This document presents a case report of a 57-year-old male who presented with sudden painless diminution of vision in his right eye for 2 days and gradual vision loss in both eyes over the past 12-13 days. His medical history includes hypertension and recently diagnosed diabetes. On examination, he was found to have a non-ischemic central retinal vein occlusion in both eyes with macular edema in his right eye. He received intravitreal injections of bevacizumab and was advised to follow up in 1 month. At follow up visits, his vision improved and macular edema resolved with further injections. He was advised to continue regular follow ups to monitor for complications.

1. CASE
PRESENTATION
ANUJA DHAKAL ADHIKARI
BOVS,FINAL YEAR

2. PATIENT PARTICULARS
OPD NO : G1049186.
NAME : MR.MAHARJAN.
AGE : 57 YEARS.
GENDER : MALE.
ADDRESS : PANAUTI,KAVRE.
OCCUPATION : AGRICULTURE AND BUSINESS, RETIRED ARMY.
DATE OF PRESENTATION : MARCH 30TH ,2023.
TIME OF EXAMINATION : 10:34 AM.
PLACE OF EXAMINATION : GENERAL OUT PATIENT DEPARTMENT,NEH.

4. CHIEF COMPLAINTS
GRADUAL PAINLESS DIMINUTION OF VISION IN BOTH EYES SINCE 12-13 DAYS WITH
SUDDEN PAINLESS DIMINUTION OF VISION IN RIGHT EYE SINCE 2 DAYS.

5. HISTORY OF PRESENT ILLNESS
• According to the patient he presented to NEH with chief complaints
of sudden painless diminution of vision of RE for 2 days .
• The diminution of vision was constant throughout the time period and
was associated with flashes.

6. • It was not associated with redness, photophobia, watering or
discharge from the eyes.
• No history of pain, floaters.
• No history of colour halos.
• No history of transient loss of vision in the past.
• No history of ocular trauma.
• No history of joint pain.

7. PAST OCULAR HISTORY
• History of using glasses for near tasks like signing cheques and using
mobile phones.
• No history of similar episodes in the eyes.
• No history of any other ocular diseases.
• No history of any surgical intervention.
• No history of use of milky eyedrops(steroids).

8. FAMILY HISTORY
• History of cataract surgery performed on father.
• No history of DM,HTN.
• No history of coagulopathies.
• No history of thrombophilia.

9. SYSTEMIC ILLNESS
• History of systemic hypertension since 6 years under medication(poor
control).
• History of diabetes mellitus recently diagnosed under medication since 3
months.
• No history of any cardiac diseases.
• No history of hyperlipidemia.
• No history of any bleeding disorders nor any history suggestive of
coagulopathy.

10. DRUG HISTORY
• Patient stated that he was taking oral medication BD for
hypertension and OD for diabetes mellitus.
• No description of medicine was provided.

11. ALLERGIC HISTORY
• Not known till date.

12. PERSONAL HISTORY
• Non vegetarian by diet.
• Patient smokes 2-3 sticks of cigarettes per day.
• Occassional consumption of alcohol.
• No history of coitus for 3 years.

13. GENERAL CONDITION
• Average built male,Well oriented to the time, place & person.
• Vital sign:
 Blood pressure : 150/100mm of Hg on left arm sitting position.
 pulse: 78 beat/min regular and normal volume left radial artery.
 Temperature:98.5 OF, axillary.
 RR : 16 breath /min.
 Spo2: 98% in room air.

14. SYSTEMIC EXAMINATION
• No pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema or dehydration.
• Bilateral carotid pulsation normal.
• No bruit.
• Chest: B/L NVBS, no added sounds.
• CVS : S1 and S2 well heard no murmur or gallop .
• P/A : soft ,non tender, no organomegaly, normoactive bowel sound.
• CNS : grossly intact.
• Skin : No ecchymosis or bruising on examination.

15. OCULAR EXAMINATION

16. EXTERNAL EXAMINATION
• FACIAL SYMMETRY : symmetrical on both sides.
• EXTERNAL FACE : normal.
• HEAD POSTURE : normal.
• OCULAR POSITION : normal.
• OCULAR ALIGNMENT : orthotropic.
• OCULAR MOTILITY : full,free and painless in all directions (BOTH EYES).

