Surgical induction of chorioretinal venous anastomosis in ischaemic central retinal vein occlusion: a non-randomised controlled clinical trial

Predictors of Neovascular Glaucoma in Central Retinal Vein Occlusion

PURPOSE

To determine the risk factors for development of neovascular glaucoma (NVG) in patients after an acute central retinal vein occlusion (CRVO).

DESIGN

Retrospective cohort study.

METHODS

Review of medical records of 646 patients with a diagnosis of CRVO between 2013 and 2017 at the Bascom Palmer Eye Institute.

INCLUSION CRITERIA

(1) CRVO onset to presentation <90 days; (2) absence of anterior segment neovascularization on presentation; (3) no intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection before presentation. Patients meeting inclusion criteria were screened for potential risk factors for development of NVG. Risk of developing NVG was assessed with Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Thirteen of 98 patients (13%) who met inclusion criteria developed NVG. The mean adjusted time to NVG diagnosis from onset of CRVO-related symptoms was 212 days. Patients presenting with a worse initial visual acuity (P = .034), a relative afferent pupillary defect (RAPD) (P = .002), or a history of systemic hypertension (P = .026) had an increased risk of NVG compared to those who did not. Age, body mass index, history of glaucoma, history of diabetes, and central retinal thickness were not significantly associated with development of NVG.

CONCLUSIONS

Risk factors for NVG development included history of systemic hypertension, worse visual acuity on presentation, and RAPD on presentation. Patients presenting with these findings should be followed at closer intervals and informed of the greater risk for neovascularization. Intravitreal anti-VEGF therapy delayed but did not prevent NVG.

Management of macular edema due to central retinal vein occlusion - The role of aflibercept

Central retinal vein occlusion (CRVO) can cause vision loss. The pathogenesis of CRVO involves a thrombus formation leading to increased retinal capillary pressure, increased vascular permeability, and possibly retinal neovascularization. Vision loss due to CRVO is commonly caused by macular edema. Multiple treatment modalities have been used to treat macular edema. Currently, the most common therapy used is intravitreal inhibition of vascular endothelial growth factor (VEGF). The three most widely used agents are aflibercept, bevacizumab, and ranibizumab and they are effective at blocking VEGF. In addition, intraocular steroids can be used to treat macular edema. This review will briefly cover the treatment options and discuss in greater detail the efficacy and safety of aflibercept.

Central Retinal Vein Occlusion: A Review of Current Evidence-based Treatment Options

A central retinal vein occlusion (CRVO) can induce an ischemic and hypoxic state with resulting sequelae of macular edema and neovascularization. Many treatment options have been studied. Our review aims to investigate the safety and efficacy of the multiple treatment options of CRVO. A PubMed and Cochrane literature search was performed. Well-controlled randomized clinical trials that demonstrated strong level 1 evidence-based on the rating scale developed by the British Centre for Evidence-Based Medicine were included. Seven clinical trials met inclusion criteria to be included in this review. These included studies that investigated the safety and efficacy of retinal photocoagulation (1 study), intravitreal steroid treatment (2 studies), and antivascular endothelial growth factor treatment (4 studies) for the treatment of CRVO. In addition, studies evaluating surgical treatment options for CRVO were also included. Many treatment modalities have been demonstrated to be safe and efficacious in the treatment of CRVO. These treatment options offer therapeutic benefits for patients and clinically superior visual acuity and perhaps the quality of life after suffering from a CRVO.

Systematic literature review of treatments for management of complications of ischemic central retinal vein occlusion

Background

To understand the clinical and economic outcomes of treatments for managing complications of ischemic central retinal vein occlusion (iCRVO).

Methods

We conducted a systematic literature review by searching multiple databases and ophthalmology conferences from 2004 to 2015. Studies published in English language and populations of age ≥45 years were included. For clinical endpoints, we defined eligibility criteria as randomized controlled trials, prospective before-and-after study designs, and non-randomized studies reporting on treatments in patients with iCRVO. For economic endpoints, all types of study design except cost-of-illness studies were included. We evaluated the definitions of ischemia, clinical and economic endpoints, and rate of development of complications. Risk of bias was assessed for clinical studies using the Cochrane risk-of-bias tool.

