Central retinal vein occlusion in a patient using the antipsychotic drug olanzapine: a case report

Background

We report our findings in a patient who developed central retinal vein occlusion (CRVO) and was a chronic user of olanzapine, an antipsychotic medication.

Case presentation

A 50-year-old Caucasian man, non-smoker, was referred to our clinic with the chief complaint of floater appearance in his left eye for the past 3 days. His past medical history indicated that he had been taking antipsychotic drugs (olanzapine) for about 3 years, with no other systemic disease or risk factors for CRVO.

In the examination, his best-corrected visual acuity (BCVA) was 0.7 in the left eye. The fundus showed signs of nonischemic CRVO with subhyaloid hemorrhage and intraretinal hemorrhage in the posterior pole and superior and inferior retina, without macular edema, confirmed by optical coherence tomography (OCT).

We ruled out other probable differential diagnoses and risk factors which lead to CRVO through a complete physical exam and blood analysis (complete blood count, glucose, urea, creatinine, lipid profile, erythrocyte sedimentation rate, C-reactive protein, prothrombin time, partial thromboplastin time, Bleeding time (BT), fibrinogen level, proteins, antiphospholipid antibodies, homocysteine blood level, antithrombin III, protein C and S, factor V Leiden, prothrombin mutation, angiotensin-converting enzyme level, other autoantibodies, and human leukocyte antigen [HLA]-B51). Finally, we confirmed the probable side effect of olanzapine in CRVO, which has not been previously reported. A possible pro-thrombogenic mechanism of olanzapine at the molecular level is an affinity for 5-HT_2Aserotonin receptors. Blocking these receptors results in increased platelet aggregation and increased blood coagulability.

Conclusions

These results indicate that CRVO can be a complication of chronic use of antipsychotic medications such as olanzapine, as shown for the first time in our case report. Clinicians should question patients who develop a sudden CRVO whether they are using antipsychotic medications such as olanzapine.

An Unusual Case of Concurrent Central Retinal Vein and Cilioretinal Artery Occlusion in a Healthy Patient

It is rare for young, healthy patients to have retinal venous or arterial occlusions and even rarer for both to occur in concert. Such an occurrence should prompt a rapid and extensive workup to prevent further complications. We present our patient, a 37-year-old Lebanese male, who reported a 3-day history of blurring of vision in his left eye. He had no medical or ocular history and is a nonsmoker. Examination of the left fundus revealed inferior macular edema and retinal whitening associated with tortuous retinal veins. He was diagnosed with a combined central retinal vein and cilioretinal artery occlusion. Emergency treatment was done for an acute arterial occlusion. Embolic and thrombotic causes were excluded with investigations. The only positive result was homozygosity for 677C>T mutation of the 5,10 methylenetetrahydrofolate reductase (MTHFR) enzyme gene. MTHFR enzyme breaks down homocysteine, which is atherogenic and prothrombotic. This mutation can lead to a prothrombotic state, precipitating this occurrence. In fact, the Lebanese population is known to have the highest incidence of such mutations, but there are surprisingly few reports on retinal vascular occlusions attributed to this. He was promptly treated with antiplatelet therapy, possibly preventing a full-blown central retinal vein occlusion. After 4 weeks, his vision improved to 6/6 bilaterally. Examination showed less tortuous veins, no more retinal whitening, resolution of macula edema and visual field defect. Hyperhomocysteinemia can be significant in patients without ischemic risk factors. It is vital to manage these patients promptly, preventing future sight and life-threatening events.

Long-term outcomes of intravitreal activated protein C injection for ischemic central retinal vein occlusion: an extension trial

Purpose

Our previous 1-year pilot study evaluated the efficacy of intravitreally injected activated protein C (APC) in 10 eyes with ischemic central retinal vein occlusion (CRVO). The reperfusion of the areas of retinal nonperfusion (RNP) exceeded 50% of the baseline in five (50%) eyes 1 year after the APC injection. The current study evaluated the long-term efficacy and safety of intravitreal APC.

Methods

The 10 eyes in the pilot study were included in this study. Other treatments were administered at the physicians’ discretion after the pilot study. We evaluated visual acuity (VA), central retinal thickness (CRT) and perfusion status, and adverse events and severity over the long term.

Results

The median follow-up was 60 months (range, 48–68 months). Compared with baseline, the post-treatment VA improved significantly (P < 0.001) from 1.39 to 1.06 logarithm of the minimum angle of resolution. The CRT improved significantly (P < 0.001) from 1090 to 195 μm at the last visit. The RNP areas decreased from an average 29.7 disc areas (DAs) at baseline to an average 16.5 DAs at the last examination (mean, 40 ± 6.5 months after the first APC treatment). No adverse events were related to intravitreal APC.

Conclusion

No complications were associated with intravitreal APC, the clinical course improved, and improved RNP was maintained for the long term, suggesting that intravitreal APC may be an alternative treatment for CRVO.

Efficacy of intravitreal ziv-aflibercept in patients with macular edema following retinal vein occlusion in Korle-Bu Teaching Hospital, Ghana: a retrospective case series

AIM

To evaluate the efficacy of ziv-aflibercept in Ghanaian patients with macular edema (ME) secondary to retinal vein occlusion (RVO).

METHODOLOGY

In this retrospective study, the medical records of patients with ME secondary to RVO who had been treated with intravitreal ziv-aflibercept (IVZ) (1.25 mg/0.05 ml), as part of routine clinical practice, on pro re nata basis with a minimum follow-up of 6 months were retrieved and analyzed. The main outcome measures are mean change in best-corrected visual acuity (BCVA) and central subfield foveal thickness (CSFT) measured on optical coherence tomography from baseline to 12 months post-IVZ, and ocular and systemic safety.

RESULTS

Forty-three eyes were included in this study. Their mean age was 62.8 ± 11.9 years, 67.4% had at least 12-month duration of follow-up, 50% had primary open-angle glaucoma and 38 (88.4%) eyes were treatment naive. There was significant improvement in mean BCVA in LogMAR at 1 month post-initiation of IVZ (0.8 ± 0.5 vs. 1.1 ± 0.6), and visual improvement was maintained up to 12 months (p < 0.001). Eyes with ME following BRVO had better mean BCVA at baseline and on subsequent visits compared to eyes with CRVO/HRVO (p = 0.01). There was significant reduction in mean CSFT up to 12 months post-IVZ injection compared to baseline (p < 0.001). Ocular complications observed were consistent with complications associated with RVO.

CONCLUSION

We have observed significant improvement in functional and anatomic outcomes 12 months post-initiation of IVZ. There is the need to confirm long-term efficacy and safety of IVZ in a large prospective study.

Photocoagulation for retinal vein occlusion

The role of photocoagulation in retinal vein occlusion (RVO) has been studied since 1974. The most serious complications of central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) are: (i) visual deterioration, most commonly due to macular edema, and (ii) the development of ocular neovascularization (NV), particularly neovascular glaucoma (NVG), with hazardous consequences for vision and even the eye itself. Before discussing the role of photocoagulation in the management of NV and macular edema in RVO, it is crucial to gain a basic scientific understanding of the following relevant issues: classification of RVO, ocular NV in RVO, and the natural history of macular edema and visual outcome of RVO. These topics are discussed. In CRVO, ocular NV is a complication of ischemic CRVO but not of nonischemic CRVO. Photocoagulation has been advocated to prevent and/or treat the development of ocular NV and NVG. Since NVG is the most dreaded, intractable and blinding complication of ischemic CRVO, the role of photocoagulation and its management are discussed. Findings of three randomized, prospective clinical trials dealing with photocoagulation in ischemic CRVO are discussed. The role of photocoagulation in the management of ocular NV and macular edema in BRVO, and three randomized, prospective clinical trials dealing with those are discussed. Recent advent of intravitreal anti-VEGF and corticosteroid therapies has drastically changed the role of photocoagulation in the management of macular edema and NV in CRVO and BRVO. This is discussed in detail.

Leakage index on ultra-widefield fluorescence angiography in different regions of retina and its correlation with cystoid macular edema in central retinal vein occlusion eyes

PURPOSE

To investigate the relationship between leakage index on ultra-widefield fluorescence angiography (UWFFA) in different regions of retina and its correlation with cystoid macular edema (CME) in central retinal vein occlusion (CRVO) eyes.

METHODS

Patients with naïve non-ischemic CRVO that had undergone UWFFA were identified. UWFFA images in the late phase were used to analyze the leakage index, which was performed by a semi-automatic method using ImageJ. The UWFFA images were subdivided into four regions by concentric circles centered on the macula for analysis. Optical coherence tomography (OCT) images were used to identify the presence of CME and obtain central macular thickness (CMT).

RESULTS

A total of 57 eyes from 57 CRVO patients were analyzed in this study, including 43 eyes with CME and 14 eyes without CME. The leakage index in panretinal, peri-macular area (PMA), and near-peripheral area (NPA) was significantly different between eyes with CME and eyes without CME. Leakage index of PMA, NPA, mid-peripheral area (MPA), and panretinal area was significantly correlated with CMT, particularly the PMA.

CONCLUSIONS

The distribution of leakage is different between patients with CME and patients without CME. The contribution of leakage index in different regions to CME was different, most predominant in PMA and NPA, and the closer to the center of the macula, the stronger the correlation between leakage index and CMT. A linear correlation was observed between CMT and the leakage index of panretinal area and all regions except far-peripheral area (FPA).

