Arteriovenous adventitial sheathotomy for the treatment of macular edema associated with branch retinal vein occlusion

Retinal arterial and vein occlusion: is surgery ever indicated?

PURPOSE OF REVIEW

To highlight the recent progression in surgical treatments for central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO).

RECENT FINDINGS

Anti-VEGF treatment, accepted as a primary treatment for CRVO, is unable to effectively treat all types of the diseases. Regarding CRAO, there are not any accepted therapies available. There have however been recent innovations in surgery, such as utilizing robotics-assisted tools in cannulation procedures for central retinal artery occlusion, or micro-cystotomy for refractory macular edema resulting from ischemic CRVO.

SUMMARY

Refractory macular edema due to CRVO can be treated with aspiration of the fluid found inside the large cysts often seen in edema. The success rate of micro-cystotomy has been reported at 78% in eyes with refractory macular edema. Recent studies have shown that cannulation with tissue plasminogen activator (tPA) is effective for eyes with CRAO due to thrombus.Recent cannulation or micro-cystotomy procedures can be enhanced with the use of robotic tools which allow us to perform this difficult procedure more easily. Newly developed technology, and consequent developments in surgical procedures, will allow us to deal with unmet needs for retinal vessel occlusive diseases.

Angiographic Risk Features of Branch Retinal Vein Occlusion Onset as Determined by Optical Coherence Tomography Angiography

Purpose

Examine associations between the vasculature at arteriovenous (AV) crossings and the onset of branch retinal vein occlusion (BRVO).

Methods

We included 78 patients with major BRVO, 35 patients with macular BRVO, and 110 controls without BRVO and determined the vessel positions at AV crossings, where the first- or second-order branches of the retinal veins associate, using a viewing angle of 12 × 12 mm² in optical coherence tomography angiography (OCTA).

Results

We reviewed 1349 and 1276 AV crossings in BRVO patients and control subjects, respectively. The proportions of venous overcrossing were 26.5%, 28.6%, and 26.8% at non-causative crossings in BRVO eyes, non-BRVO fellow eyes, and unaffected control eyes, respectively; however, the rate of venous overcrossings at the causative crossings was 45.1%. In OCTA analyses, we divided the branches into macular- or non-macular veins. The rate of venous overcrossing was 52.5% at causative crossings in major BRVO but was 28.6% in macular BRVO. Odds ratios for whether venous overcrossing was a risk factor for BRVO were 3.09 (95% confidence interval [CI], 1.96–4.88) and 0.94 (95% CI, 0.44–2.00) for non-macular veins and macular veins, respectively. The patients with major BRVO caused by venous overcrossing were younger than patients for whom the cause was arterial overcrossing (P < 0.001). The onset of macular BRVO did not differ between crossing patterns at causative crossings (P = 0.60).

Conclusions

In eyes with BRVO, venous overcrossing was a common angiographic feature at causative crossings and might be a risk factor for major BRVO onset.

Arteriovenous crossing associated with branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is defined as the focal occlusion of a first or second-order branch of retinal vein, which occurs most frequently at an arteriovenous (AV) crossing. Direct ophthalmoscopy, color fundus photography, and fluorescein angiography facilitate observation of AV crossings parallel to the retinal plane. Optical coherence tomography (OCT), with its high-depth resolution, enables observation of retinal lesions perpendicular to the retinal plane. OCT angiography (OCTA) provides depth-resolved images of the retinal vasculature by segmenting three-dimensional data. In this review, we discuss novel findings related to affected AV crossings associated with BRVO obtained via OCT and OCTA. The high-depth resolution of OCT or OCTA is useful for observation of the narrowed vein and determination of the vessel position of the affected AV crossing. Studies using OCT and OCTA have shown that BRVO caused by a venous overcrossing is more prevalent than previously reported, and that venous narrowing was significantly greater in instances caused by a venous overcrossing than in those caused by an arterial overcrossing. Moreover, OCTA also revealed that the retinal nonperfusion area size was larger in eyes with BRVO caused by a venous overcrossing than in those with BRVO caused by an arterial overcrossing. This contrasts with earlier findings obtained by conventional imaging modalities predating OCT, which showed that an arterial overcrossing was more common than a venous overcrossing at the causative venous occlusion site in eyes with BRVO. This review discusses these findings and their significance in the study of AV crossing associated with BRVO.

Vitrectomy for macular edema due to retinal vein occlusion

Purpose: To determine the long-term outcomes of vitrectomy for the macular edema associated with a retinal vein occlusion (RVO).

Methods: This was a retrospective, consecutive, interventional case series. The intraoperative procedures included internal limiting membrane peeling, arteriovenous sheathotomy, radial optic neurotomy, and intravitreal triamcinolone acetonide injection at the end of the surgery. The main outcome was the best-corrected visual acuity (BCVA).

Results: Eight hundred and fifty-four eyes of 854 patients were studied. The eyes consisted of 602 with branch RVO (BRVO), 74 with hemi-central RVO (hemi-CRVO), 87 with nonischemic central retinal vein occlusion (CRVO), and 91 with ischemic CRVO. The mean follow-up period was 68.6 months with a range of 12 to 262 months. The mean BCVA was significantly improved at the final visit (P<0.0001 to 0.0016). The final BCVA improved in 74.4% of the BRVO eyes, in 58.1% of the hemi-CRVO eyes, in 57.4% of the nonischemic CRVO eyes, and in 51.6% of the ischemic CRVO eyes. Multiple regression analysis showed there was no significant relationship between the intraoperative combined procedures and the final BCVA.

Conclusions: The results indicate that the type of RVO is significantly associated with the final BCVA, and vitrectomy is a treatment option to improve and maintain BCVA for a long term.

Long-term outcomes of intravitreous bevacizumab or tissue plasminogen activator or vitrectomy for macular edema due to branch retinal vein occlusion

Purpose

The purpose of this study was to determine the long-term outcomes of intravitreal bevacizumab (IVB) or intravitreal tissue plasminogen activator (tPA) or vitrectomy for macular edema associated with a branch retinal vein occlusion (BRVO).

Methods

This was a retrospective, interventional case series. Forty-one patients received a single 1.25 mg of IVB injection and followed by pro re nata protocol, 71 patients received a single intravitreal tPA, and 116 patients underwent phacovitrectomy with intraocular lens implantation.

Results

The baseline characteristics and follow-up periods were not significantly different among the three groups. The mean follow-up period was 55.5 months with a range of 12-160 months. Sixteen patients (39.0%) in the IVB group, 24 patients (33.8%) in the tPA group, and two patients (1.7%) in the vitrectomy group underwent additional surgeries during the follow-up period. The best-corrected visual acuity (BCVA) significantly improved in all groups at 1 year after the initial treatment (all, P<0.0001) and at the final visit (all, P<0.0001). The differences in the BCVA between the three groups were not significant at all times after the initial treatment.

