Retinal Vein Occlusion Flashcards
Predisposing factors of RVO?
Predisposing factors:
Age
HBP
High cholesterol
Diabetes
Smoking
These all lead to atherosclerotic disease, pxs who are vasculopathic – are at risk of heart attacks, strokes, any blockage of BV anywhere in body
Oral contraceptive
Glaucoma
Infection/inflammation
Types of Retinal Vein Occlusion?
Impending - about to happen, few leakages, small reduction in VA
Non-ischaemic - few haemorrhages, mild to moderate reduction in VA, still not completely lost blood supply
Ischaemic - lost blood supply
o Branch Retinal Vein Occlusion (BRVO)
o Central Retinal Vein Occlusion (CRVO)
o Hemi Retinal Vein Occlusion (HRVO)
Impending CRVO Symptoms?
Minor or transient blurring
Commonly on waking
Impending CRVO Signs?
Mild venous dilation and tortuosity
Relatively few and scattered haemorrhages
Mild macular oedema
Prognosis - good
Symptom of Retinal Vein Occlusion?
- Sudden painless loss of vision
o 6/12 to hand movements
Non-ischamic CRVO Symptoms?
Sudden painless monocular loss of vision
VA can vary
Ischaemic CRVO Symptoms?
Sudden and severe (CF or worse) painless monocular loss of vision
(Occasionally pain, redness, photophobia on presentation is undiagnosed neovascular glaucoma)
Ischaemic CRVO Signs?
- VA CF or worse
- RAPD present
Fundus:
Tortuosity and dilation of all branches
extensive haemorrhages
Prominent CWS - Acute signs generally resolve 6-12months
Later signs: NVI in 50% after 2-4months
Retinal new vssels 5% of eyes
Optic disc collaterals common
Non-ischamic CRVO Signs?
-VA variable
-RAPD – mild or absent
Fundus:
-Tortuosity and dilation of all branches
-Mild-moderate haemorrhages
-Acute signs resolve over 6-12months
Later signs: scattered persistent harmorrhages, venous tortuosity, macular pigment changes, collateral disc vessels
-Main cause of poor vision – chronic macular oedema and secondary atrophy
Signs of Retinal Vein Occlusion?
- Multiple haemorrhages distributed all over retina
- Swollen disc – particularly soon after onset
- Cotton wool spots
- Macular oedema
Impending CRVO management?
Detecting & correcting predisposing conditions
Advise px of symptoms of other types of CRVO
CRVO - urgent referral to ophthalmology
REFER ALL RVO TO GP FOR BLOODS (looking for diabetes and high cholesterol) and BP CHECK
2 pronged referral – one to HES, one to GP
Describe Ischaemic CRVO?
- Characterised by widespread capillary blockage
- Afferent pupil defect
- Severe visual loss
o <6/60 - Lots of haemorrhages – often obscuring much of retina
- High risk of developing rubeotic glaucoma
Non-ischaemic CRVO Management?
- Detecting & correcting predisposing conditions
- Tx of complications –> macular oedema, new BVs
o Refer URGENTLY if VA reduced & macular oedema
o If good VA & no obvious macular oedema –> routine referral
REFER ALL RVO TO GP FOR BLOODS (looking for diabetes and high cholesterol) and BP CHECK
2 pronged referral – one to HES, one to GP
Describe non-ischaemic CRVO?
- Less severe than ischaemic
- ~1/3 of these will become ischaemic
- No afferent pupillary defect
- Moderate visual loss
o 6/60 or better - Fewer haemorrhages
- Low risk of developing rubeotic glaucoma
Ischaemic CRVO Management?
- Always check IOP in both eyes – important risk factor for CRVO
o Urgent (EMERGENCY) referral
o 30% risk of rubeotic glaucoma - Detecting & correcting predispoding conditions
Tx of complications: macular oedema, new BVs
REFER ALL RVO TO GP FOR BLOODS (looking for diabetes and high cholesterol) and BP CHECK
2 pronged referral – one to HES, one to GP
What is rubeosis & what is the management for it?
- If ischaemic CRVO not treated, new vessels grow on iris & obstruct angle, causing v severe & intractable (hard to control/deal with) glaucoma
o Needs very URGENT (EMERGENCY) tx
o Immediate pan-retinal laser – difficult if retina obscured by haemorrhages
o Intravitreal anti-VEGF – must be repeated monthly until retina can be lasered
o If rubeotic glaucoma develops, it is unlikely that good vision can be restored but there is good visual potential
Shunt surgery e.g. ahmed valve
If visual potential is poor: Cyclodiode laser – destroys part of ciliary body, lowering IOP & making eye more comfortable but may lead to worsening VA
Symptoms of Branch Vein Occlusion?
- Frequently no symptoms
- Sudden loss of vision – usually much less severe than CRVO
Signs of Branch Vein Occlusion?
- Most commonly supero-temporal vein (but can be inferio-temporal)
- Venous nipping from hypertension
- Venous nipping at arterio-venous crossovers disrupt flow in vein & leads to thrombosis & occlusion
- Haemorrhages – confined to affected quadrant with affected vein
o May lead to macular oedema & if it’s chronic there may be exudates & cotton wool spots - Ischaemia in area of vein occlusion can lead to new vessels, which are often unnoticed until they bleed, causing a vitreous haemorrhage
Branch Vein Occlusion Management?
- If VA reduced, most likely due to macular oedema –> URGENT referral
o Can be treated with anti-VEGF injections - If VA normal, ROUTINE referral for management of risk factors
o BP, diseases etc
o A few eyes will go on to develop new vessels, which needs sectoral pan-retinal laser but unlikely to happen rapidly so routine referral is sufficient
REFER ALL RVO TO GP FOR BLOODS (looking for diabetes and high cholesterol) and BP CHECK
2 pronged referral – one to HES, one to GP
