Simultaneous Branch Retinal Artery and Central Retinal Vein Occlusion Improved with No Ocular Therapy: A Case Report

Round 1

Reviewer 1 Report

The case is of interest and it is nicely documented.

Are OCT angiography images available? If not I would at least discuss possible role of OCTA findings for visual prognosis (ie  doi: 10.1038/eye.2016.57

Minor comments:

Introduction : lines 51- 55 : the sentence is too long; please make it more readable.

Case description (I would delete 'detailed'): line 63: I would change discovered to found

DIscussion: line 113: no need to write 'the topic of the present case report' ; line 148: findings detectable on color fundus photography ; line 160- 161 identification of the involved regions and in the the identification of the underlying condition (or similar)

Conclusions line 233-252 : conclusions are too long and most of the text can be moved to the discussion

Minor editing of English language is required

The case report is of interest and it may be considered for publication after a revision.

Author Response

The case is of interest and it is nicely documented.

Are OCT angiography images available? If not I would at least discuss possible role of OCTA findings for visual prognosis (ie doi: 10.1038/eye.2016.57)

RE: Thank you for your precious comment. Unfortunately, we did not perform OCT angiography to our patient for unavailability of the angiographic software. However, we modified the text to add the importance of this diagnostic device (page 7, lines 326-332).

 

Minor comments:

Introduction: lines 51- 55: the sentence is too long; please make it more readable.

RE: Thank you very much for your suggestion. We modified the sentence (page 2, lines 52-57).

 

Case description (I would delete 'detailed'): line 63: I would change discovered to found

RE: Thank you for your suggestion. We made the changes.

Discussion: line 113: no need to write 'the topic of the present case report'; line 148: findings detectable on color fundus photography; line 160-161 identification of the involved regions and in the identification of the underlying condition (or similar)

RE: Thank you for your comments. We made all the suggested changes.

 

Conclusions line 233-252: conclusions are too long and most of the text can be moved to the discussion.

RE: Thank you for your comments: we moved part of the Conclusions to the Discussion section.

 

Minor editing of English language is required

RE: Thank you for your suggestion. We revised English throughout the manuscript.

Reviewer 2 Report

please enclosed

Comments for author File: Comments.pdf

Author Response

The manuscript entitled Simultaneous Branch Retinal Artery and Central Retinal Vein Occlusion Improved with no Ocular Therapy: a Case Report by Vitiello et al (No 2581369) evaluate a case report about a rare condition. This mixed type retinal circulatory problem belongs to sudden visual loss category and it can indeed lead to blindness. The references are appropriate. The documentations are correct, nice. The topic is not new; a review has recently been published. In this case report, the manuscript focuses on therapeutic options. The title is catchy, it suggests that in such cases ophthalmological treatment is not necessary, only systemic treatment is effective. The usage of systemic anticoagulant therapy in cases of retinal vein occlusion alone or together with retinal artery occlusion is controversial. The management of retinal artery occlusion is also controversial.

I consider this case a lucky story. As to the conclusion, more cautious are required. Treatment

options are controversial and spontaneous recovery can also occur.

RE: Thank you very much for your comments.

Suggested improvements to Case report:

How long has it been since the patient noticed the loss of vision and was referred to

an ophthalmologist? What was the systemic condition acutely, namely what was the patient's blood pressure, what did the ECG show? I am missing a description of the systemic condition of the case, the investigation, the therapy.

RE: Thank you for your precious comment. We added all this information in the beginning of the Case Description (page 2, lines 59-65). Furthermore, we have corrected some information regarding the thrombophilic screening performed on the patient, since our analysis laboratory notified us of some variations due to a sample processing error (page 2, lines 83-85).

 

The ophthalmological documentation is nice.

Some suggestion to the figures:

Fig 1. Delayed filling in the capillary network connecting to the inferior temporal BRA suggests its occlusion. I can not see any delayed filling in the aforementioned BRAO.

RE: Thank you very much for your suggestion. We modified the Figure 1 and its description (page 3)

 

Fig 2. Indicate the pale area, arteries, veins, hemorrhages; Fig2c the follow up time is missing.

