Central retinal vein occlusion: review of management

Central retinal vein occlusion in young population: risk factors and outcomes

Objective

To evaluate the risk factors and outcomes of central retinal vein occlusion (CRVO) in young patients (< 40 years).

Methods

In this retrospective monocentric case series, we included young patients (<40 years) with CRVO. Patients’ medical files were analyzed focusing on demographic characteristics, suspected risk factors, ophthalmic work-up, visual acuity (VA), treatment, and outcomes.

Results

A total of 54 eyes of 52 patients were included. Central retinal vein occlusion was considered idiopathic in 13 patients (25%). The main risk factors identified were ocular hypertension (20.4%), inflammation (20.4%), high blood pressure (14.8%), and coagulation abnormality (11.1%). Final VA was lower in patients with high blood pressure and inflammation when compared to patients with no risk factor (p = 0.03 and 0.04, respectively). Intravitreal injections were needed in 23 eyes (42.6%) and 19 eyes (35.2%) received panretinal photocoagulation treatment.

Conclusion

Central retinal vein occlusion is frequently associated with risk factors in young patients (75% of patients). In addition to the usual factors found in older patients, such as ocular hypertension and high blood pressure, coagulation abnormality and inflammation were also among the risk factors identified. Young patients with CRVO should be evaluated for the presence of risk factors and patients with high blood pressure or inflammatory findings should be followed carefully since they have a worse outcome.

Analysis of ganglion cell-inner plexiform layer thickness in retinal vein occlusion with resolved macular edema

PURPOSE

To analyze the retinal ganglion cell-inner plexiform layer (GCIPL) changes in retinal vein occlusion (RVO) eyes with resolved macular edema using optical coherence tomography.

METHODS

We compared the average and minimum GCIPL thickness in RVO eyes with fellow eyes and healthy controls including 40 unilateral RVO patients and 48 healthy subjects. The average GCIPL thickness in BRVO eyes was segmented into the affected and opposite area according to the site of lesion, comparing them with corresponding areas in fellow eyes. Furthermore, maximum central macular thickness (CMT), visual acuity (VA), and intravitreal injection times were recorded to investigate their relationship with the GCIPL thickness.

RESULTS

Despite no significant difference in CMT (P = 0.96), the average (P = 0.02 and P < 0.001, respectively) and minimum (both P < 0.001) GCIPL thicknesses were decreased in RVO eyes with resolved macular edema after treatment in comparison to fellow eyes and healthy eyes. Maximum CMT thickness was negatively correlated with the minimum GCIPL thickness (r = - 0.47, P = 0.003). VA and average GCIPL thickness were associated (r_s = - 0.49, P = 0.002). In a subgroup analysis that only included BRVO patients, the opposite area revealed no significant difference between two eyes (P = 0.91) although the affected area in BRVO eyes was decreased (P < 0.001).

CONCLUSIONS

A decrease of GCIPL thickness in RVO was observed even after anatomic restoration and associated with VA prognosis. These GCIPL defects could be attributable to systemic risks and RVO itself, not anti-VEGF effects.

Risk factors for central retinal vein occlusion in young adults

Purpose:

Several risk factors have been identified for central retinal vein occlusion (CRVO) in older population. CRVO in young is uncommon, and the risk factors for this group are unclear. This large retrospective, cross-sectional study used the National Inpatient Sample (NIS) database to evaluate the risk factors for CRVO in patients 18 to 40 years of age.

Methods:

The 2002 to 2014 NIS database was used. All patients 18 to 40 years of age with a primary diagnosis of CRVO were identified. Age- and gender-matched non-CRVO controls were randomly selected. The primary outcome was identification of risk factors for CRVO. Chi-square analysis and Firth logistic regression were performed with IBM SPSS 23 and R packages versions 3.4.3, respectively. p < 0.05 was considered significant.

Results:

A total of 95 weighted young CRVO patients were identified. The average age was 31.44 ± 6.41 years with no gender predilection. Systemic and ocular conditions found to have statistically significant associations with CRVO included primary open-angle glaucoma (POAG) (OR 836.72, p < 0.001), retinal vasculitis (OR 705.82, p < 0.001), pseudotumor cerebri (OR 35.94, p < 0.001), hypercoagulable state (OR 25.25, p < 0.001), history of deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 21.88, p < 0.001), and hyperlipidemia (OR 3.60, p = 0.003).