Association between early and late response in eyes with central or hemiretinal vein occlusion treated with anti-VEGF agents : SCORE2 report 12: secondary analysis of the SCORE2 clinical trial

PURPOSE

To assess whether early visual acuity letter score change from baseline (ΔVALS) and early spectral domain optical coherence tomography (SD-OCT) measures of center point thickness (CPT) are associated with later ΔVALS in eyes with macular edema due to central or hemiretinal vein occlusion treated with intravitreal aflibercept or bevacizumab.

METHODS

Secondary analysis of a randomized clinical trial of 362 participants.

RESULTS

Considered separately at month 3, CPT (categorized as ≤ 300 μm, > 300 μm) and ΔVALS (categorized as < 5, 5-9, ≥ 10) are predictive of ΔVALS at month 6 (aflibercept: P = 0.02 for CPT and P < 0.0001 for ΔVALS; bevacizumab: P = 0.007 for CPT and P < 0.0001 for ΔVALS) and, except for CPT in the bevacizumab arm, also predictive of ΔVALS at month 12 (aflibercept: P = 0.03 for CPT and P < 0.0001 for ΔVALS; bevacizumab: P = 0.18 for CPT and P < 0.0001 for ΔVALS). Month 3 predictors are also associated with average ΔVALS from months 4 to 12 (CPT P = 0.01 in the aflibercept arm, P = 0.02 in the bevacizumab arm; ΔVALS > 10 versus < 5; P < 0.001 for both aflibercept and bevacizumab). When month 3 measures are considered jointly, ΔVALS effect remains significant for average ΔVALS from months 4 to 12 (aflibercept: P = 0.002; bevacizumab: P < 0.0001) but not CPT (aflibercept: P = 0.18; bevacizumab: P = 0.22).

CONCLUSION

While both month 3 ΔVALS and CPT are predictive of ΔVALS after month 3 through month 12, early ΔVALS has a stronger relationship than CPT with later ΔVALS. SCORE2 registration number is NCT01969708.

Vascular Patterning as Integrative Readout of Complex Molecular and Physiological Signaling by VESsel GENeration Analysis

The molecular signaling cascades that regulate angiogenesis and microvascular remodeling are fundamental to normal development, healthy physiology, and pathologies such as inflammation and cancer. Yet quantifying such complex, fractally branching vascular patterns remains difficult. We review application of NASA's globally available, freely downloadable VESsel GENeration (VESGEN) Analysis software to numerous examples of 2D vascular trees, networks, and tree-network composites. Upon input of a binary vascular image, automated output includes informative vascular maps and quantification of parameters such as tortuosity, fractal dimension, vessel diameter, area, length, number, and branch point. Previous research has demonstrated that cytokines and therapeutics such as vascular endothelial growth factor, basic fibroblast growth factor (fibroblast growth factor-2), transforming growth factor-beta-1, and steroid triamcinolone acetonide specify unique "fingerprint" or "biomarker" vascular patterns that integrate dominant signaling with physiological response. In vivo experimental examples described here include vascular response to keratinocyte growth factor, a novel vessel tortuosity factor; angiogenic inhibition in humanized tumor xenografts by the anti-angiogenesis drug leronlimab; intestinal vascular inflammation with probiotic protection by Saccharomyces boulardii, and a workflow programming of vascular architecture for 3D bioprinting of regenerative tissues from 2D images. Microvascular remodeling in the human retina is described for astronaut risks in microgravity, vessel tortuosity in diabetic retinopathy, and venous occlusive disease.

Posterior lens capsule neovascularization treated with anti-VEGF complicated by phacogenic uveitis

Purpose

To report a case of neovascularization of posterior capsule (NVPC) successfully treated with intravitreal ranibizumab (Lucentis) and neodymium:YAG (Nd:YAG) capsulotomy, followed by phacogenic uveitis.

Observations

We report a systemically otherwise healthy 81-year-old male presenting with unilateral NVPC and iris (NVI) occurring five years after a central retinal vein occlusion. A single intravitreal injection of ranibizumab led to complete regression of NVPC and NVI within three weeks after which a Nd:YAG capsulotomy was performed. Two weeks later, the patient returned with a severe inflammatory reaction diagnosed as phacogenic uveitis and treated with surgical capsular bag/intraocular lens complex removal and peripheral pan-retinal photocoagulation. One-year follow-up demonstrated no recurrence of NVPC. Visual acuity remained at baseline of light perception.

Conclusions

We acknowledge that intravitreal anti-vascular endothelial growth factor treatment with Nd:YAG capsulotomy for NVPC is a rational option, but raise awareness to the rare possibility of phacogenic uveitis.

Central retinal vein occlusion with COVID-19 infection as the presumptive etiology

Thromboembolic phenomenon related to Coronavirus disease 2019 (COVID-19) has been well documented in literature; however, reported ocular manifestations of COVID-19 are limited to vision sparing ocular conditions like conjunctivitis. We report a case of a 17-year-old female who presented to us with central retinal vein occlusion with proven recent past COVID-19 infection as presumed etiology which was not known to her at the time of presentation.

Cost-Utility of Anti-Vascular Endothelial Growth Factor Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion

PURPOSE

To evaluate the cost-utility of treatment for macular edema in central retinal vein occlusion (CRVO) using intravitreal injections of the anti-vascular endothelial growth factor (VEGF) agents bevacizumab, ranibizumab, and aflibercept.

DESIGN

Decision analysis model of cost-utility.

PARTICIPANTS

Data from study participants in the Lucentis, Eylea, Avastin in Vein Occlusion (LEAVO) study.

METHODS

A decision analysis of a disease simulation model was used to calculate comparative cost-utility of intravitreal bevacizumab (IVB), intravitreal ranibizumab (IVR), and intravitreal aflibercept (IVA) for the treatment of macular edema associated with CRVO based on data from the LEAVO study. Center for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital- or facility-based and nonfacility setting from a third-party payer perspective, and societal costs also were calculated. Cost utility was calculated based on the preserved visual utility during the 2 years of the study and also by estimating utility for the expected lifetime.

MAIN OUTCOME MEASURES

Cost of treatment, cost per quality-adjusted life-year (QALY), and incremental cost-effectiveness ratio (ICER).

RESULTS

From the third-party payer perspective, the estimated lifetime costs per QALY in the facility and nonfacility settings were $39 325 and $17 944, respectively, for IVB; $114 095 and $92 653, respectively, for IVR; and $78 935 and $63 270, respectively, for IVA. From the societal perspective, the estimated lifetime costs per QALY in the facility setting were $52 754 for IVB, $128 242 for IVR, and $86 262 for IVA. The ICER of IVA compared with that of IVB was $153 633/QALY from the third-party facility setting and $152 992/QALY from the societal perspective. The use of IVB compared with IVR and IVA compared with IVR were cost-saving interventions (ICER, <0) regardless of the perspective or setting.

CONCLUSIONS

In the treatment of macular edema in CRVO, IVB yields the best cost utility among the 3 anti-VEGF agents modeled. Intravitreal aflibercept maintains acceptable lifetime cost per QALY while having a favorable cost utility compared with IVR.

[Combined retinal vascular occlusion after overexertion in sport at a young age : An unusual case as interdisciplinary challenge]

This case report presents a unilateral visual impairment after overexertion in sport at a young age. A combined central retinal vein occlusion with a cilioretinal arterial branch occlusion was diagnosed. This clinical picture has been described in case series and does not usually have an embolic etiology. In the cardiovascular clarification a patent foramen ovale was found, which was surgically closed.

Metabolomic analysis of the aqueous humor from patients with central retinal vein occlusion using UHPLC-MS/MS

Central retinal vein occlusion (CRVO) is one of the retinal fundus diseases and may result in irreversible visual impairment. Metabolic dysfunction has been proved to play an essential role in the pathogenesis of CRVO. We performed untargeted metabolomic analysis of the aqueous humor (AH) of patients with CRVO and controls using UHPLC-MS/MS. A total of 248 metabolites were identified in the tested AH samples, 37 of which allowed for the construction of an orthogonal partial least squares discriminant analysis model with good predictive capability (Q2cum = 0.834) and low risk of overfitting. The components contributing the most to the metabolomic signature of CRVO were those related to amino acid metabolism, carbohydrates, and fatty acid metabolites (variable importance on projection>1.0 and p < 0.05). The CRVO group appeared to have a lower AH concentration of carbohydrates and amino acids, but a relative higher concentration of carnitine-associated energetic substrates (butyryl carnitine, deoxycarnitine, N6-trimethyl-l-lysine) and osmolytes compared with those of the control group. These results indicate that patients with CRVO may have ocular aberrations in metabolic pathways involving certain amino acids, fatty acids, and carbohydrates. These metabolite changes might correlate with energy dysfunction and inflammation response in the AH of CRVO patients. This finding may provide insight into the pathophysiology of CRVO for the development of new therapeutic strategies.

Relationship between retinal blood flow and cytokines in central retinal vein occlusion

Background

We evaluated the relationship between retinal blood flow and aqueous humor levels of cytokines/growth factors in patients with central retinal vein occlusion (CRVO).

Methods

In an observational study, 64 eyes of 64 CRVO patients were examined before anti-vascular endothelial growth factor (VEGF) therapy. Blood flow was assessed in large vessels around and at the optic disk by determining the mean blur rate using laser speckle flowgraphy. Aqueous humor samples were obtained from the patients during anti-VEGF therapy and levels of the following molecules were measured by the suspension array method: soluble VEGF receptor (sVEGFR)-1, sVEGFR-2, VEGF, plancental growth factor (PlGF), platelet-derived growth factor (PDGF)-AA, soluble intercellular adhesion molecule (sICAM)-1, monocyte chemotactic protein (MCP)-1, interleukin (IL)-6, IL-8, IL-12(p70), and IL-13.

