Ocular Disease III: Exam 2: Lecture 9: Vein Occlusions

Question 1

Papillophlebitis (1)

1. ESSENTIALLY it’s what?
   a. Etiology is different from what?
   b. What is the Etiology?
2. Medical Hx is what?
3. Prognosis?

Answer 1

1. a CRVO in a YOUNG ADULT w/o SYSTEMIC Diseases.

a. from true CRVO
b. INFLAMMATORY Etiology, BUT STEROIDS DO NOT HELP!!!

2. negative/weak
3. Excellent. Majority of Cases are NON-Ischemic!

Question 2

Papillophlebitis (2)

1. Although most are Non-Ischemic, it can become Ischemic and have the same NEO issues as TRUE CRVO
2. MONITOR every what?
   a. ALWAYS WATCH FOR WHAT?
3. Who should we refer to since they’re usually younger patients?
4. ALWAYS CONSIDER PAPILLOPHLEYLEBITIS in CASES OF WHAT?

Answer 2

2. EVERY MONTH until it RESOLVES!
   a. for NEO issues
3. Internal Medicine for a complete medical w/u to r/o any other possible Systemic Diseases.
4. of ASYMPTOMATIC DISC SWELLING and DISC EDEMA

Question 3

Papillophlebitis (3)

1. It can present with only Unilateral Disc Edema and good VA, but WITHOUT what?
   a. At this point, is Dx easy?
2. New Understanding of Autoimmunity Suggests that young peeps with this SHOULD BE TESTED for WHAT?
3. What will PATIENTS COMPLAIN ABOUT?

Answer 3

1. w/o retinal hemorrhages
   a. NO. Very tough
2. for ANTIPHOSPHOLIPID ANTIBODY SYNDROME!
3. GOLD and PURPLE FLASHING LIGHTS

Question 4

Branch Retinal Vein Occlusion (BRVO)

1. Involves one of the branch what?
   a. Seen in what area?
   b. MOST involve VEINS LOCATED where? (WHY…idk..ask)
2. Usually it’s less visually disabling that what other condition?
3. How many times MORE COMMON than CRVO?
4. Seen in what AGE/GROUP?
5. Males/Females?

Answer 4

1. of the Branch retinal veins
   a. Small, Localized area of the retina or as much as a Quadrant
   b. Temporal and Superior to the Disc
2. than CRVO
3. 3x’s more common
4. ELDERLY (60-70 yrs old)
5. equal.

Question 5

BRVO: Pathogenesis

1. Venous compression at what?
   a. % of ALL BRVO?
2. Arteriosclerotic Etiology: Explain
3. DOES THE VEIN or VENULE EVER LEAK in VASCULAR OCCLUSION?
4. ALL LEAKAGE is from WHAT?!
5. May present with what?
6. Often it’s symptomatic/asymptomatic?

Answer 5

1. at A-V Crossing
   a. 75%
2. Compresses the underlying venule leading to leakage from capillary beds draining into the venule
3. NO!
4. CAPILLARIES!
5. Loss of VA and/or VF
6. ASYMPTOMATIC

Question 6

BRVO Classification

1. 2 types
2. 3 Location Classifications for BRVO
   a. HEMISPHERIC
   b. INTERMEDIATE
   c. TWIG
3. THERE are lots of RISK factors (Systemic Associations): But, what is seen with 70% of CASES?

Answer 6

1. Ischemic vs. Non Ischemic
2. a. Before 1st BIFURCATION (technically HRVO)
   b. After 1st Bifurcation: Typical BRVO Appearance
   c. Macular Area Only
3. HTN

Question 7

Non-Ischemic BRVO

1. % of CASES?
2. VA?
3. What is seen?
4. Macular Edema?
5. Do Collateral Vessels Form?

Answer 7

1. 70-80%
2. > 20/200
3. Blot, Flame shaped Hemes; RARELY CWS
4. Mild
5. YES

Question 8

Ischemic BRVO

1. DEFINED as WHAT?
2. % of Cases?
3. VA?
4. Hemes that are seen?
5. CWS?
6. Most Common cause of Vision Loss?
7. What 4 things are Common: and Cause of Permanent Severe Vision Loss?
8. NVI, NVG?
9. What might occur that causes Devastating Vision Reduction that’s IRREVERSIBLE?

Answer 8

1. 5 DD of RETINAL CAPILLARY NON-PERFUSION on FA!
2. 20-30%

3.

Question 9

BRVO: 50% RULE

1. 50% chance of have 5DD+ of Retinal Non-Perfusion?
2. 50% chance of getting NVD or NVE?
3. 50% chance of having Vitreous Heme?

