BRANCH RETINAL VEIN OCCLUSION: Epidemiology, Pathogenesis, Risk Factors, Clinical Features, Diagnosis, and Complications. An Update of the Literature

Spontaneous retinal-choroidal anastomosis in a case of branch retinal vein occlusion

PURPOSE

To report a case of a patient affected by branch retinal vein occlusion (BRVO) showing a possible spontaneous retinal-choroidal anastomosis (RCA) at the level of the fovea.

OBSERVATIONS

A 72 years old male patient with diagnosis of BRVO of left eye (LE) one year before came to our observation for a follow-up visit.The patient underwent a complete ophthalmologic examination, including fluorescein angiography, structural optical coherence tomography (OCT), OCT-Angiography (OCT-A). Interestingly, OCT-A revealed the presence of blood flow suggestive of single collateral vessel descending from the deep capillary plexus up to and possibly below a hyperreflective subfoveal deposit.

CONCLUSIONS AND IMPORTANCE

We hypothesize that it can represent a RCA, starting from retinal capillaries and reaching the choriocapillary and choroidal vessels in order to allow a vascular shunt between the 2 circulations and thus a new passage for the blood flow. A similar condition is represented by laser-induced RCA for the treatment of non-ischemic central retinal vein occlusion in order to establish a new passage for the blood flow.

10-year fundus tessellation progression and retinal vein occlusion

AIM

To access the 10-year fundus tessellation progression in patients with retinal vein occlusion.

METHODS

The Beijing Eye Study 2001/2011 is a population-based longitudinal study. The study participants underwent a detailed physical and ophthalmic examination. Degree of fundus tessellation was graded by using fundus photographs of the macula and optic disc. Progression of fundus tessellation was calculated by fundus tessellation degree of 2011 minus degree of 2001. Fundus photographs were used for assessment of retinal vein occlusion.

RESULTS

The Beijing Eye Study included 4403 subjects in 2001, 3468 subjects was repeated in 2011. Assessment of retinal vein obstruction and fundus tessellation progression were available for 2462 subjects (71.0%), with 66 subjects fulfilled the diagnosis of retinal vein occlusion. Of the 66 participants, 59 participants with unilateral branch retinal vein occlusion, 5 participants with unilateral central retinal vein occlusion, 1 participant with bilateral branch retinal vein occlusion, and 1 participant with branch retinal vein occlusion in one eye and central retinal vein occlusion in the other eye. Mean degree of peripapillary fundus tessellation progression were significantly higher in the whole retinal vein occlusion group (0.33±0.39, P<0.001), central retinal vein occlusion group (0.71±0.8, P=0.025) and branch retinal vein occlusion group (0.29±0.34, P=0.006) than the control group (0.20±0.26). After adjustment for age, prevalence of tilted disc, change of best corrected visual acuity, axial length, progression of peripapillary fundus tessellation was associated with the presence of retinal vein occlusion (P=0.004; regression coefficient B, 0.094; 95%CI, 0.029, 0.158; standardized coefficient B, 0.056). As a corollary, after adjusting for smoking duration, systolic blood pressure, anterior corneal curvature, prevalence of RVO was associated with more peripapillary fundus tessellation progression (P<0.001; regression coefficient B: 1.257; OR: 3.517; 95%CI: 1.777, 6.958).

CONCLUSION

Peripapillary fundus tessellation progresses faster in individuals with retinal vein occlusion. This may reflect the thinning and hypoperfusion of choroid in patients with retinal vein occlusion.

Association of Disorganization of Retinal Inner Layers with Ischemic Index and Visual Acuity in Central Retinal Vein Occlusion

Purpose

To determine whether disorganization of retinal inner layers (DRIL) on optical coherence tomography (OCT) is associated with ischemia on ultra-widefield fluorescein angiography (UWFFA) and with visual outcomes in eyes with acute, treatment-naïve central retinal vein occlusion (CRVO).

Design

Retrospective, single-institution, longitudinal cohort study.

Participants

Twenty-five consecutive patients with treatment-naïve CRVO and ≥ 1 year follow-up.