Results

A total of 20 studies (1338 patients) were included. Treatments included anti-vascular endothelial growth factors (anti-VEGFs), steroids, and procedures primarily targeting macular edema and neovascularization. Ischemia was not defined consistently in the included studies. The level of evidence was mostly low. Most treatments did not improve visual acuity significantly. Development of treatment complications ranged from 11 to 57 %. Incremental cost-effectiveness ratios reported for anti-VEGFs and steroids were below the accepted threshold of GB£30,000, but considering such treatments only ameliorate disease symptoms they seem relatively expensive.

Conclusions

There is a lack of evidence for any intervention being effective in iCRVO, especially in the prevention of neovascularisation. iCRVO poses a significant clinical and economic burden. There is a need to standardize the definition of ischemia, and for innovative treatments which can significantly improve visual outcomes and prevent neovascular complications.

Full-thickness retinochoroidal incision in the management of central retinal vein occlusion

Purpose. To evaluate the clinical outcomes in patients with central retinal vein occlusion (CRVO) treated with full-thickness retinochoroidal incisions and to compare whether there is difference in treatment response in ischemic and nonischemic CRVO. Methods. Retrospective study of patients of CRVO receiving full-thickness retinochoroidal incisions in Changhua Christian Hospital. Fluorescein angiography (FA), slit-lamp biomicroscopy, indirect funduscopy, best corrected visual acuity, and central macular thickness (CMT) measured by optical coherence tomography were performed pre- and postoperatively. Patients were divided into an ischemic and nonischemic group according to the findings of FA. Patients were followed up for at least 1 year. Results. Twenty-eight eyes (14 ischemic and 14 nonischemic CRVO) were included. Functional retinochoroidal venous anastomosis (RCVA) was achieved in 48 of the 65 retinochoroidal incisions (73.8%). Central macular thickness (CMT) and retinal hemorrhage decreased significantly after the surgery. Significant visual gain was observed postoperatively in the nonischemic group, but not in the ischemic group. Postoperative complications included vitreous hemorrhage (17.8%), neovascular glaucoma (7.1%), and preretinal fibrovasular membrane (10.7%), all of which were in the ischemic group. Conclusions. RCVA formation induced by retinochoroidal incisions could improve venous flow, and decrease CMT and retinal hemorrhage. However, only eyes with nonischemic CRVO showed visual improvement.

Comparative evaluation between ranibizumab combined with laser and bevacizumab combined with laser versus laser alone for macular oedema secondary to branch retinal vein occlusion

Purpose:

To evaluate the anatomical and functional efficacy of combination therapy of intravitreal ranibizumab with laser or intravitreal bevacizumab with laser treatment compared to only laser treatment for macular edema due to branch retinal vein occlusion (BRVO).

Materials and Methods:

Thirty eyes of 30 patients with BRVO of at least 6 weeks duration were randomized into three groups: Group 1 received a single dose of intravitreal Ranibizumab followed by grid laser treatment, Group 2 received a single dose of intravitreal Bevacizumab followed by grid laser treatment, and Group 3 received grid laser alone. Outcomes at 6 months follow-up were reported. Data were collected on best corrected visual acuity (BCVA), central foveal thickness (CFT), and gain in lines of Snellen acuity.

Results:

At 6 month follow-up, the difference in the mean BCVA and CFT between the three treatment groups was not statistically significant (P > 0.05, all comparisons). Six eyes (60%) in Group 1, four eyes (40%) in Group 2 and two eyes (20%) in Group 3 had a statistically significant gain of ≥3 lines of Snellen acuity (P < 0.05).

Conclusion:

Both ranibizumab and bevacizumab combined with laser photocoagulation, resulted in better outcomes than grid laser treatment.