17. VISUAL STATUS
• AIDED VA RE) 6/36 WITH +1.00 DS/-0.50 DC * 090°.
LE) 6/12 WITH -0.75 DC * 090°.
ADD BE) +2.25 DSPH -N10
-N8
 PINHOLE OVER PRESCRIPTION RE) 6/18.
LE) 6/9.
(REFRACTION WAS NOT PERFORMED IN THIS VISIT)

18. ANTEROR SEGMENT EXAMINATION

19. RIGHT EYE LEFT EYE
EYELIDS AND ADNEXAL TISSUE No swelling, ecchymosis,
laceration, misdirected lashes.
No swelling, ecchymosis,
laceration, misdirected lashes.
CONJUNCTIVA No redness, laceration, discharge. No redness, laceration, discharge.
CORNEA Clear Clear
ANTERIOR CHAMBER VH -III, quiet. VH-IV, quiet.
IRIS Normal color & pattern.
No new vessels
Normal color & pattern.
No new vessels
PUPIL 3mm in diameter, Round,
regular & reactive to both
direct and consensual light
4.5mm in diameter, Round,
regular & reactive to both
direct and consensual light
LENS Nuclear sclerosis grade 1 Nuclear sclerosis grade 1

20. POSTERIOR SEGMENT EXAMINATION

24. D/D FROM HISTORY AND INITIAL
EXAMINATION
 HYPERTENSIVE RETINOPATHY (BE)
 DIABETIC RETINOPATHY (BE)
 NON ISCHAEMIC CRVO(BE)
 ISCHAEMIC CRVO(BE)
 PAPILLOPHLEBITIS(BE)
 OCULAR ISCHEMIC SYNDROME(BE)

25. HYPERTENSIVE RETINOPATHY
POINTS IN FAVOUR POINTS AGAINST
•Dot-blot hemorrhages.
•Flame shaped hemorrhage.
•Elevated blood pressure.
•Optic disc swelling.
•No Salus’s sign: Deflection of retinal vein as it
crosses the arteriole.
•No Gunn’s sign: Tapering of the retinal vein on
either side of the AV crossing.
•No Bonnet’s sign: Banking of the retinal vein
distal to the AV crossing.

26. DIABETIC RETINOPATHY
POINTS IN FAVOUR POINTS AGAINST
 New onset diabetes mellitus.
 Bilateral condition.
 Multiple flame shaped hemorrages with dot
and blot hemorrages.
 Absence of beaded vessels.
 Absence of microaneurysms.
 Absence of hard exudates.
 Absence of neovascularization.

27. NON ISCHAEMIC CRVO
POINTS IN FAVOUR POINTS AGAINST
 Cotton-wool spots are rare; few in number if
present.
 Mild to moderate decreased visual acuity.
 Intermittent blurring or transient visual may
precede the onset.
 No relative afferent pupillary defect
 variable number of dot and flame retinal
hemorrhages, present in all four quadrants .
 Both engorgement and tortuosity of the retinal
veins are characteristic.

28. ISCHAEMIC CRVO
POINTS IN FAVOUR POINTS AGAINST
 Extensive retinal hemorrhages in 4
quadrants, most notably centered in the
posterior pole.
 Extensive deep blot and flame-shaped
hemorrhages.
 Absence of Acute, markedly decreased visual acuity
ranges from (6/60) to hand-motion.
 No prominent afferent pupillary defect.
 No such Hemorrhages that is so extensive that the retinal
and choroidal details are obscured.
 Absence of rubeosis iridis and raised intraocular pressure.
 Retinal capillary nonperfusion more than 10 disc areas in
case of ischaemic crvo.

29. PAPILLOPHLEBITIS
POINTS IN FAVOUR POINTS AGAINST
 Retinal venous dilation and tortuousity.
 Presence of varying amounts of
intraretinal hemorrhage.
 Typically occurs in young, healthy females
 mild monocular visual loss.
 Have optic disc edema out of proportion to the retinal
findings.
 cotton-wool spots that ring the optic disc.
 occasionally cilioretinal artery occlusions or even partial
central retinal artery occlusions.

