Central / Branch Retinal Vein Occlusion

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Types

  • Branch Retinal Vein Occlusion (BRVO) vs. Central Retinal Vein Occlusion (CRVO)
    • Non-ischemic: lacking capillary perfusion/ischemic area < 5 disc diameters in BRVO or < 10 disc diameters in CRVO
    • Ischemic: lacking capillary perfusion/ischemic area > 5 disc diameters in BRVO or > 10 disc diameters in CRVO

Risk Factors

  • Cardiovascular risk factors: Age > 60 years, cardiovascular disease, hypertension, obesity, nicotine abuse, diabetes mellitus (not a risk factor in BRVO)
  • Ocular: Glaucoma, optic disc drusen, increased intraorbital and/or intraocular pressure
  • Others: Syphilis, sarcoidosis, vasculitis, hyperviscosity syndromes (multiple myeloma, leukemia, Waldenström’s macroglobulinemia), sickle cell disease, HIV, hyperhomocysteinemia, elevated ESR, oral contraception

Findings

  • Dot/blot and flame-shaped hemorrhages in all quadrants (CRVO) or along the branch vein
  • (BRVO; mostly superotemporal)
  • Dilated, tortuous vessels , optic disc swelling (in CRVO) , macular edema
  • Possible cotton-wool spots, hard exudates, retinal edema
  • Neovascularisations if ischemic (iris , chamber angle , optic disc, retina ), neovascular glaucoma (“90-day glaucoma”)
  • Visual field defects, central scotoma in macular BRVO
  • Over time: shunt vessels, microaneurysms, sclerosed vessels, telangiectasia

Work-up

  • Clinical examination
  • Evaluation of cardiovascular / haematological risk factors:
    • Blood pressure
    • Laboratory: complete blood count, CRP, ESR, glucose, HbA1c, lipid profile, Quick/INR
    • In patients < 50 years, consider haemotological assessment
  • Further evaluations by primary care physician: e.g., ECG, 24h blood pressure monitoring, carotid duplex sonography (rule out ocular ischemic syndrome)
  • OCT: Macular edema?
  • Rule out glaucoma: IOP measurement
  • Fluorescein angiography after resorption of hemorrhages (after approx. 4 – 6 weeks, at the latest after 3 months): extent of ischemic areas? ischemic vs. non-ischemic

Treatment

  • Macular edema: anti-VEGF therapy; alternatively intravitreal steroids
  • IOP reduction (even with only slightly elevated pressure)
  • Retinal photocoagulation:
    • For neovascularisations of the iris, angle, optic disc, or retina (according to Central Vein Occlusion Study CVOS), possibly additional temporary anti-VEGF therapy
    • Depending on clinical findings: consider initial prophylactic treatment for ischemic CRVO/BRVO
    • Consider cyclophotocoagulation for secondary glaucoma
  • Hemodilution controversial!

Follow-up

  • In the first 6 months: monthly follow-up controls, including gonioscopy (if clearly non-ischemic, follow-up control also possible after 3 months)
    • Neovascularisations in about 60% of ischemic CRVO, mostly within 2-4 months -> “100-day glaucoma”
    • Conversion from non-ischemic to ischemic CRVO: about 16%
  • In the first two years: follow-up controls at 3-6 month intervals due to the risk of neovascularisation

Sources

  • EyeWiki Central Retinal Vein Occlusion
  • EyeWiki Branch Retinal Vein Occlusion
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)
  • Review of Ophthalmology; Autoren/Verlag: Neil J. Friedman MD, Peter K. Kaiser MD, William B. Trattler MD; Elsevier; 3rd Edition (2017)