Conclusion:

The most significant risk factors for CRVO in young adults were POAG, retinal vasculitis, and pseudotumor cerebri. Hypercoagulable states and DVT/PE were also associated with CRVO in this population. Systemic inflammatory conditions were not associated with CRVO. Traditional risk factors such as hypertension and diabetes did not pose significant risks, whereas hyperlipidemia was deemed a significant risk factor.

Retinal Artery Occlusion in Young Patients: A 6-Year Review

Purpose:

This article describes the characteristics, management, and etiology of retinal artery occlusions (RAOs) in young patients.

Methods:

A retrospective chart review of patients <50 years of age with ophthalmic and RAOs was conducted. Data were collected on demographics, clinical presentation, laboratory and imaging evaluation, management, and outcome.

Results:

Seventeen eyes of 15 patients younger than 50 (mean age, 34±8 years; 71% male, 29% female) with RAOs were identified. AOs included: 8 (47%) central RAOs (CRAOs), 5 (29%) branch RAOs (BRAOs), 3 (18%) ophthalmic AOs (OAOs), and 1 (6%) combined CRAO and vein occlusion (CRAO/CRVO). Logarithm of the minimum angle of resolution visual acuity (VA) at presentation was 2.6±4 (Snellen range 20/15 to no light perception). Systemic diseases in patients with BRAO included Susac disease (n = 1), sickle cell disease (n = 2), patent foramen ovale (PFO) (n = 1), and HIV (n = 1). CRAO was diagnosed in 4 patients after invasive surgery (3 after neurosurgery and 1 after cardiac surgery). Other patients had hypertension (n = 3), hypercoagulability due to uterine cancer (n = 1), and PFO (n = 1). OAOs were noted in 1 patient with Saturday night retinopathy and in 1 with ruptured internal carotid aneurysm at the level of the ophthalmic artery. Two eyes with CRAO were treated with tissue plasminogen activator (1 intraophthalmic artery through catheterization and 1 intravenously) without any change in final VA. In these patients, VA remained poor (VA hand motions – counting fingers) at 6 months or greater follow-up visits.

Conclusion:

RAO in young patients is uncommon. In this series, one-fourth of occlusions were seen during the perioperative period. A significant number of patients had concurrent uncontrolled hypertension. Other associated systemic findings included PFO, hypercoagulability, sickle cell disease, Susac disease, and HIV.

Genetic Background of a Recurrent Unusual Combined Form of Retinal Vein Occlusion: A Case Report

The authors report a rare case of nonischemic branch retinal vein occlusion and nonischemic hemiretinal vein occlusion in a patient with impaired fibrinolysis. A 61-year-old woman presented to the Department of Ophthalmology, Clinical Hospital Center Split, Croatia, with acute blurring of vision in the right eye (RE) due to branch retinal vein occlusion. Ophthalmologic evaluation revealed a best corrected visual acuity (BCVA) of 0.02 in the RE and of 1.0 in the left eye. Ophthalmoscopy and fluorescein angiography of the RE demonstrated signs of nonischemic branch retinal vein occlusion. She was otherwise healthy and had no other ocular and systemic diseases. She was treated with 3 consecutive intravitreal applications of anti-vascular endothelial growth factor (anti-VEGF; bevacizumab) due to cystoid macular edema with full resolution of the intraretinal fluid and improvement of the BCVA to 0.9. After 8 months, she presented again with acute blurring of vision in the same (right) eye with a BCVA of 0.5. Ophthalmoscopy and fluorescein angiography of the RE indicated nonischemic hemiretinal vein occlusion. She was treated with a single intravitreal application of anti-VEGF (ranibizumab) due to macular edema. Full resolution of the intraretinal fluid and improvement of the BCVA to 0.9 were achieved. A laboratory workup was performed to rule out all known causes of retinal venous occlusive disease, which showed negative results. A molecular analysis showed the gen of thrombophilia – plasminogen activator inhibitor (PAI)-1 4G/5G polymorphism genotype – as the only risk factor for retinal venous occlusive disease in our patient.