Conclusion

The three groups led to similar long-term good visual outcomes. However, additional surgeries were performed in more than 30% of patients in the IVB and tPA groups.

Extrafoveal Vitreous Traction Associated with Branch Retinal Vein Occlusion

Purpose.

To present patients with extrafoveal vitreous traction associated with diffuse macular edema secondary to branch retinal vein occlusion (BRVO).

Methods.

A retrospective study on consecutive patients with BRVO using optical coherence tomography (OCT)-2000 is reported. Excluded were patients with eyes with other retinopathies that could affect analysis and eyes following pars plana vitrectomy (PPV). A control group of 30 age-matched patients allowed for normal OCT6-mm macular maps.

Results.

Vitreous traction was detected in 4 of 17 eyes (17 patients, 23.5%). The traction was located extrafoveally in each of the 4 eyes. In one eye there was a simultaneous central macular traction. Only the manually controlled OCT-Line group program, but not the central automatic 6-radial lines program, confirmed vitreous traction in each case. Retinal edema (n=4) and serous retinal detachment (n=2) underlining the traction sites were in continuum with the central macula in 3 eyes, presenting either as diffuse macular edema or combined with serous macular detachment, respectively. In one eye the edema subsided after PPV, and visual acuity stabilized during 7 postoperative months of follow-up. Macular thickness and visual acuity of another eye improved temporarily in repeated conventional treatments after PPV was discarded, but its fovea markedly atrophied 12 months later.

Conclusions.

Extrafoveal vitreous traction maybe apparent following BRVO. Further studies are required to assess whether such traction membranes may play a role in the persistence of diffuse macular edema.

Comparative Study of Vitrectomy with and without Vein Decompression for Branch Retinal Vein Occlusion: A Pilot Study

Purpose

To report the clinical outcomes in patients undergoing pars plana vitrectomy with and without vein decompression for treatment of branch retinal vein occlusion (BRVO).

METHODS

Thirty-five eyes with macular edema and visual acuity worse than 20/100 secondary to BRVO were prospectively evaluated. Vitrectomy with posterior hyaloid removal and vein decompression at the arteriovenous crossing was performed on 15 eyes (Group 1); consecutively, the same technique without vein decompression was performed on 20 eyes (Group 2). Primary outcome was visual acuity and secondary outcomes were resolution of macular edema and development of neovascularization.

Results

No differences were found between groups in either patient age (p=0.566) or preoperative visual acuity (p=0.505). No differences were found in visual acuity at 3 (p=0.651), 6 (p =0.697), 9 (p =0.763), 12 (p=0.881), or 18 (p=0.748) months. Mean time for macular edema resolution and visual acuity improvement was 9 months in both groups, with a mean improvement of 3.5 ± 2.35 lines in Group 1 and 3.2 ± 2.97 lines in Group 2. No eyes in either group developed new vessels.

CONCLUSIONS

Results suggest that vitrectomy with posterior hyaloid removal without vein decompression can resolve macular edema, improve vision, and prevent development of new vessels in BRVO.

Morphologic and Functional Retinal Vessel Changes in Branch Retinal Vein Occlusion: An Optical Coherence Tomography Angiography Study

PURPOSE

The present study aimed to investigate the morphology of the retinal vasculature in eyes with branch retinal vein occlusion (BRVO) using optical coherence tomography (OCT) angiography.

DESIGN

Observational case series.

METHODS

Fluorescein angiography (FA) and OCT angiography were used to examine macular area and the retinal vasculature at the affected arteriovenous (AV) crossing in 46 patients with BRVO.

RESULTS

FA revealed that the affected AV crossing pattern involved arterial overcrossing in 23 eyes (50.0%) and venous overcrossing in 11 eyes (23.9%). However, FA failed to detect the crossing pattern in 10 eyes (21.7%). OCT angiography was significantly more effective for identification of the AV crossing pattern than FA (44 eyes; 95.7%; P = .013). The number of eyes with venous overcrossing detected via OCT angiography (20 eyes, 43.5%) was also higher than that detected via FA (P = .047). OCT angiography revealed that venous narrowing (25.5 ± 21.1 μm) was significantly greater in instances of venous overcrossing than in those of arterial overcrossing (46.4 ± 23.7 μm, P = .005). Macular nonperfusion areas (NPAs) were larger in eyes with venous overcrossing than in those with arterial overcrossing (P = .011 for superficial plexus, P = .049 for deep plexus). The peripheral NPA was significantly larger in eyes with venous overcrossing (65.1 ± 35.3 disc area [DA]) than in those with arterial overcrossing (17.2 ± 24.1 DA; P < .001).

CONCLUSIONS

Our findings suggest that BRVO characterized by venous overcrossing may be more prevalent than previously reported, and that there is a significant association between NPA size and AV crossing pattern.

Intravitreal Aflibercept for Macular Edema Following Branch Retinal Vein Occlusion: 52-Week Results of the VIBRANT Study

PURPOSE

To determine week 52 efficacy and safety outcomes in eyes with macular edema after branch retinal vein occlusion (BRVO) treated with 2 mg intravitreal aflibercept injection (IAI) compared with grid laser.

DESIGN

VIBRANT was a double-masked, randomized, phase 3 trial.

PARTICIPANTS

Eyes randomized and treated in VIBRANT were followed to week 52.

METHODS

In the IAI group, eyes received IAI every 4 weeks through week 24 and IAI every 8 weeks through week 48 with rescue grid laser if needed at week 36. In the grid laser group, all eyes received grid laser at baseline and, if prespecified rescue criteria were met, 1 additional laser from week 12 to 20 and IAI every 8 weeks after 3 monthly doses from week 24 onward (the laser/IAI group).

MAIN OUTCOME MEASURES

The primary outcome measure was percentage of eyes with improvement from baseline best-corrected visual acuity (BCVA) letter score ≥15 at week 24. All outcome measures at week 52 were exploratory, and P values are considered nominal.

RESULTS

The percentage of eyes with improvement from baseline letter score ≥15 in the IAI and laser/IAI groups was 52.7% versus 26.7% (P = 0.0003) at week 24 and 57.1% versus 41.1% (P = 0.0296) at week 52. The corresponding mean change from baseline BCVA letter score was 17.0 versus 6.9 (P < 0.0001) at week 24 and 17.1 versus 12.2 (P = 0.0035) at week 52. The mean reduction from baseline central retinal thickness was 280.5 μm versus 128.0 μm (P < 0.0001) at week 24 and 283.9 μm versus 249.3 μm (P = 0.0218) at week 52. In the IAI group, 10.6% of eyes received rescue laser at week 36, and in the laser/IAI group, 80.7% received rescue IAI from week 24 to week 48. Traumatic cataract in 1 eye (1.1%) in the IAI group was the only ocular serious adverse event.

CONCLUSIONS

After 6 monthly IAI, injections every 8 weeks maintained control of macular edema and visual benefits through week 52. In the laser group, rescue IAI given from week 24 onward resulted in substantial visual improvements at week 52.