Answer 9

1. if BRVO involves AT LEAST 1 QUADRANT
2. If BRVO is Associated w/5DD+ of Non-Perfusion
3. BRVO Associated w/NVD or NVE

Question 10

BVOS Study

1. Can Peripheral Scatter Laser Photocoagulation Prevent NV?
   a. % risk reduction
   b. Clinical benefit of Prophylactic Tx over Treating once NV Develops?
2. Can Peripheral Scatter Laser Photocoagulation prevent Vit Heme in eyes w/NV?
   a. % ABSOLUTE RISK REDUCTION?
   b. Natural Hx of Vit Heme?
   c. Conclusion?
3. Can Photocoagulation Improve VA in Eyes w/Macular EDEMA
   a. % INCREASE VA 2 LINES?
   b. Does it WORK?

Answer 10

1. NO ADVERSE or BENEFICIAL EFFECT on VA.
   a. 10% ABSOLUTE RISK REDUCTION
   b. No.
2. a. 32%
   b. Very LITTLE SEVERE VISION LOSS
   c. SCATTER LASER after RETINAL NV HAS APPEARED
3. a. 65%
   b. YES!! (Just like in Diabetes). so GRID LASER is STANDARD OF CARE for BRVO!!!

Question 11

BRVO: Macula Edema Classification

1. Perfused
   a. How common?
   b. Leakage?
   c. Spontaneous Resolution?
   d. Frequently persists resulting in what?
2. Ischemic
   a. type of SWELLING?
   b. Leakage on FA?
   c. % that spontaneously resolve?
   d. Appears to be what?

Answer 11

1. a. MOST COMMON
   b. Yes (FA)

c. 1/3
d. in DECREASE VA
2. a. CYTOTOXIC/VASOGENIC SWELLING
b. NO
c. 90%
d. a Transient phenomenon w/Visual improvement as edema resolves.

Question 12

BVOS Study Results

1. WINDOW of OPPORTUNITY to TREAT?
2. DO NOT TREAT WHAT?
3. What SHOULD NOT BE USED if MACULAR ISCHEMIA is PRESENT with MACULAR EDEMA?
   a. UNLESS WHAT is NOT IMPROVING?
4. Treat ONLY if what?
5. What works for MACULA EDEMA DUE to BRVO?
6. Is Prophylactic TX to Avoid NEO Indicated?

Answer 12

1. 3-18 MONTHS
2. Macular Hemorrhage
3. LASER PHOTOCOAGULATION
   a. Unless VA is NOT improving
4. if VA

Question 13

BRVO Management

1. Refer to whom?
2. Monitoring Schedule?
3. Possible FA at what month?
4. Retinal Photography when?
5. SEND TO RETINOLOGIST WHEN?

Answer 13

1. Internist for directed W/U
2. EVERY MONTH until resolution
3. 3 months
4. every visit
5. ONLY if COMPLICATIONS DEVELOP!

Question 14

Complications/Vision Loss

1. Most Common CAUSE?
   a. Reversible?
2. Other possible causes?
3. BRVO behaves MOST LIKE what?

Answer 14

1. MACULAR EDEMA
   a. YES
2. Perifoveal capilary loss, Vit. Heme., Tractional RD, (NVG: RARE).
3. HRVO: Neo is predominantly POSTERIOR SEGMENT & RARE in the ANTERIOR SEGMENT!

Question 15

Hemi Retinal Vein Occlusion (HRVO)

1. Same risk factors as what?
2. Major Branch Occlusion where?
3. Risk Factors

Answer 15

1. As BRVO
2. AT or NEAR OPTIC DISC (“Hemispheric” BRVO)
3. Diabetes, Hypertension, Glaucoma

Question 16

HRVO

1. Historically has been CONSIDERED a VARIANT of what?
   a. BUT, PATHOPHYSIOLOGICALLY, it most closely resembles what?

b. Natural Hx and NEO Complications most CLOSELY resemble what?

2. INVOLVES what DRAINAGE?
   a. Majority are Ischemic/or Non-ischemic?
3. Treatment?

Answer 16

1. of BRVO
   a. CRVO
   b. BRVO
2. SUPERIOR or INFERIOR DRAINAGE ONLY!
   a. Non-Ischemic (67%)
3. Photography, Monitor EVERY MONTH until RESOLUTION. FA no good in early course of disease (cuz it’s blocked by Hemorrhage)

Send to Internal medicine consult for Systemic Health workup.

HRVO DEVELOPS MOST LIKE CRVO, BUT BEHAVES MOST LIKE BRVO!

