Retinal vein occlusion

Intro

Retinal vein occlusion refers to an interruption of normal venous circulation. It can occur either in the central retinal vein, termed central retinal vein occlusion (CRVO) or in one of its branches, termed branched retinal vein occlusion (BRVO). BRVO is more common than CRVO.

Presentation

  • Sudden, painless loss of vision
  • Can very rarely be painful

History

  • Loss of vision occurs more slowly than in Retinal artery occlusion; may develop overnight
  • Risk Factors
    • Age>65 (almost ¾ over 65)
    • Cardiovascular risk factors
    • Short axial length
    • Glaucoma
    • Clotting disorders
    • Vasculitis

Examination

  • Nil significant

Special investigations

Slit-lamp examination: Fundoscopy

  • Intra-retinal haemorrhage
    • CRVO: haemorrhages in all 4 quadrants
    • BRVO: haemorrhages in respective segment
  • Tortuous retinal veins
  • Optic nerve oedema
  • Macular oedema
  • Vitreous haemorrhage
  • Neovascularisation and associated vitreous haemorrhage

Fluorescein angiography

  • Areas of blocked fluorescence with delayed venous filling
  • Areas of non-perfusion with petalloid leakage, susceptible to ischaemic damage

Optical coherence tomography

  • Consider IF suspected macular oedema

Management

Immediate management

  • Observation and management of risk factors
  • Treat complications

Complications

  • Macular oedema
    • For CRVO: Intra-vitreal injections of anti-VEGF/ steroids (e.g. ranibizumab 0.5 mg, every 4 weeks/ triamcinolone 4 mg, every 3 months)
    • For BRVO:
      • IF < 3 months, intravitreal therapy as above
      • IF > 3 months, grid-pattern laser photocoagulation (application of laser energy in a grid-configuration around in areas of leakage)
  • Neovascularisation
    • For CRVO: pan-retinal photocoagulation (360o application of laser in peripheral retina
    • For BRVO: scatter laser photocoagulation (application of laser energy directly to areas of non-perfusion)
  • Vitreous haemorrhage: pars plana vitrectomy
  • Loss of vision (from macular oedema, macular ischaemia or subsequent to neovascularisation)
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