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Posterior Segment Disease > B14-1 Retinal Vein Occlusions (RVO) > Flashcards

B14-1 Retinal Vein Occlusions (RVO) Flashcards

1
Q

Retinal Vein Occlusions (RVO’s) are most commonly associated with what?

A

Age and HTN

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2
Q

How common are RVO’s? (Relative to other retinal vascular diseases)

A

2nd most commmon retinal vascular disease after Diabetic Retinopathy

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3
Q

All patients with an RVO should be medically evaluated, but what are two particular circumstances when special consideration is necessary?

A
  1. Patient w/o cardiovascular disease: consider searching for other causative or predisposing systemic conditions
  2. Patients under 50 years old: very rare, full systemic evaluation
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4
Q

Describe a Branch Retinal Vein Occlusion. What causes it?

A

Arteriosclerotic thickening of a branch arteriole compresses a retinal vein at an A/V crossing point

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5
Q

What are some secondary vascular changes that can occur following a BRVO?

A

Endothelial cell loss
Turbulent flow
Thrombus formation

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6
Q

Name an atherosclerotic anatomical predisposition that is thought to be important in a minority of cases of RVO

A

Hematological Pro-thrombotic Factors

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7
Q

What happens to the retina due to hypoxia secondary to a retinal vein occlusion?

A

Virchow’s Triad:

  • Endothelial Cell Damage
  • Extravasation of blood contituents
  • Release of mediators like VEGF
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8
Q

Describe a Central Retinal Vein Occlusion (CRVO). What causes it?

A

Similar to BRVO’s, at the A/V crossing point where they share a common sheath, atherosclerotic changes of the artery can compress the vein; however, for a CRVO, this happens posterior to the lamina cribrosa and affects the central vein instead of a branch

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9
Q

What ocular disease is a major risk factor for developing a RVO? What study supports this and what were its findings?

A
  • Glaucoma
  • Eye Disease Case-Control Study (EDCC)
  • Hx of glaucoma increased a Pt risk of CRVO by a factor of 5
  • Hx of glaucoma increased a Pt risk of BRVO by a factor of 2
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10
Q

Why should Patients with RVO avoid taking blood pressure medications at bedtime?

A

Since retinal venous pressure may increase in the supine position and the medications can reduce perfusion pressure and blood flow

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11
Q

Name systemic risk factors for RVO’s

A
  • Age: most important factor, over 50% of cases occur in Patient’s older than 65
  • HTN: particularly important for BRVO’s, but present in 2/3 of all RVO patients over the age of 50 and 1/4 of younger patients
  • Hyperlipidemia: 1/3 of patients
  • Diabetes: 15% of RVO pateints over 50
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12
Q

Name 2 non-health condition related risk factors for RVO’s

A

Birth control pills and smoking

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13
Q

What tests should be ran for a systemic assessment of all RVO patients?

A 
Blood Pressure 
ESR
CBC
Random Blood glucose 
Lipid panel 
Plasma Protein Electrophoresis
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14
Q

What are the “classic findings” of a retinal vein occlusions (RVO)?

A

Intraretinal hemorrhages and dilated tortuous retinal vasculature

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15
Q

Other than intraretinal hemmorrhages and dilated tortuous vessels, what other findings can be seen in an RVO-affected retina?

A
  • Cotton wool spots
  • Macular edema, Optic disc edema, or Edema of surrounding retina
  • Macular ischemia
  • Pre-retinal neovascularization (chronic phases)
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16
Q

What determines the VA with a retinal vein occlusion?

A

Severity of macular ischemia, macular edema, and the presence/absence of intraretinal hemmorrhages affecting the fovea

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17
Q

The amount of neovascularization is directly correlated with what?

A

Amount of ischemia

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18
Q

Where does Neovascularization most commonly occur with a BRVO?

A

At the border of the heallthy and affected ischemic retina

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19
Q

Where does Neovascularization most commonly occur with a Central Retinal Vein Occlusion (CRVO)?

A

Anterior segment, either as NVI or NVA

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20
Q

What kind of RVO patients should you perform an undilated iris exam and gonioscopy of the iridocorneal angle?

A

ALL RVO patients, even though ant seg neo is more commonly seen with a CRVO

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21
Q

Spontaneous improvement or resultion can occcur in patients with a RVO, what is this usually associated with?

A

In BRVO, the formation of “collaterals” or “shunt vessels”, which is the dilation of capillaries extending across the median raphe to compensate for the compromised drainage

In CRVO, the formation of “Optociliary shunt vessels”, which is basically collaterals that connect the optic nerve head to choroidal circulation

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22
Q

What should be considered if a BRVO occurs somewhere other than at the A/V crossing?