Methods

Two independent masked graders evaluated the extent of DRIL, ellipsoid zone disruption, external limiting membrane disruption, and other OCT parameters at the baseline, 6- month, 12-month, and final visits. Baseline UWFFA images were assessed for ischemic index values and foveal avascular zone (FAZ) enlargement.

Main Outcome Measures

Associations of DRIL with UWFFA findings and clinical outcomes including corrected visual acuity (VA).

Results

The median time to final follow-up was 24 months (range 12.1 - 43.9 months). Median DRIL extent at baseline was 765 µm (range 0 - 1000 µm). Eighteen of 25 eyes (72%) had some degree of DRIL at baseline, and 20 of 25 eyes (80%) had cystoid macular edema (CME). Neither the presence nor extent of DRIL at baseline was associated with presenting VA. In a cross-sectional analysis of each visit, extent of DRIL correlated with worse VA at both the 6-month (ρ = 0.656; p = 0.001) and final (ρ = 0.509; p = 0.016) visits. At final follow-up, DRIL extent was the OCT parameter most strongly correlated with baseline ischemic index (ρ = 0.418; p = 0.047) and baseline enlarged FAZ (p = 0.057) on UWFFA. On multivariate regression analysis, DRIL extent at final follow-up was the only OCT parameter associated with worse VA (p = 0.013) and remained significant when accounting for CME as a potential confounder.

Conclusions

Extent of DRIL was not associated with presenting VA in treatment-naïve eyes with acute CRVO. Following six months of follow-up however, DRIL extent correlated with worse VA and was predictive of worse VA throughout more than 2 years of follow-up. Ischemic features on UWFFA at baseline are predictive of the extent of DRIL development at final follow-up.

RANIBIZUMAB FOR RETINAL VEIN OCCLUSION: Predictive Factors and Long-Term Outcomes in Real-Life Data

PURPOSE

The purpose of the study was to evaluate the long-term anatomical and functional outcomes in patients with retinal vein occlusion (RVO), either central retinal vein occlusion or branch retinal vein occlusion, treated with intravitreal ranibizumab and to determine the predictive factors of the final visual outcome.

METHODS

This retrospective study included 54 treatment-naive patients with macular edema due to RVO (25 with central retinal vein occlusion and 29 with branch retinal vein occlusion), who were treated with intravitreal ranibizumab (3 monthly injections and pro re nata). Predictive factors for visual outcome were assessed. In addition, the best-corrected visual acuity change and the percentage of patients with edema resolution were evaluated.

RESULTS

The mean follow-up time was 47.4 ± 11.1 months. At the end of the follow-up, patients with central retinal vein occlusion gained +6.9 letters (∼1 Snellen line), whereas patients with branch retinal vein occlusion gained +15.1 letters (3 Snellen lines). Forty-eight percent of patients in central retinal vein occlusion group and 69.0% in branch retinal vein occlusion group presented resolution of macular edema. Negative predictive factors for the final visual outcome were found to be increasing age, increasing macular thickness, the presence of intraretinal fluid, the duration of RVO >3 months, the ischemic type of RVO, the cystoid type of edema, and the external limiting membrane and ellipsoid zone disruption.

CONCLUSION

The various predictive factors that determine the visual outcome and possibly define the patients' prognosis after ranibizumab treatment in RVO have been studied. The long follow-up period showed that ranibizumab seems to be safe and effective in the treatment of the disease.

A 12-month, multicenter, parallel group comparison of dexamethasone intravitreal implant versus ranibizumab in branch retinal vein occlusion

Purpose:

Dexamethasone intravitreal implant and intravitreal ranibizumab are indicated for the treatment of macular edema secondary to retinal vein occlusion. This non-inferiority study compared dexamethasone with ranibizumab in patients with branch retinal vein occlusion.

