CRVO is very common cause of retinopathy .Anti VEGF treatment has brought hope for treatment of macular odema .

1. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
CRVO
MANAGEMENT 2019
DRISHTI THE VISION VIJAYNAGAR
INDORE

2. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
CRVO
•CRVO is a common retinal vascular
disease typically affecting the
patients over the age of 60 years .
•More common than arterial
occlussion

3. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Pathophysiology
• Occlusion of central retinal vein by
arteriosclerotic central retinal artery
when it crosses the vein at or behind
the lamina cribrosa, where the two
share a common adventitia .
• Occlusion by primary venous wall
degeneration or inflammation .

4. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
HAEMODYNAMIC DISTURBANCES
Retinal hypoxia
Damage of capillary
endothelial cells
Extravasation of blood
constituents
Liberation of
mediators such
as VEGF
venous occlusion
elevation of
venous and
capillary pressure
stagnation of
blood flow

5. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
RISK FACTORS
• 50 % ABOVE THE AGE OF 60 YRS
• HYPERTENSION +NT IN 2/3 OF RVO PTS ABOVE 50 YRS
AGE
• HYPERLIPIDAEMIA 1/3 OR GREATER IRRESPECTIVE OF
AGE
• DIABETES 15% ABOVE 50 YRS AGE
• GLAUCOMA AND OCULAR HYPERTENSION
• ORAL CONTRACEPTIVES YOUNGER FEMALES
• MYELOPROLIFERATIVE DISORDERS , SARCOIDOSIS , SLE

6. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
SYSTEMIC ASSESSMENT
EVERY PT OF CRVO SHOULD UNDERGO
• BLOOD PRESSURE
• ESR / PLASMA VISCOSITY
• TOTAL BLOOD COUNT
• FBS / RBS
• RANDOM TOTAL AND HIGH DENSITY LIPOPROTEINS ( HDL )
• PLASMA PROTEIN ELECTROPHORESIS
• CR PROTEIN
• THYROID FUNCTION TESTS

7. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Classification TWO TYPES
NON ISCHAEMIC CRVO
• VENOUS STASIS RETINOPATHY
ISCHAEMIC CRVO
• HAEMORRHAGIC CRVO

8. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
NON ISCHAEMIC CRVO
• MORE COMMON
• AFFECTING 75 TO 80 %
• MILD TO MODERATE VISUAL LOSS
• MILD OR NO RAPD (RELATIVE AFFERENT PUPILLARY DEFECT )
• MILD TORTUOSITY AND DILATATION OF ALL THE BRANCHES
OF CRV .
• DOT BLOT AND FLAME HAEMORRHAGES
• COTTON WOOL SPOTS
• MILD OR NO MACULAR ODEMA

9. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT

10. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
NON ISCHAEMIC CRVO
About 15% cases of non-Ischaemic
CRVO are converted to
•Ischaemic CRVO in 4 months
•and about 30% in 3 years.

11. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
ISCHAEMIC CRVO
•Ischaemic CRVO refers to
acute ( sudden ) complete occlusion
of Central retinal vein .
•SUDDEN MONOOCULAR Painless
loss of vision VA REDUCED TO CF
OR HM .
•WITH RAPD .

12. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
ISCHAEMIC CRVO
• Ischaemic CRVO
refers to acute (
sudden ) complete
occlusion of Central
retinal vein
characterized by
marked sudden visual
loss and RAPD .

13. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
ISCHAEMIC CRVO

14. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
ISCHAEMIC CRVO
• Massive congestion and tortuousity of retinal veins,
• Massive retinal haemorrhages (almost whole fundus is full
of haemorrhages giving a ‘splashed tomato’ appearance),
• Numerous cotton wool spots (usually more than 6 to 10),
• Disc shows oedema and hyperaemia,
• Macular area is full of haemorrhages and is severely
oedematous
• Break through vitreous haemorrhage may be in some cases.
• Neovascularization may be seen at the disc (NVD) or in the
periphery (NVE).

15. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
SEVERE MACULAR ODEMA IN CRVO

16. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
ISCHAEMIC CRVO
Pathognomonic features for ischaemic CRVO
differentiating it from non-ischaemic CRVO are
• Presence of relative afferent pupillary defect
(RAPD),
• Visual field defects, and
• Reduced amplitude of b-wave of electroretinogram.
Complications.
RUBEOSIS IRIDIS AND NEOVASCULAR GLAUCOMA
OCCURS IN 25 % OF CASES .

17. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
MANAGEMENT OF CRVO
• VISUAL ACUITY
• IOP TO RULE OUT POAG
• SLITLAMP EXAMINATION TO RULE OUT RUBEOSIS IRIDIS
• GONIOSCOPY TO RULE OUT NEOVASCULARISATION AT
ANGLE
• DETAILED FUNDUS EXAMINATION WITH DIRECT AND
INDIRECT OPHTHALMOSCOPE AND 90 D SLIT LAMP
EXAMINATION .

18. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
MANAGEMENT OF CRVO
• ERG Reduced amplitude of b-wave of
electroretinogram IN PHOTOPIC SCOPTIC
CONDITIONS & prolonged a & b wave
implicit time
• On FA AREA OF CAPILLARY NON PERFUSION
GREATER THAN 10 DD AREA IN ISCHAEMIC
CRVO
• MACULAR CHANGES PETALOID LEAKAGE &
INCREASED FAZ IN MACULAR ISCHAEMIA .

19. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
MANAGEMENT OF CRVO
• OCT shows
1. intra / subretinal fluid in presence of ME .
2. Hyperreflective areas at locations with intra retinal haemorhages or
exudates
3. ERM and retinal atrohty in longstanding cases .
• OCTA shows
1. enlarged FAZ
2. Increased parafoveal capillary non perfusion
3. Decreased parafoveal vascular density

20. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Treatment

21. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
I. Treatment of systemic and
ocular associations
• Treatment of systemic and ocular
associations such as
• hypertension,
• diabetes,
• Hyper lipidaemias,
• POAG, and other conditions is
important in all cases.

22. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
II. Observation and monitoring
• Observation and monitoring is all that is
required in patients with mild to
moderate visual loss (VA better than
6/18), as the condition (especially non
ischaemic CRVO), in more than 50%
cases of CRVO resolves with almost
normal vision.

23. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
III. Ocular therapy
• Pharmacologic management has
become the mainstay treatment of
Macular Odema secondary to CRVO .
• Various studies were done to find out
the role of anti VEGF and steroids .

24. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
TREATMENT OF MACULAR ODEMA
INDICATED FOR
• VISUAL ACUITY WORSE THAN
6/ 12
•WITH SIGNIFICANT MACULAR
THICKENING > 250 µm on OCT

25. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
INTRAVITREAL ANTI VEGF
agents
• Ranibizumab .5 mg given monthly for 6
months and subsequently less intensively
• There will be 2 3 lines gain in visual acuity
• In non responsive cases aflibercept resulted
in better anatomical and visual improvement
and prolonged the relapse free interval
between injections .

26. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Intra
vitreal
injection

27. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
INTRAVITREAL ANTI VEGF
agents
• Bevacizumab has been tested against
aflibercept in the score 2 study and
afibercept showed more favorable
outcome on oct with resolution of
macular odema in 54 % versus 29 %
with bevacizumab .

28. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Intravitreal triamcinolone
• The score study showed an
improvement of 3 or more lines of vision
at one year in over 25 % of patients
treated with a dosage of two injections
of 1 mg triamcinolone preservative free
preparation .
• There were side effects of raised iop
and cataract formation .

29. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Intravitreal dexamethasone
implant
• The Geneva trial of sustained release biodegradable
dexamethasone intravitreal implant ( ozudrex )
shows substantial anatomical and visual
improvement over first two months following a
single implantation which declined to baseline by 6
months .
• The treatment could be repeated after 4 to 6 months
• As compared to triamcinolone there are more
cases of increase in IOP and cataract formation .

30. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Laser Photocoagulation
• Although macular odema is anatomically improved
but not beneficial for visual outcomes except in
younger patients .
• Treatment of neovascularization should be done
promptly .
• PRP should be performed without delay in eyes
with NVI or angle neovascularization .
• Placing 1500 – 2000 burns of .1 sec duration
spaced one burn apart with sufficient energy to
produce a pale to moderate reaction , avoiding
areas of haemorrhage .

31. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
2. Laser therapy
• Grid laser is NOT recommended for
macular oedema in CRVO
• Panretinal photocoagulation (PRP) is
generally not recommended as
prophylaxis even in cases with marked
ischaemia (except in patients not likely
to comply with regular follow-up).

32. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
2. Laser therapy
• PRP should be performed without delay
in CRVO when neovascularization
develops any where, i.e., in angle (NVA),
iris (NVI), retina (NVE & NVD).
• PRP involves application of 1500–3000
burns (0.5–1.0 second), spaced one
burn width apart using frequency
doubling YAG laser or argon green laser.

33. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
III. Ocular therapy
• So Intravitreal anti-VEGFs, e.g., 1.25 mg
Bevacizumab (Avastin), or 0.3 mg Ranibizumab
(Lucentis) are the treatment of choice for the
associated CME.
• Intravitreal triamcinolone (1 mg) or
dexamethasone implant (Ozurdex) may
be given for the CME as second line drug .
• Usually Repeated injections of anti-VEGFs or
triamcinolone may be required.

34. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
CRVO
CRVO WITH MACULAR ODEMA
INVOLVING CENTRE OF RETINA
NO
OBSERVATION
YES
INTRAVITREAL anti VEGF.
STEROIDS MAY BE
CONSIDERED
FA
OBSERVATION FOR NVE & NVD & NVI
ESP IF CNP AREA MORE THAN 10 DD AREANO NVE
NVD, NVI
NVE,NVD OR NVI PRESENT
VITREOUS HGE & NVG
PRP
NO GRID LASER

35. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
3. Surgical therapy
• Pars plana vitrectomy may be required for the
treatment of following complications associated
with venous occlusions:
• Persistent vitreous haemorrhage,
• Tractional retinal detachment,
• Intractable neovascular glaucoma (NVG).
PPV may be combined with endolaser PRP when
required.

36. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
SOME CASES

37. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
IST case
• This patient was aged 60 yr
old male presented with mild
decrease in vision .On exam
visual acuity in the affected rt
eye was 6 / 12 .
• Fundus photograph show
scattered intraretinal
hemorrhages, mild optic
nerve head edema and
hyperemia, and dilated and
tortuous veins.

38. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Clinical cases
• Fluorescein angiogram
showing scattered intraretinal
hemorrhages, mild optic
nerve head hyperemia, and
dilated and tortuous veins.
• No leak in the macular area .
• Minimal ischaemic areas .
• diagnosis of Non ischaemic
CRVO was made .

39. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
Clinical cases
• Optical coherence
tomography showing no
significant macular edema.
• Patient was examined for any
hypertension and diabetes
mellitus . These were not
found .
• Observation was done and
patient improved without any
intervention .

40. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
2ND case
• This patient had sudden
decrease in vision of left eye
on exam visual acuity 5 / 60 .
• Fundus photograph show
extensive intraretinal
hemorrhages. Optic nerve
head margins blurred .
Marked macular odema
present .

41. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
2ND case
• On fluorescein angiogram ,
the vasculature is barely
visible and extensive
intraretinal hemorrhages are
present .
• Marked ischaemia of retina is
also present .

42. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
2ND case
• OCT show cystoid macular
edema with subretinal fluid.
• This patient responded to
intravitreal AVASTIN . After
repeated injections ( 5
injections ) this patient
improved and macular odema
subsided .

43. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
CONCLUSION
• intravitreal corticosteroids and anti-VEGF agents have
demonstrated impressive improvements in macular
edema, visual acuity .
• The use of ranibizumab (Lucentis) and dexamethasone
implant (Ozurdex) have been FDA-approved for the
treatment of CRVO.
• Intravitreal pharmacotherapy has now replaced
observation as the standard of care for the management
of macular edema associated with CRVO.

44. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
TAKE HOME MESSAGE
NON ISCHAEMIC CRVO NO MACULAR ODEMA
• CONTRO BLOOD PRESSURE, BLOOD SUGAR AND BLOOD
LIPIDS , NO INTERVENTION JUST OBSERVATION
MACULAR ODEMA INVOLVING CENTRE
• SYSTEMIC CONTROL
• INTRAVITREAL ANTI VEGF
ISCHAEMIC CRVO WITH DEVELOPMENT OF
NEOVASCULARISATION NVD, NVE,NVI DO PRP

45. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT
THANK
YOU
DR DINESH
DR SONALEE

46. INTRODUCTION CLINICAL PICTURE DIAGNOSIS COMPLICATION TREATMENT