Results

The mean blur rate of the affected eye was significantly lower than that of the unaffected eye. The mean blur rate showed a significant negative correlation with the log-transformed aqueous humor levels of PlGF, sICAM-1, and IL-8, but not VEGF.

Conclusions

These findings suggest that retinal blood flow velocity might be more strongly correlated with inflammatory factors than VEGF in patients with nonischemic CRVO and macular edema.

Baseline clinical features predict visual outcome in young patients with central retinal vein occlusion

PURPOSE

To evaluate prognostic factors in young patients with central retinal vein occlusion (CRVO).

METHODS

Retrospective case series. CRVO patients aged ≤ 50 and follow-up ≥ 6 months were enrolled. The best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, 3 months, 6 months, and last visit were documented. Severity of retinopathy was graded by comparing to standard photos. Prognostic factors associated with visual outcome at 6 months were evaluated by multiple linear regression models.

RESULTS

A total of 73 eyes from 69 patients with mean age 37.6 ± 8.5 were enrolled. Forty-seven (68%) patients were male. The mean follow-up duration was 25.9 ± 23.0 months. LogMAR BCVA improved from 0.979 ± 0.785 at baseline to 0.594 ± 0.748 at the 6 months (p < 0.001) and CRT improved from 475 ± 222 μm to 299 ± 104 μm (p < 0.001). Forty-eight (66%) eyes required anti-vascular endothelial growth factor (anti-VEGF) treatment. The mean number of injections was 2.25 ± 1.41 in the first 6 months and 75% of eyes received ≦ 3 injections during the clinical course. The baseline BCVA (coefficient 0.518, p < 0.001), grade of retinal hemorrhage (coefficient 0.230, p = 0.006), grade of retinal venous engorgement (coefficient 0.238, p = 0.011), grade of optic disc edema (coefficient - 0.226, p = 0.005), and diabetes mellitus (coefficient 0.264, p = 0.047) were the independent factors associated with visual outcome at 6 months.

CONCLUSIONS

Baseline clinical features are useful for the prediction of visual outcome at 6 months in young CRVO patients.

Time-Frequency Analysis of Photopic Negative Response in CRVO Patients

PURPOSE

The PhNR is driven by retinal ganglion cells (RGCs). Therefore, the function of RGCs could be objectively evaluated by analyzing the PhNR. The aim of this article is to determine the effect of central retinal vein occlusion (CRVO) on PhNR and RGCs performances.

METHODS

Seventeen patients with CRVO were included. Full-field photopic ERGs, including PhNR, were recorded and compared with the fellow normal eyes. ERG signals were analyzed based on the standard time-domain analyses of the PhNR as well as a continuous wavelet transform (CWT) to extract time-frequency components that correspond to the PhNR using MATLAB. We obtained the main frequencies and their occurrence time from CWT.

RESULTS

All a-wave, b-wave, and PhNR amplitudes of CRVO eyes showed a significant reduction compared to those of the fellow eyes (P < .01, P < .001, and P < .001, respectively). The peak times of a-wave, b-wave, and PhNR were increased significantly in the CRVO eyes (P = .04, P = .04, and P = .003, respectively). The dominant f₃ frequency, which corresponds to the PhNR in CRVO patients, showed a more significant decrease (P < .001) compared to other dominant frequencies (f₀, f₁, and f₂). The occurrence time of f₃ (t₃) was significantly higher in the CRVO eyes (P < .001). Time-domain of the PhNR was also affected in CRVO patients (P < .001).

CONCLUSION

CWT allows quantifications of ERG responses, especially for PhNR. The PhNR was severely affected in CRVO eyes implicating loss of RGCs. CWT might demonstrate the severity of CRVO more precisely and identify diagnostically significant changes of ERG waveforms that are not resolved when the analysis is only limited to the time-domain measurements.

Central Retinal Vein Prethrombosis Secondary to Retinal Vasculitis: Early Detection and Treatment

The aim was to report a case of central retinal vein prethrombosis (CRVP), responsive to systemic steroids. An 18-year-old male presented with right sudden blurred vision and central scotoma for 2 days. Right best-corrected visual acuity (BCVA) measured 6/36, and fundoscopy revealed vascular congestion and blurred disc margins. Fluorescein angiography (FA) showed CRVP secondary to retinal vasculitis. Systemic oral prednisone was started. Six months later, right BCVA was 6/6, FA showed reduced vascular congestion, and retinal vasculitis and residual optic disc hyperfluorescence resolved. CRVP should be considered in young patients with sudden central scotoma. Early systemic steroids might be effective in the treatment of “active” retinal vasculitis.

Changes of focal macular and full-field electroretinograms after intravitreal aflibercept in patients with central retinal vein occlusion

PURPOSE

To evaluate the physiology of the macular and whole retina after intravitreal aflibercept (IVAs) injections in patients with macular edema associated with a central retinal vein occlusion (CRVO) by electroretinography (ERG).

METHODS

We studied 20 eyes of 20 patients with non-ischemic CRVO (72.0 ± 9.2 years). All patients were treated with monthly injections of IVA for the initial 3 months and then treated by the treat-and-extend (TAE) regimen for 12 months. The best-corrected visual acuity (BCVA), optical coherence tomographic images, focal macular ERGs (fmERGs), and full-field ERGs recorded before and after the treatment were compared. The fmERGs were elicited by a 15° white stimulus spot centered on the fovea. The full-field ERGs were recorded by a protocol recommended by International Society for Clinical Electrophysiology of Vision. The amplitudes and implicit times determined before and after the IVA were compared.

RESULTS

The foveal thickness was significantly reduced accompanied by improvement of the BCVA after the treatments, and the improvements were maintained for at least 12 months. The amplitudes and implicit times of the fmERGs improved continuously for the 12 months. On the other hand, the reduced amplitudes of the full-field ERG, summed oscillatory potentials, and the photopic negative responses remained unchanged for the 12-month period. However, the implicit times of the maximum and cone responses were significantly shortened after the IVA.

CONCLUSIONS

IVA injections by the TAE regimen led to a continuous improvement of the macular function in patients with ME associated with a CRVO. However, the function of the whole retina changed differently than the macula after the treatment.

Glioblastoma multiforme mimicking optic neuritis

PURPOSE

To present a case of glioblastoma multiforme which initially presented with only ophthalmic manifestations.

OBSERVATIONS

A 48-year-old man presented with decreased vision and pain with eye movements of the right eye. MRI of the brain showed increased T2/FLAIR signal involving the right optic nerve with no other identified abnormalities. He was treated with intravenous steroids for presumed optic neuritis. His visual acuity then rapidly worsened to no light perception, with new orbital apex symptoms including central retinal artery and vein occlusions and inferior division third and fourth nerve palsies. Repeat MRI with contrast showed perineural enhancement surrounding the right optic nerve and markedly reduced diffusion along its entire course. After an unrevealing initial workup and then a 7 month period during which the patient refused follow up, he re-presented with left sided weakness, headache, and confusion. Repeat brain MRI revealed a large mass involving the right optic nerve, optic chiasm, basal ganglia, corpus callosum and brainstem. Biopsy led to a diagnosis of WHO grade IV glioblastoma multiforme. The disease was poorly responsive to temozolomide, bevacizumab and external beam radiation, and the patient passed away 5 months later.

CONCLUSIONS AND IMPORTANCE

Malignant optic glioma of adulthood is a challenging diagnosis with a poor prognosis. This rare case highlights the importance of maintaining neoplasm in the differential for optic neuritis masqueraders.

Acute macular neuroretinopathy with coexistent central retinal vein occlusion as the presenting feature in intraocular tuberculosis

Aim

To report a case of intraocular tuberculosis presenting as acute macular neuroretinopathy and central retinal vein occlusion.

Case description

A 29-year-old man presented to the retina clinic with complaints of sudden blurring of vision in the left eye of 3 days duration. His visual acuity was 6/6 and 6/18 in the right and left eye, respectively. Fundus examination of the left eye showed features of central retinal vein occlusion. OCT showed features of type 2 acute macular neuroretinopathy (AMN) as well. Over a period of 2 weeks, the patient developed choroidal granulomas with overlying retinal elevation and peripapillary choroidal neovascular membrane and retinal granuloma. Mantoux test and HRCT chest confirmed the diagnosis of pulmonary tuberculosis.

Results

The patient was treated with a course of antitubercular therapy, oral corticosteroids and a single dose of intravitreal anti-vascular endothelial growth factor (1.25 mg/0.05 ml Bevacizumab, Roche Pharma) injection. After 6 months of therapy with ATT and tapering course of oral steroids, there was a complete resolution of all clinical signs including the choroidal granuloma with an improvement in visual acuity to 6/6.

Conclusion

Acute macular neuroretinopathy can complicate intraocular TB. Tuberculosis should be kept as one of the differential diagnosis in patients with AMN. Prognosis is generally good in patients of ocular TB presenting with retinal vascular occlusions.

Combined central retinal vein occlusion and branch retinal artery occlusion treated with intravitreal dexamethasone implant: A case report

PURPOSE

To report a case of combined central retinal vein occlusion and branch retinal artery occlusion in a 51-year-old male with a very good response to dexamethasone implant therapy.

METHODS

This is a descriptive case report based on data from clinical records, patient observation and follow-ups, and analysis of acquired diagnostic tests.

