Branch Vein Occlusions (BRVOs) Fritz Allen MD May 22 nd  2011
Background <ul><li>This presentation will be addressing exclusively the branch retinal vein occlusions (BRVOs). The Centra...
Pathophysiology <ul><li>The artery and the vein share a common adventitial sheath. Arterial compression of the vein is bel...
 
Epidemiology <ul><li>* Frequency </li></ul><ul><li>USA: prevalence 0.9% </li></ul><ul><li>International: prevalence 1.1-1....
Clinical Presentation <ul><li>* History  : </li></ul><ul><li>The Eye Disease Case-Control Study findings: </li></ul><ul><l...
Clinical Presentation  <ul><li>Physical </li></ul><ul><li>*In 1877, Leber first described the BRVO ophthalmoscopically: Du...
 
 
 
 
 
 
Clinical Presentation <ul><li>Physical </li></ul><ul><li>*In eyes with large area of nonperfusion, retinal neovascularizat...
Clinical presentation <ul><li>Causes </li></ul><ul><li>*Most cases of BRVO are due to idiopathic factors (AV crossing) </l...
Clinical Presentation <ul><li>Causes </li></ul><ul><li>*Thrombophilic conditions may be involved </li></ul><ul><li>- Prote...
Differential Diagnoses <ul><li>Differentials </li></ul><ul><li>* Central Retinal vein Occlusion </li></ul><ul><li>* Hypert...
Workup <ul><li>Laboratory Studies </li></ul><ul><li>The authors of the Branch Vein Occlusion Study (BVOS) have recommended...
Workup <ul><li>Imaging Studies </li></ul><ul><li>* Fluorescein Angiography </li></ul><ul><li>IVFA is done as soon as the h...
 
 
 
 
 
 
 
 
 
Workup <ul><li>Histologic Findings </li></ul><ul><li>confirmed the importance of AV crossings in the pathogenesis of BRVO ...
Treatment & Management  <ul><li>Medical Care </li></ul><ul><li>-Medical treatment of BRVO is not effective . </li></ul><ul...
Treatment &Management  <ul><li>Medical Care </li></ul><ul><li>-Intravitreal injection of VEGF inhibitors Bevacizumab (Avas...
Treatment & Management  <ul><li>Surgical care </li></ul><ul><li>* Macular grid laser photocoagulation </li></ul><ul><li>re...
 
Treatment & Management  <ul><li>Surgical Care </li></ul><ul><li>* Laser-induced chorioretinal anastomosis </li></ul><ul><l...
Treatment & Management  <ul><li>Surgical Care </li></ul><ul><li>*Vitrectomy and arteriovenous decompression </li></ul><ul>...
 
Treatment & Management  <ul><li>Consultations </li></ul><ul><li>*Consult a vitreoretinal specialist if complications arise...
Medication <ul><li>* Medication Summary </li></ul><ul><li>The goals of pharmacotherapy are to reduce morbidity and prevent...
Follow up care <ul><li>Monitor the development of possible complications : IVFA to guide further therapy </li></ul><ul><li...
Prognosis <ul><li>Analysis of several series indicates that 53% of eyes obtain 20/40 or better visual acuity, 25% have  be...
Patient Education <ul><li>* Instruct patient about reducing risks :  </li></ul><ul><li>Keep good Blood pressure control an...
Bibliography/Acknowledgement <ul><li>Lihteh Wu, MD  ,Costa Rica </li></ul><ul><li>Teodoro Evans, MD ,Canada </li></ul><ul>...
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BRANCH RETINAL VEIN OCCLUSION by Fritz Allen MD COPE ID 31524-CL

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Visionary Ophthalmology Lectures Series 12, May 22nd 2011

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BRANCH RETINAL VEIN OCCLUSION by Fritz Allen MD COPE ID 31524-CL

