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Branch Retinal Vein Occlusion

Case Presentation
Dr. Chinmay Kharade
Content
• Introduction
• Chief Complaints
• Known Case
• Examination
• Investigations
• Differential Diagnosis
• Management
• Pathology
Chief Complaints
A 44 Year old female patient was appearently alright till she
presented with the following complaints
• Both Eyes Heaviness
• Headache

She is also known case of the


• Diabetes Mellitus since 11 years
• Hypertension since 10 years
Examination
• Vision
Right Eye - 6/12
Left Eye – 6/12
• Near Vision
Both Eyes – N.8
• Lid, Conjunctiva, Cornea, Anterior Chamber, Iris,
Pupil Intra Ocular Pressure all are Normal
Fundoscopy
• Media – Clear
• Disc
Cup – 0.3 to 0.4
Size - Normal
Shape - Normal
Colour - Normal
Margins - Sharp
Fundoscopy
Blood Vessels
AV Ratio - Arterial Diameter is half the Veinous Diameter
AV Nicking - Seen Super Nasally to the disc

Green arrow shows - A small artery (arteriole) is seen


crossing a small vein (venule), which results in the
compression of the vein with bulging on either side of the
crossing

Venous Dilatation – Is seen


Venous Tortuosity - Is seen
Light Reflex – Normal
Fundoscopy
Hemorrhages
Flame shaped – Seen Supero Nasally to the disc
Intraretinal hemorrhages in wedge shaped delineating
the area drained by the occluded vein are seen

Exudates
Soft Exudates i.e. Cotton Wool Spots are seen
Red arrow shows the Cotton Wool Spots on the
fundus photo
Fundoscopy
Macula
Foveal Light Reflex - Normal
No Macular edema
No Macular ischemia
No Hemorrhage over the fovea
Investigations
• Fundus Photo Blue Arrow – Flame Shaped Hemorrhages

00

Red Arrow – Cotton wool Spot Green Arrow – Venous Dilatation


Differential Diagnosis

• Central retinal vein occlusion


• Branch retinal vein occlusion
• Tributary retinal vein occlusion
• Hypertensive retinopathy
• Diabetic retinopathy
Investigations
• Fluorescein angiography (FA)
In patients with BRVO, FA helps to characterize retinal
vasculature including the extent of nonperfusion, macular
ischemia, macular edema and leakage.
Delayed filling of occluded vein will be seen
• Optical Coherence Tomography
OCT allows for rapid, non-invasive, and quantitative analysis of
the macula and has become an important imaging modality in
the assessment and treatment of BRVO. OCT has been used in
many studies as the primary study modality in preference to FA,
since assessment and treatment most often focus on macular
edema.
Investigations
Laboratory Tests
Young Patients – Hx of Oral Contraceptive Pills, DM & HTN
Infectious Causes – Lyme Disease, Syphilis, HIV
CBC
PT/PTT/INR
Lipid Profile
Older Patients – Other investigations are not neccessary since the cause is
idiopathic or hypertension or atherosclerosis in origin.
Visual Field defect test
Patients can present with visual field defects. Patients with macular BRVO
presents with a central field defect, while major BRVO present with a
peripheral field defect corresponding to the retinal quadrant that is affected.
Management
2 main objectives

1. Identification of modifiable risk factors (example HT, DM,


CVS) and their management – for other eye

2. Recognition and management of sight- threatening


complications
Management
• LASER Photocoagulation
Prior to the advent of anti-vascular endothelial growth factor (VEGF) agents,
laser photocoagulation was considered the gold standard for the treatment
of BRVO as established by the BVOS Group.
The mechanism of action of laser photocoagulation in macular edema is
thought to be destruction of nearby capillary beds, reducing input of arterial
blood supply and allows remaining capillaries to drain into less congested
intact capillary bed.
Laser photocoagulation is also used to prevent vitreous hemorrhage.
According to results of the BVOS Group, patients with BRVO and > 5 disc
diameters of retinal capillary nonperfusion should undergo scattered laser
photocoagulation only once neovascularization has developed. BVOS data
showed that scatter photocoagulation after neovascularization develops is
as effective as before neovascularization in preventing vitreous hemorrhage.
Management
The recommended parameters for scatter laser include duration of 0.2
seconds, 200-500 µm diameter spot size, and power to produce a
medium white burn.
The recommended parameters for grid laser include duration of 0.1
seconds, 100 µm diameter spot size, and power to produce a medium
white burn.
Steroids
Corticosteroids have been shown to be effective for treatment of macular
edema in BRVO. However, intraocular corticosteroids have significant
side effects including progression of cataracts formation and elevation of
intraocular pressure. The SCORE-BRVO study is the largest trial that
evaluated the safety and efficacy of intravitreal triamcinolone compared
to grid laser in the treatment of macular edema.
Management
At 12 months, the study concluded that there is no difference in visual
acuity gained between the two triamcinolone groups and grid laser
group. There was significant cataract formation and elevation of
intraocular pressure in the intravitreal triamcinolone groups. However,
the three year results showed a significant increase in vision in the
laser group compared to the intravitreal triamcinolone groups. From
the results of this study, intravitreal triamcinolone is not recommended
as a first-line therapy for macular edema due to BRVO. It is utilized as
an adjunct to laser or anti-VEGF agents or as second line agent.
Ozurdex, a dexamethasone implant has been evaluated in the
GENEVA study for macular edema in CRVO and BRVO. The implant
is injected using a 22-guage custom injector and gradually releases
dexamethasone over several months (1-3 months), with peak
response at 60 days.
Management
Anti-Vascular Endothelial Growth Factor (VEGF) Agents
In patients with BRVO, retinal ischemia results in elevated secretion of
VEGF leading to increased vascular permeability and vasodilation.There
are several anti-VEGF agents available to treat macular edema due to
BRVO including ranibizumab (Lucentis), bevacizumab (Avastin), and
aflibercept (Eylea).
Surgical Management
Sheathotomy
Most venous obstructions in BRVO occur at an arteriovenous
crossing. In histopathologic studies in BRVO, arteries and veins
share a common adventitial sheath. The first case report for pars-
plana vitrectomy combined with sheathotomy for BRVO was done
by Osterloh et al.
Management
Vitrectomy
In those cases where neovascular complications such as
non-clearing vitreous hemorrhage, pars-plana vitrectomy
may be considered usually in combination with
intraoperative endolaser to the portion of the retina affected
by the BRVO.
Pathology
• Disease Intro
• Clinical Features
• Pathogenesis
• Classification
• Risk Factors
• Complications
• Prognosis
Introduction
- The first case of BRVO was described by Richard Liebreich in
1855