RESULTS

A 51-year-old man presented with sudden vision loss and best-corrected visual acuity of 20/40 in his left eye. A pale inferotemporal arterial branch course area along with increased vascular tortuosity, retinal hemorrhages, optic disk swelling, and macular edema were observed on slit lamp biomicroscopy examination. Right eye was normal. Diagnosis of combined central retinal vein occlusion and branch retinal artery occlusion in left eye was confirmed by fluorescein angiography and color fundoscopy, respectively. Optical coherence tomography confirmed subretinal fluid and intraretinal cysts with a prominent middle-limiting membrane in the inner synaptic portion of the outer plexiform layer, corresponding to areas of paracentral acute middle maculopathy. Intravitreal dexamethasone implant was administered to the patient. One month later, visual acuity was recovered with complete absorption of macular edema. Functional and anatomical stabilization were confirmed after 24 months.

CONCLUSION

Combined central retinal vein occlusion and branch retinal artery occlusion represents a rare condition, with variable functional outcomes due to the long-term complications such as macular edema. We hypothesize that prompt diagnosis and immediate intravitreal corticosteroid implant therapy reduced macular edema, thus contributing to arterial perfusion improvement, which in this case lead to a full sustainable recovery with limited functional and anatomical damage.

A treat and extend protocol with Aflibercept for cystoid macular oedema secondary to central retinal vein occlusion - an 18-month prospective cohort study

Background

To evaluate the safety and efficacy of a treat-and-extend protocol of aflibercept for cystoid macular oedema (CMO) secondary to central retinal vein occlusion (CRVO).

Methods

Twenty patients with CMO secondary to CRVO were included in this prospective cohort study. After 3 loading 4-weekly injections, treatment intervals were increased by 2 weeks if there was no clinical activity, to a maximum of 12 weeks. If clinical activity recurred or persisted, the interval between injections was shortened by 2 weeks, to a minimum of 4 weeks. Main outcome measures were change in visual acuity and the proportion of patients gaining 15 or more Early Treatment of Diabetic Retinopathy Study (ETDRS) letters from baseline at 6, 12 and 18 months.

Results

Mean BCVA gain from baseline was 19.7 ± 13.8, 22.2 ± 13.9 and 21.9 ± 15.8 ETDRS letters at 6, 12 and 18 months, respectively. Sixty-five percent of patients gained 15 or more ETDRS letters at 6 months, increasing to 70.6% at 12 and 18 months. Patients received 5.0 [4.0 to 6.0], 8.5 [8.0 to 10.3] and 11.0 [9.0 to 12.5] injections by 6, 12 and 18 months, respectively.

Conclusions

The visual outcomes achieved with a treat-and-extend protocol in this study were similar to the pivotal trials of aflibercept for CMO secondary to CRVO, which used monthly and then as-needed protocols.

Trial registration

Australian and New Zealand Clinical Trials Registry, registration number ACTRN12615000417583, 01/05/2015.

A treat and extend protocol with Aflibercept for cystoid macular oedema secondary to central retinal vein occlusion - an 18-month prospective cohort study

BACKGROUND

To evaluate the safety and efficacy of a treat-and-extend protocol of aflibercept for cystoid macular oedema (CMO) secondary to central retinal vein occlusion (CRVO).

METHODS

Twenty patients with CMO secondary to CRVO were included in this prospective cohort study. After 3 loading 4-weekly injections, treatment intervals were increased by 2 weeks if there was no clinical activity, to a maximum of 12 weeks. If clinical activity recurred or persisted, the interval between injections was shortened by 2 weeks, to a minimum of 4 weeks. Main outcome measures were change in visual acuity and the proportion of patients gaining 15 or more Early Treatment of Diabetic Retinopathy Study (ETDRS) letters from baseline at 6, 12 and 18 months.

RESULTS

Mean BCVA gain from baseline was 19.7 ± 13.8, 22.2 ± 13.9 and 21.9 ± 15.8 ETDRS letters at 6, 12 and 18 months, respectively. Sixty-five percent of patients gained 15 or more ETDRS letters at 6 months, increasing to 70.6% at 12 and 18 months. Patients received 5.0 [4.0 to 6.0], 8.5 [8.0 to 10.3] and 11.0 [9.0 to 12.5] injections by 6, 12 and 18 months, respectively.

CONCLUSIONS

The visual outcomes achieved with a treat-and-extend protocol in this study were similar to the pivotal trials of aflibercept for CMO secondary to CRVO, which used monthly and then as-needed protocols.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, registration number ACTRN12615000417583, 01/05/2015.

A novel method for electroretinogram assessment in patients with central retinal vein occlusion

PURPOSE

Central retinal vein occlusion (CRVO) is the second most common retinal vascular disorder after diabetic retinopathy that affects the eyes. We propose a method for distinction of normal and central CRVO eyes based on electroretinogram (ERG).

METHODS

Seventeen patients with CRVO in one eye were analyzed. Their ERG signals were collected in six different stimuli, including four records in the darkness (dark-adapted 0.01, dark-adapted 3.0, dark-adapted oscillatory potentials, and dark-adapted 10) and two records in brightness (light-adapted 3.0 and light-adapted 30 Hz flicker). Nonlinear features such as Hurst exponent (HE) and approximate entropy (ApEn) were extracted from healthy and CRVO eyes. Finally, a parabolic mapping and two criteria (theta angle and the density of points) were proposed to distinguish the groups.

RESULTS

For ApEn, the P values of dark-adapted 3.0 oscillatory (P = 0.0433) and flicker (P = 0.0425) confirmed significant differences between the groups. For HE, the P values of dark-adapted 3.0 oscillatory (P = 0.0421) and flicker 30 Hz (P = 0.0402) confirmed differences between the healthy and CRVO groups. The P values of theta angle for dark-adapted 3.0 (P = 0.0199), dark-adapted oscillatory (P = 0.0265), dark-adapted 10.0 (P = 0.0166), light-adapted 3.0 (P = 0.0411), and flicker (P = 0.0361) showed significant differences. Using the density criterion, the statistical test demonstrated a significant difference between the groups in dark-adapted 3 (P = 0.0038), dark-adapted oscillatory (P = 0.0102), dark-adapted 10.0 (P = 0.0071), light-adapted 3.0 (P = 0.0319), and flicker 30 Hz (P = 0.0076).

CONCLUSION

The proposed features have made it possible to distinguish between healthy and CRVO eyes. This method could be helpful in some cases with no definite diagnosis or to estimate the severity of CRVO.

Evaluation of the Initial Optical Coherence Tomography Parameters in Anticipating the Final Visual Outcome of Central Retinal Vein Occlusion

Purpose

To evaluate the predictive and associated factors in determining the visual outcome in patients having central retinal vein occlusion (CRVO)-related macular edema (ME).

Methods

The charts of the patients who were treated due to CRVO-related visual disturbance were reviewed. The optical coherence tomography (OCT) images of eyes were analyzed, and disorganization of retinal inner layers (DRILs), ellipsoid zone (EZ) and external limiting membrane (ELM) disruption length, hyper-reflectivity of retinal inner layer (HRIL) existence, baseline and final visual acuity (VA), subfoveal thickness (SFT), subretinal fluid (SRF), and injection numbers were noted. The regression and correlation analyses were applied.

Results

Thirty eyes of thirty patients were included in the study. The mean follow-up time was 17.5 ± 11 (8-47) months. The mean baseline VA was 1.4 ± 0.7 (0.2-3.1) logMAR. A total of 87 intravitreal injections were applied for the treatment of ME during the follow-up. The initial mean central subfield thickness was 795 ± 264 (1470-398) μm. HRIL and SRF were observed in 16 and 23 eyes at the initial visit, respectively. The final mean VA was 1.2 ± 0.9 (0.1-3.1) logMAR. At the final visit, additional OCT parameters were evaluated. The mean DRIL length was 463 ± 324 μm. The mean disruption length of EZ and ELM was 367 ± 247 μm and 414 ± 327 μm, respectively. The final mean SFT was 290 ± 91 μm. SRF presence at the initial visit was found to be associated with elongated EZ and ELM disruption length at the final visit (P = 0.03 and P = 0.04, respectively). On linear regression analyses, none of the baseline features (SRF, SFT, and HRIL) except baseline poor best corrected visual acuity were found to be predictive in anticipating the final visual outcome (P = 0.04). On linear bivariate analysis, the final poor visual outcome was found to be affected by EZ disruption length of ≥500 μm at the last visit (P = 0.02).

Conclusion

Baseline VA was the only predictive factor in anticipating the final visual outcome. At the final visit, extensive disruption length of EZ in the subfoveal area was associated with a poor visual outcome.

Long-Term Follow-Up Changes of Central Choroidal Thickness Thinning after Repeated Anti-VEGF Therapy Injections in Patients with Central Retinal Vein Occlusion-Related Macular Edema with Systemic Hypertension

PURPOSE

We investigated the thinning of central choroidal thickness (CCT) following intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs to treat central retinal vein occlusion (CRVO)-related macular edema in patients with and without systemic hypertension (HT) to assess the influence of repeated anti-VEGF therapy and HT on the choroid in CRVO eyes.

METHODS

We conducted a retrospective study involving 27 patients with CRVO-related macular edema from January 2014 to July 2017, with follow-ups exceeding 18 months. Visual acuity (VA), central retinal thickness (CRT), and CCT were evaluated before and after initial anti-VEGF drug treatment during follow-up.

RESULTS

The mean follow-up period was 35.2 months. Seventeen (63.0%) patients had HT. At 1 month after treatment, VA had improved in 21 (77.8%) patients, and CRT had decreased in 25 (92.6%). At the final visit, 22 (81.5%) showed improved VA, 19 (70.4%) had resolved macular edema, and the CCT had gradually become thinner with additional drug injections in all the patients. Furthermore, the mean CCT in HT patients (209.0 µm) was significantly lower than in non-HT patients (256.1 µm), and the mean injections were 7.8 and 5.3, respectively (p = 0.2067).