The ABCs of RVO: a review of retinal venous occlusion

Retinal vein occlusions are important causes of loss of vision; indeed, they are the second most common retinal vascular disease, following diabetic retinopathy. For this reason alone, primary eye-care providers must be well versed in diagnosis and management. Risk factors, though not universally agreed upon, include but are not limited to advancing age, systemic hypertension, arteriolarsclerosis, diabetes, hyperlipidaemia, blood hyperviscosity, thrombophilia, ocular hypertension and glaucoma. Typically, visual loss is secondary to macular oedema and/or retinal ischaemia. Treatment modalities have included observation, systemic thrombolysis and haemodilution, radial optic neurotomy, chorioretinal anastomosis, vitrectomy, laser photocoagulation and intravitreal injection of anti-inflammatory and, most recently, anti-vascular endothelial growth factors.

Pars plana vitrectomy with multiple transvenous chorioretinotomies for macular edema due to retinal vein occlusion

BACKGROUND AND OBJECTIVE

To review results of vitreous surgery for branch and central retinal vein occlusion (BRVO and CRVO).

PATIENTS AND METHODS

All cases of vitrectomy with multiple transvenous chorioretinotomies for retinal vein occlusion at a vitreoretinal subspecialty practice were reviewed.

RESULTS

Twenty eyes of 20 patients (four with BRVO and 16 with CRVO) were included. Mean time from diagnosis to surgery was 15 months, and mean postoperative follow-up was 22 months. Injections of bevacizumab or ranibizumab decreased postoperatively (P < .0001; Poisson regression model), while log-MAR visual acuity improved (P = .0396; Wilcoxon signed-rank test). Ten eyes required no further injections postoperatively, and three eyes required one postoperative injection. Macular edema expressed as OCT maximum macular thickness was significantly reduced postoperatively at 6 months and 12 months (P = .0077 and .0093, respectively).

CONCLUSION

In a pilot study of retinal vein occlusion treatment, multiple transvenous chorioretinotomy surgery significantly improved visual acuity and macular edema and reduced intravitreal drug dependency. Further study is warranted.

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.

Management of retinal vein occlusion--consensus document

Retinal vein occlusion (RVO) can have severe consequences for the people affected by the disease, including visual loss with costly social repercussions. Currently, there is no European consensus with regard to the management of RVO. Following a careful review of the medical literature as well as the data from several clinical trials, a collaborative group of retina specialists put forth practical recommendations based on the best available scientific evidence for the clinical approach to RVO. Taking into consideration the recent advances in diagnostic tools and management options, the present document aims to provide the European ophthalmologists with guidelines for clinical practice to the benefit of their patients.

Natural history of central retinal vein occlusion: an evidence-based systematic review

OBJECTIVE

To describe the natural history of central retinal vein occlusion (CRVO) based on the best available evidence from the literature.

CLINICAL RELEVANCE

Central retinal vein occlusion is a common sight-threatening retinal vascular disease. Despite the introduction of new interventions, the natural history of CRVO is unclear.

METHODS

Systemic review of all English language articles retrieved using a keyword search of MEDLINE, EMBASE, Current Contents, and the Cochrane Library to November 13, 2008. This was supplemented by hand-searching references of review articles published within the last 5 years. Two investigators independently identified all relevant observational studies evaluating the natural history of RVO and all clinical trials evaluating interventions for CRVO; an untreated control arm was included.

RESULTS

Of 5966 citations retrieved, 53 studies were reviewed, providing 3271 eyes with CRVO for analysis of its natural history. Visual acuity (VA) was generally poor at baseline (<20/40) and decreased further over time. Although 6 studies reported an improvement in VA, none of these improvements resulted in VA better than 20/40. Up to 34% of eyes with nonischemic CRVO converted to ischemic CRVO over a 3-year period. In ischemic CRVO cases, neovascular glaucoma developed in at least 23% of eyes within 15 months. In nonischemic CRVO cases, macular edema resolved in approximately 30% of eyes over time, and subsequent neovascular glaucoma was rare.