[Management of macular edema secondary to retinal vein occlusion]

BACKGROUND

In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO.

METHODS

A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article.

RESULTS

The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters.

DISCUSSION

Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

Matched control study of visual outcomes after arteriovenous sheathotomy for branch retinal vein occlusion

Background

The purpose of this study was to evaluate visual outcomes of arteriovenous sheathotomy for macular edema due to branch retinal vein occlusion (BRVO).

Methods

The medical records of 45 eyes from 45 patients who had undergone vitrectomy surgery with arteriovenous sheathotomy for BRVO were studied. Forty-five eyes of 45 patients with a BRVO but without intervention were studied as the control group. The best-corrected visual acuity and central macular thickness were compared between the two groups at baseline and at 1, 3, 6, and 12 months postoperatively.

Results

Improvement of best-corrected visual acuity was 0.42 logarithm of the minimum angle of resolution (logMAR) units in the sheathotomy group and 0.22 logMAR units in the control group (P=0.007). The mean postoperative central macular thickness was significantly thinner in the sheathotomy group at 1 month (P=0.01), but not at 3, 6, and 12 months (P=0.75, P=0.81, and P=0.46, respectively). Improvement of best-corrected visual acuity at 12 months was significantly correlated with baseline best-corrected visual acuity, age, duration of symptoms, and sheathotomy (P<0.05).

Conclusion

Arteriovenous sheathotomy for BRVO improves best-corrected visual acuity significantly more than the natural course of the BRVO disease process.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Retinal vein occlusion: beyond the acute event

Retinal vein occlusion is a major cause of vision loss. We provide an overview of the clinical features, pathogenesis, natural history, and management of both branch retinal vein occlusion and central retinal vein occlusion. Several recent multicenter randomized clinical trials have been completed which have changed the approach to this disorder. Management of retinal vein occlusions can be directed at the underlying etiology or the resulting sequelae. Options include surgical intervention, laser photocoagulation, intravitreal pharmacotherapy, and sustained drug delivery devices.

Extrafoveal traction in retinal vein occlusion using spectral domain optical coherence tomography

BACKGROUND

To present extrafoveal vitreous traction membranes, and their prevalence and association with diffuse macular oedema in eyes with retinal vein occlusion (RVO), using 3-D spectral-domain optical coherence tomography (SD-OCT).

METHODS

In a retrospective institutional observational study, charts and qualified SD-OCT findings of consecutive patients with either central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) associated with macular oedema were analyzed. Exclusion criteria covered eyes that had: 1) another retinopathy that could affect the data analysis, 2) vitreoretinal adherence without signs of retinal traction, 3) undergone vitreoretinal surgery, or 4) been treated by intravitreal administration of medication(s). An age-matched control group (n = 72) afforded the normal central subfield thickness.

RESULTS

Twenty-six eyes (of 26 patients) with either CRVO (n = 12) or BRVO (n = 14) were analyzed. Four eyes were excluded because they had a lack of macular oedema (n = 2), had an earlier pars plana vitrectomy (n = 1), or had previous treatment by intravitreal bevacizumab (n = 1). Of the 22 remaining eyes, both the SD-OCT B-mode video clip and the 3-D image reconstruction enabled a detection of extrafoveal traction membranes, either unifocally or multifocally, in nine eyes: four (of 11; 36.4 %) in CRVO, and five eyes (of 11; 45.5%) in BRVO. The retinal oedema in these nine eyes, which underlined at least one of the traction sites per eye, and the accompanied subretinal fluid in four of these nine eyes, were in continuum in each eye with the diffuse macular oedema and serous macular detachment respectively. During follow-up, a spontaneous release of a traction membrane coupled with resolution of the macular oedema occurred in one eye with BRVO. Of the four eyes that were excluded, two eyes had extrafoveal vitreous traction membranes.

CONCLUSIONS

The SD-OCT B-mode video clip and its 3-D image reconstruction enabled relatively frequent detection of extrafoveal vitreous traction membranes in RVO and their association with diffuse macula oedema and macular detachment. A larger cohort is required to validate these findings and to compare the efficacy of early release of such traction membranes, either surgically or possibly by pharmacologic vitreolysis, with the current therapeutic modalities.

A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6

OBJECTIVE

To compare the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with standard care (grid photocoagulation in eyes without dense macular hemorrhage and deferral of photocoagulation until hemorrhage clears in eyes with dense macular hemorrhage) for eyes with vision loss associated with macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

Multicenter, randomized clinical trial of 411 participants. Main Outcome Measure Gain in visual acuity letter score of 15 or more from baseline to month 12.

RESULTS

Twenty-nine percent, 26%, and 27% of participants achieved the primary outcome in the standard care, 1-mg, and 4-mg groups, respectively. None of the pairwise comparisons between the 3 groups was statistically significant at month 12. The rates of elevated intraocular pressure and cataract were similar for the standard care and 1-mg groups, but higher in the 4-mg group.

CONCLUSIONS

There was no difference identified in visual acuity at 12 months for the standard care group compared with the triamcinolone groups; however, rates of adverse events (particularly elevated intraocular pressure and cataract) were highest in the 4-mg group. Application to Clinical Practice Grid photocoagulation as applied in the SCORE Study remains the standard care for patients with vision loss associated with macular edema secondary to BRVO who have characteristics similar to participants in the SCORE-BRVO trial. Grid photocoagulation should remain the benchmark against which other treatments are compared in clinical trials for eyes with vision loss associated with macular edema secondary to BRVO. Trial Registration clinicaltrials.gov Identifier: NCT00105027.

Visual prognosis and vitreous cytokine levels after arteriovenous sheathotomy in branch retinal vein occlusion associated with macular oedema

PURPOSE

To investigate the relationship between vitreous levels of cytokines, including interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF), and visual prognosis after pars plana vitrectomy (PPV) with arteriovenous sheathotomy in patients with branch retinal vein occlusion (BRVO) associated with macular oedema.

METHODS

We studied 60 patients with logMAR visual acuity (VA) scores of < 0.3 and visual impairment secondary to BRVO-associated macular oedema. All patients underwent PPV with arteriovenous sheathotomy. At the time of PPV, vitreous samples were collected from the operated eye and vitreous levels of VEGF and IL-6 were measured. Best corrected VA (BCVA) (using a logMAR chart) and foveal thickness (FT) (using optical coherence tomography) were monitored for up to 6 months after PPV.

RESULTS

Both BCVA and FT significantly improved after PPV. According to multiple regression analysis, both the improvement in BCVA and decrease in FT were closely related to the vitreous level of IL-6 but not to that of VEGF. The vitreous level of VEGF was strongly correlated with duration of BRVO.

CONCLUSIONS

Both improvement in BCVA and decrease in FT were observed after PPV in BRVO patients with macular oedema. Interestingly, these visual prognoses strongly correlate with the vitreous level of IL-6, whereas the duration of BRVO strongly correlates with the vitreous level of VEGF.

