1. Arterial and Venous Occlusive Disease of the Retina Dr.M NAQEEB Assistant professor Um Al-Qura university

2. Objective 1. Central retinal artery occlusion 2. Branch retinal artery occlusion 3. Branch retinal vein occlusion 4. Central retinal vein occlusion

3. retinal artery obstructions u 57% of obstructions involved the central retinal artery u 38% involved one of the branch retinal arteries u 5% involved the cilioretinal artery

4. Central Artery Obstruction u Characteristics v Sudden severe visual loss v Painless v Retinal appearance »Opaque and edematous u Most prominent in posterior pole –Thickest ganglion cell layer »Cherry-red spot u Visible intact choroidal vasculature beneath the foveola

5. Central Artery Obstruction u Characteristics v With time »Artery re-canalizes »Edema clears »Visual loss is devastating and permanent u Irreversible damage to neural tissue after 90 minutes

6. Intravenous fluorescein angiography

7. Central Artery Obstruction u Prognosis v 20/400 or worse: 2/3 of eyes v 20/40 or better: 1/6 eyes »Intact cilioretinal artery v Vision of NLP »Implies ophthalmic artery occlusion u Choroidal ischemia as well

8. Central Artery Obstruction u Pathogenesis v Majority »atherosclerosis-related thrombosis u At the level of the lamina cribrosa v Other causes »Arterial spasm »Dissecting aneurysm »GIANT CELL ARTERITIS u 1% of cases –Check ESR in elderly patients! –Start high does steroids if suspicious

9. Central Artery Obstruction u Management v No good therapy exists, all treatments questionable »Ocular message »Anterior chamber paracentesis u Attempt to acutely reduce IOP u Dislodge thrombosis »Inhalation therapy u 95%O 2, 5%CO 2 –Stimulate vasodilatation v Iris neovascularization »Occurs in 18% of eyes u 1-12 weeks later (usually 3-4 weeks later) »Full PRP treatment required

10. Branch Retinal Artery Obstruction u Characteristics v Vision loss v Visual filed defect v Within hours/days »Edematous opacification of the retina u In the distribution of the affected vessel

11. Branch Retinal Artery Obstruction u Pathogenesis v Embolization or thrombosis of vessel v Three types of emboli »Cholesterol u Hollenhorst plaques u Arise from carotid »Platelet-fibrin u Associated with arteriosclerosis »Calcific u Diseased cardiac valves

12. Retinal Embolization u Hollenhorst plaque v Glistening cholesterol emboli v Found within retinal arteriole »Typically lodge at bifurcations v Arise in carotid arteries

13. Retinal Embolization u Hollenhorst plaque v Glistening cholesterol emboli v Found within retinal arteriole »Typically lodge at bifurcations v Arise in carotid arteries

14. Branch Retinal Artery Obstruction u Other causes of BRVO v Migraine »Particularly in smokers v Trauma v Coagulation disorders v Sickle cell disease v Oral contraceptive use »Smoking, older women v Mitral valve prolapse v Infections »Toxoplasmosis, syphilis v Giant cell arteritis »Check ESR in elderly patients u Good prognosis

15. Workup u ESR,CBC and C-reactive protein u Fasting blood sugar u Glycosylated hemoglobin u Doppler US for carotid artery u ECG, echocardiogram u Refer for haematology

16. Mortality/Morbidity u Further emboli to the brain resulting in CVA v 55% death over 10 years v 27% age matched population u Further emboli to same or contralateral eye resulting in further visual loss u Progression of temporal arteritis

17. Venous Occlusive Disease

18. Central Retinal Vein Occlusion u Findings v Dilated and tortuous retinal veins v Swollen optic disc v Intra-retinal hemorrhages v Retinal edema All four quadrants

19. Central Retinal Vein Occlusion u Classification v Based on amount of non-profusion on fluorescein angiography »Ischemic u ≥10 disk areas »Non-ischemic u < 10 disk areas »Indeterminate u Too much hemorrhage to tell u 80% progress to ischemic

20. Central Retinal Vein Occlusion u Pathogenesis v Thrombosis of the central retinal vein »At or posterior to the lamina cribrosa v Atherosclerotic central retinal artery »Impinges on central retinal vein u Turbulent flow → thrombus

21. Central Retinal Vein Occlusion u Non-ischemic CRVO v Less dilation and vascular tortuosity v Dot and flame hemorrhages in all quadrants v Less or no disk swelling v Angiogram shows »Delayed A-V transit time »Leakage »Minimal capillary dropout v Neovascularization is rare

