Retinal vein occlusion


BRANCH RETINAL VEIN OCCLUSION

Main risk factors:

  1. HTN
  2. Hyperlipidaemia
  3. DM
  4. OCP
  5. Raised IOP
  6. Smoking

What to consider in under 50?

  1. Myeloproliferative disease – polycythaemia, abnromal plasma protein (myeloma)
  2. Acquired hypercoagulable states – raised homocysteine levels, lupus anticoagulant, antiphospholipid antibodies
  3. Inhired hypercoagulable states – Factor V Leiden mutation, protein C or S deficiency, antithrombin deficiency, Factor VII deficiency
  4. Inflammation – Behcet syndrome, sarcoidosis, Wegener’s granulomatosis, Goodpasture syndrome
  5. Others – CRF, secondary HTN (Cushing syndrome), secondary hyperlipidaemia (hypothyroidism), orbital disease, dehydration.

Main investigations:

  1. BP
  2. FBC / U+E / ESR / PV / TFT / glucose / cholesterol
  3. Plasma protein electrophoresis
  4. ECG

Other test to consider:

  1. CXR
  2. CRP
  3. Thrombophilia screen – thrombin time, prothrombin time, activated partial thromboplastin time, protein C & S, factor V Leiden mutation, prothrombin mutation, anticardiolipin antibody (IgG and IgM), lupus anticoagulant
  4. Autoantibodies – rheumatoid factor, ANA, anti-DNA antibody
  5. ACE
  6. Syphilis serology
  7. Carotid dopplers

Clinical presentation:

  1. Variable VA presentation.
  2. Flame-shaped +/- dot blot haemorrhages with retinal oedema and cotton wool spots

Investigations: OCT, FFA, OCTA

Long-term prognosis:

  • 6 months – 50% VA 6/12 or better.
  • 25% less than 6/60 vision.

Complications of RVO:

  1. Chronic macular oedema
  2. Macular ischaemia
  3. Neovascularisation – 40% of eyes > 5 disc diameter of non-perfusion.

Treatment:

  1. Medical treatment – treat systemic risk factor or hypercoagulable state (anticoagulant)
  2. Laser treatment – BVOS: macular laser after 3-6 months observation, good macular perfusion and vision 6/12 or worse. PRP if signs of neovascularisation.
  3. Steroid treatment – SCORE: only use IVTA in refractory and pseudophakic cases; GENEVA: Ozurdex for macular oedema (last 3 months)
  4. Anti-VEGF treatment – BRVO (ranibizumab) study – ranibizumab is superior to laser for macular oedema ; BRIGHTER study – ranibizumab + laser made no difference to macular oedema ; BERVOLT study – bevacizumab is safe for macular oedema associated BRVO ; VIBRANT study – aflibercept is superior to laser for macular oedema
  5. Surgical treatment – PPV for BRVO related vitreous haemorrhage or tractional retinal detachment.

Pathway for treatment:

  1. Observe for 2-3 months for VA progression and neovascularisation
  2. Macular oedema present – anti VEGF for first 3 months then see response.
  3. If not improving macular oedema – consider steroid treatment
  4. If still not response – consider grid macular laser.
  5. If signs of neovascularisation – PRP

CENTRAL RETINAL VEIN OCCLUSION

Demographics: Usually unilateral; M=F; >65 years old; Annual risk of 1% in fellow eye.

Clinical features:

  1. Sudden painless loss of vision
  2. Check for NVI and NVA (NVA appears in 12% on first presentation)
  3. Raised IOP – risk NVG – ‘100 day glaucoma – neovascularisation within 3 months of CRVO
  4. RAPD
  5. Flame shaped & Dot/blot haemorrhages in all 4 quadrants of retina
  6. Other changes in retina – macular oedema, cotton wool spots, optic disc oedema, vitreous haemorrhage or NVD/NVE.
  7. Chronic changes (6-12 months) – collaterals, venous sheathing & sclerosis at site of obstruction, RPE changes or ERM.

Investigations: FFA; OCT

Central retinal vein occlusion study (CVOS):

  • Visual acuity 6/12 or better – maintained their vision.
  • Poor visual acuity presentation (6/60 or worse) – 20% improvement chance.
  • NVA without NVI in 12% of cases.
  • Perfused (non-ischaemic) 80% cases vs. Non-perfused (ischaemic) 20% cases.

Treatment:

  1. Primary treatment – Systemic treatment (BP, DM); hypercoagulable states.
  2. Macular oedema treatment – observation (first few weeks); SCORE study (IVTA useful – this study led to to the use of Ozurdex); CRUISE study (ranibizumab use – RETAIN study shows ranibizumab use maintain condition in < 1/2 patients at 4 years); COPERNICUS & GALILEO study (aflibercept use maintain vision long-term when used early); Bevacizumab (off license use)
  3. Neovascularisation treatment: PRP for signs of NVI/NVA/NVD/NVE; topical/systemic anti-glaucoma agents; cycloplegic agents; surgery if IOP uncontrolled; anti-VEGF prior to PRP as adjunct (note: PRP best perform within a week after anti-VEGF).
  4. Non-clearing vitreous haemorrhage: PPV + endolaser PRP.

Reference: Retinal Vein Occlusion Guidelines 2015 (RCOphth)


ACE: angiotensin converting enzyme; ANA: Antinuclear antibody; BP: Blood pressure; BRVO: Branch retinal vein occlusion; BVOS: Branch Vein Occlusion Study; CRF: Chronic Renal Failure; CRP: C-reactive protein; CXR: chest X-ray; DM: Diabetes Mellitus; ECG: electrocardiogram; ESR: erythrocyte sedimentation rate; ERM: epiretinal membrane; FBC: Full blood count; FFA: fundus fluorescein angiogram; GENEVA: Global Evaluation of Implantable Dexamethasone in Retinal Vein Occlusion with Macular Edema; HTN: hypertension; IOP: Intraocular pressure; IVTA: intravitreal triamcinolone; NVA: neovascularisation of angles; NVD: neovacularisation at disc; NVE: neovascularsiation elsewhere; NVG: neovascular glaucoma; NVI: neovascularisation of iris; OCP: oral contraceptive pills; OCT: optical coherence tomography; OCTA: optical cohorence tomography angiography; PPV: pars plana vitrectomy; PRP:panretinal photocoagulation; PV: plasma viscosity; RAPD: relative afferent pupillary defect;RPE: retinal pigment epithelium; RVO: retinal vein occlusion; SCORE: standard care versus corticosteroids for retinal vein occlusion; TFT: thyroid function test; U+E: urea and electrolytes; VA: visual acuity


Location Birmingham Midlands Eye Centre 76 Dudley Road Birmingham B18 7QH UK Phone 0121 554 3801 Hours Mr Ch'ng | Vitreoretinal Clinic Sessions: Monday: 8.30am - 12.30pm Wednesday (alternate): 8.30am - 5.00pm Thursday: 8.30am - 12.30pm Friday: 8.30am - 12.30pm | Vitreoretinal Theatre Sessions: Wednesday (alternate): 8.30am - 5.00pm & Friday (emergency cases): 1.30pm - 5.00pm | Eye Casualty Session: Monday 1.00pm - 4.30pm |
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