 2]. The macula’s optical coherence tomography (OCT) showed inner retinal edema [Figure 1c]. A complete auto-immune, cardiac, and basic bloodline investigation was done, which revealed her homocysteine levels were elevated (>50 icromol/L) with a significant folate deficiency. A diagnosis of branched retinal artery occlusion (BRAO) due to hyperhomocysteinaemia was made. Physician opinion was obtained, and she was started on oral folic acid supplementation. At 1 week follow-up, her vision in OD improved to 6/6. There was a decrease in clinical retinal oedema and OCT [Figure 1b and d] with persisting field defects. BRAO, though uncommon, has been documented to occur in individuals less than 40 years of age. The risk factors for retinal arterial occlusive disease vary among the elderly and younger population. Many studies have shown that hypercoagulable states are commonly associated with BRAO in young. Though systemic vasculitis and carotid stenosis were shown to be common causes of BRAO in young worldwide,[1] hyperhomocysteinaemia is one of the common causes of hyper coagulable states resulting in BRAO in the Indian population.[2] The treatment of hyperhomocysteinemia typically focusses on lowering high levels of homocysteine in the blood by Vitamin B6 and B12 and folic acid supplementation. The clinician has to keep this in mind while working up a younger patient with BRAO.Figure 1: (a) Colour fundus photograph of the right eye showing retinal oedema along the inferotemporal branch retinal artery. (b) Resolution of retinal oedema at 1 week follow-up. OCT scans of the right eye showing inner retinal oedema (c) at presentation and resolution of retinal oedema at 1 week follow-up (d)Figure 2: Automated perimetry using a Humphrey visual field analyser showing superior altitudinal field defectDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.