CONCLUSION

The CCTs were thinner in eyes with HT than in eyes without HT both before and after the repeated anti-VEGF injections.

MEK Inhibitor-Associated Central Retinal Vein Occlusion Associated with Hyperhomocysteinemia and MTHFR Variants

Background

Central retinal vein occlusion (CRVO) is a visually threatening event that has rarely been observed in patients taking MEK1/2 inhibitors and that may necessitate permanent discontinuation of a potentially efficacious therapy. We investigated the clinical characteristics of CRVO in patients on mitogen-activated protein kinase kinase (MEK) inhibition to better understand their predisposing factors and clinical course.

Case Series

This was a single-center, retrospective cohort study (between December 2006 and September 2018). Three of 546 patients enrolled in 46 prospective trials involving treatment with MEK inhibitors at Memorial Sloan Kettering Cancer Center were identified as having CRVO. Clinical examination and course, multimodal ophthalmic imaging, and serum laboratory results (including homocysteine levels and genetic variants of methylene tetrahydrofolate reductase [MTHFR]) were reviewed for the 3 affected patients. All 3 patients with MEK inhibitor-associated CRVO had elevated serum homocysteine and gene variants of MTHFR (1 homozygous for A1298C, 1 heterozygous for A1298C, and 1 homozygous for C677T). Following intravitreous injections of anti-VEGF and discontinuation of drug, all patients regained vision to their baseline.

Discussion

MEK inhibitor-associated CRVO is a rare event which can exhibit visual recovery after drug cessation and intravitreous anti-VEGF injections. In this cohort, it was associated with hyperhomocysteinemia and genetic mutations in MTHFR, suggesting a potential role for hyperhomocysteinemia screening prior to initiation of MEK inhibitor therapy.

Paracentral acute middle maculopathy as a cause of unexplained visual loss in central retinal vein occlusion

A 79-year-old man presented with unilateral unexplained sudden onset visual loss in the setting of central retinal vein occlusion (CRVO). Non ischemic CRVO in the right eye (RE) was confirmed on fluorescein angiography. Spectral domain optical coherence tomography (SD-OCT) showed absence of macular edema and hyperreflective band-like lesions in the middle retinal layers of the RE suggesting a diagnosis of paracentral acute middle maculopathy (PAMM). Patient was observed and after 3 months, best-corrected visual acuity in the RE spontaneously improved from 38 to 56 ETDRS letters. SD-OCT scans showed thinning of the inner nuclear layer of the RE. OCT angiography in the RE revealed a mild attenuation of the vascular flow signal in the superficial capillary plexus and patchy areas of vascular flow void in the deep capillary plexus, as compared to the fellow eye.

The present case outlines the importance of recognising PAMM as a cause of unexplained visual loss. In the setting of a CRVO with sudden vision loss and absence of macular edema, clinicians should pay attention to any hyperreflectivity and/or to thinning of the middle retinal layers on SD-OCT.

Evaluation of lamina cribrosa thickness in patients diagnosed with central retinal vein occlusion

PURPOSE

To evaluate the thickness of lamina cribrosa (LC) in both eyes of patients with unilateral central retinal vein occlusion (CRVO) and to compare with eyes of age-matched healthy control subjects.

METHODS

This prospective case-control study included a total of 38 patients with unilateral CRVO and 42 healthy control subjects. The LC thickness was measured at the center of the optic disc using an enhanced depth imaging with the spectral domain optical coherence tomography in both eyes of patients with unilateral CRVO and eyes of healthy control subjects. The LC thickness of CRVO patients was evaluated one month after dexamethasone intravitreal implant (Ozurdex) injection.

RESULTS

The mean LC thickness in affected eyes of patients with CRVO was significantly thinner than that of the healthy eyes (204.4 ± 8.8 and 228.0 ± 7.1 μm, p < 0.001, respectively). Also, the unaffected fellow eyes had significantly thinner LC compared with eyes of healthy subjects (205.3 ± 9.3 and 228.0 ± 7.1 μm, p < 0.001, respectively). There was no statistically significant difference in the thickness of LC between the affected and unaffected fellow eyes (p = 0.669).

CONCLUSIONS

The LC thickness in both eyes of CRVO patients was thinner than that of the healthy eyes. This finding suggests that thin LC may contribute to the development of CRVO as an ocular risk factor in addition to systemic factors.

Coexistent central retinal vein and artery occlusion in a patient with psoriasis receiving ustekinumab

A 44 year-old Caucasian male with a history of plaque psoriasis currently being treated with ustekinumab presented with sudden loss of vision in his left eye. Fundus examination showed central retinal vein occlusion coexisting with central retinal artery occlusion. Posterior examination revealed mild polycythemia, being the underlying cause unknown.

Intravitreal dexamethasone implant for central retinal vein occlusion without macular edema

Background

To evaluate the efficacy of an intravitreal dexamethasone (IVD) implant (Ozurdex®) for the treatment of central retinal vein occlusion (CRVO) without macular edema (ME).

Methods

A retrospective cohort study was designed, and 20 eyes of 20 patients diagnosed with non-ischemic CRVO without ME were included. A total of 10 CRVO eyes were observed without treatment, and another 10 CRVO eyes received a single IVD injection at baseline. Mean changes in pathomorphologic parameters of fundus and optical coherence tomography parameters were measured at baseline and at 1, 3, 6, and 12 months.

Results

The decreases in venous tortuosity (p = 0.014 for superior; 0.036 for inferior arcades) and width (p = 0.024 for superior; 0.003 for inferior arcades) from baseline to 12 months after injection were significantly greater in the treated group than the observed group. The improvements in RNFL swelling (p = 0.010) and retinal hemorrhage (p = 0.006) were also significantly greater in the treated group. Visual symptom improvement was significantly faster in the treated group (p = 0.001). In two cases, IVD injection resulted in complete resolution of cilioretinal artery occlusion associated with the CRVO, leading to complete visual recovery in 1 week. None of the treated eyes showed signs of ME development, ischemia progression, or neovascularization.

Conclusions

IVD implant was significantly effective in improving venous engorgement, retinal hemorrhage, RNFL swelling, and visual symptoms by presumed alleviation of disc swelling and venous outflow. This treatment may be a considerable treatment option in CRVO patients with no ME.

Treat and extend regimen with aflibercept for chronic central retinal vein occlusions: 2 year results of the NEWTON study

BACKGROUND

To determine whether aflibercept (Eylea; Regeneron Pharmaceuticals, Inc., Tarrytown, NY) could continue to extend the macular edema free interval in patients on a treat and extend (TAE) with non-ischemic central retinal vein occlusions (CRVOs) previously treated with ranibizumab (Lucentis; Genentech, Inc., South San Francisco, CA) or bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) in the second year.

METHODS

Twenty patients with macular edema secondary to non-ischemic CRVOs previously treated with ranibizumab or bevacizumab were prospectively treated with intravitreal aflibercept injection (IAI) using a TAE dosing regimen. Injection frequencies were extended 2 weeks if there were no signs of disease activity on OCT or change in visual acuity. In the second year of the study, patients who have recurrences of macular edema could be re-challenged with a longer treatment interval under the following criterion: absence of any macular edema on three consecutive visits with the same treatment interval.

RESULTS

Twenty patients had an average duration of a CRVO for 22 months (range 7-90) and averaged an anti-VEGF treatment every 42 days (range 28-60 days). The macular edema free interval increased from 38 to 75 days when switched to aflibercept (p = 0.000003) at month 24. There was an average increase of 37 days (median 34 days; range 0-91 days) in the macular edema free interval with aflibercept. At the month 24 visit, 50% (8/16) went > 12 weeks with a macular edema free interval between IAI. There was an improvement in vision (+ 8 ETDRS letters, p = 0.006) and decreased retinal thickness (158 µm, p = 0.00003) with aflibercept treatment at month 24.

CONCLUSIONS

The 2-year results of the NEWTON study demonstrated the sustained benefits of a TAE dosing regimen with aflibercept in patients with chronic CRVOs. The visual acuity gains and anatomic improvements observed at year one were maintained through month 24 with less visits and treatments. This may help minimize the treatment burden in patients with recurrent macular edema secondary to non-ischemic CRVO.Trial Registration ClinicalTrials.gov, NCT01870427, Registered June 6, 2013, https://clinicaltrials.gov/ct2/show/NCT01870427?cond=NEWTON&rank=1.Presented at the RETICON 2017: The Retina Congress with Live Surgery, Chennai, India-April 2017.

Combined central retinal artery and vein occlusion; first manifestation of lupus in a pediatric patient

Combined central retinal artery and vein occlusion is uncommon in adults and even more so in young people. The main origins are vasculitis and thromboembolic disorders. The prognosis is poor due to irreversible visual loss and the development of neovascular glaucoma (NVG). A 14 year-old male arrived at the clinic complaining of sudden and painless visual loss in the left eye. Best corrected visual acuity was light perception with clinical and fluoro-angiographic findings characteristic of combined central retinal artery and vein occlusion in his left eye. The findings in the systemic and laboratory studies led to a diagnosis of systemic lupus erythematosus (SLE) and antiphospholipid syndrome. The patient received treatment with steroids and oral anticoagulant. Seven days later, due to prolonged coagulation time, he presented with a vitreous haemorrhage. He was then treated with intravitreal ranibizumab in order to prevent NVG. Afterwards, vitrectomy and retinal endophotocoagulation were performed. To the best of our knowledge, this is the first presentation of a male, paediatric with SLE and combined occlusion to be published in the literature, and is also the first case treated with antiangiogenic agents that has not developed NVG at 12 months of follow-up.