Visual acuity and multifocal electroretinographic changes after arteriovenous crossing sheathotomy for macular edema associated with branch retinal vein occlusion

PURPOSE

To evaluate the influence of arteriovenous (AV) sheathotomy on retinal function with central multifocal electroretinography (mfERG) in eyes with macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

Fifteen patients (15 eyes) who underwent AV sheathotomy for macular edema secondary to BRVO were included in the study. Best-corrected visual acuity and mfERG responses from the most central seven hexagons were analyzed before and 6 months after the operation.

RESULTS

The mean preoperative Early Treatment Diabetic Retinopathy Study (ETDRS) score +/- SD was 34.1 +/- 12.7 letters (Snellen equivalent, 20/50) and significantly improved up to 40.5 +/- 10.9 letters (Snellen equivalent, 20/40) at 6 months after AV sheathotomy (P = 0.027, Wilcoxon signed rank test). The mean preoperative P1 amplitude +/- SD of the most central 7 hexagons was 39.30 +/- 10.86 nV/deg(2) for the affected eye versus 47.72 +/- 6.67 nV/deg(2) for the normal fellow (control) eye (P = 0.013, Mann-Whitney U test) and significantly increased up to 50.71 +/- 15.58 nV/deg at 6 months after the operation (P = 0.014, Wilcoxon signed rank test). Significant correlations between preoperative and postoperative ETDRS score and preoperative P1 amplitude were present (r = 0.929, P < 0.001; r = 0.768, P = 0.001; respectively [Spearman correlation]).

CONCLUSIONS

AV sheathotomy improved macular function and anatomical outcome as measured by ETDRS score and mfERG responses in patients with macular edema due to BRVO.

Arteriovenous crossing sheathotomy versus intravitreal triamcinolone acetonide injection for treatment of macular edema associated with branch retinal vein occlusion

PURPOSE

To compare the functional and anatomical outcomes of arteriovenous (AV) sheathotomy and intravitreal triamcinolone acetonide (IVTA) injection in the treatment of macular edema associated with branch retinal vein occlusion (BRVO).

METHODS

Forty eyes of 40 patients with macular edema secondary to BRVO were randomized into two treatment groups. A total of 20 patients received AV sheathotomy (sheathotomy group), and the second group of 20 patients was treated with IVTA (IVTA group). Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) score, total macular volume measured, and foveal thickness by 3rd generation optical coherence tomography (OCT3) were evaluated as main outcome measurements.

RESULTS

The average changes in ETDRS scores, total macular volumes, and foveal thicknesses compared to baseline values, were significant 3 months and 6 months after treatment in both groups (P < 0.05, paired t-test), but only the IVTA group showed significant improvements 1 month after treatment. The between-group differences in average ETDRS score, total macular volume, and foveal thickness changes were significantly better at 1 month after treatment in the ITVA group (P = 0.026, P < 0.001, P = 0.001, respectively, Student's t-test), at which time IVTA patients had better vision and anatomical outcomes than did those in the sheathotomy group.

CONCLUSIONS

After either AV sheathotomy or IVTA treatment, patients with macular edema secondary to BRVO showed similar functional and anatomical outcomes 6 months later. When the cost and the risks of vitreoretinal surgery are considered, IVTA treatment may be a better treatment option, as the drug yields better short-term outcomes.

Sheathotomy in complicated cases of branch retinal vein occlusion

PURPOSE

To report the clinical experience and results of using a microsurgical technique to decompress the arteriovenous connection in complicated branch retinal vein occlusion (BRVO) combined with haemorrhage, oedema and ischaemia.

METHODS

We carried out a retrospective, non-randomized, interventional case study of the surgical sheathotomy decompression procedure. We enrolled 12 patients (seven women, five men; median age 64 years) with BRVO and decreased visual acuity (VA) caused by haemorrhage, oedema and ischaemia. The mean duration of thrombosis was 7 months (2-15 months). The patients were examined for pre- and postoperative best corrected VA (BCVA), intraocular pressure (IOP) and fundus photography. Ten patients were examined with fluorescein angiography and eight with ocular coherence tomography (OCT). Postoperative progression of cataract was recorded, as were other complications. The mean follow-up time was 20 months (8-39 months).

RESULTS

Best corrected VA had improved in nine patients, was unchanged in one patient and had deteriorated in two patients at the last follow-up. Noted complications were venous haemorrhage at surgery in five patients, retinal detachment in one patient and progression of cataract in four patients.

CONCLUSIONS

Microsurgical treatment with sheathotomy of BRVO is a technically feasible procedure with few complications. Postoperative increased reperfusion could explain the resolution of macular haemorrhage, oedema and ischaemia, and may improve visual function in patients with this common vascular eye disease.

Branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities

In branch retinal vein occlusion (BRVO), abnormal arteriovenous crossing with vein compression, degenerative changes of the vessel wall and abnormal hematological factors constitute the primary mechanism of vessel occlusion. In general, BRVO has a good prognosis: 50-60% of eyes are reported to have a final visual acuity (VA) of 20/40 or better even without treatment. One important prognostic factor for final VA appears to be the initial VA. Grid laser photocoagulation is an established treatment for macular edema in a particular group of patients with BRVO, while promising results for this condition are shown by intravitreal application of steroids or new vascular endothelial growth factor inhibitors. Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane may improve vision in eyes with macular edema which are unresponsive to or ineligible for laser treatment.

LONG-TERM VISUAL OUTCOMES AFTER VITRECTOMY FOR MACULAR EDEMA WITH FOVEAL HEMORRHAGE IN BRANCH RETINAL VEIN OCCLUSION

PURPOSE

To determine the long-term visual outcomes after vitreous surgery for macular edema with foveal hemorrhage associated with branch retinal vein occlusion (BRVO).

METHODS

One hundred twenty eyes of 120 patients underwent pars plana vitrectomy with or without internal limiting membrane (ILM) peeling for macular edema with foveal hemorrhage due to BRVO with a minimum 12 months of follow-up. Simultaneous cataract extraction with intraocular lens implantation was performed on 117 phakic eyes.

RESULTS

Follow-up after surgery ranged from 12 months to 129 months (average, 48 months). Visual acuity improved in 71% of cases at the 1-year visit. Mean visual acuity significantly increased from 0.24 (median, 0.3) before surgery to 0.57 (median, 0.7) 1 year after surgery (P < 0.0001) and 0.66 (median, 0.9) at the final visit (P < 0.0001). There was a significant difference between visual acuity at 1 year after surgery and visual acuity at the final visit (P < 0.0001). Of 120 patients, 95 (79%) had final visual acuity of > or =0.5, and 55 (46%) had final visual acuity of > or =1.0. ILM removal did not seem to have significant beneficial effects on visual outcomes in this series. No serious complications occurred during the follow-up period.

