CASE 1: CRVO
A 53-year-old man with diabetes and hypertension presented with visual changes in his right eye for 1 week. His visual acuity measured 20/20 with an intraocular pressure (IOP) of 17 mm Hg and a blood pressure of 148/105. Figure 1A is a composite of the fundus photograph of the right eye showing dilated and tortuous veins in all four quadrants, mild disc edema, and dot blot hemorrhages throughout the posterior pole, indicating central retinal vein occlusion (CRVO). Optical coherence tomography (OCT), however, shows a completely flat macula with a normal foveal architecture and a good foveal reflex and depression (Figure 1B), which likely accounts for the patient’s 20/20 visual acuity.
We initially chose to observe this patient. Three weeks later, however, the patient presented with worsening symptoms and visual acuity decreased to 20/25. Although this was still relatively good visual acuity, the OCT showed distinct retinal thickening (Figure 2).
The treatment options that we considered were: A) observation; B) anti-VEGF therapy with either ranibizumab or bevacizumab; or C) steroid therapy with either the intravitreal dexamethasone implant or intravitreal triamcinolone acetonide.
We chose to treat the patient with bevacizumab. Although the patient had a good initial response, at 6 months follow-up, his visual acuity continued to decline to 20/80. There was worsening intraretinal hemorrhage in the macula and significant retinal thickening and retinal cyst formation (Figure 3).
At this point, we decided to administer an intravitreal injection of 1 mg triamcinolone acetonide. The patient had visual acuity and retinal thickness improvement, but had subsequent relapse that required a number of intravitreal triamcinolone acetonide injections.
CASE 2: BRVO
An 86-year-old man presented with visual acuity that had been decreased to 20/50 for 3 weeks. His IOP was 9 mm Hg, and he had a blood pressure of 162/80. On his fundus image, a small branch retina vein occlusion (BRVO) could be seen (Figure 4A) with more focal intraretinal hemorrhage and a more focal area of cotton wool spots compared with CRVO. Retinal thickening is apparent on OCT (Figure 4B); the hemorrhage can be seen in the inner layer of the retina with shadowing of the outer retina. The fovea is split in half in typical BRVO cases, one half being normal and the other half showing significant distortion of the architecture. In contrast, the entire fovea is abnormal in CRVO.
Treatment options for this patient are slightly different and include not only A) anti-VEGF; and B) the intravitreal dexamethasone implant or intravitreal triamcinolone acetonide; but also C) grid laser photocoagulation.
Grid laser photocoagulation was proven effective for patients in the original BVOS (Branch Vein Occlusion Study),1 and these findings were supported by the SCORE (Standard Care vs Corticosteroid for Retinal Vein Occlusion)-BRVO trial,2 which showed that laser therapy alone over 2 to 3 years was successful in treating macular edema secondary to BRVO. The effect of laser photocoagulation, however, from our clinical anecdotal experience, is gradual and was substantiated by the SCORE-BRVO study. Thus, for many patients, we choose to use anti-VEGF therapy, which was shown to provide faster visual acuity improvement for patients with BRVO in the BRAVO trial (a phase 3, multicenter, randomized, sham injection-controlled study of the efficacy and safety of ranibizumab injection compared with sham in patients with macular edema secondary to BRVO).3
The patient received two injections over 2 months, and his visual acuity improved to 20/30. He received three more injections over the next 3 months, and his visual acuity was stable at 20/40 with improvement on OCT (Figure 5).
Michael S. Ip, MD, is an Associate Professor of Ophthalmology at the University of Wisconsin and the Fundus Photograph Reading Center in Madison, WI. He is a member of the Retina Today Editorial Board. Dr. Ip can be reached at +1 608 410 0627; or fax: +1 608 410 0568.
- The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98:271-282.
- The SCORE Study Research Group. SCORE Study Report 6. 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. Arch Ophthalmol. 2009;127:1115-1128.
- Campochiaro PA, Heier JS, Feiner L, Gray S, Saroj N, Rundle AC, Murahashi WY, Rubio RG; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112. .
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