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RETINAL VEIN OCCLUSION
Dr KN POORNESH
WGH
03.11.2004
CLASSIFICATION
BRVO CRVO Major BRVO Non-ischemic
Minor Macular BRVO Ischemic
Peripheral BRVO Papillophlebitis
Hemiretinal Vein occlusion
PATHOGENESIS
Arteriosclerosis
Compression of the vein
Venous endothelial cell loss
Thrombus formation
Venous Occlusion
PATHOGENESIS
Venous occlusion elevation of venous
& capillary pressure
Stagnation of blood flow
Increased tissue pressure Hypoxia of the retina
Damage to capillary endothelial cells &
extravasation of blood constituents
RISK FACTORS(in order of importance)
1. Advancing age: 50% cases over 65 yrs.2. Systemic: HT, Hyperlipidemia, Diabetes,
Smoking, Obesity.3. Raised IOP: risk of CRVO4. Inflammatory: Behcet’s, Sarcoid,AIDS,
SLE, Toxoplasma.5. Hyperviscosity: Polycythemia, MM,
Waldenstrom macroglobulinemia.
RISK FACTORS6. Acquired thrombophilic: Hyperhomocystinemia,
Antiphospholipid antibody syndrome.7. Inherited thrombophilic: increased levels of
clotting factors 7 & 11, deficiency of antithrombin 3, protein C &S, resistance to activated protein C.
Other Risk factors: • Hypermetropia (BRVO), Congenital anomaly of
Central retinal vein (CRVO), Optic disc drusen, • Drugs (OC, Diuretics), Migraine (rare). • Retrobulbar external compression: Dysthyroid eye
disease, Orbital tumor
Major BRVO
COURSE of BRVO
6 to 12 months to resolve • Venous sheathing • Collateral venous channels • Microaneurysms, Hard exudates,
Cholesterol crystal deposition. • Macula: RPE changes or ER gliosis, chronic CME.
Prognosis and Complications of BRVO
Depends on • Site & Size of occluded vein • Integrity of perifoveal capillary network
50% : Recover VA of 6/12 or better.
Complications: 1. Chronic macular edema 2. Macular ischemia 3. Neovascularisation, NV (within 3 yrs) 10%- NVD, 20-30%- NVE 4. Recurrent VH, TRD.
Management of BRVO(BVOS)
Wait for haemorrhage to clear (3 months).FFA : Macular edema and VA 6/12 or worse after 3
months –grid laser & follow-up after 2-3 months.
Macular ischemia—no treatment. 5 DD or > area of CNP– 4 monthly follow- up
for 12-24 months. Neovascularisation– scatter laser
CRVO Ischemic Non-ischemic
Frequency 25% 75%VA 20/400 or < (90%) > than 20/400 (90%)
Site at lamina cribrosa Far behind lam crib
RAPD marked slight
VF defect common rare
Fundus Ext hgs & cotton wool spots, severe disc edema, marked tortuosity of vessels
Less exten hgs, few cotton wool spots, mild disc edema, variable tortuosity of vessels
CRVO Ischemic Non-ischemic
FFA Wide spread capillary non- perfusion
Delayed venous return, late leakage, good perfusion.
ERG Reduced “b” wave amplitude, reduced “b/a” ratio
normal
Prognosis 50% develop rubeosis & NVG in 2-4 months
3% develop rubeosis and NVG.
50% return to VA 6/12 or better.
Non-ischemic CRVO(Course and Follow-up)
Residual signs: Disc collaterals, epiretinal gliosis, pigmentary changes at macula.
Conversion to ischemic CRVO occurs in 15% of cases within 4 months and 34% within 3 years.
Follow-up: should be for 3 years.Prognosis: depends on initial VA, near normal
VA in 50%, Chronic CMO- unresponsive to laser (CVOS).
8-10% risk of BRVO or CRVO in the fellow eye.
Ischemic CRVO:Management (CVOS)
Follow-up: monthly for 6 months IOP, undilated gonioscopy & SLEAngle NV is the best clinical predictor
of NVG.Treatment: PRP in eyes with angle
or iris NV. Monthly follow-up until stabilisation or regression.
Hemiretinal vein occlusion
Less common than BRVO and CRVO
Occlusion of superior or inferior branch of the CRV.
Features of BRVO, involving the superior or inferior hemisphere
Prognosis depends on severity of macular edema and ischemia.
PAPILLOPHLEBITIS(Optic disc vasculitis)
Healthy individuals, < 50 years Optic disc swelling with secondary
venous congestion rather than venous thrombosis.
APD absent, retinal haemorrhages confined to posterior fundus.
Prognosis: 80% -- 6/12 or better 20% visual loss -- macular edema
Management:Recent advances Recent onset of non-ischemic CRVO–
high intensity laser to create chorioretinal shunt.
AV sheathotomy for treatment of CME due to BRVO.
Ischemic CRVO:- PP Vitrectomy + Intraocular gas + Radial neurotomy
Management: Recent advances
Intravitreal tPA Transvitreal vein cannulation Section of posterior scleral ring Drug therapy -- Troxerutin
-- Petroxyfylline
-- Hemodilution Intravitreal Triamcinolone