a presentation directed to Ophthalmology residents about CRVO and BRVO

1. Retinal Venous OcclusiveRetinal Venous Occlusive
DiseaseDisease
presentation : Dr.Ali Maaroufpresentation : Dr.Ali Maarouf
supervision : Dr.Reem Moustafasupervision : Dr.Reem Moustafa

2. DefinitionDefinition
 the second most prevalent retinalthe second most prevalent retinal
vascular disorder following diabeticvascular disorder following diabetic
retinopathyretinopathy
and is often associated with vision loss .and is often associated with vision loss .
 Partial or Complete obstruction .Partial or Complete obstruction .
 Varying degrees of retinal vascularVarying degrees of retinal vascular
leakageleakage
leading to : - macular edemaleading to : - macular edema

3. PrevalencePrevalence
 Age :Age : > 40 y> 40 y
66thth - 7- 7thth decadesdecades
< 40 y relatively uncommon< 40 y relatively uncommon
 3.1 - 4.6 % of population3.1 - 4.6 % of population
 BRVOs 6-7 times more than CRVOsBRVOs 6-7 times more than CRVOs
 ocuurence in fellow eye is 7 % within 4ocuurence in fellow eye is 7 % within 4
yy

4. predisposing factorspredisposing factors
• systemic :systemic : ( vessel-wall dysfunction )( vessel-wall dysfunction )
- Advanced age- Advanced age
- HTN :- HTN :
- especially in not well treated patiens- especially in not well treated patiens
- 63.6 % of RVO vs. 36.2 % of controls- 63.6 % of RVO vs. 36.2 % of controls
- DM :- DM :
- significantly more frequent in CRVO- significantly more frequent in CRVO
- Hyperlipidemia- Hyperlipidemia
- Smoking- Smoking
- OCCs- OCCs
- Homocysteinemia : >>- Homocysteinemia : >>
- Coagulation disorders : >>- Coagulation disorders : >>
proteins C & S deficiencies , antiphospholipid synproteins C & S deficiencies , antiphospholipid syn
in young
patients

5. perdisposing factorsperdisposing factors
• local :local :
- Glaucoma :- Glaucoma :
occlusion at disc rimocclusion at disc rim
- Hypermetropia- Hypermetropia

6. pathogenesispathogenesis
• Diseases of both Veins & ArteriesDiseases of both Veins & Arteries
arteriosclerosis :arteriosclerosis : small arteries andsmall arteries and
arteriolesarterioles
important in BRVOimportant in BRVO
atherosclerosis :atherosclerosis : large & medium sizedlarge & medium sized
arteriesarteries
important in CRVOimportant in CRVO

7. pathogenesispathogenesis
• endothelial cell loss , stagnationendothelial cell loss , stagnation
thrombus formationthrombus formation
>>> Occlusion>>> Occlusion

8. pathogenesispathogenesis
hypoxia
↑ Vein & Capillary pressure
& stagnation
occlusion
endothelial damage
& extravasation of
constituents
↑ tissue pressure

9. Signs & SymptomsSigns & Symptoms
• Vision Loss :Vision Loss :
- macular ischemia or edema- macular ischemia or edema
- retinal hemorrhages- retinal hemorrhages
• Slit Lamp Test & Fundus Examination :Slit Lamp Test & Fundus Examination :
- vitreous hemorrhage- vitreous hemorrhage
- epiretinal membrane formation- epiretinal membrane formation
- rubeosis iridis- rubeosis iridis
- neovascular glaucoma- neovascular glaucoma

10. ClassificationClassification
- Central Retinal Vein Occlusion ( CRVO )- Central Retinal Vein Occlusion ( CRVO )
at or posterior to optic nerve headat or posterior to optic nerve head
- Branch Retinal Vein Occlusion- Branch Retinal Vein Occlusion ( BRVO )( BRVO )
at a branch or tributary of CRVat a branch or tributary of CRV

11. CRVOCRVO

12. CRVOCRVO

13. CRVOCRVO
• Variable visual lossVariable visual loss
• Fundus : - retinal hemorrhagesFundus : - retinal hemorrhages
- dilated tortuous retinal veins- dilated tortuous retinal veins
- macular edema- macular edema
- optic disc edema- optic disc edema
- cotton wool spots- cotton wool spots

14. CRVO - scattered hemorrhagesCRVO - scattered hemorrhages

15. CRVOCRVO
Important investigations :Important investigations :
- FFA- FFA
- OCT- OCT

16. CRVOCRVO

17. CRVOCRVO
• Complications :Complications :
- Macular edema- Macular edema
- Neovascularisation :- Neovascularisation :
NVDNVD
NVENVE
NVINVI

18. CRVOCRVO
significant disc edema - dilated tortuos veins -significant disc edema - dilated tortuos veins -
scattered hemorrhagesscattered hemorrhages

19. CRVOCRVO
same patient - leakage from disc - staining of veinssame patient - leakage from disc - staining of veins

20. CRVOCRVO

21. CRVO - FFACRVO - FFA
dilated tortuos veins - leakage into macula - cystoid patterndilated tortuos veins - leakage into macula - cystoid pattern