A

The possibility of an underlying retinochoroiditis or retinal vasculatitis

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23
Q

What quadrant is most likely to be affected by a BRVO?

A

Superotemporal, 63% of the time

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24
Q

How likely is NVI and NVG with a BRVO?

A

2% at 3 years

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25
Q

How long do the acute features of a BRVO last?

A

Usually only 6-12 months

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26
Q

How likely is retinal neo with a BRVO? What finding would indicate someone has a significantly higher risk?

A

8% at 3 years unless they have more than 5 DD of non-perfusion on FA

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27
Q

What kind of retinal neovascularization is most common with a BRVO? When and where does it occur?

A

NVE’s (Neovascularization of the retina elsewhere) are more common than NVD (neovascularization of the disc) and typically appear within 6-12 months at the border of the ischemic retina

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28
Q

What is the most common cause of persistantly poor VA after a BRVO?

A

Chronic macular edema

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29
Q

Prognosis of a BRVO?

A

Generally, a good visual prognosis: 50-60% maintaining a final VA of better than 20/50

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30
Q

The BVOS found that what percentage of eyes with extensive retinal ischemia would develop retinal or optic nerve neo?

A

36%

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31
Q

Over the long term, permanent vision loss following a BRVO is most likely due to what?

A

Macular ischemia, cystoid macular edema (CME), hard exudates (lipid residues) in the fovea, pigmentary macular disturbances

32
Q

When is observation without intervention indicated in BRVO’s?

A

If VA is 20/30 or better, or slightly worse but improving

33
Q

How did the BVOS define “extensive retinal ischemia”?

A

At least 5 DD

34
Q

According to BVOS, what percentage of eyes developed a Vitreous Hemorrhage if laser photocoagulation wasn’t performed (with neo present)?

A

60-90%

35
Q

Patient has an ischemic BRVO with large areas of nonperfusion but w/o neo, what’s the treatment plan? Should scatter photocoagulation be performed? What study supports this decision?

A

The branch vein occlusion study (BVOS) concluded that even though they’re at a significant risk of developing neo, ischemia alone in not an indication for Tx provided that follow-up could be maintained

36
Q

Scatter photocoagulation Tx for BRVO. How is it used, how effective is it, and what study supports its use?

A

BVOS - branch vein occlusion study, showed:

  • scatter photocoagulation to the area of retinal capillary nonperfusion is effective in causing regression of new vessel growth in eyes with NVD, NVE, and NVI
  • reduced the risk of vitreous hemorrhage from 60% to 30%
37
Q

What percentage of BRVO’s will result in NVI?

A

2%

38
Q

Macular Laser Surgery - Laser grid photocoagulation for BRVO, what is it used for? How effective is it? What study supports this?

A

Macular Edema: BRVO found that laser-treated eyes with intact foveal vasculature, macular edema, and VA’s in the 20/40-20/200 range were more likely to gain 2 lines of VA (65%) than untreated eyes (37%)

39
Q

What study showed that ranibizumab is superior to tradition grid laser Tx at 12 months?

A

BRAVO

40
Q

What study revealed that VA gains established after monthly injections of Aflibercept can be maintained with “when required” Tx?

A

VIBRANT

41
Q

Intravitreal steroids: when are they indicated?

A

May be useful in patients who aren’t candidates for anti-VEGF but less effective and can cause/worsen cataracts & elevate IOP so are more of a last-resort option

42
Q

Subthreshold (micropulse) laser: what is it used for?

A

Evolving Tx that appears to be as effective as conventional photocoagulation for ME while inflicting less damage

43
Q

What is an “intermediate” or “indeterminate” CRVO?

A

When a CRVO is neither clearly ischemic or non-ischemic

44
Q

What percentage of “intermediate CRVO’s” progressed to ischemic disease in the Central Vein Occlusion Study (CVOS)?

A

80%

45
Q

What factors are most contributory to a CRVO?

A

Hx of Glaucoma
HTN, DM, Hypercholestrolemia
Hypercoagulable factors

46
Q

In the CVOS study, what % of non-ischemic CRVO’s progressed to ischeic at 4 months? At 36 months?

A

16% at 4 months, 34% at 36 months

47
Q

What characteristics should help differentiate a non-ischemic CRVO from an ischemic CRVO?

A

Non-ischemic should have VA’s of 20/200 or better and NO afferent pupillary defect

48
Q

What are the primary causes of permanent vision loss following an ischemic (severe) CRVO?

A

Macular ischemia and NVG

49
Q

What percentage of Ischemic CRVO cases will develop NVI? When does this usually show up in these patients?