Methods:

In this randomized, 12-month head-to-head comparison, subjects with branch retinal vein occlusion were assigned to dexamethasone 0.7 mg at day 1 and month 5 with the option of retreatment at month 10 or 11, or ranibizumab 0.5 mg at day 1 and monthly through month 5 with subsequent as-needed injections at month 6–month 11. The primary efficacy outcome was the mean change from baseline in best-corrected visual acuity at month 12; secondary outcomes included average change in best-corrected visual acuity, proportion of eyes with ≥10- and ≥15-letter gain/loss, change in central retinal thickness, and change in Vision Functioning Questionnaire-25 score.

Results:

In all, 307 of a planned 400 patients were enrolled in the study and received (mean) 2.5 dexamethasone injections (n = 154) and 8.0 ranibizumab injections (n = 153) over 12 months. The mean change from baseline in best-corrected visual acuity at month 12 was 7.4 letters for dexamethasone versus 17.4 letters for ranibizumab (least-squares mean difference (dexamethasone minus ranibizumab), −10.1 letters; 95% confidence interval, −12.9, −7.2; p = 0.0006).

Conclusion:

Dexamethasone and ranibizumab improved best-corrected visual acuity and anatomical outcomes; however, dexamethasone did not show non-inferiority to ranibizumab in this under-powered study. Dexamethasone was associated with an increased risk of intraocular pressure elevation and cataract progression, but a lower injection burden, compared to ranibizumab.

Anti-VEGF treatment of macular edema associated with retinal vein occlusion: patterns of use and effectiveness in clinical practice (ECHO study report 2)

Purpose

To evaluate the efficacy, safety, and injection frequency of vascular endothelial growth factor (VEGF) antagonists in the treatment of macular edema secondary to retinal vein occlusion (RVO) in clinical practice.

Patients and methods

A multicenter retrospective study of the medical records of 165 patients (95 branch RVO, 70 central RVO) treated with at least three anti-VEGF injections in the study eye was conducted. Available data collected for at least 6 months after the first injection included Snellen best-corrected visual acuity (BCVA), central retinal thickness (CRT) by time-domain optical coherence tomography (TD-OCT) or spectral-domain optical coherence tomography (SD-OCT), anti-VEGF injections, other treatments/procedures for RVO, and adverse events.

Results

At baseline prior to anti-VEGF treatment, mean BCVA was 20/80 Snellen equivalent and mean CRT was 499 μm. Mean number of anti-VEGF injections received was 7.1 during the first year, 5.4 during the second year, and 5.9 during the third year; 51.3% (842/1,641) of injections were ranibizumab, 44.1% (724/1,641) were bevacizumab, and 4.6% (75/1,641) were aflibercept. One in five patients received concomitant focal laser treatment. The percentage of patients achieving both BCVA of 20/40 or better and CRT ≤250 μm on TD-OCT or ≤300 μm on SD-OCT at the same visit (primary endpoint) was 26.1% (30/115) after the first anti-VEGF injection and ranged from 20.0% (7/35) to 36.7% (11/30) after the first 16 injections. After each anti-VEGF injection from the 1st to the 16th, <60% of patients achieved 20/40 or better BCVA and ≤70% of patients achieved CRT ≤250 μm on TD-OCT or ≤300 μm on SD-OCT. The most common treatment-related adverse event was blurry or cloudy vision.

Conclusion

In this real-world study, a mean of five to seven anti-VEGF injections was administered yearly, and the response to anti-VEGF therapy was suboptimal in many patients. Anti-VEGF therapy was well tolerated.

SIGNIFICANT REDUCTION OF PERIPAPILLARY CHOROIDAL THICKNESS IN PATIENTS WITH UNILATERAL BRANCH RETINAL VEIN OCCLUSION

PURPOSE

To evaluate changes in peripapillary choroidal thickness in patients with branch retinal vein occlusion (BRVO) over 12 months, using spectral-domain optical coherence tomography with enhanced depth imaging.

METHODS

This retrospective, interventional case series included 20 treatment-naive patients with unilateral BRVO with at least 12 months follow-up. The peripapillary choroidal thickness was measured over 12 months.