Question 17

SCORE Study (Standard Care vs. COrticosteroids for REtinal Vein Occlusion Study)

1. What were they looking up?
2. How many studies did they do?
3. They did 2 types of intravitreal injections: What were they?
4. Then they did Standard of Care
   a. What is SOC for Macular EDEMA in CRVO?
   b. SOC for BRVO?

Answer 17

1. Steroids on CRVO to see if it works.
2. 2 Studies: SCORE-CRVO and SCORE-BRVO
3. They did Triamcinilone (either 1 mg or 4 mg injections)
4. a. JUST WATCHING IT (DO NOTHING)
   b. GRID LASER

Question 18

SCORE Study Results: CRVO

1. Which Triamcinolone groups were superior to the Obs. Group w/respect to VA at the PRIMARY OUTCOME Visit?
2. On OCT, which Groups has a reduction on retinal thickness from baseline to 24 months?
3. Which group had a far better safety profile?
4. Conclusion: What should be applied?

Answer 18

1. Both
2. All three groups
3. 1-mg dose better safety than 4 mg dose

AND

1 mg dose better safety profile than Observation group

4. IV Triamcinolone in 1-Mg DOSE, w/RETREATMENT CRITIERIA APPLIED in SCORE Study should be considered for UP TO 12 MONTHS and POSSIBLY 2 YEARS!

Question 19

SCORE: BRVO Conclusions

1. Differences b/w 3 Tx groups (Standard Care vs. Intra Vitreal Triamcinolone injections) at PRIMARY OUTCOME VISIT (12 months)?
   a. After this time and thru 36th month, which group had a better mean improvement?
2. Which group had a better Safety Profile?
3. SO SCORE-BRVO proved that what treatment was best?
   * But CRVO Tx changed due to CRVO!

Answer 19

1. No significant differences
   a. Standard Care Group (Laser)
2. Standard Care Group…
3. Continue SOC Tx for Macular Edema Secondary to BRVO

and

GRID LASER Should stay as BENCHMARK

• Before it was to do nothing. NOW, we know INJECTIONS DO WORK, so WE WOULD REFER.
• REFER ALL CRVO and BRVO w/Macular Edema.

CRVO for Injection

BRVO for Grid.

Question 20

VEGF

1. Angiogenesis
   a. New studies focus on what?

Answer 20

1. Growth of new BVs

a. On efficacy of ANTI-VEGF Therapy

Question 21

Lucentis (Ranibizumab)

1. Antagonist to what?
   a. Blocks actions of ALL isoforms of what?

b. FDA approved when?
c. Can do MONTHLY intravitreal injections for up to how long?

Answer 21

1. VEGF
   a. All Isoforms of VEGF-A
   b. in June 2006
   c. for up to 2 YEARS

Question 22

Avastin (Bevacizumab)

1. Antagonist to what?
2. 2 ways to put it in?
3. FDA approved for what?
4. Lucentis Derived from Avastin

Answer 22

1. VEGF
2. IV and Intravitreal
3. Metastatic Colorectal Cancer

Question 23

CRUISE Trial (CRVO)

1. Goal:
   a. They kind of just compared it with what SOC?
2. To get into the study, needed to have what BCVA?
3. CONCLUSION
   a. Efficacy?
   b. Safety
4. how long does it take to start working?

Answer 23

1. Evaluate 6 month efficacy and Safety of IV Ranibizumab compared with SHAM (nothing) injections in peeps w/MACULAR EDEMA secondary to CRVO.
   a. that of just WATCHING CRVO instead of doing the new SOC of injections of Triamcinolone.
2. Reduced BCVA (20/40 to 20/30)
3. a. Strong evidence of Efficacy of Intravitreal by DAY 7 up to Month 6
   b. No new safety events identified
   * SO PRETTY SAFE. So which do we do, this or Steroid injections? WE DONT KNOW YET. THEY SHOULD OF COMPARED IT.
4. ITS FAST!. (so anti-VEGF is for QUICK IMPROVEMENT that only LASTS for a MONTH and no side effects (unlike STEROIDS)
   * but steroids still are beneficial!

Question 24

BRAVO Trial

1. Same thing as the CRUISE Trial, but now with what?
2. Conclusion?
   a. So SOC currently?

Answer 24

1. with BRVO! (looked at Anti-VEGF)
2. Good safety, good rapid and sustained improvement, BUT THIS STUDY FELL APART ON ITS OWN.
   a. LASER GRID photocoagulation still REMAINS the GOLD STANDARD for BRVO related MACULAR EDEMA!