Retinal Venous Occlusive Retinal Venous Occlusive DiseaseDisease

presentation : Dr.Ali Maaroufpresentation : Dr.Ali Maaroufsupervision : Dr.Reem Moustafasupervision : Dr.Reem Moustafa

DefinitionDefinition the second most prevalent retinal vascular the second most prevalent retinal vascular

disorder following diabetic retinopathy disorder following diabetic retinopathy and is often associated with vision loss .and is often associated with vision loss .

Partial or Complete obstruction .Partial or Complete obstruction .

Varying degrees of retinal vascular leakageVarying degrees of retinal vascular leakageleading to : - macular edemaleading to : - macular edema - intraretinal hemorrhages - intraretinal hemorrhages

PrevalencePrevalence

Age : Age : > 40 y > 40 y 6 6thth - 7 - 7thth decades decades < 40 y relatively uncommon < 40 y relatively uncommon

3.1 - 4.6 % of population3.1 - 4.6 % of population

BRVOs 6-7 times more than CRVOsBRVOs 6-7 times more than CRVOs

ocuurence in fellow eye is 7 % within 4 yocuurence in fellow eye is 7 % within 4 y

predisposing factorspredisposing factors

• systemic : systemic : ( vessel-wall dysfunction )( vessel-wall dysfunction )- Advanced age- Advanced age- HTN : - HTN : - especially in not well treated patiens - especially in not well treated patiens - 63.6 % of RVO vs. 36.2 % of controls - 63.6 % of RVO vs. 36.2 % of controls- DM : - DM : - significantly more frequent in CRVO - significantly more frequent in CRVO- Hyperlipidemia- Hyperlipidemia- Smoking- Smoking- OCCs- OCCs- Homocysteinemia : >>- Homocysteinemia : >>- Coagulation disorders : >>- Coagulation disorders : >> proteins C & S deficiencies , antiphospholipid synproteins C & S deficiencies , antiphospholipid syn

in young patients

perdisposing factorsperdisposing factors

• local :local :- Glaucoma :- Glaucoma : occlusion at disc rim occlusion at disc rim

- Hypermetropia- Hypermetropia

pathogenesispathogenesis

• Diseases of both Veins & Arteries Diseases of both Veins & Arteries

arteriosclerosis : arteriosclerosis : small arteries and small arteries and arteriolesarterioles important in BRVOimportant in BRVO atherosclerosis : atherosclerosis : large & medium sized large & medium sized arteriesarteries important in CRVOimportant in CRVO

pathogenesispathogenesis

• endothelial cell loss , stagnation endothelial cell loss , stagnation

thrombus formation thrombus formation

>>> Occlusion >>> Occlusion

pathogenesispathogenesis

hypoxia

↑ Vein & Capillary pressure & stagnationocclusion

endothelial damage & extravasation of constituents

↑ tissue pressure

Signs & SymptomsSigns & Symptoms

• Vision Loss :Vision Loss : - macular ischemia or edema - macular ischemia or edema - retinal hemorrhages - retinal hemorrhages

• Slit Lamp Test & Fundus Examination :Slit Lamp Test & Fundus Examination : - vitreous hemorrhage - vitreous hemorrhage - epiretinal membrane formation - epiretinal membrane formation - rubeosis iridis - rubeosis iridis - neovascular glaucoma - neovascular glaucoma

ClassificationClassification

- Central Retinal Vein Occlusion ( CRVO ) - Central Retinal Vein Occlusion ( CRVO ) at or posterior to optic nerve head at or posterior to optic nerve head

- Branch Retinal Vein Occlusion- Branch Retinal Vein Occlusion ( BRVO )( BRVO )

at a branch or tributary of CRVat a branch or tributary of CRV

CRVOCRVO

CRVOCRVO

CRVOCRVO

• Variable visual lossVariable visual loss• Fundus : - retinal hemorrhagesFundus : - retinal hemorrhages

- dilated tortuous retinal veins - dilated tortuous retinal veins - macular edema - macular edema - optic disc edema - optic disc edema - cotton wool spots - cotton wool spots

CRVO - scattered hemorrhagesCRVO - scattered hemorrhages

CRVOCRVO

Important investigations :Important investigations :- FFA- FFA- OCT- OCT

CRVOCRVO

CRVOCRVO

• Complications :Complications : - Macular edema - Macular edema - Neovascularisation : - Neovascularisation : NVD NVD NVE NVE NVI NVI

CRVOCRVOsignificant disc edema - dilated tortuos veins -significant disc edema - dilated tortuos veins -

scattered hemorrhages scattered hemorrhages

CRVOCRVOsame patient - leakage from disc - staining of veinssame patient - leakage from disc - staining of veins

CRVOCRVO

CRVO - FFACRVO - FFAdilated tortuos veins - leakage into macula - cystoid patterndilated tortuos veins - leakage into macula - cystoid pattern