22. CRVO - FFACRVO - FFA
perifoveal capillary leakage - cystoid pattern - late phaseperifoveal capillary leakage - cystoid pattern - late phase

23. CRVO - FFACRVO - FFA
perifoveal leakage - cystoid patternperifoveal leakage - cystoid pattern

24. CRVO Non-IschemicCRVO Non-Ischemic
perifoveal leakage - Arteriovenous phaseperifoveal leakage - Arteriovenous phase

25. CRVOCRVO
resolving NVD - PRP spotsresolving NVD - PRP spots

26. CRVOCRVO
optociliary shunt vesselsoptociliary shunt vessels

27. CRVOCRVO
• impending :impending :
uncommon , poorly describeduncommon , poorly described
• non-ischemic :non-ischemic :
~75%~75%
Afferent pupillary defect (APD) : absent or mild .Afferent pupillary defect (APD) : absent or mild .
delay in AV transit time -good capillary perfusion -delay in AV transit time -good capillary perfusion -
late leakagelate leakage
prognosis : reasonably good , related to inital VAprognosis : reasonably good , related to inital VA
• ischemic :ischemic :
APD : markedAPD : marked
marked delay in AV transit time ( > 20 S )marked delay in AV transit time ( > 20 S )
extensive areas of capillary non-perfusionextensive areas of capillary non-perfusion
prognosis : extremely poor .prognosis : extremely poor .

28. Non-ischemic CRVONon-ischemic CRVO

29. Non-Ischemic CRVONon-Ischemic CRVO

30. Non-Ischemic CRVONon-Ischemic CRVO

31. BRVOBRVO
• Occurs typically at A-V crossing pointOccurs typically at A-V crossing point
( commom adventitial sheath )( commom adventitial sheath )
• more common detected in the superiormore common detected in the superior
temporal quadranttemporal quadrant

32. BRVOBRVO
majormajor
minor macularminor macular
peripheralperipheral

33. BRVOBRVO

34. BRVO - FFABRVO - FFA

35. BRVO - FFABRVO - FFA

36. investigationsinvestigations
• All patients :All patients :
- VA , Slit Lamp Exam- VA , Slit Lamp Exam
- OCT , FFA- OCT , FFA
- Laboratory Tests :- Laboratory Tests :
BP , CBC , Random BG , Fasting BG , ESRBP , CBC , Random BG , Fasting BG , ESR
ECG , Cholesterol and Lipids , Plasma protein electrophoresisECG , Cholesterol and Lipids , Plasma protein electrophoresis
Urea , Creatinine , Electrolytes ,Thyroid tests .Urea , Creatinine , Electrolytes ,Thyroid tests .
• Selected patients :Selected patients :
- Thrombophilia screen , CRP , Autoantibodies , Fasting- Thrombophilia screen , CRP , Autoantibodies , Fasting
Plasma Homocystein levelPlasma Homocystein level
- CXR , ACE ,- CXR , ACE ,
- Treponemal serology , Carotid duplex imaging .- Treponemal serology , Carotid duplex imaging .

37. ComplicationsComplications
• Macular Edema :Macular Edema :
the most important factor for reducedthe most important factor for reduced
VA after RVOVA after RVO
• Neovascularisation :Neovascularisation :
vitreous hemorrhagevitreous hemorrhage
tractional RDtractional RD
neovascular glaucomaneovascular glaucoma

38. TreatmentTreatment
• Anti VEGFAnti VEGF
• F/G LaserF/G Laser
• Sectoral LaserSectoral Laser
• VitrectomyVitrectomy
• Treatment of underlying diseaseTreatment of underlying disease

39. a clinical case presentationa clinical case presentation
• a 50-year-old woman diagnosed with HTNa 50-year-old woman diagnosed with HTN
1 month ago , HTN treatment has been1 month ago , HTN treatment has been
stopped on patient’s own after 2 w ofstopped on patient’s own after 2 w of
treatment .treatment .
• FH : HTN , DM .FH : HTN , DM .
• BP : 19-18 / ? mmHg .BP : 19-18 / ? mmHg .
• FBS : W.N.LsFBS : W.N.Ls

40.  presentation :
reduced visual acuity OS with a sudden partial-
field Vision Loss one week ago + chronic
headache treated with analgesics .
 VA : - OS : CF . vision field : superiomedial
quadrant
- OD : 10/10
 slit lamp examination :
inferior archade BRVO

41. clinical case

42. clinical caseclinical case

43. clinical caseclinical case

44. ReferencesReferences
• American Academy of OphthalmologyAmerican Academy of Ophthalmology
publicationspublications
• emedicine-Medscapeemedicine-Medscape
• Charité Einblick-AusblickCharité Einblick-Ausblick
Fachpublikation Band 2Fachpublikation Band 2
• Ophthalmic photographer’s societyOphthalmic photographer’s society
• Kanski’s clinical ophthalmology 7Kanski’s clinical ophthalmology 7thth
editionedition

45. Presented atPresented at ::
Eye Surgical Hospital ,Eye Surgical Hospital ,
Damascus , Syria .Damascus , Syria .
18/1/201618/1/2016