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Clinical Case Presentation
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Branch Retinal Vein Occlusion
Sarita M.Registered NurseWhangarei Base Hospital
Content● Introduction● Case Study● Pathogenesis● Clinical Features● Investigations● Treatment● Follow-up● Nurses’ Role● Reference
Retinal Vein Occlusion
● 2nd most common retinal vascular disorder
● 2 main types: Central Retinal Vein Occlusion (CRVO)Branch Retinal Vein
Occlusion (BRVO)
● one of the most common cause of sudden painless unilateral vision loss
History and Presentation
Mrs. X, 72 y.o, healthy, fit and active
>hx of distortion L eye for 1 yr
> 1st clinic visit : Va R6/6 L6/24 IOP R15 L14
O/E: CMO left superotemporal area, R macula: normal
Plan:
Bevacizumab x 2 doses
Review + OCT 4/52
Clinic review after 2nd dose of Bevacizumab
> VA 6/6 6/15-1 IOPs: normal
O/E: slight blot hrge left ST macula
Plan: Bevacizumab x2
Review + OCT
OCT: persistent L superior macular oedema
Review after 4x doses of Bevacizumab
VA: L 6/9
O/E: L old hrge or a small area of pigmentation
Plan: 2 months f/u + OCT
OCT: nil swelling
2/12 clinic review:
VA : L 6/9
IOP: normal
O/E: recurrence of L mac oedema
Plan: 5th dose Avastin
Review 6/52 + OCT
OCT: recurrence of CMO
Review after 5x doses Bevacizumab
VA: L 6/7.5+1
O/E: stable, no oedema noted
Plan: 2 months f/u + OCT
OCT: nil CMO
Clinic review 2/12
2/12
VA: L 6/7.5
O/E: some collaterals ST macula
OCT: Slight thickening of RPE
Plan: Discharge
2/12
VA: L 6/7.5
O/E: some collaterals ST macula
Final Diagnosis: Left BRVO● defined as a segmental intraretinal haemorrhage ● 4x more than CRVO● Affects males and females equally ● Usually unilateral, 9% bilateral● Risk factors:
advancing age“Classic trio” : HTN, hyperlipidaemia, DM
50% of BRVO are hypertensive
PathophysiologyUsually occur at the arteriovenous (AV) junction
arterial compression to adjacent vein -->partial obstruction → inc intraluminal
pressure → transudation of blood to retina
Mac
oedema
Dec capillary tissue
perfusion
Tissue
ischaemia release of VEGF → inc vascular permeability
Hypoxia
Ischaemia
Clinical Features
Symptoms:
Sudden onset of painless unilateral distortion or loss of vision
Occasionally, floaters from vitreous haemorrhage
Signs:
Wedge-shape distribution of retinal haemorrhage
retinal thickening & oedema
cotton wool spots and hard exudates
dilated and tortuous veins
Investigations:
Optical Coherence Tomography
- Best method
- Measures macular oedema, and monitor the response to treatment
- Findings
Cystoid macular oedema, serous macular detachment, subretinal fluid
OCT angiography - newer technology
can measure vascular density
can observe the superficial and deep capillary networks, non flow areas, vascular dilation,and intraretinal oedema
Investigations:
Fundal Fluorescein Angiography-
information on the extent and location of the disease
to study the choroidal and retinal vascular filling
Findings
- delayed venous filling in the area of occlusion
- capillary nonperfusion
- Dye extravasation from macular oedema or retinal
neovascularization
Treatment:
is address to limit damage and progression of the disease
Main purpose : is the resolution of the macular oedema before the foveal
photoreceptor layer is damaged
Treat the BRVO complications eg macular oedema, retinal neovascularization,
vitreous hrge, and tractional retinal detachment
Treatment
1. Anti -VEGFs - treatment of choice for mac oedema and choroidal
neovascularization
Bevacizumab
Ranibizumab
Aflibercept
Treatment
2. Laser photocoagulation
TreatmentMechanism:
Destruction of photoreceptor of the ischaemic retina
Decrease oxygen demand
Increase oxygen influx
Arteriolar constriction and inc resistance
Dec capillary hydrostatic pressure
Less transudation of fluid
Less oedema
TreatmentCorticosteroids
Triamcinolone acetate
Anti-inflammatory effect
Antiangiogenic properties
Inhibition of VEGF and other inflammatory cytokines
Complications: inc IOP and cataract formation.
Treatment
Surgery
Arteriovenous sheathotomy (AVS)
Pars plana vitrectomy + AVS
Vitrectomy
Retinal artery bypass
Treatment
Medical
Anti-platelet treatments
- Ticlopidine
- Beraprost
- Heparin
- Tissue plasminogen activator
Follow-up
Initially, followed closely every month or 2 months to monitor macular
oedema and neovascularization
Anti-VEGF treatment with or without laser should be started if without
spontaneous improvement
With stable or resolved macular oedema, follow-up interval can be 3-6
months or even longer for stable chronic cases.
Northland DHB: Monthly intravitreal injections
Nurses’ Role
Triage and history taking
Monitor and assess stable BRVO cases
Administer IV anti-VEGF injection
Education
References:[1] Jaulim,A.,Ahmed,B.,Khanam,T.,Chatziralli,I. (2013): Branch retinal vein occlusion:Epidemiology,pathogenesis,risk factors, clinical
features,diagnosis, and complications. An update of the literature. Retina,33(5), 901-910. doi: 10.1097/IAE.0b013e3182870c15
[2] Patel, M., Prisant, L., & Marcus, D. (2003). Branch Retinal Vein Occlusion. The Journal of Clinical Hypertension, 5(4), 295-297. doi:
10.1111/j.1524-6175.2003.02469.x
[3] Karia, N. (2010). Retinal vein occlusion: pathophysiology and treatment options. Clinical ophthalmology, 4, 809-816. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915868/
[4] Chatziralli, I., Nicholson, L., Sivaprasad, S., & Hykin, P. (2015). Intravitreal steroid and anti-vascular endothelial growth agents for the
management of retinal vein occlusion: Evidence from randomized trials. Expert Opinion on Biological Therapy.,15(12),1685-1697.
http://dx.doi.org/10.1517/14712598.2015.1086744
[5] Duker, J., Waheed, N., & Goldman, D. (2014). Handbook of retinal OCT : Optical coherence
tomography. Retrieved from
https://www-clinicalkey-com-au.ezproxy.auckland.ac.nz:9443/#!/content/book/3-s2.0-B978032318884500032X
[6] Biousse, V., & Newman, N. (2009). Neuro-ophthalmology Illustrated. New York, NY: Thieme Medical Publishers, Inc.
[7] Lattanzio, R., Torres Gimeno, A., Battaglia Parodi, M., & Bandello, F. (2011). Retinal Vein Occlusion: Current Treatment. Ophthalmologica,
225(3), 135-143. doi:10.1159/000314718)
Li, J., Paulus, Y. M., Shuai, Y., Fang, W., Liu, Q., & Yuan, S. (2017). New Developments in the Classification, Pathogenesis, Risk Factors, Natural
History, and Treatment of Branch Retinal Vein Occlusion. Journal of Ophthalmology, 2017.