Baseline characteristics associated with early visual acuity gains after ranibizumab treatment for retinal vein occlusion

Background

To identify baseline patient characteristics associated with early clinically significant visual acuity (VA) improvements within 3 months of treatment initiation in ranibizumab-treated patients with retinal vein occlusion (RVO) in the SHORE study.

Methods

Post hoc analysis of baseline patient characteristics in the randomized, open-label, vision examiner–masked SHORE phase 4 study that compared monthly versus pro re nata dosing of ranibizumab in patients with branch and central RVO. Patients who enrolled in SHORE fulfilled eligibility criteria per protocol (N = 202). SHORE data were retrospectively analyzed to identify baseline patient characteristics associated with early clinically significant improvements in VA, defined as improvement to a Snellen equivalent of 20/40 or better vision (≥ 69 Early Treatment Diabetic Retinopathy Study [ETDRS] letters) or an increase in best-corrected VA (BCVA) of 15 or more ETDRS letters from baseline within 3 months of treatment initiation. Main outcome measures were BCVA gain of 15 or more ETDRS letters from baseline, Snellen equivalent of 20/40 or better vision, and baseline factors associated with early clinically significant improvement in BCVA.

Results

The median time for patients to achieve a BCVA of 20/40 or better was 59 days and the median time for patients to gain 15 or more ETDRS letters was 63 days. Better baseline BCVA (> 50 ETDRS letters/Snellen equivalent ≥ 20/100), greater baseline total macular volume (> 9.99 mm³), and presence of subretinal fluid at baseline were all associated with early improvement to 20/40 or better vision (ETDRS equivalent ≥ 69 letters; P < .0001, P = .02, and P = .03, respectively).

Conclusions

This retrospective analysis found that better BCVA, greater total macular volume, and presence of subretinal fluid at baseline were associated with more rapid vision gains. Clinicians may find these helpful when considering the likelihood of achieving early clinically significant VA improvements with ranibizumab in patients with RVO.

Trial registration

ClinicalTrials.gov NCT01277302.

Quantitative measurement of vascular density and flow using optical coherence tomography angiography (OCTA) in patients with central retinal vein occlusion: Can OCTA help in distinguishing ischemic from non-ischemic type?

Background

To evaluate microvascular changes and quantitative parameters in patients with central retinal vein occlusion (CRVO) by using optical coherence tomography angiography (OCTA) and finding difference between presumably ischemic and non ischemic CRVO.

Methods

Patients with CRVO (31) and healthy control (20) were enrolled in this observational case control study. The OCTA was done for each patient and control subject. In macular area 2 images were taken for each eye (3 × 3 mm and 8 × 8 mm). The images were analyzed at three capillary plexuses (superficial and deep retinal capillary layers and choriocapillaris layer).

Results

Thirty-one patients with CRVO (mean age 60.00 ± 13.72 years) and 20 healthy age/gender matched subjects (mean age 54.10 ± 12.33 years) were enrolled in this study (p = 0.095). The mean visual acuity of patients was 0.47 ± 0.54 LogMAR. Eyes with CRVO as compared with fellow eyes and control group showed significant reduction of flow in superficial (1.171 ± 0.262 vs. 1.362 ± 0.285 vs. 1.453 ± 0.105) and deep capillary plexus (1.042 ± 0.402 vs. 1.331 ± 0.315 vs. 1.526 ± 0.123) and choriocapillaris (1.206 ± 0.543 vs. 1.841 ± 0.308 vs. 1.966 ± 0.05) and vascular density in superficial (45.92 ± 4.2 vs. 50.99 ± 4.35 vs. 52.85 ± 2.99) and deep (48.03 ± 4.71 vs. 55.86 ± 3.81 vs. 58.2 ± 2.65) capillary plexuses. Some parameters (flow of both retinal capillary plexuses and parafoveal vascular density in deep plexus) showed significantly reduction in fellow eyes than control group. The parameters including flow [superficial (1.014 ± 0.264 vs. 1.279 ± 0.19) and deep (0.873 ± 0.442 vs. 1.152 ± 0.32) capillary plexuses and choriocapillaris (0.79 ± 0.327 vs. 1.424 ± 0.51)] and vascular density [superficial (44.24 ± 2.13 vs. 46.58 ± 4.13) and deep (45.28 ± 3.5 vs. 49.32 ± 3.94) capillary plexuses] were lower significantly in ischemic type than non ischemic CRVO. The most damaged parameter was flow in deep capillary plexus. The model with smallest Akaike information criterion and Bayesian information criterion was chosen as the best model. For easier calculation, we also calculated the reduced model. By choosing the threshold of 12.6, the formula [3.9 × F_1S + 0.8 × F_3S] can diagnose the presumably ischemic CRVO from non ischemic type with AUC of 0.84, sensitivity of 100% and specificity of 69%. (F_1S: flow in the central 1 mm-radius-circle of superficial plexus and F_3S: flow in the central 3 mm-radius-circle of superficial plexus).

Conclusion and relevance

In CRVO patients, the OCTA can accurately evaluate changes in microvascular structures. It may help in differentiation ischemic CRVO from non-ischemic CRVO.

Effect of aflibercept on persistent macular edema secondary to central retinal vein occlusion

PURPOSE

To evaluate the efficacy of switching treatment from intravitreal ranibizumab to intravitreal aflibercept on the treatment of refractory macular edema secondary to central retinal vein occlusion (CRVO).

METHODS

In this retrospective study; 12 eyes with refractory macular edema secondary to CRVO after multiple monthly repeated intravitreal 0.5mg/0.05mL ranibizumab injections prior to switching therapy to intravitreal 2mg/0.05mL aflibercept, between March 2012 and April 2016 were reviewed. The follow-up time was 12 months. Changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), central retinal volume (CRV) and injection interval between baseline and month 1, 3, 6 and 12 after switching therapy to aflibercept were reviewed and evaluated.

RESULTS

Mean baseline CRT decreased from 516±101 mic. to 252±114 mic. at month 12 (P=0.008). Mean baseline CRV decreased from 8.74±2.13 mm³ to 6.82±1.64 mm³ at month 12 (P=0.005). Baseline BCVA improved from 0.73±0.21 to 0.53±0.17 logMAR at month 12 (P=0.004). Mean BCVA gain was two logMar lines (10 letters) at month 12. After switching therapy to aflibercept; the mean injection interval increased significantly from 1.34 months at baseline to 1.86 months at month 12, by an increase of 0.52 months (P=0.02).

CONCLUSION

Intravitreal aflibercept is evaluated to be presenting significant visual and anatomical improvements in patients with persistent macular edema due to CRVO despite previous intravitreal ranibizumab.

[Profile of neovascular glaucoma in Senegalese patients]

OBJECTIVE

To describe the etiologies, clinical presentation and therapeutic management of neovascular glaucoma (NVG) in Senegalese patients.

PATIENTS AND METHODS

We retrospectively studied the records of patients followed for NVG between 1993 and 2016. We included eyes with Iridis rubeosis with or without ocular hypertension. We recorded age, sex, medical and ophthalmologic history, results of the eye examination, treatment modalities broken up into hospitalisation, procedural interventions and number of antiglaucoma medications prescribed. The data analysis was performed by epi-info 7.

RESULTS

Forty-eight eyes of 44 patients were included. The mean age was 59.7 years and sex ratio 2.1. Etiologies were type 2 diabetes in 31.8 % cases and central retinal vein occlusion in 16.6 % cases. All eyes were blind. Eye pain was present in 75 % of eyes, a limbal flush in 29.1 % of eyes and mydriasis in 31.25 % of eyes. Mean intraocular pressure was 49.7mmHg. Corneal edema occured in 54.1 % of eyes. Fundus examination showed proliferative retinopathy in 14.5 %. Treatment required hospitalisation for 43.75 % of patients. Therapeutic procedures were cyclocryoapplication for 31.25 % of eyes, retrobulbar xylo-alcohol injection for 14.5 % of eyes and panretinal laser photocoagulation (PRP) for 12.5 % eyes. Antiglaucoma preparations were used in dual therapy for 29 % of eyes, in triple therapy and quadruple therapy for 25 % of eyes each.

DISCUSSION

The etiologies are comparable to those described in the literature. The diagnosis was late and treatment limited by adverse economic conditions.

CONCLUSION

NVG in Senegalese patients is an affection of men in their sixties. It is responsible for irreversible painful blindness for which treatment is difficult - thus the interest in prevention by strict monitoring and prompt treatment of any retinal ischemia.

Combined bilateral ophthalmic artery occlusion & central retinal vein occlusion from presumed giant cell arteritis

Purpose

To report on a severe case of presumed giant cell arteritis (GCA) presenting with partial and complete ophthalmic artery occlusion along with bilateral central retinal vein occlusions (CRVO).

Observations

A 73-year-old female presented with bilateral complete vision loss of sudden onset. The patient also experienced a mild frontal headache prior to onset of vision loss. Fundus examination revealed bilateral central retinal artery occlusion (CRAO) and CRVO. Subsequent fluorescein angiography indicated partial right ophthalmic artery occlusion and complete left ophthalmic artery occlusion. Acute phase reactants were elevated. The patient was clinically diagnosed with GCA and intravenous (IV) steroids were initiated. Four days later, a temporal artery biopsy (TAB) was performed and resulted as negative for granulomatous inflammation. The patient did not regain vision and remained with no light perception (NLP) in both eyes.

