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Review Article
*Corresponding Author: Lascu Rodica, Misan Med” Clinic – Sibiu – Romania.
Citation: Dumitrache Marieta, Lascu Rodica (2023), Clinical-Therapeutic Orientation in Retinal Venous Obstruction. Archives of Medical Case Reports and Case Study, 7(1); DOI:10.31579/2692-9392/157
Copyright: © 2023 Lascu Rodica, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 18 November 2022 | Accepted: 20 December 2022 | Published: 10 January 2023
Keywords: branch retinal vein occlusion; cystoid macular edema; bevacizumab; retinal vein occlusion; vascular endothelial growth factor; neovascular glaucoma NVG
Retinal vein occlusion (RVO) is a retinal vascular disease that can affect the central retinal vein in central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO), which causes decreased vision (the second leading cause of blindness after diabetic retinopathy).
CRVO is accompanied by retinomacular edema and retinal / peripapillary / iris neovascularization that cause serious complications: absolute neovascular secondary glaucoma, vitreous hemorrhage, retinal traction detachment, possibly present in both forms of CRVO.
Branch retinal vein occlusion (BRVO) is often asymptomatic and can be diagnosed accidentally or by retinal control, and is 5 times more common than CRVO.
CRVO prophylaxis is done by identifying and appropriate treatment of risk factors (multiple): hypertension, diabetes, smoking, obesity, Primary Open Angle Glaucoma (POAG), hypercoagulability.
RVO treatment, the non-ischemic form, requires the treatment of macular edema with: intravitreal AntiVEGF - Ranibizumab, Aflibercept, Bevacizumab, repeatedly, cortisone therapy with intravitreal Triamcinolone or Dexamethasone implant, focal / grid laser photocoagulation and / or panretinal photocoagulation.
In all cases of RVO, the non-ischemic form, the following are required: clinical surveillance, fluorescein angiography (FA), OCT for immediate detection of progression to the ischemic form.
The treatment of RVO, ischemic form, is the treatment of macular edema with repeated intravitreal antiVEGF treatment, corticosteroids, focal laser photocoagulation, grid, pan-photocoagulation indicated in the treatment of exudative ischemic areas with neovessels proliferation. Panretinal photocoagulation (PRP) is an effective treatment for iris peripapillary retinal neovascularization and secondary complications.
The current prognosis of RVO is improved by regular examination of OCT-SD, antiVEGF medication, intravitreal cortisone and laser photocoagulation that provide prophylactic and curative treatment of RVO and complications: vitreous hemorrhage, neovascular glaucoma, retinal traction detachment.
The risk factors should be identified and their treatment can ensure RVO prevention:
RVO physiopathology
Retinal venous occlusion causes venous blood to stagnate above obstructive blockage (venous stasis) with increased pressure at this level and altered endovascular structure, endothelial proliferation and capillary occlusion in the secondary ischemic area after obstruction and blood hypercoagulability.
RVO clinical overview
According to localization, the retinal venous obstruction may be:
- Central retinal vein occlusion - CRVO
- Branch retinal vein occlusion – BRVO, which is often asymptomatic and its diagnosis can be accidental or by routine check-up / both sometimes late.
In BRVO, the vision loss is NOT high, so the ocular disease can be diagnosed late by complications.