A

28%, with 60% of these cases developing within 3-5 months (commonly reffered to as “90-day glaucoma”)

50
Q

How are ischemic (severe) CRVO’s defined?

A

Having at least 10 DD of capillary non-perfusion on FA

51
Q

What characteristics should help you differentiate an ischemic CRVO from a non-ischemic?

A

An ischemic CRVO usually has VA’s worse than 20/200 and an afferent pupillary defect

52
Q

What percentage of ischemic CRVO cases will develop pre-retinal Neo? How does this compare to BRVO’s?

A

5% of cases, much less than with BRVO’s (8%)

53
Q

Prognosis of Ischemic CRVO’s?

A

The central retinal vein occlusion study (CVOS) showed that only approximately 10% of eyes achieved better than 20/400 when treating with laser photocoagulation

54
Q

Prognosis of non-ischemic CRVO’s?

A
  • Poor VA typically results from chronic unresolved ME and/or secondary macular atrophy
  • Most acute phase signs resolve in 6-12 months, and in eyes that do not convert to ischemic, VA’s may return to normal or near normal in 50% of cases
55
Q

How common are hemi-retiinal vein occlusions?

A

Less likely than either BRVO’s or CRVO’s

56
Q

Describe what causes a Central Retinal Vein Occlusion (CRVO)

A

A thrombosis of the central retinal vein at or posterior to the lamina cribrosa

57
Q

What is “Virchow’s Triad”?

A

Turbulence
Endothelial Damage
Hemodynamic stasis

58
Q

What is the incidence of ant seg neovascularization with severely ischemic CRVO?

A

28% of cases

59
Q

When does anterior segment neovascularization secondary to an ischemic CRVO usually develop?

A

60% of cases occur 3-5 months after the onset of symptoms, termed “90-day glaucoma”

60
Q

What is the #1 predictor of iris neovascularization development in CRVO disease?

A

VA

61
Q

What are the most serious complications that can stem from a CRVO?

A

NVG
Vitreous Hemorrhage
TRD

62
Q

What kind of laser is used to treat macular edema caused by a BRVO but NOT a CRVO? Why not?

A

Focal/Grid pattern laser, CRVO study demonstrated it to be ineffective

63
Q

How is PRP/scatter panretinal photocoagulation used in the management of CRVO?

A
  • The CVOS found that prophylactic PRP did not result in a significant decrease in the development of iris Neo
  • Therefore, they recommended waiting until an undilated gonio exam revealed 2 clock hours of iris neo before performing PRP
  • However, in clinical practice, PRP is performed at the first sign of NVI
64
Q

CRVO’s complicated by vitreous hemorrhage may benefit from what?

A

Pars Plana Vitrectomy

65
Q

Which study looked at Ranibizumab’s efficacy in the Tx of Macular Edema secondary to BRVO?

A

BRAVO

66
Q

Which study looked at Ranibizumab’s efficacy in the Tx of Macular Edema secondary to CRVO?

A

CRUISE

67
Q

Which study showed that Bevacizumab was non-inferior to Aflibercept in the Tx of Macular Edema secondary to CRVO?

A

SCORE2

68
Q

Which study showed that all anti-VEGF Tx’s are equally effective for Macular Edema secondary to RVO’s?

A

CRAVE

69
Q

Which study showed that intravitreal Triamcinoone injections in eyes with a BRVO was comparable in efficacy to Macular Grid Laser?

A

SCORE

70
Q

Name the sham-controlled trial of Dexamethasone Intravitreal Implant in patients with RVO-induced Macular edema. What did it show?

A

GENEVA, showed to help initialy but by day 180 showed no statistical difference compared to sham

71
Q

Which study compared Dexamethasone to Ranibizumab for Macular Edema secondary to RVO? What did it show?

A

COMRADE, Ranibizumab was far superior (13 ETDRS letters gained compared to 3 with Dex)

72
Q

What is the follow-up schedule for a patient with BRVO?

A
  • W/ macular edema: follow-up monthly

- W/O macuar edema: 3-6 moths (unless high-risk, then monthly)

73
Q

What is the follow-up schedule for a patient with CRVO?

A
  • W/ Macular Edema: monthly follow-ups
  • Ischemic w/o macular edema: monthly for the first 6 months
  • Non-ischemic w/o macular edema: treat like a BRVO w/o ME (so 3-6 months)
74
Q

What is the follow-up schedule for a patient with HRVO?

A

Follows the same schedule as a CRVO

75
Q

What is a “Papillophebitis”?

A
  • Possibe variant of a CRVO that typically affects individuals under the age of 50 who may have a higher prevalence of HTN and diabetes

Posterior Segment Disease (5 decks)

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