RESULTS

In BRVO-affected eyes, the mean peripapillary choroidal thickness was 213.5 ± 51.7 μm (126.1[FIGURE DASH]326.9 μm) at baseline and 129.6 ± 39.3 μm (65.9[FIGURE DASH]197.1 μm) at 12 months. In nonaffected contralateral eyes, the mean peripapillary choroidal thickness was 194.1 ± 39.8 μm (158.5[FIGURE DASH]238.3 μm) at baseline and 156.6 ± 56.2 μm (125.9[FIGURE DASH]213.9 μm) at 12 months. The mean peripapillary choroidal thickness decreased significantly over 12 months in both BRVO-affected and nonaffected eyes (P < 0.001, both eyes). Although the mean peripapillary choroidal thickness was not significantly different between groups at baseline (P = 0.472), it was significantly lower in BRVO-affected eyes than in nonaffected eyes at 12 months (P = 0.036).

CONCLUSION

Peripapillary choroidal thickness decreased significantly over 12 months in BRVO-affected eyes and nonaffected eyes in patients with unilateral BRVO.

QUALITATIVE AND QUANTITATIVE FOLLOW-UP USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF RETINAL VEIN OCCLUSION TREATED WITH ANTI-VEGF: Optical Coherence Tomography Angiography Follow-up of Retinal Vein Occlusion

PURPOSE

To evaluate changes of vascular flow of patients treated with intravitreal injections of anti-vascular endothelial growth factor for macular edema secondary to retinal vein occlusion (RVO) with optical coherence tomography angiography (OCTA).

METHODS

Patients with RVO with macular edema and treated with intravitreal injections of anti-vascular endothelial growth factors were retrospectively evaluated. The following examinations were performed before and after treatment: best-corrected visual acuity, spectral domain optical coherence tomography, fluorescein angiography, and OCTA (Optovue, Inc). Automatic measurement of vascular density of the superficial and deep capillary plexus was also performed and compared with age- and sex-matched healthy subjects.

RESULTS

Twenty-eight eyes of 28 patients (mean age 66.2 years; males 19%) were evaluated, including 13 central RVO, 11 branch RVO, and 4 hemicentral RVO. After treatment, mean central macular thickness significantly decreased from 644 μm to 326 μm and best-corrected visual acuity increased from 20/125 to 20/63 (P < 0.01 for both results). On OCTA, perifoveal capillary disruption (P = 0.029) and the number of cysts in the superficial capillary plexus and deep capillary plexus (P < 0.002) significantly decreased after treatment. The mean vascular density in the superficial capillary plexus slightly decreased during follow-up from 46.44% to 45.01% (not significantly). These densities were significantly less than those observed in healthy controls (P < 0.001).

CONCLUSION

Optical coherence tomography angiography showed regression of macular edema, reduced capillary disruption and cysts, and slight decrease in mean macular vascular density with time and despite treatment. Thus, OCTA enables qualitative and quantitative evaluation during follow-up of patients treated for RVO.

CORRELATION OF MICROVASCULAR STRUCTURES ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY WITH VISUAL ACUITY IN RETINAL VEIN OCCLUSION

PURPOSE

To analyze the correlation of superficial and deep capillary plexuses using optical coherence tomography (OCT) angiography with visual acuity in eyes with retinal vein occlusion (RVO).

METHODS

We retrospectively reviewed the medical records of 33 patients with retinal vein occlusion (RVO; branch retinal vein occlusion in 21 patients, central retinal vein occlusion in 12 patients) and included 33 healthy subjects as a control group, who were evaluated by OCT angiography. The OCT angiography was performed on a 3 mm × 3-mm region centered on the fovea and parafoveal area. The foveal avascular zone (FAZ), and foveal and parafoveal vascular density (VD) in superficial and deep vascular plexuses were analyzed using OCT angiography.