RE: Thank you very much for your suggestion. We modified the Figure 2 and its description (page 4)

 

Fig 3. Indicate PAMM, intraretinal and subfoveal fluid, posterior hyaloid.

RE: Thank you very much for your suggestion. We modified the Figure 3 and its description (page 5)

 

Was the visual field investigated? If possible, a visual field test, or even microperimetry, should be added.

RE: Thank you very much for your precious comment. Unfortunately, we were not able to perform a visual field test because the device is out of order, while a microperimetry is not available in our Eye Unit.

 

to Discussion

Please add to discussion: When should we consider a mixed type CRVO, especially if the patient presents with complaints 2-4 weeks old?

RE: Thank you for your comment. We should consider all the detectable signs of a BRAO + CRVO, especially with the use of multimodal imaging, as explained in different parts of the manuscript.

However, as shown in page 6, “Concurrent BRAO + CRVO is a clinical condition different from CRVO linked with CLRAO [2,3]. Unless extremely high-quality fluorescein angiography with early frame is performed in eyes with a cilioretinal artery, it can be difficult to separate the two retinal vascular diseases. In fact, fluorescein angiograms show a characteristic oscillating blood column in the cilioretinal artery in individuals with combined CLRAO + CRVO assessed early after the onset” and “Concerning the diagnosis, color fundus photography, OCT and fluorescein angiography were all demonstrated to be crucial for the identification and the monitoring of this rare ocular vascular syndrome [1]. In particular, in addition to the typical findings detectable on color fundus photography and fluorescein angiography (CRVO features, such as diffuse retinal hemorrhages, tortuous and dilated retinal veins, disc and macular edema, cotton wool spots and generalized delay in arteriovenous transit on fluorescein angiography, and retinal whitening in the territory of the affected retinal arterial branch) [2-4], PAMM is an early OCT characteristic in eyes with concurrent BRAO + CRVO [16-20].”

So, early diagnosis is crucial to identify this mixed CRVO, that could be not recognized after 2-4 weeks.

 

Can we skip FLAG if we find PAMM on OCT?

RE: Thank you for your comment. Nowadays, it is not possible to skip FLAG to diagnose this condition, as explained in pages 6-7: “PAMM is an OCT finding that appears as a placoid, hyperreflective band at the level of the inner nuclear layer, with or without extension into the adjacent inner and outer plexiform layers, in individuals with retinal capillary ischemia and unspecific persistent scotomas [23,24]. This OCT feature indicates retinal infarction caused by hypoperfusion within the deep vascular complex and more specifically the deep retinal capillary plexus. As this condition resolves, a legacy of inner nuclear layer thinning can develop [23]. It can occur as a standalone event or as a result of an underlying retinal vasculopathy, such as central artery or vein occlusions [21,25]. As a result, OCT can aid in the identification of the involved regions and in the identification of the underlying condition. However, regardless of the usefulness of color fundus photography and OCT, fluorescein angiography remains a fundamental diagnostic exam for the diagnosis of retinal vascular and ischemic disease, and for this reason it should always be performed in case of BRAO + CRVO suspicion to confirm the diagnosis [1].”

 

What are the side effect of systemic anticoagulant therapy in cases of CRVO?

RE: Thank you for your precious comment. We added this aspect in the Discussion section (page 8, lines 405-412).

 

To Conclusion: The conclusion based on a few cases is hard. More cautious is required since CRVO component could also improve spontaneously or after prompt treatment of extreme hypertension; please take it into account.

RE: Thank you very much for your suggestion. We modified the Conclusions (page 8, lines 429-431).

Reviewer 3 Report

Well-documented case report. You could include the results of pupillary examination in the case.

Author Response

Well-documented case report. You could include the results of pupillary examination in the case.

RE: Thank you very much for your comments. We added the results of pupillary examination in the Case Description (page 2 lines 69-70).

Round 2

Reviewer 2 Report

The manuscript improved significantly.

Only one suggestion; please add to the Abstract: increased risk for thrombotic event was revealed in this case.

Thank you!

Author Response

The manuscript improved significantly.

Only one suggestion; please add to the Abstract: increased risk for thrombotic event was revealed in this case.

Thank you!

RE: Thank you for all your precious comments. We included the suggested addition in the Abstract.