CONCLUSIONS

Untreated eyes with CRVO generally had poor VA, which declined further over time. One quarter of eyes with nonischemic CRVO converted to ischemic CRVO.

Surgical treatment of central retinal vein occlusion

The treatment of central retinal vein occlusion (CRVO) is still a subject of debate. Medical therapy efforts, as well as retinal laser photocoagulation, have mostly dealt with management of the sequelae of CRVO, and have shown limited success in improving visual acuity. The unsatisfactory results of such therapeutic efforts led to the development of new treatment strategies focused on the surgical treatment of the occluded retinal vein. The purpose of this review is to summarize the outcomes of commonly reported surgical treatment strategies and to review different opinions on the various surgical approaches to the treatment of CRVO.

Induction of retinochoroidal venous anastomosis in central retinal vein occlusion with macular edema via a full-thickness retinochoroidal incision

PURPOSE

To report the induction of retinochoroidal venous anastomosis (RCVA) in the treatment of nonischemic central retinal vein occlusion (CRVO) with macular edema via a full-thickness retinochoroidal incision.

METHODS

In nine eyes with nonischemic CRVO and intractable macular edema, one or two full-thickness incisions transacting a major retinal branch vein to the level of inner sclera were made in conjunction with vitrectomy. Fluorescein angiography was conducted to evaluate the formation of functional RCVA. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were compared before and after the surgery.

RESULTS

The mean follow-up period +/- SD was 12.0 +/- 5.1 months. All nine eyes developed functional RCVA after the surgery. The mean BCVA +/- SD improved from 0.75 +/- 0.30 logMAR (logarithm of the minimal angle of resolution) to 0.55 +/- 0.26 logMAR (P = 0.018), and the mean CMT +/- SD was reduced from 686 +/- 265 microm to 251 +/- 150 microm (P = 0.011). Additional surgery was performed on one eye due to persistent vitreous hemorrhage.

CONCLUSION

Full-thickness retinochoroidal incision appears to raise the rate of successful RCVA formation and may improve the outcome of CRVO with macular edema.

Interventions for Central Retinal Vein Occlusion

TOPIC

To assess the evidence for the effectiveness of interventions to improve visual acuity (VA) and prevent or treat neovascularization secondary to central retinal vein occlusion (CRVO).

CLINICAL RELEVANCE

Central retinal vein occlusion is a common cause of visual morbidity and blindness. Many different interventions have been advocated, but the evidence justifying their use remains unclear.

METHODS/LITERATURE REVIEWED

English and non-English language articles were retrieved using a keyword search of Medline (1966 onwards), Embase, the Cochrane Collaboration, the National Institutes of Health Clinical Trials database, and the Association for Research in Vision and Ophthalmology (2003-2005). This was supplemented by manually searching references of review articles. Two investigators independently identified all randomized clinical trials (RCTs) on interventions in CRVO with more than 3 months' follow-up.

RESULTS

Of 4133 citations retrieved, 17 RCTs comparing intervention with a control group were identified. There were 4 RCTs on laser photocoagulation. Grid macular laser photocoagulation did not improve VA in CRVO with macular edema. Prophylactic panretinal photocoagulation did not prevent angle and iris neovascularization in ischemic CRVO, but resulted in regression of angle and iris neovascularization and reduced progression to neovascular glaucoma. There were 4 RCTs that reported improvement in VA with inpatient hemodilution, 2 RCTs with no significant improvement, and 1 RCT showing deterioration in VA after outpatient hemodilution. Randomized clinical trials evaluating ticlodipine, troxerutin, and streptokinase showed a limited or no benefit.

CONCLUSIONS

This review found limited level I evidence for any intervention to improve VA in patients with CRVO. Panretinal photocoagulation resulted in regression of neovascularization. Hemodilution may improve vision in some patients, but the data conflict. More robust randomized controlled trials evaluating current treatments for CRVO are needed. The results of ongoing RCTs on intravitreal triamcinolone, anti-vascular endothelial growth factor agents, and chorioretinal anastomosis are awaited with interest.