CONCLUSION

After vitreous surgery for macular edema with foveal hemorrhage associated with BRVO, visual acuity continued to improve beyond 1 year after surgery. A randomized, multicenter clinical trial is warranted to determine the efficacy of this procedure.

Long-term outcomes of vitrectomy with or without arteriovenous sheathotomy in branch retinal vein occlusion

PURPOSE

To evaluate the long-term effect of vitrectomy with or without arteriovenous sheathotomy for macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

The study was a prospective, randomized, comparative, interventional case series of 36 patients (36 eyes) who underwent pars plana vitrectomy with or without arteriovenous sheathotomy for macular edema due to BRVO of <or=8 weeks' duration of symptoms. Eighteen eyes with arteriovenous sheathotomy (sheathotomy group) were compared with 18 eyes without sheathotomy (vitrectomy group). Main outcomes measures were best-corrected visual acuity and central foveal thickness as evaluated by optical coherence tomography.

RESULTS

Baseline demographic characteristics of the groups were similar. Postoperative follow-up period ranged from 12 months to 45 months (31 months). Median best-corrected visual acuity significantly improved from 0.4 at baseline to 1.0 at the final visit in both groups, and there was no significant difference in best-corrected visual acuity at any postoperative period between the groups. Of 16 patients with duration of symptoms of <4 weeks, those with arteriovenous sheathotomy had a tendency toward better visual outcomes than those without arteriovenous sheathotomy (P = 0.064). The central foveal thickness also significantly decreased after surgery in both groups, but the differences were not significant for the two groups at each time point. No patients had severe intraoperative and/or postoperative complications.

CONCLUSIONS

Our findings suggest that vitrectomy with or without arteriovenous sheathotomy may improve the long-term functional and tomographic outcomes for patients with macular edema secondary to BRVO. Although additional arteriovenous sheathotomy did not lead to a distinct functional benefit in this series, early surgical intervention may result in better visual outcomes.

Intravitreal steroids in the management of macular oedema

The use of intravitreal corticosteroids in the management of macular oedema has recently gained widespread acceptance. New long-acting steroid preparations and methods of delivery have facilitated the use of these new modalities. This review describes the various types of macular oedema for which this therapeutic option is used and the results.

Preoperative visual acuity as a prognostic indicator for laser treatment of macular edema due to branch retinal vein occlusion

BACKGROUND AND OBJECTIVE

To determine the visual outcome of laser treatments for macular edema due to branch retinal vein occlusion (BRVO) in patients with a preoperative visual acuity (VA) of 20/200 or worse compared to patients with a preoperative VA of better than 20/200.

PATIENTS AND METHODS

Records of 88 patients with macular edema secondary to BRVO undergoing laser treatment from 1984 to 2003 were reviewed. Mean VA was measured before and after each treatment and after the final treatment.

RESULTS

All patients received between one and five laser treatments. Preoperative VA was better than 20/200 in 56 patients (group 1) and 20/200 or worse in 32 patients (group 2). Patients in group 1 had a mean improvement of 0.48 lines and 57% had a final VA of 20/40 or better. Patients in group 2 had a mean improvement of 1.69 lines and 20% had a final VA of 20/40 or better.

CONCLUSIONS

Patients with poor VA (20/200 or worse) secondary to macular edema due to BRVO responded positively to laser treatment. The level of preoperative VA can be a useful predictor of visual outcome. These patients should consider laser treatment before alternative, more aggressive approaches.

Arteriovenous adventitial sheathotomy for branch retinal vein occlusion: report of a case with longterm follow-up

PURPOSE

To report the longterm follow-up of a case of branch retinal vein occlusion (BRVO) treated with vitrectomy and adventitial sheathotomy.

METHODS

A three-port vitrectomy was performed in a 55-year-old man with symptoms of BRVO of about 3 months' duration. After a core vitrectomy, the adventitial sheath of the affected arteriovenous crossing was dissected so that the anterior surface of the arteriole was freely exposed.

RESULTS

On the second postoperative day, visual acuity (VA) in the affected left eye had increased from preoperative 0.3 to 0.6. Within 6 months the fundus had almost normalized and vision improved to 1.0. Cataract surgery was performed about 2 years after the vitrectomy. At a follow-up 4 years and 11 months after the sheathotomy, VA was 1.0 and no signs of recurrence were seen.

CONCLUSIONS

Adventitial sheathotomy may improve vision in selected cases of BRVO. Further studies are necessary to determine the role of sheathotomy in the management of cases with BRVO.

Evaluation of arteriovenous crossing sheathotomy for decompression of branch retinal vein occlusion

PURPOSE

To report the effects of arteriovenous adventitial sheathotomy on anatomical and functional improvements in patients with macular oedema due to branch retinal vein occlusion (BRVO).

METHODS

Pars plana vitrectomy and arteriovenous sheathotomy was performed on 11 patients with BRVO who had vision loss due to macular oedema. Ten patients with macular oedema due to BRVO and who have been treated with grid laser photocoagulation were included in the control group. The measurement of visual acuity with ETDRS chart was taken preoperatively and at 1, 3, 6, and 9 months follow-up in the study group and at 1, 3, 6, and 9 months after grid laser in the control group.

RESULTS

The mean preoperative logMAR visual acuity was 0.84+/-0.3 in the surgical group and 1.06+/-0.4 in the control group. The postoperative mean logMAR visual acuity was 0.41+/-0.2, 0.40+/-0.2, 0.40+/-0.3, and 0.36+/-0.3 at 1, 3, 6, and 9 months follow-up, respectively. In the control group the postlaser mean logMAR visual acuity was 0.92+/-0.3, 0.87+/-0.4, 0.85+/-0.3, and 0.82+/-0.3 at 1, 3, 6, and 9 months follow-up, respectively. The improvements of visual acuity in both groups were statistically significant when compared to pretreatment (P=0.003 and P=0.007 at 9 months in the study and control group, respectively).

CONCLUSION

Arteriovenous sheathotomy for decompression of BRVO in patients who have vision loss due to macular oedema was safe and effective for anatomical and functional improvement and resulted in significantly better visual outcomes than a matched control group of laser-treated eyes.

The management of retinal vein occlusion: is interventional ophthalmology the way forward?

Retinal vein occlusions (RVO) are the second commonest sight threatening vascular disorder. Despite its frequency treatments for RVO are unsatisfactory and include several that have not been tested by large, well designed, prospective, randomised controlled trials. There is also the lack of long term follow up in many of the available small uncontrolled studies, and the timings of interventions are haphazard. This review aims to evaluate the current knowledge relating to the pathogenesis, suggested treatments for the different types of RVO, and their complications. Isovolaemic haemodilution is of limited benefit and should be avoided in patients with concurrent cardiovascular, renal, or pulmonary morbidity. Evidence to date does not support any therapeutic benefit from radial optic neurotomy, optic nerve decompression, or arteriovenous crossing sheathotomy on its own. Vitrectomy combined with intravenous thrombolysis may offer promise for central RVO. Similarly, vitrectomy combined with arteriovenous sheathotomy intravenous tissue plasminogen activator may offer benefits for branch RVO. RVOs occur at significantly high frequency to allow future prospective randomised controlled studies to be conducted to evaluate the role of different therapeutic modalities singly or in combination.

