RETINAL VEIN OCCLUSION

Epidemiology

51% >65y

10-15% <45y

ν Afro-caribbean and Asian descent in UK

Pathogenesis

Primary retinal venous disease/ endothelium

Thrombus secondary event (Hypercoaguability)

AETIOLOGICAL CONDITIONS

COMMON SYSTEMIC LOCAL

1. BP Glaucoma

2.Hyperlipidemia Trauma

3.DM Orbital lesions

4.Smoking Oedema-drusen optic disc

RARER 1.MM and Waldestrom 6.Secondary causes of 1, 2, 3 such as acromegaly cushing, hypothyroidism

2.CRF

3.Vasculitis

4.Thrombotic disorders

5. Oral contraceptives (oestrogen)/ no HRT

DIAGNOSIS

1. Painless loss of vision- unilateral

2. Asymptomatic

BRVO

Arteriovenous crossings

Macular branch (DD from diabetic maculopathy)

Haemorrhages Venous sheathing

Retinal oedema Exudates

Cotton wool spots Collaterals

Tortuous veins CMO

>5 dd non-perfusion: NVE

ACUTE CHRONIC

CRVO

ACUTE CHRONIC

Dilated tortuous retinal veins

Swollen optic disc

Intraretinal haemorrhage

Cotton wool spots

Retinal oedema

Sheathing of veins

Absorption of haemorrhage

Disc collaterals

Macular oedema

MECHANISMS OF VISUAL LOSSIschaemic (direct- indirect)

Exudative (macular oedema)

Eyes at High Risc for Ischaemic Complications

1.RAPD

2. VA

3. FFA >10DD, 5-10 DD

4.Cotton wool spots >10, 5-10

5. Deep dark haem. (infarct)

6. Elderly ( rubeosis)

30% non-isch. Convert to ischaemic type first 4/12

DIFFERENTIAL DIAGNOSIS

1.Accelerated hypertension

2.DM

3.Slow-flow retinopathy

4.Peripapillary telangiectasia

5. AION

6.Lupus/ radiation retinopathy

7. CMV retinitis

8.Ocular ischaemic syndrome

MEDICAL INVESTIGATIONSALL PATIENTS

FBC, ESR, U&E, LFT, GLC, Lipid profile

Protein electrophoresis

ECG

TFT

MORE SPECIALISED

CXR

Cardiolipin, Lupus anticoagulant

CRP, ACE, FTA-ABS

RF, ANA, DNA, ANCA

MRI: orbit, brain

MANAGEMENT

OCULAR

BRVO

Argon laser for macular oedema if foveal vasculature intact (FFA), VA 6/12-6/60 3-6/12 after the initial event

Sectoral PRP for proliferative complications or if areas of non-perfusion >5DD

FU: 6/52, up to 2years after (collaterals)

CRVO

Prevention of neovascularisation

Grid: no benefit

FFA and Laser: haemorrhages sufficiently resolved

Monthly FU/ total of 2years

>40DD: PRP

10-40DD: no

<10 (non-ischaemic): no

Non-ischaemic cases convert to ischaemic

13%: 6/12

18%: 18/12

CHECK RAPD ALWAYS IN FU

MEDICAL

1. Maximise visual outcome

2. cardiovascular morbidity/ mortality (risk factors)

3. Prevent recurrence to other eye (15% over 5 years) + Aspirin/ dipyridamole