Ischemic Injury of the Papillomacular Bundle Is a Predictive Marker of Poor Vision

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Retinal artery occlusion (RAO) is a relatively common, visually disabling, ocular vascular occlusive disorder. Although most of central retinal artery occlusion showed poor visual prognosis, branch retinal artery occlusion (BRAO) is recognized as a disease with a relatively favorable outcome. However, in clinical situation, we often see patients who present with severely deteriorated central vision and this can sometimes not be explained with a classic diagnostic approach, fundus photography (FP) and fluorescein angiography (FA). Accordingly, using spectral-domain optical coherence tomography (SD-OCT), we investigated the retinal structural changes in eyes with macula-involving branch retinal artery occlusion and searched for anatomic factors that could predict the visual prognosis.

This study is designed as retrospective comparative case study and reviewed medical records of 66 eyes from 66 patients with acute branch retinal artery occlusion who visited Seoul National University Bundang Hospital between January 2009 and October 2014. Initial FP, FA, and SD-OCT images were compared with those obtained at the final images which was at least 3months after the initial visit.

Through analysis of FP, FA, and SD-OCT images, we noticed that ischemic injury of papillomacular bundle is a determining factor of poor vision and it has a degree-dependent association with the visual prognosis of branch retinal artery occlusion. Interestingly, edema or morphological change of central fovea were absent in all patients in this study.

The central region with the highest visual acuity in the retina is known as the fovea. In the central fovea, there is a depression, known as the foveal pit, which results from a lack of overlying inter-neurons. The central fovea is known to be composed of outer retinal structures lacking an inner retinal layer. Therefore, the papillomacular bundle does not include the central fovea. Importantly, in our study we found that even the normal structures of both the central fovea and the optic disc can show poor vision if accompanied by ischemic changes of the papillomacular bundle that connects the fovea and the optic disc. This implies that the crucial factor affecting vision loss in branch retinal artery occlusion is not the state of the central fovea, but the degree of inner-retinal ischemia in the papillomacular bundle area.

Despite a few limitations inherent to a retrospective study design, the present study, with a relatively large number of analyzed cases, demonstrated for the first time that the integrity of papillomacular bundle is the key factor for visual outcome of branch retinal artery occlusion.

In conclusion, there is a degree-dependent association between ischemic injury of the papillomacular bundle and visual prognosis in eyes with macula-involving branch retinal artery occlusion. Our findings emphasize the importance of a detailed papillomacular bundle area evaluation using SD-OCT in the acute stage of branch retinal artery occlusion, because the degree of papillomacular bundle invasion shows significant association with visual prognosis.

Figure legend: Representative photographic images of the fundus and horizontal foveal scan of spectral domain-optical coherence tomography at the initial visit in the Improvement group (Top row) and the Non-Improvement group in the Poor Vision group (Second row) in patients with branch retinal artery occlusion. Dashed eclipses indicate morphological changes to the inner-retinal layer of the papillomacular bundle area. The Improvement group showed only focal hyperreflectivity change, however, the Non-improvement group showed increased retinal thickness, hyper-reflectivity, and loss of layer by layer integrity in the papillomacular bundle. In the three-dimensional images of Good Vision (Third row) and Poor Vision–Non improvement group (Bottom row), the yellow line indicates an imaginary line of the papillomacular bundle and the white line indicates the ischemic retinal area. The invasion of the papillomacular bundle area by ischemic retinal injury can be seen in the Poor Vision-Non improvement group, but was absent in the Good Vision group.

About the author

Se Joon Woo, MD, is an associate professor of Seoul National University Bundang Hospital, Seongnam, South Korea. His research interests include development of new drugs and biomarkers for age-related macular degeneration, ocular drug delivery, vascular biology, and clinical research on retinal artery occlusion, diabetic retinopathy, myopia, central serous chorioretinopathy, polypoidal choroidal vasculopathy, vitreoretinal surgery, genetics, and epidemiology.

About the author

Kwan Hyuk Cho, MD, is a clinical fellow at Seoul National University Bundang Hospital, Seongnam, South Korea. His current clinical research interests include retinal artery occlusion, diabetic retinopathy, various macular diseases including epiretinal membrane and vitreoretinal surgery.

Journal Reference

Am J Ophthalmol. 2016 Feb;162:107-120.e2.

Cho KH¹, Ahn SJ², Jung C³, Han MK⁴, Park KH¹, Woo SJ⁵.

[expand title=”Show Affiliations”]

Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Ophthalmology, Armed Forces Capital Hospital, Seongnam, South Korea.
Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea. Electronic address: [email protected].[/expand]

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Ischemic Injury of the Papillomacular Bundle Is a Predictive Marker of Poor Vision in Eyes With Branch Retinal Artery Occlusion. Cho KH, Ahn SJ, Jung C, Han MK, Park KH, Woo SJ. Am J Ophthalmol. 2016;162:107-120.e2.

American Journal of Ophthalmology

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