Decreased vision in BRVO is present in both forms of the disease – CRVO and RVO - but to varying degrees
- vision loss is progressive for days, weeks, small, medium, sometimes severe
RVO has two clinical forms:
- NON-ISCHEMIC–EDEMATOUS – perfused – 75-80% - Retinopathy of venous stasis, very rarely with neovessels, but it is possible to convert the non-ischemic form to the ischemic form - 16%
- ISCHEMIC – non-perfused hemorrhagic with retinal edema and peripapillary retinal iris neovascularisation. (1,3,4)
Clinical forms in RVO
RVO presents 2 clinical forms: non-ischemic CRVO and ischemică CRVO and BRVO
NON-ISCHEMIC CENTRAL RETINAL VEIN OCCLUSION
NON-ISCHEMC CRVO
- slight visual impairment, sometimes not perceived by the patient (or neglected)
-minimal deficiencies of the visual field with blind spot enlargement, central scotoma
- relative afferent pupillary defect (RAPD) - absent
-Early Eye Fundus
-Late Eye Fundus
- favourable evolution, rarely complications
-functional and organic recovery in 50% of cases; complete in 6-12 months
- interdisciplinary monitoring of the patient because conversion to ischemic form is possible
- preserved VA
Ischemic Crvo
- severely decreased VA in 60% of the cases
-Visual field – central deficits, absolute scotoma
-RAPD – present
- Iris neovessels - 33% complicated by secondary neovascular glaucoma
-Eye Fundus – the same signs as in non-ischemic RVO but more pronounced
-Early Eye Fundus
-Late Eye Fundus
• Signs of gravity in CRVO [5]
- VA – n.d.
- Eye Fundus – interpapilllary-macular numerous, confluent cotton nodules
- deep bleeding (sign of major ischemia)
- macular edema, cystoid macular edema (CME)
- extended retinal neovascularization
- rubeosis iridis at the edge of the pupil and the iridocorneal angle with absolute neovascular secondary glaucoma
Branch Retinal Vein Occlusion Brvo
It affects one of the 4 retinal vein branches at the level of the arteriovenous junctions by compressing the venous branch by the thickened and rigid artery inside the common sheath.4
Hemiretinal Vein Occlusion (Hrvo)
Venous Stasis Retinopathy
…-young people - 30-40 years old
Papillophlebitis
Complementary examinations in RVO
- Laboratory tests: glycemia, glycosylated Hb, CRP, urea, electrophoresis, lipid profile, coagulability check, blood count, Leiden factor, clinical tests according to associated pathology (1)
- FA identifies areas of unperfused capillaries, extent and presence of macular ischemia
- ERG - reduced b-wave amplitude is associated with increased risk of ischemia
- OCT (optical coherence tomography) - monitor of macular and intraretinal edema (determining the thickness of the retina) and by regular examination, it highlights the evolution of edema under treatment
- complete clinical evaluation of cardiovascular disease, diabetes
Treatment objectives in RVO
Reduction of retinal edema and macular edema
- the incidence of macular edema is more frequent after venous branch obstruction
- macular edema is individualized in OCT-SD, an extremely important investigation in the management of RVO for its identification and quantification, but also for the detection of the conversion of venous obstruction from non-ischemic to ischemic form [5,6].
The treatment used for this purpose is:
- antiangiogenic agents - antivascular endothelial growth factor - antiVEGF: ranibizumab, bevacizumab, aflibercept injected intravitreally
- corticosteroids - intravitreal Triamcinolone and Dexamethasone biodegradable implant with slow diffusion of corticosteroid 3-4 months
- treatment of risk factors: antihypertensive treatment, control of diabetes, treatment of blood dyscrasia, diagnosis and treatment of glaucoma
- correct and timely treatment of macular edema (major cause of vision loss) and treatment of neovascularization
Medical treatment in RVO
Intravitreal anti-VEGF agents
Laser photocoagulation
Laser photocoagulation effects are produced by:
- selective destruction of the external retina and partially of the photoreceptors with increasing oxygen diffusion in the choroidal vessels in the internal retina
- reduction of the production of neovascular factors - VEGF that improves hypoxia
- reduction of neovascularization and amelioration of retinal ischemia with decrease in cytokines that favour the regression of neovessels [9,2]
Laser photocoagulation is used to treat retinal macular edema and retinal neovascularization.
Laser photocoagulation is guided by FA exploration.
Laser photocoagulation treatment can limit retinal edema, can promote its extension and by scars between EP and neuroepithelium it limits serous detachment of the neuroepithelium [11].
Laser photocoagulation in CRVO is focal, grid, panretinal.
