Retinal Vein Occlusion

Question 1

Predisposing factors of RVO?

Answer 1

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

Question 2

Types of Retinal Vein Occlusion?

Answer 2

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)

Question 3

Impending CRVO Symptoms?

Answer 3

Minor or transient blurring
Commonly on waking

Question 4

Impending CRVO Signs?

Answer 4

Mild venous dilation and tortuosity
Relatively few and scattered haemorrhages
Mild macular oedema
Prognosis - good

Question 5

Symptom of Retinal Vein Occlusion?

Answer 5

• Sudden painless loss of vision
  o 6/12 to hand movements

Question 6

Non-ischamic CRVO Symptoms?

Answer 6

Sudden painless monocular loss of vision
VA can vary

Question 7

Ischaemic CRVO Symptoms?

Answer 7

Sudden and severe (CF or worse) painless monocular loss of vision
(Occasionally pain, redness, photophobia on presentation is undiagnosed neovascular glaucoma)

Question 8

Ischaemic CRVO Signs?

Answer 8

• 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

Question 9

Non-ischamic CRVO Signs?

Answer 9

-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

Question 10

Signs of Retinal Vein Occlusion?

Answer 10

• Multiple haemorrhages distributed all over retina
• Swollen disc – particularly soon after onset
• Cotton wool spots
• Macular oedema

Question 11

Impending CRVO management?

Answer 11

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

Question 12

Describe Ischaemic CRVO?

Answer 12

• 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

Question 13

Non-ischaemic CRVO Management?

Answer 13

• 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

Question 14

Describe non-ischaemic CRVO?

Answer 14

• 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

Question 15

Ischaemic CRVO Management?

Answer 15

• 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

Question 16

What is rubeosis & what is the management for it?

Answer 16

• 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

Question 17

Symptoms of Branch Vein Occlusion?

Answer 17

• Frequently no symptoms
• Sudden loss of vision – usually much less severe than CRVO

Question 18

Signs of Branch Vein Occlusion?

Answer 18

• 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

Question 19

Branch Vein Occlusion Management?

Answer 19

• 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