  1. 1. Branch Vein Occlusions (BRVOs) Fritz Allen MD May 22 nd 2011
  2. 2. Background <ul><li>This presentation will be addressing exclusively the branch retinal vein occlusions (BRVOs). The Central retinal vein occlusions and Hemiretinal vein occlusions have a different natural history and complication rate </li></ul>
  3. 3. Pathophysiology <ul><li>The artery and the vein share a common adventitial sheath. Arterial compression of the vein is believe to be the main cause of BRVO. Compression of the vein may lead to turbulent in the vein causing intravascular thrombus formation with his cascade of retinal ischemia, VEGF production, macular edema and retinal neovascularization </li></ul>
  4. 5. Epidemiology <ul><li>* Frequency </li></ul><ul><li>USA: prevalence 0.9% </li></ul><ul><li>International: prevalence 1.1-1.3% </li></ul><ul><li>* Mortality/Morbidity </li></ul><ul><li>BRVO usually associated with higher cardiovascular mortality </li></ul><ul><li>* No race or sex predilection </li></ul><ul><li>* Age : patient in their 5 th and 6 th decades </li></ul>
  5. 6. Clinical Presentation <ul><li>* History : </li></ul><ul><li>The Eye Disease Case-Control Study findings: </li></ul><ul><li>1- Systemic Hypertension is a risk factor for BRVO </li></ul><ul><li>2- DM and POAG are not risk factors for BRVO </li></ul><ul><li>3- Moderate alcohol consumption reduces the risk of BRVO </li></ul><ul><li>Chief complaint: </li></ul><ul><li>Sudden painless decrease vision in the affected eye </li></ul><ul><li>Scotoma </li></ul>
  6. 7. Clinical Presentation <ul><li>Physical </li></ul><ul><li>*In 1877, Leber first described the BRVO ophthalmoscopically: During the acute phase, Intraretinal hemorrhages (usually flame shaped), Retinal edema, Cotton-wool spots. Horizontal raphe respected. </li></ul><ul><li>*During the chronic phase, hemorrhages may be absent , macular edema may be present and telangiectatic vessels usually seen. </li></ul><ul><li>*Exudative Retinal Detachment (rare) </li></ul>
  7. 14. Clinical Presentation <ul><li>Physical </li></ul><ul><li>*In eyes with large area of nonperfusion, retinal neovascularization may be seen leading to : vitreous hemorrhage , tractional retinal detachments. Neovascular Glaucoma and NVD are rare in BRVO </li></ul>
  8. 15. Clinical presentation <ul><li>Causes </li></ul><ul><li>*Most cases of BRVO are due to idiopathic factors (AV crossing) </li></ul><ul><li>*Some inflammatory reported associated with BRVO: Sarcoidosis, Lyme disease, Serpiginous Choroiditis. </li></ul><ul><li>*Arterial Hypertension + Hypercholesterolemia leading to Atherosclerosis/Atherogenesis </li></ul>
  9. 16. Clinical Presentation <ul><li>Causes </li></ul><ul><li>*Thrombophilic conditions may be involved </li></ul><ul><li>- Protein S deficiency </li></ul><ul><li>- Protein C deficiency </li></ul><ul><li>- Resistance to activated Protein C </li></ul><ul><li>(factor V Leiden) </li></ul><ul><li>- Antithrombin III deficiency </li></ul><ul><li>- Antiphospholipid antibody syndrome </li></ul><ul><li>- Lupus Erythematosus </li></ul><ul><li>- Gammopathies </li></ul>
  10. 17. Differential Diagnoses <ul><li>Differentials </li></ul><ul><li>* Central Retinal vein Occlusion </li></ul><ul><li>* Hypertension </li></ul><ul><li>* Macular Edema (diabetic) </li></ul><ul><li>* Diabetic Retinopathy ,Background and Proliferative </li></ul>
  11. 18. Workup <ul><li>Laboratory Studies </li></ul><ul><li>The authors of the Branch Vein Occlusion Study (BVOS) have recommended against extensive testing in patient with typical BRVO </li></ul><ul><li>In atypical cases (bilateral, young patient and history of thromboembolism) </li></ul><ul><li>-PT, aPTT </li></ul><ul><li>-Protein C, protein S, factor V Leiden, antithrombin III </li></ul><ul><li>-Homocystein </li></ul><ul><li>-ANA, lupus anticoagulant, anticardiolipin </li></ul><ul><li>-Serum protein electrophoresis (SPEP) </li></ul>
  12. 19. Workup <ul><li>Imaging Studies </li></ul><ul><li>* Fluorescein Angiography </li></ul><ul><li>IVFA is done as soon as the hemorrhages have cleared, usually 3 months after the event </li></ul><ul><li>The purpose is to determine the cause of vision loss (macular edema vs macular ischemia) in order to plan treatment. </li></ul><ul><li>*OCT can be useful in the follow up of macular edema secondary to BRVO. </li></ul>