Aflibercept in macular edema secondary to retinal vein occlusion: A real life study

Purpose

To evaluate the real life outcomes of intravitreal aflibercept (IVAfl) treatment in patients with macular edema (ME) secondary to retinal vein occlusion (RVO) during the first year of treatment.

Methods

Retrospective case series. Newly diagnosed or persistent ME patients secondary to RVO who were treated with IVAfl and had a follow-up period of at least 12 months were included. Twenty-two patients (54.8%) received 3 loading month loading doses IVAfl initially, whereas 20 patients (45.2%) did not receive. Then the patients were treated on an as-needed treatment regimen. Primary outcome measures of this study included the change in best corrected visual acuity (BCVA) and central retinal thickness (CRT). Secondary outcome measures were the number of visits and injections.

Results

Forty-two eyes of 42 patients were included. Fourteen patients (33.3%) had central RVO, and 28 (66.7%) had branch RVO. Mean BCVA at baseline and month 12 was 0.98 ± 0.58 and 0.82 ± 0.65 LogMAR, respectively (p = 0.04). Mean CRT at baseline and month 12 was 511 ± 141 and 304 ± 95 μm, respectively (p < 0.0001). Mean number of visits was 5.9 ± 2.1 (range 3–11) and injections was 3.2 ± 1.7 (range 1–8) at month 12.

Conclusion

In conclusion, IVAfl treatment seemed to be effective in patients with ME secondary to RVO with respect to visual and anatomical outcomes in real life. In this study the number of visits and injections was lower that randomized controlled trials, but the functional and anatomical outcomes are probably still acceptable.

En-face optical coherence tomography angiography of neovascularization elsewhere in hemicentral retinal vein occlusion

Purpose

To evaluate how the growth of neovascularization elsewhere (NVE) was delineated in an eye with hemicentral retinal vein occlusion (CRVO) using optical coherence tomography (OCT) angiography.

Patients and methods

We examined a 64-year-old man diagnosed with hemi-CRVO. The area around the occluded vein was scanned using a spectral-domain OCT device (RTVue XR Avanti). Blood flow was detected using the split-spectrum amplitude-decorrelation angiography (SSADA) algorithm. Color fundus photography, fluorescein angiography (FA), and OCT angiography examinations were performed at the first visit and at 3 and 6 months postpresentation.

Results

At the first visit, FA revealed delayed retinal venous filling and extensive areas of capillary nonperfusion. The patient underwent a trial of intravitreal ranibizumab injection (0.5 mg/0.05 mL) for the treatment of macular edema. At 3 months postpresentation, there was no NVE around the occluded vein in the en-face SSADA image, but at 6 months, NVE appeared on the occluded veins. The en-face SSADA image showed the NVE structure in the fibrovascular membrane on the occluded vein more clearly than FA images.

Conclusion

OCT angiography clearly visualized the sprouting of NVE in an eye with hemi-CRVO. New findings of the vascular structure of NVE in hemi-CRVO were revealed using the en-face SSADA algorithm.

Intravitreal bevacizumab in the treatment of neovascular glaucoma secondary to central retinal vein occlusion: a case report

Introduction

Every eye with central retinal vein occlusion (CRVO) is at risk for developing neovascular glaucoma (NVG). Vascular endothelial growth factor (VEGF) has been shown to play a key role in the development of NVG in CRVO. Bevacizumab (Avastin; Genentech, San Francisco, CA) is a recombinant monoclonal antibody binding all isoforms of VEGF. Several studies have demonstrated intravitreal bevacizumab-induced regression of iris and angle neovascularisation associated with NVG.

Case presentation

A 74 year old female presented with acute onset decreased vision in the right eye. Ophthalmic exam revealed acute non-ischemic CRVO in the right eye. A month later, follow up exam showed progression into ischemic CRVO and secondary NVG, which was successfully treated with intravitreal Bevacizumab followed by pan retinal photocoagulation (PRP).

Conclusion

Our case report highlights the use of intravitreal Bevacizumab in combination with PRP for the treatment of NVG secondary to CRVO.

Central retinal vein occlusion: a case report and review of the literature

Introduction

Central retinal vein occlusion is one of the major causes of severe vision impairment and blindness in adults.