Conclusions

and Importance: This case highlights the discrepancy between clinical diagnosis and pathologic tissue diagnosis in a patient that presented with such extensive ocular vasculitic disease. Such extensive bilateral disease has not been reported. In addition, there are few studies regarding the effect of pulse-dosed IV steroids on TAB results. This case report suggests that the gradual histologic changes that occur over one or two weeks while on oral steroids may occur over three to four days while on high dose IV steroids, necessitating early biopsy.

Comparing Cytokine Kinetics between Ranibizumab and Aflibercept in Central Retinal Vein Occlusion with Macular Edema

PURPOSE

To investigate dynamic changes in aqueous humor levels of vascular endothelial growth factor (VEGF), placental growth factor (PlGF), and inflammatory factors in patients receiving intravitreal ranibizumab injection (IRI) or intravitreal aflibercept injection (IAI) to treat central retinal vein occlusion (CRVO) with macular edema.

METHODS

In 22 CRVO patients scheduled to receive 3 doses of ranibizumab (11 eyes) or aflibercept (11 eyes) at monthly intervals, aqueous samples were collected at the time of intravitreal injection. The concentrations of VEGF, PlGF, soluble intercellular adhesion molecule-1, monocyte chemotactic protein (MCP)-1 (CCL2), platelet-derived growth factor-AA, interleukin (IL)-6, IL-8 (CXCL8), IL-12(p70) (IL12B), and IL-13 in aqueous samples were measured by the suspension array method.

RESULTS

Visual acuity and foveal thickness improved significantly in both the IRI group and the IAI group. In addition, aqueous levels of VEGF and PlGF as well as MCP-1 and IL-6 decreased significantly over time in both groups. These parameters did not significantly differ between both groups.

CONCLUSIONS

In CRVO patients, both ranibizumab and aflibercept achieved similar improvement in clinical parameters and similar reductions in aqueous VEGF, PlGF, MCP-1, and IL-6 levels.

Intravitreal dexamethasone implant versus triamcinolone acetonide for macular oedema of central retinal vein occlusion: quantifying efficacy and safety

PURPOSE

Among the retinal vascular diseases, burden of retinal vein occlusion is most common immediately after diabetic retinopathy. Intravitreal corticosteroids are gaining popularity in managing macular edema (ME) of RVO. Our study compares efficacy and safety of intravitreal triamcinolone (IVTA) and dexamethasone implant (IVD) over 6 months.

METHODS

This comparative, prospective, randomized study on 40 patients of non-ischemic central RVO with significant ME (> 330 μm) of < 3 months duration. Study was done at Army Research Hospital between Sep-2012 and May-2014 in accordance to Helsinki Declaration. IVD group (n = 20) received Ozurdex® while IVTA group (n = 20) received triamcinolone-acetonide (4 mg/0.1 ml), followed up at day-1 and weeks 4, 8, 12, 24.

RESULTS

At 6 months, mean improvement in best corrected visual acuity and retinal thickness (CMT) in the IVD group was 0.43 logmar and 323 μm and in IVTA group was 0.49 logmar and 322 μm respectively. Proportion of patients achieving ≥ 15 letters was about 40% in both groups. IOP rise was significantly higher in IVTA group at 12 and 24 weeks. In IVTA group ≥ 10 mmHg IOP rise was seen in 60% of patients, 41.6% among them had > 35 mmHg and 66% needed combination treatment and failed to reach baseline line IOP at 6 months. In IVD group, 5 pts had IOP rise with all being < 26 mmHg and were easily managed with single agent with IOP reaching baseline by 6th month in all pts. Relative risk of IOP rise with IVTA is 2.4 times higher compared to IVD. Cataract progression and cataract surgeries were required at significantly higher rates in IVTA group. In IVTA group, cataract progression was seen in 35% patients, with 71.5% requiring cataract surgery at 6 months. IVD group, 10% patients had cataract progression while none required surgery at 6 months. Relative risk of cataract progression with IVTA is 3.5 times higher compared to IVD.

CONCLUSION

Intravitreal steroids are effective in managing macular edema of retinal vein occlusion, while newer formulation of sustained release dexamethasone implant is significantly safer than IVTA.

The short-term efficacy of intravitreal ranibizumab, aflibercept and dexamethasone implant in the treatment of macular edema due to non-ischemic central retinal vein occlusion

PURPOSE

To assess and compare the efficacy over 6 months of intravitreal ranibizumab (IR), aflibercept (IA) and dexamethasone implant (IDI) in eyes with macular edema (ME) secondary to non-ischemic central retinal vein occlusion (CRVO).

METHODS

This is a retrospective single-center study. Patients who received pro re nata treatment of IR 0.5 mg, IA 2 mg or IDI 0.7 mg (as Group 1, Group 2, and Group 3, respectively) for the treatment of ME due to non-ischemic CRVO were included in the study. Efficacy outcomes were considered as the changes in mean best-corrected visual acuity (BCVA) and central macular thickness (CMT) from baseline over 6 months.

RESULTS

Eighteen patients (Group 1) received IR, 16 patients received (Group 2) IA, and 24 patients (Group 3) received IDI. The mean numbers of injections were 2.56 ± 1.0, 2.68 ± 0.9, and 1.62 ± 0.5 in Group 1, 2, and 3, respectively (p = 0.000). In Groups 1 and 2, the mean BCVA values increased significantly after the treatment (p < 0.001). However, in Group 3, no increase in mean BCVA was statistically significant in any month (p = 0.061). The proportion of eyes gaining at least three lines in BCVA was 33.3% in Group 1, 43.8% in Group 2, and 33.3% in Group 3 (p = 0.762). In all groups, significant improvements were observed in CMT after treatment (p < 0.001). At month 6, the mean changes in CMT were - 162.7 ± 186.5 µm in Group 1, - 310.1 ± 345.9 µm in Group 2, and - 193.8 ± 228.3 µm in Group 3, with no significant difference among groups (p = 0.474). Cataract formation and IOP increase were higher in the IDI group, but the differences were not statistically significant (p = 0.054 and p = 0.392, respectively).

CONCLUSIONS

IR and IA may be preferred treatment for ME due to non-ischemic CRVO as visual improvement remains the primary ophthalmological objective. The most important advantages of IDI are its effect on CMT and the need for fewer injections. The increase in IOP and the formation of cataract may be observed more in IDI-treated eyes.

Pre-treatment clinical features in central retinal vein occlusion that predict visual outcome following intravitreal ranibizumab

Background

Predicting how patients with central retinal vein occlusion (CRVO) will respond to intravitreal anti-VEGF is challenging. The purpose of this study was to identify pre-treatment clinical features in CRVO that predict visual acuity (VA) following intravitreal ranibizumab.

Methods

Medical records, fundus images and optical coherence tomography (OCT) scans of treatment naïve patients with CRVO receiving PRN intravitreal ranibizumab were retrospectively reviewed. Early Treatment Diabetic Retinopathy Study (ETDRS) VA and central retinal thickness (CRT) were recorded at baseline, 3 and 12 months after starting therapy. Regression analysis was used to determine independent predictors of VA at 3 and 12 months follow-up. Possible predictors included baseline VA, age, presence of cotton wool spots (CWS), haemorrhages (few scattered or multiple deep), foveal detachment, CRT, time from presentation to treatment, number of injections given, presence of RAPD, and cause of CRVO.

Results

Data from 52 eyes of 50 patients receiving intravitreal ranibizumab treatment for CRVO were analyzed. The mean pre-treatment VA was 43.3 (SD 22.5) letters, which improved to 52.0 (SD 24.3) letters at 3 months, then dropped to 42.0 (SD 30.26) at 12 months. Baseline CRT reduced from 616.7 μm (SD 272.4) to 346.0 μm (SD 205.2) at 3 months and 304.0 μm (SD 168.3) at 12 months. The following features were predictive of poorer VA after starting intravitreal ranibizumab: Poorer pretreatment VA (3-months, P = 0.010; 12-months, P = 0.006), increasing age (3-months, P = < 0.001; 12-months, P = 0.006), and presence of CWS (3-months, P < 0.001; 12-months, P = 0.045).

Conclusion

Pre-treatment VA, older age, and presence of CWS are easily identifiable clinical features in the hospital setting which help predict visual outcome in patients with CRVO receiving intravitreal ranibizumab.

Papillophlebitis in a young male patient with Buerger's disease

CLINICAL CASE

A 27-year-old male with sudden visual loss of OD. He had a past history of heavy smoking, as well as a chronic ischaemia of his left lower limb of one-year onset. This led to a diagnosis of Buerger's disease, which is an inflammatory thrombotic disorder that affects small and medium vessels. The visual acuity (VA) of OD was 0.9, and in the funduscopy a very congestive papilla was observed, along with venous tortuosity, scattered retinal haemorrhages, but without macular oedema. He progressed favourably, with a complete recovery of VA.

DISCUSSION

Papillophlebitis may be an ocular complication of Buerger's disease.

Central retinal vein occlusion after coronary artery bypass surgery: A case report

OBJECTIVE

The aim of this study is to report a case of central retinal vein occlusion (CRVO) after coronary artery bypass graft (CABG) surgery. In this report, we present the third case in the literature with CRVO after cardiopulmonary bypass (CPB), and the first case after CABG.

CASE REPORT

A 59-year-old male patient complaining of chest pain was admitted to our hospital. The patient underwent an elective coronary angiography and was diagnosed with three-vessel coronary artery disease. An uneventful coronary artery bypass graft operation was performed using CPB. On the second postoperative day, the patient described blurring and decreased vision in his left eye, whereas the right eye was normal. The anterior-posterior segment was examined by an ophthalmologist who diagnosed central retinal vein occlusion, using a visual acuity test, fundoscopy. After 5 months of treatment, there has been no improvement in the patient's visual acuity.

