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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)
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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
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DIAGNOSIS Painless loss of vision- unilateral Asymptomatic
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BRVO Arteriovenous crossings Macular branch (DD from diabetic maculopathy) ACUTE CHRONIC Haemorrhages Venous sheathing Retinal oedema Exudates Cotton wool spots Collaterals Tortuous veins CMO >5 dd non-perfusion: NVE
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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
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MECHANISMS OF VISUAL LOSS
Ischaemic (direct- indirect) Exudative (macular oedema) 30% non-isch. Convert to ischaemic type first 4/12 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)
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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
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MEDICAL INVESTIGATIONS
ALL 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
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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)
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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
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MEDICAL Maximise visual outcome cardiovascular morbidity/ mortality (risk factors) Prevent recurrence to other eye (15% over 5 years) + Aspirin/ dipyridamole
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