Arterio-venous dissection after isovolaemic haemodilution in branch retinal vein occlusion: a non-randomised prospective study

PURPOSE

The rationale for this pilot study was to add arterio-venous dissection (AVD) after unsuccessful medical treatment in a well-defined group of patients with branch retinal vein occlusion (BRVO).

METHODS

In this prospective, interventional case series 35 consecutive patients with a visual acuity (VA) of 0.4 (logMar) or worse were scheduled for surgery within the first 3 months of the onset of BRVO. The study endpoint was VA 1 year after AVD. Secondary study endpoints were: correlation of VA and successful vessel dissection; complication rate; and number of additional surgical procedures within the first year of AVD.

RESULTS

Preoperative VA (logMar) was 0.82+/-0.05 (range 0.2-1.6). VA 6 weeks postoperatively was 0.54+/-0.06 (range 0-1.6), 3 months postoperatively 0.61+/-0.07 (0-1.56), 6 months postoperatively 0.74+/-0.08 (range 0-2) and 12 months postoperatively 0.55+/-0.07 (range 0.1-1.5). VA improved 1 year after AVD (p=0.0004). An improvement in VA did not depend on successful separation of the artery and the vein. Four patients had a retinal detachment, 19 patients needed cataract surgery within the first year of AVD. A total of 24 additional surgical procedures were needed.

CONCLUSIONS

Patients with BRVO may profit from AVD compared with a historical control group. Visual improvement was found irrespective of the successful dissection of vessels. The cataract formation rate and additional surgery was a shortcoming of the AVD procedure.

Intravitreal versus retrobulbar injections of triamcinolone for macular edema associated with branch retinal vein occlusion

PURPOSE

To compare the short-term effect of intravitreal versus retrobulbar injection of triamcinolone acetonide for the treatment of macular edema caused by branch retinal vein occlusion.

DESIGN

Randomized clinical trial.

METHODS

Sixty eyes of 60 patients who had macular edema associated with branch retinal vein occlusion were randomly assigned to receive a single intravitreal injection (4 mg) or repeated retrobulbar injections (40 mg, three times) of triamcinolone. These injections (first injection in the retrobulbar group) were given approximately 1 week after focal laser photocoagulation. Using optical coherence tomography, the central retinal (foveal) thickness and total macular volume were measured before and at 1 and 3 months after injection. Visual acuity, intraocular pressure, and the incidence of reinjection were also examined. Fifty-two patients (86.7%) completed the 3-month follow-up.

RESULTS

The mean foveal thickness and total macular volume decreased significantly after either intravitreal or repeated retrobulbar triamcinolone injections. Foveal thickness and macular volume were significantly less after intravitreal injection than after repeated retrobulbar injections, although there had been no significant differences at baseline. The percent reductions in foveal thickness and macular volume were also greater after intravitreal injection than after retrobulbar injections. Improvement in visual acuity was significantly better after intravitreal injection than after the retrobulbar injections. The incidence of intraocular pressure rise (to > or =20 mm Hg) was greater in the intravitreal group than in the retrobulbar group, but this was readily controlled by the use of antiglaucoma medications. After completion of the 3-month follow-up, 24 patients (46.2%) underwent reinjection. The need for reinjections was significantly greater in the retrobulbar group than in the intravitreal group (P = .0001).

CONCLUSIONS

A single intravitreal injection of triamcinolone is significantly more effective than are repeated retrobulbar injections in reducing macular edema associated with branch retinal vein occlusion, and leads to greater improvement in visual acuity.

Transvitreal limited arteriovenous-crossing manipulation without vitrectomy for complicated branch retinal vein occlusion using 25-gauge instrumentation

PURPOSE

To evaluate a new technique, 25-gauge transvitreal limited arteriovenous-crossing manipulation without vitrectomy (LAM), for the treatment of branch retinal vein occlusion (BRVO) complicated by macular hemorrhage and/or macular edema recalcitrant to grid laser photocoagulation.

METHODS

Twelve eyes of 12 patients underwent LAM for BRVO performed by a single surgeon (M.S.H.) using the 25-gauge nitinol flexible-extendable blunt pick. The presence or absence of intraoperative reperfusion visualization, pre- and postoperative visual acuity, macular thickness as measured by optical coherence tomography, intraocular pressure, and lens status were evaluated.

RESULTS

Restoration of blood flow was noted in all patients and was based on intraoperative reestablishment of a red column of erythrocytes through the previously closed vessel. Mean visual acuity improved from 20/200 (logarithm of the minimal angle of resolution [LogMAR] +/- SD, 1.00 +/- 0.32) preoperatively to 20/70 (LogMAR +/- SD, 0.56 +/- 0.28) (P = 0.0003) at the final visit. Eleven (92%) of 12 eyes had >or=2 lines of visual improvement. Five eyes (45%) had final visual acuity of 20/50 or better. Mean macular thickness +/- SD improved from 401.0 +/- 73.2 to 178.7 +/- 19.6 microm (P < 0.0001) at the final visit. No statistically significant difference was noted in cataract progression or intraocular pressure. Mean follow-up +/- SD was 49.9 +/- 19.6 weeks. All patients were observed for at least 12 weeks.

CONCLUSION

LAM may achieve outcomes comparable with those of arteriovenous adventitial sheathotomy for complicated BRVO.

Multiple laser treatments for macular edema attributable to branch retinal vein occlusion

PURPOSE

To report the visual outcome of multiple laser treatments for macular edema attributable to branch retinal vein occlusions (BRVO) and to determine if any prognostic factors exist for improvement.

DESIGN

Retrospective chart review.

METHODS

A private practice with four vitreoretinal surgeons performed laser treatments on 88 eyes of 88 patients with macular edema secondary to BRVO from 1984 to 2003. Mean preoperative and postoperative visual acuities were collected after each laser treatment. Final visual acuities were also documented.

RESULTS

All 88 patients received at least one laser treatment, and 46 patients of the initial 88 underwent multiple treatments. Overall, forty-one (46.6%) of the total 88 patients improved by 2 or more lines, whereas 33 patients (37.5%) were within 1 line of the preoperative vision, and 14 patients (15.9%) worsened by 2 or more lines. The mean final visual improvement was 0.92 lines for all 88 patients. The group of patients that responded favorably to the first laser treatment (n = 37) showed an overall improvement of 3.5 lines. However, patients who responded poorly to the first laser treatment resulted in an overall worsening of vision by 0.96 lines.

CONCLUSIONS

Our study found that multiple laser treatments can improve visual acuity and resolve macular edema and that each additional laser treatment gives a patient a modest chance of visual improvement. A positive or stable visual response to first laser treatment portends a favorable prognosis with subsequent laser treatments.