Case presentation

We present a case of unilateral ischemic central retinal vein occlusion in a 54-year-old woman with history of uncontrolled hypertension and open angle glaucoma. Laboratory tests including complete hypercoagulability and thrombotic workup were completed.

Conclusion

Our case illustrates an interesting presentation of unilateral ischemic central retinal vein occlusion, where hypertension and glaucoma were thought to be the main risk factors. Close follow up, tight blood pressure and glaucoma control are crucial to prevent similar scenario in the fellow eye.

Central retinal vein thrombosis and hyperhomocysteinemia in a young patient with renal transplantation

A 28-year-old woman was admitted with a sudden loss of vision in the right eye. She underwent renal transplantation in June 1999 for chronic renal failure secondary to amyloidosis. Upon ophthalmologic examination, the patient was diagnosed with central retinal vein occlusion. Physical and laboratory examinations failed to disclose any remarkable pathology except for high homocysteine levels. Hyperhomocysteinemia has been reported as a potential risk factor requiring treatment and a significant association has been found between this condition and central retinal vein thrombosis.

ASSESSMENT OF THE ROLE OF THROMBIN ACTIVATABLE FIBRINOLYSIS INHIBITOR IN RETINAL VEIN OCCLUSION

PURPOSE

To determine whether elevated levels of thrombin activatable fibrinolysis inhibitor (TAFI) may contribute to thrombotic risk for patients with retinal vein occlusion (RVO) and to investigate the possible correlations between TAFI activity level and other conventional risk factors.

METHODS

Ninety patients with RVO (cases), except those receiving medication affecting the study parameters, those undergoing a surgical procedure within the last week, and those with kidney and/or liver failure, were enrolled in the study. The control group included similar patients matched for age and sex. After written informed consent was obtained, parameters including TAFI activity levels, conventional risk factors, results of routine hematological examination, and factor V Leiden and prothrombin G20210A mutations were evaluated by analysis of blood samples obtained after an 8-hour fast.

RESULTS

Although TAFI activity levels were slightly elevated in cases (190.5 +/- 43.8) compared with controls (183.9 +/- 41.8), the difference was not statistically significant (P = 0.36). According to evaluation of TAFI activity in subgroups (>200%, 150-200%, and 0-150%), 36.7% with central RVO, 40.0% with branch RVO, and 30% of controls were found to have TAFI activity of >200% (P = 0.83). TAFI activity levels did not correlate with age, sex, demographics, clinical status, and hematological variables. Finally, in stepwise regression analysis, TAFIa (carboxypeptidase U) activity was not found to be an important risk factor for RVO.

CONCLUSION

On the basis of these data, TAFI activity was not found to be a new risk factor for either type of RVO. However, further larger studies may better identify the exact role of TAFI in the pathogenesis of RVO.

Is elevated level of soluble endothelial protein C receptor a new risk factor for retinal vein occlusion?

BACKGROUND

To evaluate the systemic and thrombophilic risk factors for retinal vein occlusion (RVO) and to determine whether the elevated level of soluble endothelial protein C receptor (sEPCR) is a risk factor for thrombosis.

METHODS

In this case-control study, 56 patients with central RVO (CRVO), 26 patients with branch RVO (BRVO) and 78 healthy sex- and age-matched subjects were enrolled. Following ophthalmological examination, venous blood was analysed for glucose, lipid profile, lipoprotein (a), homocysteine, activated partial thromboplastin time, fibrinogen, factor VIII, protein C activity, protein S activity, activated protein C resistance, antithrombin III activity, lupus anticoagulant, anti-cardiolipin antibody, anti-phospholipid antibody, sEPCR, factor V Leiden mutation and prothrombin G20210A mutation.

RESULTS

Apart from hypertension, glaucoma, lipoprotein (a), homocysteine and factor VIII, elevated levels of sEPCR were found to be a risk factor for CRVO (odds ratio, 1.02; 95% confidence interval, 1.007-1.028; P = 0.001). Patients with CRVO had significantly higher levels of sEPCR than those with BRVO and controls (respectively, 160.1 +/- 83.8, 116.8 +/- 65.2 and 111.3 +/- 60.5; P = 0.005). Moreover, 39% of patients with CRVO had levels of sEPCR more than 200 ng/mL, and only 5% of controls and 11% of patients with BRVO had similar high levels.

