Arterial and Venous Occlusive Disease

of the Retina

Dr.M NAQEEB

Assistant professor Um Al-Qura university

Objective

1. Central retinal artery occlusion

2. Branch retinal artery occlusion

3. Branch retinal vein occlusion

4. Central retinal vein occlusion

retinal artery obstructions

57% of obstructions involved the central retinal artery

38% involved one of the branch retinal arteries

5% involved the cilioretinal artery

Central Artery Obstruction

Characteristics Sudden severe visual loss Painless Retinal appearance

» Opaque and edematous Most prominent in posterior pole

– Thickest ganglion cell layer

» Cherry-red spot Visible intact choroidal

vasculature beneath the foveola

Central Artery Obstruction

Characteristics With time

» Artery re-canalizes» Edema clears» Visual loss is devastating and

permanent Irreversible damage to neural

tissue after 90 minutes

Intravenous fluorescein angiography

Central Artery Obstruction

Prognosis 20/400 or worse: 2/3 of eyes 20/40 or better: 1/6 eyes

» Intact cilioretinal artery

Vision of NLP» Implies ophthalmic artery

occlusion Choroidal ischemia as well

Central Artery Obstruction

Pathogenesis Majority

» atherosclerosis-related thrombosis

At the level of the lamina cribrosa

Other causes» Arterial spasm» Dissecting aneurysm» GIANT CELL ARTERITIS

1% of cases– Check ESR in elderly

patients!– Start high does steroids if

suspicious

Central Artery Obstruction

Management No good therapy exists, all

treatments questionable» Ocular message» Anterior chamber paracentesis

Attempt to acutely reduce IOP Dislodge thrombosis

» Inhalation therapy 95%O2, 5%CO2

– Stimulate vasodilatation

Iris neovascularization» Occurs in 18% of eyes

1-12 weeks later (usually 3-4 weeks later)

» Full PRP treatment required

Branch Retinal Artery Obstruction

Characteristics Vision loss Visual filed defect Within hours/days

» Edematous opacification of the retina

In the distribution of the affected vessel

Branch Retinal Artery Obstruction

Pathogenesis Embolization or thrombosis of vessel Three types of emboli

» Cholesterol Hollenhorst plaques Arise from carotid

» Platelet-fibrin Associated with arteriosclerosis

» Calcific Diseased cardiac valves

Retinal Embolization

Hollenhorst plaque Glistening cholesterol emboli Found within retinal arteriole

» Typically lodge at bifurcations

Arise in carotid arteries

Retinal Embolization

Hollenhorst plaque Glistening cholesterol emboli Found within retinal arteriole

» Typically lodge at bifurcations

Arise in carotid arteries

Branch Retinal Artery Obstruction

Other causes of BRVO Migraine

» Particularly in smokers Trauma Coagulation disorders Sickle cell disease Oral contraceptive use

» Smoking, older women Mitral valve prolapse Infections

» Toxoplasmosis, syphilis Giant cell arteritis

» Check ESR in elderly patients

Good prognosis

Workup

ESR,CBC and C-reactive protein Fasting blood sugar Glycosylated hemoglobin Doppler US for carotid artery ECG, echocardiogram Refer for haematology

Mortality/Morbidity

Further emboli to the brain resulting in CVA 55% death over 10 years 27% age matched population

Further emboli to same or contralateral eye resulting in further visual loss

Progression of temporal arteritis

Venous Occlusive Disease

Central Retinal Vein Occlusion

Findings Dilated and tortuous

retinal veins Swollen optic disc Intra-retinal hemorrhages Retinal edema

All four quadrants

Central Retinal Vein Occlusion

Classification Based on amount of non-profusion on fluorescein

angiography» Ischemic

≥10 disk areas

» Non-ischemic < 10 disk areas

» Indeterminate Too much hemorrhage to tell 80% progress to ischemic

Central Retinal Vein Occlusion

Pathogenesis Thrombosis of the central retinal vein

» At or posterior to the lamina cribrosa

Atherosclerotic central retinal artery » Impinges on central retinal vein

Turbulent flow → thrombus

Central Retinal Vein Occlusion

Non-ischemic CRVO Less dilation and vascular

tortuosity Dot and flame hemorrhages

in all quadrants Less or no disk swelling

Angiogram shows» Delayed A-V transit time» Leakage» Minimal capillary dropout

Neovascularization is rare

Central Retinal Vein Occlusion Ischemic CRVO

Extensive hemorrhage Retinal edema Marked venous dilation Cotton-wool spots

Angiogram show» Widespread capillary nonprofusion

Visual prognosis poor» Only 10% have >20/400 vision

NVI» As high as 60% of eyes» Occurs 3-5 months post occlusion

“the three month glaucoma”