CRVO - FFA CRVO - FFA perifoveal capillary leakage - cystoid pattern - late phaseperifoveal capillary leakage - cystoid pattern - late phase

CRVO - FFACRVO - FFAperifoveal leakage - cystoid patternperifoveal leakage - cystoid pattern

CRVO Non-IschemicCRVO Non-Ischemicperifoveal leakage - Arteriovenous phaseperifoveal leakage - Arteriovenous phase

CRVOCRVOresolving NVD - PRP spots resolving NVD - PRP spots

CRVOCRVOoptociliary shunt vesselsoptociliary shunt vessels

CRVOCRVO• impending :impending :

uncommon , poorly describeduncommon , poorly described• non-ischemic :non-ischemic :

~75%~75%Afferent pupillary defect (APD) : absent or mild .Afferent pupillary defect (APD) : absent or mild .delay in AV transit time -good capillary perfusion - delay in AV transit time -good capillary perfusion - late leakagelate leakageprognosis : reasonably good , related to inital VAprognosis : reasonably good , related to inital VA

• ischemic : ischemic : APD : markedAPD : markedmarked delay in AV transit time ( > 20 S )marked delay in AV transit time ( > 20 S )extensive areas of capillary non-perfusionextensive areas of capillary non-perfusionprognosis : extremely poor .prognosis : extremely poor .

Non-ischemic CRVONon-ischemic CRVO

Non-Ischemic CRVONon-Ischemic CRVO

Non-Ischemic CRVONon-Ischemic CRVO

BRVOBRVO

• Occurs typically at A-V crossing pointOccurs typically at A-V crossing point ( commom adventitial sheath ) ( commom adventitial sheath )

• more common detected in the superior more common detected in the superior temporal quadranttemporal quadrant

BRVOBRVO

majormajor

minor macularminor macular

peripheralperipheral

BRVOBRVO

BRVO - FFABRVO - FFA

BRVO - FFABRVO - FFA

investigationsinvestigations

• All patients :All patients :- VA , Slit Lamp Exam - VA , Slit Lamp Exam - OCT , FFA- OCT , FFA- Laboratory Tests :- Laboratory Tests : BP , CBC , Random BG , Fasting BG , ESR BP , CBC , Random BG , Fasting BG , ESR ECG , Cholesterol and Lipids , Plasma protein electrophoresis ECG , Cholesterol and Lipids , Plasma protein electrophoresis Urea , Creatinine , Electrolytes ,Thyroid tests . Urea , Creatinine , Electrolytes ,Thyroid tests .

• Selected patients :Selected patients :- Thrombophilia screen , CRP , Autoantibodies , Fasting - Thrombophilia screen , CRP , Autoantibodies , Fasting Plasma Homocystein level Plasma Homocystein level - CXR , ACE ,- CXR , ACE ,- Treponemal serology , Carotid duplex imaging .- Treponemal serology , Carotid duplex imaging .

ComplicationsComplications

• Macular Edema :Macular Edema :the most important factor for reduced the most important factor for reduced VA after RVOVA after RVO

• Neovascularisation :Neovascularisation : vitreous hemorrhage vitreous hemorrhage tractional RD tractional RD neovascular glaucoma neovascular glaucoma

TreatmentTreatment

• Anti VEGF Anti VEGF • F/G Laser F/G Laser

• Sectoral LaserSectoral Laser

• VitrectomyVitrectomy

• Treatment of underlying diseaseTreatment of underlying disease

a clinical case presentation a clinical case presentation

• a 50-year-old woman diagnosed with HTN a 50-year-old woman diagnosed with HTN 1 month ago , HTN treatment has been stopped 1 month ago , HTN treatment has been stopped on patient’s own after 2 w of treatment .on patient’s own after 2 w of treatment .

• FH : HTN , DM .FH : HTN , DM .

• BP : 19-18 / ? mmHg .BP : 19-18 / ? mmHg .

• FBS : W.N.LsFBS : W.N.Ls

presentation : reduced visual acuity OS with a sudden partial-field Vision Loss one week ago + chronic headache treated with analgesics .

VA : - OS : CF . vision field : superiomedial quadrant - OD : 10/10

slit lamp examination :inferior archade BRVO

clinical case

clinical caseclinical case

clinical caseclinical case

ReferencesReferences

• American Academy of Ophthalmology American Academy of Ophthalmology publicationspublications

• emedicine-Medscapeemedicine-Medscape• Charité Einblick-Ausblick Charité Einblick-Ausblick

Fachpublikation Band 2Fachpublikation Band 2• Ophthalmic photographer’s societyOphthalmic photographer’s society• Kanski’s clinical ophthalmology 7Kanski’s clinical ophthalmology 7thth

editionedition

Presented atPresented at : :

Eye Surgical Hospital , Eye Surgical Hospital , Damascus , Syria .Damascus , Syria .

18/1/2016 18/1/2016