CONCLUSION

As two previous case reports indicated CRVO can be a rare complication after CPB, this study demonstrated that CRVO can also be a complication of CABG. Therefore, CRVO should always be considered as a potential complication after cardiac surgery.

Real-life clinical data for dexamethasone and ranibizumab in the treatment of branch or central retinal vein occlusion over a period of six months

PURPOSE

To evaluate the therapeutic outcome for dexamethasone implant (DEX) or intravitreal ranibizumab (IVR) injections over 6 months in patients with macular edema due to branch or central retinal vein occlusion (BRVO, CRVO), in a real-life setting.

METHODS

A total of 107 patients with BRVO or CRVO were included into this retrospective single-center observational study. Patients were treated with monotherapy consisting of DEX or three monthly IVR injections following a pro re nata regimen (PRN). Best-corrected visual acuity (BCVA), central retinal thickness (CRT) and intraocular pressure (IOP) were compared between the two therapy groups after 1, 3 and 6 months.

RESULTS

BRVO patients treated with DEX achieved a statistically significant gain in BCVA measured in logMAR after 1 month (mean gain, 95% CI: 0.21, 0.08-0.34, p = 0.001), 3 months (0.16, 0.03-0.28, p = 0.012) and 6 months (0.19, 0.07-0.32, p = 0.002), whereas patients treated with IVR showed a statistically significant BCVA gain in month 3 (mean improvement, 95% CI: 0.13, 0.01-0.26, p = 0.039) and month 6 (0.16, 0.03-0.29, p = 0.018). BCVA in CRVO patients with DEX worsened slightly at month 6 (mean worsening, 95% CI: -0.08, -0.24 to 0.08, p = 0.305), while IVR treated-patients achieved a statistically significant BCVA gain at 3 months (mean improvement, 95% CI: 0.14, 0.02-0.25, p = 0.021). Both therapies were accompanied by statistically significant CRT reductions of 150 to 200 μm (median). Adverse events reported were predictable and limited.

CONCLUSIONS

In a clinical setting, comparable improvement in BCVA and CRT were observed after DEX and IVR injections for treatment of BRVO. CRVO patients showed greater benefit with IVR.

Anti-Vascular Endothelial Growth Factor Therapy for Macular Edema following Central Retinal Vein Occlusion: 1 Initial Injection versus 3 Monthly Injections

PURPOSE

To compare the 12-month efficacy of 1 initial intravitreal injection of an anti-vascular endothelial growth factor (VEGF) agent followed by pro re nata (PRN) dosing with that of 3 initial monthly injections followed by PRN dosing in patients with macular edema (ME) after central retinal vein occlusion (CRVO).

METHODS

Twenty-nine eyes received 1 initial injection (1+PRN group) and 20 received 3 monthly injections (3+PRN group).

RESULTS

At month 12, changes in logMAR visual acuity from baseline were -0.172 ± 0.372 and -0.142 ± 0.317 in the 1+PRN and 3+PRN groups, respectively; the difference was not significant (p = 0.769). The number of anti-VEGF injections administered in the 3+PRN group (5.9 ± 2.1) was significantly greater than that in the 1+PRN group (4.1 ± 2.8; p = 0.022).

CONCLUSION

When used for ME after CRVO, a 1+PRN regimen achieved 12-month outcomes similar to those of a 3+PRN regimen with fewer injections.

Prevalence, pattern and risk factors of retinal vein occlusion in an elderly population in Nepal: the Bhaktapur retina study

Background

This study aims to explore the prevalence, pattern and risk factors of retinal vein occlusion (RVO) in an elderly population of Nepal.

Method

One thousand eight hundred sixty subjects of age 60 years and above were enrolled in a population-based, cross-sectional study. Detailed history, visual acuity, anterior segment and posterior segment examinations were done. Blood pressure, non-fasting blood sugar, body mass index and abdominal girth were measured. Retinal vein occlusions were further divided into branch retinal (BRVO), hemi-retinal and central retinal vein occlusion (CRVO).

Result

Age ranged from 60 to 95 years with a mean of 69.64 ± 7.31 years. Overall population prevalence for RVO was 2.95% (95% Confidence interval (CI): 2.23–3.83), BRVO 2.74% (95% CI: 2.05–3.58) and CRVO 0.21% (95% CI: 0.06–0.55). BRVO was seen in 51 subjects (92.73%) and CRVO in 4 (7.27%). Among the total RVO, unilateral and bilateral involvement was 85.45% and 14.55%, respectively. Among the subjects with BRVO and CRVO, 37.25% and 50% had low vision, respectively. The risk of RVO increased with ageing and was more among males. There was an increased risk of RVO among those with hypertension, and with diabetes and hypertension. There was also an increased risk of RVO among subjects with hypermetropia, those with pseudophakia and those who were smokers and consumed alcohol.

Conclusion

Retinal vein occlusion is a common retinal vascular disorder in the elderly population of Nepal. The main risk factors for RVO were increasing age and hypertension.

Short-term results of endovascular surgery with tissue plasminogen activator injection for central retinal vein occlusion

PURPOSE

To examine the effects of retinal endovascular surgery (REVS) with tissue plasminogen activator injection into the retinal vein in central retinal vein occlusion (CRVO) eyes.

METHODS

Sixteen consecutive CRVO patients with macular edema and decreased visual acuity who were referred to Toyama University Hospital between March 2014 and February 2016 were included in this study. Changes in visual acuity (VA) and central retinal thickness (CRT) were evaluated up to 6 months after REVS. Staining and leakage of the retinal veins in fluorescein angiography (FA) was graded in nine patients.

RESULTS

Ten of 16 eyes were determined to be non-ischemic while the remaining six were ischemic. The mean logarithm of the minimum angle of resolution (logMAR) of VA was significantly improved from 0.98 ± 0.58 (mean ± standard deviation) at baseline to 0.78 ± 0.61 at 3 months (p = 0.002), and 0.64 ± 0.60 at 6 months (p = 0.003) after REVS. At 6 months, VA was improved in eight eyes (50%), while the other eight (50%) showed no change; none showed worsening. In the 10 eyes with non-ischemic CRVO, the mean VA was significantly improved at 6 months (p = 0.002), whereas no improvement was found in the six eyes with ischemic CRVO, . In all eyes, the mean CRT was significantly improved from 804 ± 343 μm at baseline to 506 ± 304 μm at 2 months (p = 0.014), 332 ± 229 μm at 3 months (p = 0.0001), and 305 ± 235 μm at 6 months (p = 0.00001). The postoperative complications observed were prolonged vitreous hemorrhage in one eye and neovascular glaucoma in two eyes. For postoperative recurrence of macular edema, sub-tenon injection of triamcinolone acetonide was given to five eyes, and intravitreal injection of an anti-VEGF agent was given to five eyes. Pan-retinal photocoagulation was performed on six eyes with ischemic type CRVO. The FA score was significantly improved after REVS (p = 0.018).

CONCLUSIONS

REVS using a specially made micro-needle may be a surgical treatment option for non-ischemic CRVO, but it did not seem effective for ischemic CRVO.

Central Retinal Vein Occlusion in 2 Patients Using Antipsychotic Drugs

Purpose

To report our findings in 2 patients who developed a central retinal vein occlusion (CRVO) and were chronic users of antipsychotic medications.

Case Presentation

Case 1 was a 62-year-old woman who had a sudden reduction of vision in her right eye to 20/2,000. Her fundus showed signs of an impending CRVO with marked macular edema. She had been taking antipsychotic drugs (quetiapine fumarate and risperidone) for about 2 years. She refused anti-VEGF therapy for her macular edema but selected systemic kallidinogenase. Two days later, the macular edema was significantly reduced but the number of cotton wool spots (CWS) was increased. Ten days later, the macular edema was resolved and her BCVA improved to 20/60. The CWS gradually disappeared, and her BCVA improved to 20/20. Case 2 was a 43-year-old man who presented with vision reduction in his right eye of 1 week's duration. His BCVA was 20/50 and his fundus showed signs of a CRVO-related macular edema with CWS in the peripapillary area. He had been taking sulpiride (Dogmatyl^™) for depression for 1 year, and his blood test showed an increase in red blood cells and hematocrit. Anti-VEGF therapy was performed, and the macular edema was resolved with vision improving to 20/20. There has been no recurrence to date in both cases.

Conclusions

These results indicate that a CRVO can be a complication of chronic use of antipsychotic medications. However, early treatment can lead to good outcomes. Clinicians should question patients who develop a sudden CRVO whether they are using antipsychotic medications.

Ranibizumab versus dexamethasone implant for central retinal vein occlusion: the RANIDEX study

PURPOSE

To compare intravitreal ranibizumab and dexamethasone implant in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO).

METHODS

Participants were 42 treatment naive patients with ME due to CRVO, who received either intravitreal 0.5 mg ranibizumab (n = 25) or intravitreal 0.7 mg dexamethasone implant (n = 17). The main outcomes included the mean change in best corrected visual acuity (BCVA) and central subfield thickness (CST) at month 12 compared to baseline in the two groups.

RESULTS

At month 12, there was no statistically significant difference in BCVA and CST change between the two groups. However, there was recurrence in ME at month 5 in the dexamethasone group.

CONCLUSIONS

Both ranibizumab and dexamethasone implant were found to be safe and effective at the 12-month follow-up in patients with ME secondary to CRVO. Since there was a recurrence in ME at month 5 in the dexamethasone group, we suggested that intravitreal injection of dexamethasone implant should be potentially administered sooner than 6 months.