Central Retinal Vein Occlusion

Risk Factors Eye Disease Case-Control

Study» Hypertension» Diabetes

Unlike BRVO

» Glaucoma Check and treat IOP!

CRVO in young patients requires more extensive workup for cause

CRVO In Young Patients – Causes

Systemic vascular disease Hypertension Diabetes mellitus Cardiovascular disease

Blood dyscrasias Polycythemia vera Lymphoma Leukemia

Clotting disorders Activated protein C resistance Lupus anticoagulant Anticardiolipin antibodies Protein C Protein S Antithrombin III

Paraproteinemia and dysproteinemias Multiple myeloma Cryoglobulinemia

Vasculitis Syphilis Sarcoidosis

Autoimmune disease Systemic lupus erythematosus

Oral contraceptive use in women Other rare associations

Closed-head trauma Optic disc drusen Arteriovenous malformations of retina

Central Retinal Vein Occlusion

Management Family medical doctor to

manage» Hypertension» Diabetes» Elevated cholesterol

Central Retinal Vein Occlusion

Management Macular edema

» Central Vein Occlusion Study Group

Grid laser treatment in the macula

– DOES reduce angiographic evidence of edema

– DOES NOT improve vision

Central Retinal Vein Occlusion

Management Macular edema

» Intravitreal trimcinolone/Avastin » Capable of transiently

improving vision Risks

– Glaucoma– RD– Cataract– Endopthalmitis

Central Retinal Vein Occlusion

Management Iris neovascularization

PRP to eyes prior to NVI» NO benefit

Even if very ischemic

Once neovascularization detected

» Prompt PRP

Central Retinal Vein Occlusion

Outcome Most important predictor is

initial visual acuity:» 20/40 or better

Likely to remain unchanged

» 20/400 or less Likely to remain worse than

20/400

» 20/50-20/200 1/3 unchanged 1/3 improve 1/3 worse

Branch Retinal Vein Occlusion

Findings Within one sector of the

retina» Superficial hemorrhages» Retinal edema» Cotton-wool spots» Dilated and tortuous vein» Corresponding artery narrowed

and sheathed

Branch Retinal Vein Occlusion

Findings Superotemporal quadrant

most common» 63%

Occurs at arteriovenous crossing

» Artery and vein bound together in a common sheath

» Arterial thickening compresses vein

Turbulent flow → thrombus formation

Branch Retinal Vein Occlusion

Risk factors Identified by the Eye Disease

Case-Control Study» Hypertension» Cardiovascular disease» Increased BMI at age 20» Glaucoma

Note : Diabetes not an independent risk factor

Branch Retinal Vein Occlusion

Visual Loss Acute

» Macular hemorrhage» Macular edema» Capillary occlusion

Chronic» Macular ischemia» CME» Macular pigmentary changes» Epiretinal membrane formation» Subretinal fibrosis

Branch Retinal Vein Occlusion

Photocoagulation Used to treat:

» Macular edema Requires intact foveal perfusion

» Neovascularization

Macular edema» Allow three months for

improvement» Vision 20/40 or worse» Light grid pattern of laser spots to

involved sector of retina

» Branch vein occlusion study Treated eyes more likely to gain

2 lines of vision– Treated 65%, untreated 37%

Branch Retinal Vein Occlusion

Photocoagulation Neovascularization

» BVOS defined ischemic BRVO Area of non-profusion > 5 disk

diameters

» Large areas of non-profusion increase risk of neovascularization

Apply scatter PRP to areas of retinal ischemia

» Only when neovascular complications develop

NVI, NVE, NVD

Branch Retinal Vein Occlusion

Vascular Remodeling

Photocoagulation» Must differentiate

Neovascular tissue– Leaks on fluorscein angiogram

Collateral vessels– Help to reduce vascular tissue– Do not treat

Thank you xoxo