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Branch Retinal Artery Occlusion (BRAO) 👁️ Internal Medicine Ophthalmology | USMLE Step 2 CK

Branch Retinal Artery Occlusion (BRAO) is a form of acute retinal ischemia resulting from occlusion of a branch of the central retinal artery, leading to sudden, painless, partial monocular vision loss. It is a high-yield vascular emergency on USMLE Step 2 CK, especially in patients with atherosclerotic risk factors such as hypertension, diabetes, carotid artery disease, atrial fibrillation, or cardiac valvular disease.

BRAO typically presents with a sudden onset of visual field defect, such as a scotoma or sectoral loss of vision, corresponding to the area supplied by the occluded arterial branch. Unlike central retinal artery occlusion (CRAO), which causes complete monocular vision loss, BRAO affects only a portion of the visual field. The painless nature of the vision loss and the focal presentation are key diagnostic clues.

On fundoscopic examination, the affected retinal region appears pale and edematous, with a sharp demarcation between ischemic and normal retina. A visible embolus (Hollenhorst plaque) may be seen at the site of arterial bifurcation, especially if the embolus is cholesterol-based.

Common causes of BRAO include:
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Atherosclerotic emboli from carotid plaques
Cardioembolic sources (e.g., atrial fibrillation, valvular heart disease)
Hypercoagulable states
Giant cell arteritis in elderly patients

Evaluation involves:
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Immediate ophthalmology consultation
Fundoscopy and possibly fluorescein angiography
Carotid Doppler ultrasound to evaluate for embolic source
Echocardiography (often with bubble study) to assess cardiac causes
ESR, CRP, and temporal artery biopsy if giant cell arteritis is suspected

Management is largely supportive, as no treatment reliably restores vision once ischemia is established. Ocular massage, lowering intraocular pressure, and breathing into a paper bag to increase CO₂ and dilate vessels are sometimes attempted if the patient presents very early.

The focus is on preventing further embolic events through:

Antiplatelet therapy (aspirin)
Statins
Cardiovascular risk factor management
Anticoagulation if a cardiac source is found

On USMLE Step 2 CK, expect a question involving a patient with sudden partial vision loss in one eye, painless onset, and segmental pallor of the retina. The test may ask for next steps in evaluation (e.g., carotid Doppler) or management of underlying embolic risk.


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