- Focal laser photocoagulation is applied in the area of edema and promotes its resorption
- Laser grid photocoagulation
- Panretinal photocoagulation (scatter PRP) destroys ischemic territories and prevents preretinal, prepapillary and iris neovascularization in ischemic CRVO.
Treatment recommendations in CRVO / RVO:
- indicated in macular ischemia
Surgical treatment in RVO aims at the treatment of venous occlusion and secondary macular edema [3].
• Endovascular retinal surgery with injection of tissue plasminogen activator.
• Radial optic neurotomy by incision in the nasal part of the optical disc radially and parallelly to the nerve fibers - partially controversial, can be performed in selected cases [12].
• Chorioretinal venous anastomoses - by creating a shunt between a retinal and choroidal vein (bypassing the occluded vein), (with the improvement of retinal venous drainage), with the help of laser or by vitreoretinal surgery [13,14]
• Yag laser transluminal embolization [14]
• Adventiceal dissection at the arteriovenous junction - Arteriovenous sheatotomy with posterior vitrectomy.
• Posterior vitrectomy with or without peeling of the inner limiting membrane would rapidly resolve macular edema; could be beneficial by improving retinal oxygenation and removing vitreous retinal traction
Therapeutic efficacy in various clinical forms of RVO
CRVO treatment, non-ischemic form1.9
• Anticoagulants - are not effective
• Fibrinolytics in the ophthalmic artery difficult to apply with risks and complications (Not used)
• Isovolemic hemodilution in the first months after the onset of the disease with decreased blood viscosity and improved retinal circulation (controversial)
• Macular edema treatment in CRVO
CRVO treatment, ischemic form1,9
- intravitreal antiVEGF: Ranibizumab (Lucentis) – 0,5 mg, Aflibercept (Eylea) – 2 mg, Bevacizumab (Avastin) – 1,25 mg monthly for 6 months. Intravitreal injection with repeated antiVEGF agents, is the basic treatment of macular edema in CRVO with VA <6>
- corticosteroids: intravitreal triamcinolone acetonide - 4 mg, Biodegradable dexamethasone implant - Ozurdex
- Laser photocoagulation
- Laser photocoagulation is indicated in the treatment of exudative ischemic areas with proliferation of neovessels [10].
• Pascal laser photocoagulation through numerous impacts, in fractions of a second, with short duration of pulses with high power through cumulative energy induces harmless thermal effect, decreases treatment time, improves patient comfort.
• The prognosis of CRVO is clearly improved by laser photocoagulation indicated according to FA, as an effective treatment of complications of ischemic capillary disease.
• Laser photocoagulation in the treatment of CRVO provides prophylactic and curative therapy for eye complications.
• Laser photocoagulation is effective in the treatment of CRVO, but should be indicated and applied with discernment.
Visual prognosis in ischemic CRVO is more reserved
- Initial low VA value and extension of retinal ischemia are correlated with reduced final VA.
Treatment of branch retinal vein obstruction
- treatment of risk factors
- sectoral photocoagulation for the treatment of ischemia in the obstructed territory to prevent the development of vitreous hemorrhage by preretinal neovascularization
- macular photocoagulation is indicated in branch obstruction complicated with persistent macular edema with VA less than 5/10 for VA stabilization and amelioration
- RVO prognosis is generally good, 50-60% have final VA 20/40 or better even without treatment
Ophthalmic antiglaucomatous treatment for decreasing high intraocular pressure
- Prevention of secondary neovascular glaucoma by systematic ophthalmologic examination by slit lamp and gonioscopy
- Emergency retinal panophotocoagulation if rubeosis iridis and angular neovascularization are present.
Other drugs with questionable effects: urokinase (through microcatheter, it would improve VA), oral or infused pentoxifylline (seems to improve VA in some RVO patients) ticlopidine.
Conflict of interest: The authors report no potential conflicts of interest in research, authorship, and / or publication of this article.
Financing: The authors have not received any financial support for the research, authorship and / or publication of this article
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