- Retinal vein occlusion (RVO) is the second most common


retinal vascular disorder after diabetic retinopathy.

- Affects males and females equally 60-70 y/o


Clinical Features
Symptoms
- Sudden painless Loss of vision or loss of visual field defects
- Rarely – Floaters from vitreos Hemorrhage

Signs
- Wedge shaped distribution of Intraretinal Hemorrhage
- Macular Oedema
- Dilated & Tortuos Vein
- Cotton wool spots
Pathogenesis
- BRVO mostly occurs at arteriovenous crossings

- Retinal Artery and Vein share same adventitial sheath and in


some case common medium
The lumen of the vein may be compressed up to 30% at the crossing site
- Turbulent blood flow at the crossing site causes focal swelling
of the endothelium and deeper vein wall tissue, leading to
venous obstruction
- Actual Venous thrombus at the point of the occlusion
Pathogenesis
Venous obstruction

Venous pressure

Overloading of collateral drainage capacity

Macular edema & ischemia

Unrelieved venous pressure

Rupture of vein wall & intraretinal hemorrhage


Classification
Central Retinal Vein Occlusion
Non ischaemic CRVO (Venous Stasis Retinopathy)
Ischaemic CRVO (Haemorrhagic Retinopathy)

Branch Retinal Vein Occlusion


Major BRVO –
a. Occlusion of the 1st order temporal branch at disc
b. Occlusion of the 1st order temporal branch away from disc but involving branch to
macula
Minor Macular BRVO – Involving only macular branch
Peripheral BRVO – not involving the macular circulation
Risk Factors
- Systemic hypertension
- Diabetes
- Hyperlipidemia
- Glaucoma
- Smoking
- Age related atherosclerosis
Risk Factors
Others risk factors
• Eyes with shorter axial lengths
• Anti-phospholipid antibody syndrome
• Elevated plasma homocysteine levels
• Low serum folate levels
• Inflammatory disease( Sarcoidosis, Bechet’s disease)
• Acquired & inherited thrombophilic conditions
• Hyper viscosity state ( polycythemia, myeloma, etc.)
Complications
MACULAR CHANGES
1) Chronic macular oedema: 48% cases 1/3 rd edema regresses spontaneously
2) Macular non-perfusion : vision is unlikely to improve
3) Epiretinal membrane
4) Hard Exudates, pigment clumping at macula

NEOVASCULARIZATION :
• In major brvo: NVD 10%,NVE 36% (if CNP areas > 5DD)
• develops at border of ischemic & non-ischemic retina.
• occurs max. upto 6-12 months, may occur upto 3 years.
• NV doesn't develop in macular brvo
Complications
VITREOUS & PRE- RETINAL H’GES:
60 % (22-36% develop NVE if CNP areas >5DD,
of them 40% develop VH)

Tractional RD
Rhegmatogenous RD
-Ischemia leads to atrophic hole formation
-secondary to tear formed due to fibrovascular traction Retinal detachment

ANT. SEGMENT NV : 1.6 %


Prognosis
Analysis of several series indicates that
53% of eyes obtain 20/40 or better visual acuity,
25% have between 20/50 and 20/100, and
22% have visual acuity of 20/200 or worse.

The more distal the occlusion is from the optic disc, the
better the visual prognosis.
Patient Education
Instruct patient about reducing risks :

Keep good Blood pressure control and maintain good


Cholesterol level.

Instruct patient with BRVO to seek attention if further vision


loss occurs during follow-up.
Thank You