30. OCULAR ISCHEMIC SYNDROME
POINTS IN FAVOUR POINTS AGAINST
 commonly occurs in the elderly with men
more affected than women.
 Bilateral involvement.
 Presence of dot and blot haemorrhages.
 Engorged veins, but they are generally not
tortuous in ocular ischemic syndrome.
 Absence of amaurosis fugax.
 Absence of ischaemic ocular pain.
 Optic disc is normal in OIS.
 Microaneurysms are present in cases of OIS.
 Macular edema is absence in case of OIS.

31. PROVISIONAL DIAGNOSIS
NON ISCHAEMIC CENTRAL RETINAL VEIN OCCLUSION RE>LE
WITH RIGHT EYE MACULAR EDEMA.

33. INTRAOCULAR PRESSURE
RE) 18 MM/HG
LE) 17 MM/HG (MEASURED WITH AIR PUFF TONOMETER AT
1:28 PM)

37. FUNDUS PHOTOGRAPHY

38. HAEMOGRAM
• TLC : 8,600
• DC - Neutrophils:59 %,Lymphocyte : 29%, Monocyte : 8%, Esinophils:4%,
basophils : 0
• Hb - 12 mg/dl (13.8-17.2 grams per deciliter (g/dL)
• ESR 5mm /hr in Wintrobe (0-15 mm/hr in men)
• Random blood sugar : 209 mg/dl
• Fasting blood sugar: 172mg/dl
• PP blood sugar: 211 mg/dl
• Hba1c: 6.2 (48mmol/mol (6.5%) or below)

39. LIPID PROFILE
• Cholesterol -107mg/dl. (150 – 250 mg/dl )
• HDL -37mg/dl. (30 – 70 mg /dl)
• LDL - 105mg/dl. (upto 150 mg/dl)
• Triglyceride - 214mg/dl. (60 – 165 mg/dl)

40. CLOTTING FACTORS
• BT: 3.30 min. (2-8 minutes)
• CT: 8.00 min. (2-8 minutes)
• PT: 13.00 sec (10-13 seconds)
SEROLOGY
• ANTI HCV: nonreactive
• HBsAg: nonreactive
• HIV I and II: nonreactive
• RHEUMATOID FACTOR : negative
• VDRL : non reactive

41. FINAL DIAGNOSIS
BE)NON-ISCHAEMIC CENTRAL RETINAL VEIN OCCULUSION.
RE) MACULAR EDEMA.

42. TREATMENT
• BE) First dose Intravitreal Injection of Bevacizumab 1.25mg/ 0.05 ml
given on April 4th 2023.
CONSENT FORM

43. Post intravitreal injection of Bevacizumab
(first dose) On April 4th ,2023.
Vital signs:
• Blood pressure : 110/80mm of Hg.
• Pulse : 70 beat/min regular and normal volume on left radial
artery.
• Temperature: 98.5 OF.
• RR : 18 breath/min.
• Spo2 : 98% in room air.

44. MEDICATION
• GTT OFLOXACIN 0.3% QID*BE FOR 1 WEEK.
• GTT CARBOXYMETHYLCELLULOSE 0.5% QID*BE FOR 1MONTH.

45. ADVISE
Continue medications for hypertension and diabetes mellitus.
Cardiovascular consultation for uncontrolled hypertension.
Endrocrinology consultation for diabetes mellitus.
Stop smoking and consumption of alcohol.
Lifestyle changes .

46. DISCHARGED
• WITH POST PROCEDURAL MEDICATIONS
• FOLLOW UP AFTER 1 MONTH / SOS.
• DISCHARGED WITH APPROVAL FROM THE SENIOR VITREORETINAL CONSULTANT.

