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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.

On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.

A dilated fundus examination was performed demonstrating the following:

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Neuro-Ophthalmology

Case 29

Patient Presentation: A 73-year-old man with no past medical or ocular history was referred to a neuro-ophthalmology clinic for decreased vision in his right eye. He noticed this decreased vision OD 3 years ago but denied any acute vision change or trauma. The vision was described as a “haze” that was worse in the superonasal quadrant OD. He denied GCA symptoms. He denied a painful red eye, flashes, floaters or visual field deficit.

On examination, visual acuity was 20/60 OD and 20/20 OS. There was no RAPD and intraocular pressure was normal. Extraocular motility and colour vision were normal. Anterior segment examination demonstrated symmetric 1+ nuclear sclerotic cataracts OU. Fundus photographs were taken and are shown below:

Fundus examination, as shown above, showed a normal optic nerve and macula OU. OCT macula imaging was then performed and is shown below:

Question 1: What is the main finding in the OCT macula images above?

A. Disruption of the ellipsoid zone

B. Vitreomacular traction

C. Atrophy of the right temporal macula

D. Reticular pseudo-drusen

Due to the findings on the right eye OCT macula, OCT ONH/RNFL imaging was conducted and is shown below:

Question 2: What is the main finding in the OCT ONH/RNFL above?

A. Thin right inferior RNFL

B. Bilateral optic disc edema

C. Glaucomatous optic neuropathy OD

D. Disc at risk OD

Based on the OCT macula and RNFL images, the fundus photos were reviewed again. When coursing through the vessels emanating off the nerve, there was subtle attenuation of an arteriole branching off the inferior arcade.

Question 3: Based on the patient presentation, fundus findings and OCT imaging, what is the most likely diagnosis?

A. Paracentral acute middle maculopathy

C. Resolved papilledema

D. Chronic BRAO

Learning Objectives:

Understand how chronic branch retinal artery occlusions present
Learn the OCT features of chronic BRAOs

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