22. Central Retinal Vein Occlusion u Ischemic CRVO v Extensive hemorrhage v Retinal edema v Marked venous dilation v Cotton-wool spots v Angiogram show »Widespread capillary nonprofusion v Visual prognosis poor »Only 10% have >20/400 vision v NVI »As high as 60% of eyes »Occurs 3-5 months post occlusion u “the three month glaucoma”

23. Central Retinal Vein Occlusion u Risk Factors v Eye Disease Case-Control Study »Hypertension »Diabetes u Unlike BRVO »Glaucoma u Check and treat IOP! v CRVO in young patients requires more extensive workup for cause

24. CRVO In Young Patients – Causes u Systemic vascular disease v Hypertension v Diabetes mellitus v Cardiovascular disease u Blood dyscrasias v Polycythemia vera v Lymphoma v Leukemia u Clotting disorders v Activated protein C resistance v Lupus anticoagulant v Anticardiolipin antibodies v Protein C v Protein S v Antithrombin III u Paraproteinemia and dysproteinemias v Multiple myeloma v Cryoglobulinemia u Vasculitis v Syphilis v Sarcoidosis u Autoimmune disease v Systemic lupus erythematosus u Oral contraceptive use in women u Other rare associations v Closed-head trauma v Optic disc drusen v Arteriovenous malformations of retina

25. Central Retinal Vein Occlusion u Management v Family medical doctor to manage »Hypertension »Diabetes »Elevated cholesterol

26. Central Retinal Vein Occlusion u Management v Macular edema »Central Vein Occlusion Study Group u Grid laser treatment in the macula –DOES reduce angiographic evidence of edema –DOES NOT improve vision

27. Central Retinal Vein Occlusion u Management v Macular edema »Intravitreal trimcinolone/Avastin »Capable of transiently improving vision u Risks –Glaucoma –RD –Cataract –Endopthalmitis

28. Central Retinal Vein Occlusion u Management v Iris neovascularization v PRP to eyes prior to NVI »NO benefit u Even if very ischemic v Once neovascularization detected »Prompt PRP

29. Central Retinal Vein Occlusion u Outcome v Most important predictor is initial visual acuity: »20/40 or better u Likely to remain unchanged »20/400 or less u Likely to remain worse than 20/400 »20/50-20/200 u 1/3 unchanged u 1/3 improve u 1/3 worse

30. Branch Retinal Vein Occlusion u Findings v Within one sector of the retina »Superficial hemorrhages »Retinal edema »Cotton-wool spots »Dilated and tortuous vein »Corresponding artery narrowed and sheathed

31. Branch Retinal Vein Occlusion u Findings v Superotemporal quadrant most common »63% v Occurs at arteriovenous crossing »Artery and vein bound together in a common sheath »Arterial thickening compresses vein u Turbulent flow → thrombus formation

32. Branch Retinal Vein Occlusion u Risk factors v Identified by the Eye Disease Case-Control Study »Hypertension »Cardiovascular disease »Increased BMI at age 20 »Glaucoma v Note : Diabetes not an independent risk factor

33. Branch Retinal Vein Occlusion u Visual Loss v Acute »Macular hemorrhage »Macular edema »Capillary occlusion v Chronic »Macular ischemia »CME »Macular pigmentary changes »Epiretinal membrane formation »Subretinal fibrosis

34. Branch Retinal Vein Occlusion u Photocoagulation v Used to treat: »Macular edema u Requires intact foveal perfusion »Neovascularization v Macular edema »Allow three months for improvement »Vision 20/40 or worse »Light grid pattern of laser spots to involved sector of retina »Branch vein occlusion study u Treated eyes more likely to gain 2 lines of vision –Treated 65%, untreated 37%

36. Branch Retinal Vein Occlusion u Photocoagulation v Neovascularization »BVOS defined ischemic BRVO u Area of non-profusion > 5 disk diameters »Large areas of non-profusion increase risk of neovascularization v Apply scatter PRP to areas of retinal ischemia »Only when neovascular complications develop u NVI, NVE, NVD

37. Branch Retinal Vein Occlusion Vascular Remodeling u Photocoagulation »Must differentiate u Neovascular tissue –Leaks on fluorscein angiogram u Collateral vessels –Help to reduce vascular tissue –Do not treat

38. Thank you xoxo