Retinal venous occlusive disease (RVO)

Question 1

what is risk factors for retinal venous occlusive disease?

Answer 1

Age (most important factor; > 50% of cases occur in age > 65)

HTN, HLD, DM (cardiovascular risk factors [CVRF])

OCP – in younger females. OCP is the most common underlying association. If female, consider OCP use

If young & no ischaemic risk factors, Ix to r/o myeloproliferative disorders, hypercoagulability states or inflammatory conditions predisposing to occlusive vasculopathy:

• Myeloproliferative neoplasms (MPN), e.g. myeloma, polycythaemia vera
• Thrombophilia, e.g. hyperhomocysteinaemia, antiphospholipid syndrome, Factor V Leiden
• Inflammatory disease a/w occlusive periphlebitis, e.g. Behcet syndrome, sarcoidosis, Wegener’s granulomatosis

Question 2

what are the symptoms of BRVO?

Answer 2

sudden onset unilateral/ monocular painless blurred vision, metamorphopsia and a relative field defect if there is macular involvement; may be asymptomatic with peripheral occlusion.

Visual acuity (VA) at presentation is very variable; good VA if fovea is spared

Question 3

what are the symptoms of CRVO?

Answer 3

sudden onset severe unilateral/monocular blurred vision with reduction of VA (usually counting finger [CF] or worse)

Question 4

what are the signs of CVO?

Answer 4

Decreased visual acuity (more severe in ischaemic CRVO)

RAPD (degree of defect correlates with amount of ischaemia) – more marked in ischaemic CRVO

Fundoscopy: ‘blood and thunder’ appearance in CRVO (fundoscopy clinches the diagnosis)

• *Dilated, tortuous vessels in the affected segment
• *Flame and dot & blot haemorrhages (in all 4 quadrants in CRVO)
• *Cotton wool spots (indicates RNFL infarction 🡪 implies ischaemia)
• Optic disc swelling (ocular cause of optic disc swelling)

Question 5

How does ischaemic CRVO lead to permanent visual loss?

Answer 5

Due to tractional retinal detachment (TRD), macular oedema, neovascular glaucoma (NVG)

Question 6

what are the investigations done CVO?

Answer 6

• Fundus fluorescein angiography (FFA) to definitively dx ischaemic vs non-ischaemic
• Ischaemic workup: BP, fasting glucose and lipids
• Non-ischaemic workup: FBC; INR/PT, PTT, protein C, protein S, antithrombin III, factor V Leiden, antiphospholipid; ANA, dsDNA, ANCA, anti-cardiolipin

Question 7

what is the management for CVO?

Answer 7

• No treatment exists to reverse the retinal vein occlusions, but the neovascularisation can be managed by PRP and anti-VEGF agents
• Pan-retinal laser photocoagulation (PRP) – reduce metabolic load of retina, to prevent neovascularisation
• Intravitreal anti-VEGF agents (e.g. ranibizumab, bevacizumab) for macular oedema