Angiographic findings in arteriovenous dissection (sheathotomy) for decompression of branch retinal vein occlusion

BACKGROUND

Arteriovenous dissection (sheathotomy) is a new therapeutic option in patients with branch retinal vein occlusion (BRVO) and macular involvement. We present an angiographic follow-up of 22 patients who underwent arteriovenous dissection (AVD).

METHODS

Twenty-two patients (15 women; mean age 68.7+/-8.0 years) were examined preoperatively and 6 weeks, 3 months, 6 months, and 1 year after AVD. For assessment of retinal hemodynamics, arteriovenous passage time (AVP) of the affected and unaffected branches at first (AVPe) and at maximal (AVPmax) venous filling were measured. Changes in the foveal avascular zone (FAZ) were calculated to determine foveal structural changes. Visual acuity was assessed as functional parameter.

RESULTS

The early AVP (AVPe) of the affected branch increased from 4.4+/-0.8 s preoperatively to 4.9+/-0.6 s 6 weeks after surgery and decreased to 2.7+/-0.4 s 1 year after surgery (p=0.05). When compared to the unaffected control branch, AVPe was significantly increased in the affected branch preoperatively (4.5+/-0.8 s versus 1.5+/-0.2 s, p<0.01), 6 weeks (4.9+/-0.6 s versus 2.1+/-0.3 s, p<0.01), 3 months (2.7+/-0.4 s versus 1.5+/-0.2 s, p<0.01), and 6 months (3.1+/-0.4 s versus 2.2+/-0.3 s, p=0.02) after AVD. After 1 year, AVPe no longer differed between the affected and the control branch (2.7+/-0.4 s versus 2.6+/- 0.3 s). AVPmax was significantly increased in the affected branch preoperatively (11.8+/-0.8 s versus 7.7+/-1.0 s, p<0.05). The AVPmax in the affected branch with the exception of 3 months after surgery (10.2+/-1.1 s, p<0.01) was no longer elevated when compared to preoperative values. The area of the FAZ did not change significantly but showed a trend for enlargement.

CONCLUSION

AVD for decompression of BRVO leads to a significant decrease of AVP and may ameliorate retinal perfusion in the affected branch.

Vitrectomy with or without arteriovenous adventitial sheathotomy for macular edema associated with branch retinal vein occlusion

PURPOSE

compare the results of vitrectomy with or without arteriovenous (AV) crossing sheathotomy for macular edema associated with branch retinal vein occlusion (BRVO).

DESIGN

Interventional case series.

METHODS

A retrospective study of 36 eyes with BRVO-associated macular edema. Twenty eyes underwent AV sheathotomy (AS group), and 16 eyes underwent posterior vitreous detachment (PVD group). Best-corrected visual acuity (BCVA), fluorescein angiography (FA), and optical coherence tomography to determine foveal thickness were conducted preoperatively and at 12 months postoperatively.

RESULTS

The mean postoperative BCVAs were significantly better in both the AS and the PVD group (P = .008 and P = .001, respectively). Foveal thickness decreased significantly 1 month after surgery in both groups (P = .002 and P = .007) and continued to decrease up to 12 months. The postoperative mean BCVA and improvement of BCVA and foveal thickness were not significantly different for the two groups at any postoperative period. Postoperative FA showed reperfusion of the occluded vein in 10 eyes in the AS group and 2 eyes in the PVD group, and formation of shunt vessels at the AV crossing site or around the macular region in all of the other eyes of both groups.

CONCLUSIONS

Both AV sheathotomy and simple PVD significantly reduced macular edema associated with BRVO. However, there was no significant difference in the improvement of macular function following either procedure. Postoperative improvement of retinal circulation by either reperfusion of the occluded vein or collateral vessel formation was found. This accounted for functional and morphologic improvements.

MANAGEMENT OF MACULAR EDEMA IN BRANCH RETINAL VEIN OCCLUSION WITH SHEATHOTOMY AND RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR

PURPOSE

The common adventitial sheath that surrounds the retinal venule and arteriole at the crossing site plays a crucial role in branch retinal vein occlusion (BRVO). The purpose of this study was to report the surgical recanalization of the occluded vein using a bimanual technique and recombinant tissue plasminogen activator (tPA) and its effect on final visual acuity.

METHODS

Arteriovenous sheathotomy was performed, using a bimanual technique, followed by fluid-air exchange and injection of 25 mg of recombinant tPA over the area of the occluded vein.

RESULTS

Intraoperative sectioning of the common arteriovenous sheath was achieved in all 40 patients. Thrombus release was observed in 11 cases (27.5%) and was correlated with early surgery (P < 0.001) and better final visual recovery (P < 0.06). Optical coherence tomography showed macular thickness that decreased by greater than 40% in 31 patients (77.5%) compared with preoperatively, and correlated to postoperative visual acuity (P < 0.001). The mean visual acuity increased from 20/100 to 20/40, with 70% of patients gaining three or more lines of visual acuity (Pearson 0.378, P = 0.016).

CONCLUSION

Surgical venous decompression and injection of recombinant tPA may effectively manage macular edema secondary to BRVO, thus improving anatomic and visual outcome. Early surgical intervention may obtain maximum final visual recovery.

Internal limiting membrane peeling for decompression of macular edema in retinal vein occlusion: a report of 14 cases

BACKGROUND

Currently, there is no proven treatment for macular edema due to central retinal vein occlusion (CRVO). Moreover, not all cases with macular edema due to branch retinal vein occlusion (BRVO) respond to laser photocoagulation. We postulated that internal limiting membrane (ILM) peeling for decompression of macular edema in cases of retinal vein occlusion would facilitate egress of blood and extracellular fluid out of the inner retinal layers, leading to reduction of macular edema and improvement in visual acuity.

METHODS

Fourteen consecutive patients with macular edema due to CRVO or selected cases of BRVO, not eligible for laser photocoagulation, underwent pars plana vitrectomy with removal of preretinal hyaloid and peeling of the ILM stained with indocyanine green dye.

RESULTS

In all cases, intraretinal blood and retinal thickening diminished within 6 weeks of surgery. Visual acuity improved in 78.6% of cases. No surgical complications occurred, although one patient developed nuclear cataract 10 months postoperatively.

CONCLUSION

Pars plana vitrectomy with ILM peeling in selected cases of CRVO and BRVO showed improvement in visual acuity in this nonrandomized, noncontrolled study. This pilot study adds support to the concept that ILM peeling may of visual benefit when compared with the natural history in these vaso-occlusive diseases.

Management of branch retinal vein occlusion with vitrectomy and arteriovenous adventitial sheathotomy, the possible role of surgical posterior vitreous detachment

BACKGROUND

To analyze the results of vitrectomy and adventitial sheathotomy in the management of branch retinal vein occlusion (BRVO). This is a nonrandomized interventional case series.