CONCLUSIONS

Besides known classical risk factors, elevated levels of sEPCR seem to be an important candidate risk factor for especially CRVO.

Les occlusions vasculaires rétiniennes : diagnostic et prise en charge

PURPOSE

The diagnosis of retinal venous and arterial occlusions is usually easily evoked on visual symptoms and ophthalmoscopic features. However, their management (etiologic explorations and treatment) has not been formally established and remains controversial.

CURRENT KNOWLEDGE AND KEY POINTS

Some retinal vascular occlusions may result of loco-regional ocular causes. They more often occur in patients with cardiovascular pathologies or risk factors, or sometimes other systemic diseases that need to be recognized for a proper treatment. Therefore, a comprehensive management of patients with retinal vascular occlusions is necessary to correct associated diseases or predisposing abnormalities that could lead to local recurrences or systemic events.

CONCLUSION

Along with a review of the literature, we suggest a practical approach for the management of retinal vascular occlusions, which requires a collaboration between the ophthalmologist and other physicians: general practitioner, cardiologist, internist... as appropriate according to each case.

Cardiovascular and thrombophilic risk factors for central retinal vein occlusion

Retinal vein occlusion (RVO) is a relatively common disease that is often associated with a variety of systemic disorders including arterial hypertension, diabetes mellitus, dyslipidemia, and systemic vasculitis. There are various types of RVO, categorized on the basis of the site of occlusion and on the type of consequent vascular damage. Central retinal vein occlusion (CRVO) is the most frequently occurring and clinically relevant type of RVO. In addition to the well-known classical risk factors, new hemostasis-related ones have been investigated in patients affected by CRVO. The data concerning a number of parameters remain contradictory; yet, high levels of type 1 plasminogen activator inhibitor (PAI-1) and hyperhomocysteinemia appear to play a significant role in the pathogenesis of this disease. Although based on a limited number of studies, this new knowledge could eventually provide important indications regarding prognosis and therapeutic strategies.

Is activated factor VII associated with retinal vein occlusion?

AIM

To determine whether a newly identified thrombophilia factor, activated factor VII (FVIIa), is associated with retinal vein occlusion (RVO).

METHODS

54 consecutive cases with RVO seen between March and September 1999 were included in the study. 22 cases had central retinal vein occlusion (CRVO) and 32 had branch retinal vein occlusion (BRVO). Ophthalmoscopic examination with detailed medical history was followed by blood analyses for liver and renal functions, cholesterol, triglycerides, complete blood count, and coagulation factors including protein C activity, free protein S, antithrombin III, fibrinogen, and factor VIIa (FVIIa). Data were compared with those of the control group, composed of 19 cases under ophthalmological follow up for refractive errors, presbyopia, or senile cataract.

RESULTS

Hypertension was highly prevalent in cases with BRVO. Complete blood count, and liver and kidney function tests were within normal limits in the study group. Two cases had low protein C activity, and one had low free protein S. FVIIa levels were significantly higher in the RVO group than in the control group (p=0.0004). There was no significant difference in FVIIa levels between the CRVO and BRVO groups (p=0.51).

CONCLUSION

No haematological parameter except FVIIa differed significantly from that of the control group. Elevation of FVIIa level may play a part in the pathophysiology of both CRVO and BRVO.

Central retinal vein occlusion: report of two familial cases

The authors report a 46-year-old father and 17-year-old son who each presented with unilateral central retinal vein occlusion (CRVO) and bilateral abnormalities of retinal vascular perfusion. The son presented with a nonperfused CRVO in the left eye, developed traction-rhegmatogenous retinal detachment treated with vitreous surgery, and developed prolonged arteriovenous filling in the retina of the fellow eye. The father presented with progressive CRVO in the right eye, developed choroido-vitreal neovascularization following laser treatment to create a chorioretinal anastomosis, underwent vitrectomy for retinal detachment and vitreous hemorrhage in that eye, and developed prolonged arm-eye and retinal arteriovenous circulation times in the fellow eye. An extensive evaluation (including hematological studies and imaging of the major vessels of the neck) failed to reveal a predisposing cause in either patient although echocardiography disclosed a mitral valve thrombus in the father. After institution of coumadin therapy, the circulatory parameters in the fellow eye of each patient improved.