47. 1ST FOLLOWUP (6TH MAY 2023)
• Visual acuity
Aided RE:6/18p (MEASURED WITH SNELLEN’S OPTOTYPE)
LE: 6/6p
• IOP with GAT (11:30 am)
RE: 16 mmHg LE :18mmHg

48. 1ST FOLLOW UP RIGHT EYE LEFT EYE
EYELIDS AND ADNEXAL TISSUE No swelling, ecchymosis,laceration,
misdirected lashes.
No swelling, ecchymosis,laceration,
misdirected lashes.
CONJUNCTIVA No redness, laceration,discharge. No redness, laceration,discharge.
CORNEA Clear clear
ANTERIOR CHAMBER VH-III, quiet. VH-IV, quiet.
IRIS Normal color & pattern.
No new vessels
Normal color & pattern.
No new vessels
PUPIL 4mm in diameter, Round,
regular & reactive to both
direct and consensual light
4.5mm in diameter, Round,
regular & reactive to both
direct and consensual light
LENS Nuclear sclerosis grade 1 Nuclear sclerosis grade 1

49. POSTERIOR SEGMENT

50. RE)Second dose Intravitreal Injection of
Bevacizumab 1.25mg/ 0.05 ml given on may 8th,
2023.

51. DISCHARGED WITH PREVIOUS
MEDICATIONS AND ADVISED TO FOLLOW
UP AFTER 1 MONTH.

52. 2ND FOLLOWUP (2ND JUNE 2023)
• Visual acuity
Aided RE:6/9P (MEASURED WITH SNELLEN’S OPTOTYPE)
LE: 6/6P.
+0.75 +0.50
• RETINOSCOPY
-0.25 +0.00
WDR
ACCEPTANCE RE) +0.50 DSPH/-0.50 DC * 090°- 6/6 P.
LE) - 0.50 DC * 090°- 6/6. ADD BE) +2.50DSPH-N6

53. 2nd FOLLOW UP RIGHT EYE LEFT EYE
EYELIDS AND ADNEXAL TISSUE No swelling,
ecchymosis,laceration, misdirected
lashes.
No swelling,
ecchymosis,laceration, misdirected
lashes.
CONJUNCTIVA No redness, laceration,discharge. No redness, laceration,discharge.
CORNEA Clear Clear
ANTERIOR CHAMBER VH-III, quiet. VH-IV, quiet.
IRIS Normal color & pattern.
No new vessels
Normal color & pattern.
No new vessels
PUPIL 3.5 mm in diameter, Round,
regular & reactive to both
direct and consensual light
4.00 mm in diameter, Round,
regular & reactive to both
direct and consensual light
LENS Nuclear sclerosis grade 1 Nuclear sclerosis grade 1

54. INTRAOCULAR PRESSURE
MEASURED WITH GAT ( AT 10:22 AM)
RE: 16 mmHg LE :18mmHg

55. FURTHER RETINAL IMAGING TECHNIQUES
•Fluorescein Angiography.
•Electroretinogram.
•Fundus autofluorescence.
•Color Doppler imaging.
•OCT Angiography.

56. PROGNOSIS
• Central retinal vein occlusion has a better prognosis in younger
patients.
• One-third of older patients improve without treatment, one-third
stay the same, and one-third get worse.
• If the central retinal vein occlusion does not become ischemic,
return to baseline or near baseline vision occurs in about 50% of
patients.
• Chronic macular edema is the main cause of poor vision. In most
cases, the prognosis correlates with initial visual acuity.

57. COMPLICATIONS
• Macular edema can lead to significant vision loss in patients with
central retinal vein occlusion.
• The most important risk factors for iris neovascularization are
poor visual acuity, large areas of retinal capillary nonperfusion,
and intraretinal blood.

58. BEFORE DISPATCH
• DETERRENCE AND PATIENT EDUCATION
• GTT CARBOXYMETHYLCELLULOSE 0.5% QID*BE FOR 1MONTH.
• SPECTACLE CORRECTION FOR BOTH DISTANCE AND NEAR.
• PATIENT SHOULD BE MONITORED FOR UPTO 2 YEARS TO ASSESS FOR
SIGNIFICANT ISCHAEMIAAND MACULAR EDEMA.
• FOLLOWUP AFTER 3MONTHS/SOS.

60. WHAT DO WE KNOW?
DISCUSSION