METHODS

Patients with BRVO with progressive decrease in visual acuity underwent surgery and were prospectively evaluated in two centers. Surgical procedure included a 3-port pars plana vitrectomy, removal of the internal limiting membrane and arteriovenous crossing sheathotomy. Clinical evaluation consisted of best-corrected visual acuity, fluorescein angiography and optical coherence tomography.

RESULTS

Thirteen eyes were analyzed consecutively. An improvement in visual acuity of two ETDRS lines or more was observed in nine eyes (69%). The mean gain was 1.9 ETDRS lines. The absence of previous posterior vitreous detachment (PVD), poor initial visual acuity and the presence of retinal ischemia were correlated to the improvement in vision (P=0.014, P=0.002 and P=0.052, respectively). Eyes with initial PVD had a mean loss postoperatively of -5.7 lines, but eyes without PVD experienced a gain of 4.2 lines (P<0.001). Macular edema decreased significantly (preoperative thickness: 714 micro m, postoperative thickness: 353 micro m, P=0.04), whereas the aspect of the vein at the crossing and the non-perfused area remained unchanged.

CONCLUSION

Vitrectomy with sheathotomy seems to be of benefit in the management of BRVO, particularly in eyes with no previous PVD, and the main postoperative feature was the decrease in macular edema. The surgical detachment of posterior hyaloid could be as important (or more) as the sheathotomy itself. Further studies are needed to define the most efficient surgical management of BRVO.

The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch retinal vein occlusion

BACKGROUND

Arteriovenous (AV) sheathotomy, a potential treatment for branch retinal vein occlusion (BVO), surgically separates retinal vessels at an AV crossing. Relief of the aetiological obstruction, with resolution of cystoid macular oedema (CMO), may result in improved visual acuity.

METHODS

A retrospective review of consecutive cases of AV sheathotomy for BVO was undertaken. Eyes were categorised as having resolution (group 1), reduction (group 2), or persistence (group 3) of CMO. Intergroup comparisons were made with regard to preoperative, intraoperative, and postoperative parameters. Preoperative and postoperative visual acuities were compared within each group.

RESULTS

Of the 27 eyes identified, eight (29.6%) had resolution, 14 (51.8%) had reduction, and five (18.6%) had persistence of CMO. Median preoperative visual acuity was similar in all groups (1.0, 1.0, 1.3, respectively; p = 0.29). Overall median follow up was 12.0 months (Q1 = 12.0, Q2 = 22.5). Eyes in group 1 had significantly better median postoperative visual acuity than eyes in groups 2 and 3 (0.6, 1.0, 2.0 respectively; p = 0.01). A significantly higher proportion of eyes in group 1 had visual acuity improvement compared with eyes in the other groups (87.5% v 35.7% and 20.0%; p = 0.03). Median postoperative visual acuity was significantly better than median preoperative visual acuity in group 1 eyes only (p = 0.02). A higher percentage of group 1 eyes had evidence of postoperative retinal perfusion (83.0% v 21.43% and 40.0%; p = 0.16). Postoperative retinal detachment occurred in three eyes (11.1%).

CONCLUSION

Complete resolution of CMO after AV sheathotomy occurred in one third of patients, and postoperative vision improved significantly in this group. However, in the majority of cases, despite an improvement in CMO, there was no improvement in vision after AV sheathotomy.

Arteriovenous crossing dissection without separation of the retina vessels for treatment of branch retinal vein occlusion

PURPOSE

To evaluate visual outcome after arteriovenous (AV) crossing dissection for the treatment of branch retinal vein occlusion (BRVO) and secondary macular dysfunction in which difficulty separating the retinal vessels was experienced.

METHODS

A pars plana vitrectomy and dissection of the involved AV crossing site were performed consecutively in 20 eyes of 20 patients with BRVO and vision loss. The overlying retinal artery was dissected free from the retinal surface, and separation of the artery and vein at the crossing site was attempted.

RESULTS

In 19 of 20 eyes, the retinal artery was dissected around the crossing site, but a marked adhesion between the artery and vein precluded separation. After a mean follow-up of 10.5 months, VA improved by at least two lines in 16 eyes (80%), remained unchanged in three eyes (10%), and worsened by at least two lines in three eyes (10%). Mean change (+/- SE) in logMAR acuity was -0.28 +/- 0.11 (two or three lines of improvement, P = 0.016) at 1 to 2 months' follow-up and -0.44 +/- 0.14 (three or four lines of improvement, P = 0.008) at the final follow-up. Cataract formation or progression occurred in 88%.

CONCLUSIONS

A surgically important adhesion between the retinal artery and vein at proximal AV crossings was encountered in all eyes undergoing AV crossing dissection, correlating with previous histologic and cadaver eye studies. Cataract formation or worsening was a frequent complication. Visual improvement may occur after vitrectomy and AV crossing dissection without separation of the retinal vessels.

Vitrectomy with arteriovenous decompression and internal limiting membrane dissection in branch retinal vein occlusion

PURPOSE

The therapeutic armamentarium for functional improvement after branch retinal vein occlusion (BRVO) is limited with uncertain efficacy. Some surgeons have proposed surgical decompression of the vein at the arteriovenous (AV) crossing.

METHODS

Forty-three patients with BRVO were treated in the authors' department from August 1999 to April 2001 with AV decompression. Twenty-five patients with comparable BRVO who refused this surgical intervention served as a control group. All 68 patients received an isovolemic hemodilution therapy for 10 days. The surgical procedure consisted of a standard pars plana vitrectomy and separation of the overlying artery from the vein using microscissors. In 16 cases dissection of the internal limiting membrane (ILM) in the macular area and around the AV crossing was also performed. Assessment of visual acuity, fluorescein angiography, and multifocal electroretinography were performed preoperatively and 6 weeks after surgery in seven patients.

RESULTS

Surgical procedure and postoperative course were uneventful. In most of the treated eyes visual acuity improved and fluorescein angiography revealed capillary reperfusion. Functional results in patients with AV decompression were highly significantly better than in the control group. Furthermore, removal of the ILM seems to have an additional beneficial effect on the functional outcome.

CONCLUSION

These results demonstrate the therapeutic effect of surgical AV decompression in BRVO. Additional removal of the ILM seems to improve the functional results. Further experience may answer some open questions.

Vitreoretinal surgery for complications of branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is second only to diabetic retinopathy as a cause of retinal vascular disease. Vision loss from BRVO may be associated with multiple causes, including macular edema, macular ischemia, foveal hemorrhage, vitreous hemorrhage, epiretinal membrane, and retinal detachment. The few published studies that report outcomes of pars plana vitrectomy for complications of BRVO consist only of case reports and small case series, limitations of which include small sample sizes and lack of comparison groups. Given the variable outcomes among patients with untreated BRVO, comparison groups are necessary for accurate evaluation of the efficacy of pars plana vitrectomy for BRVO.