  13. 29. Workup <ul><li>Histologic Findings </li></ul><ul><li>confirmed the importance of AV crossings in the pathogenesis of BRVO </li></ul><ul><li>Inner retinal ischemic areas have been described distal to occlusion site </li></ul><ul><li>Arteriolar sclerosis have been reported </li></ul><ul><li>Intravascular thrombus at site of occlusion </li></ul>
  14. 30. Treatment & Management <ul><li>Medical Care </li></ul><ul><li>-Medical treatment of BRVO is not effective . </li></ul><ul><li>Anticoagulants, fibrinolytic agents, clofibrate capsule, Carbogen inhalation have been tried without success </li></ul><ul><li>-Intravitreal injection of Triamcinolone (4mg?) </li></ul><ul><li>-Retrobulbar injection of Triamcinolone (20mg). Complications: cataract, glaucoma, endophthalmitis. </li></ul>
  15. 31. Treatment &Management <ul><li>Medical Care </li></ul><ul><li>-Intravitreal injection of VEGF inhibitors Bevacizumab (Avastin) 1.25-2.5mg , effective in reducing macular edema and improving visual acuity </li></ul>
  16. 32. Treatment & Management <ul><li>Surgical care </li></ul><ul><li>* Macular grid laser photocoagulation </li></ul><ul><li>remained the standard treatment for macular edema from BRVO after 3 months observation and only for perfused maculas. After 3 years of follow up 63% of treated eyes improve by 2 lines or more vs 36% of control eyes. </li></ul><ul><li>* Scatter photocoagulation </li></ul><ul><li>reduces the prevalence of neovascularization by 50% (from 40% to 20%). </li></ul>
  17. 34. Treatment & Management <ul><li>Surgical Care </li></ul><ul><li>* Laser-induced chorioretinal anastomosis </li></ul><ul><li>tries to create a communication between occluded vessel and choroid . Technique is unreliable (30-50% success rate) and potential complications include retinal detachment and vitreous hemorrhage. </li></ul>
  18. 35. Treatment & Management <ul><li>Surgical Care </li></ul><ul><li>*Vitrectomy and arteriovenous decompression </li></ul><ul><li>claimed to improve macular edema and macular perfusion </li></ul><ul><li>* Vitrectomy and posterior hyaloid separation improve visual acuity </li></ul>
  19. 37. Treatment & Management <ul><li>Consultations </li></ul><ul><li>*Consult a vitreoretinal specialist if complications arise </li></ul><ul><li>*In atypical cases when thrombophilic conditions are suspected, consultation with an hematologist is recommended. </li></ul>
  20. 38. Medication <ul><li>* Medication Summary </li></ul><ul><li>The goals of pharmacotherapy are to reduce morbidity and prevent complications </li></ul><ul><li>*Corticosteroids: have potent anti-inflammatory and antipermeability properties </li></ul><ul><li>- Triamcinolone (Kenalog-40) </li></ul><ul><li>*Vascular Endothelial Growth Factor (VEGF) inhibitors </li></ul><ul><li>- Bevacizumab (Avastin) inhibits angiogenesis </li></ul><ul><li>- Ranibizumab (Lucentis) </li></ul>
  21. 39. Follow up care <ul><li>Monitor the development of possible complications : IVFA to guide further therapy </li></ul><ul><li>Complications </li></ul><ul><li>- Macular edema </li></ul><ul><li>- Retinal neovascularization </li></ul><ul><li>*Vitreous hemorrhage </li></ul><ul><li>*Tractional retinal detachment </li></ul><ul><li>*Rubeosis iridis </li></ul><ul><li>- Epiretinal membrane </li></ul>
  22. 40. Prognosis <ul><li>Analysis of several series indicates that 53% of eyes obtain 20/40 or better visual acuity, 25% have between 20/50 and 20/100, and 22% have visual acuity of 20/200 or worse. </li></ul><ul><li>The more distal the occlusion is from the optic disc, the better the visual prognosis. </li></ul>
  23. 41. Patient Education <ul><li>* Instruct patient about reducing risks : </li></ul><ul><li>Keep good Blood pressure control and maintain good Cholesterol level. </li></ul><ul><li>* Instruct patient with BRVO to seek attention if further vision loss occurs during follow-up. </li></ul>
  24. 42. Bibliography/Acknowledgement <ul><li>Lihteh Wu, MD ,Costa Rica </li></ul><ul><li>Teodoro Evans, MD ,Canada </li></ul><ul><li>Hampton Roy Sr, MD ,USA </li></ul>

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