RESULTS

The area of superficial and deep FAZ in eyes with RVO were larger than those in fellow eyes and control eyes (P = 0.034, P = 0.018). The superficial and deep parafoveal VDs in eyes with RVO were significantly lower than those in fellow eyes and control eyes (P = 0.001, P< 0.001). The area of superficial FAZ was negatively correlated with best-corrected visual acuity, and the superficial and deep parafoveal VDs were positively correlated with best-corrected visual acuity. Eighteen of the total 21 eyes with branch retinal vein occlusion (85.7%) showed a high concordance rate with respect to the location of branch retinal vein occlusion and the lowest parafoveal VD area. The multivariate analysis showed that the deep parafoveal VD was associated with best-corrected visual acuity.

CONCLUSION

The OCT angiography allows to detect FAZ enlargement, increased parafoveal capillary nonperfusion, and decreased parafoveal VD in eyes with RVO. The area of superficial FAZ and the parafoveal VD are correlated with best-corrected visual acuity in eyes with RVO.

Ellipsoid Zone Mapping Parameters In Retinal Venous Occlusive Disease With Associated Macular Edema

Purpose

To evaluate the association of baseline ellipsoid zone (EZ) parameters on optical coherence tomography (OCT) as calculated by a semi-automated computer algorithm with baseline visual acuity in eyes with retinal vein occlusion (RVO).

Design

Retrospective consecutive case series.

Subjects

Patients affected by RVO presenting from January 2011 to December 2014.

Methods

Baseline demographics, clinical characteristics, and SD-OCT data at presentation were collected. Macular cube scans were exported into a retinal layer analysis software platform and outer retinal parameters were evaluated. Outer retinal/EZ parameters included EZ-retinal pigment epithelium (RPE) volume, central foveal EZ-RPE area, EZ-RPE central subfield thickness (CST), and EZ-RPE central foveal thickness (CFT). In addition, en face EZ mapping features were extracted including percent area with EZ attenuation (i.e., EZ-RPE thickness < 20 μm) and percent area with total EZ loss (i.e., EZ-RPE thickness = 0 μm).

Main Outcome Measure

Correlation of EZ parameters and baseline visual acuity (VA). Secondary outcome measures: Correlation of EZ parameters with other clinical characteristics and OCT measures of cube volume, cube average thickness, central subfield thickness.

Results

One hundred and twelve eyes were included in this analysis. Mean baseline VA was 56.53 ±17.68 ETDRS letters and was inversely associated with total EZ loss and EZ-RPE attenuation (r= - 0.33 and -0.38 respectively, p<0.001). VA was directly associated with all other EZ parameters (r=0.37 to 0.45, p<0.001). The presence of subretinal fluid was strongly linked to central parameters of central foveal EZ-RPE, EZ-RPE-CST, and EZ-RPE-CFT (Kruskal-Wallis test). Conventional OCT parameters (central subfield retinal thickness, cube volume and cube average thickness) did not have significant correlations with EZ measures (-0.3<R<0.3 and/or P>0.05).

Conclusion

Baseline EZ integrity is closely linked to presenting visual acuity in eyes with RVO and macular edema. EZ mapping provides an additional metric for evaluating RVO impact on retinal anatomy and potential function.

One-year outcomes of ziv-aflibercept for macular edema in central retinal vein occlusion

Purpose

To report the 12-month efficacy and safety outcomes of intravitreal ziv-aflibercept in macular edema secondary to central retinal vein occlusion (CRVO).

Methods

Interventional case series documenting 12-month outcomes of intravitreal ziv-aflibercept (1.25 mg in 0.05 mL) in 6 patients with treatment-naive macular edema secondary to CRVO. All patients had comprehensive ophthalmic examination, spectral domain optical coherence tomography at baseline and all follow-up visits, and fluorescein. Retreatment decisions were based on recurrence or persistence of intraretinal or subretinal fluid, deterioration in visual acuity (VA), increase in central subfield thickness (CST) by ≥ 50 μm from the previous visit, or lowest recorded CST.

Results

Participants had (2 males, 4 females) an average age of 53.5 years. From baseline to 12 months, the mean logMAR VA improved from 0.86 (Snellen ≈ 20/145) to 0.33 (Snellen ≈ 20/40), central macular thickness decreased from 519 μm to 255 μm, and total macular volume decreased from 14.7 mm³ to 7.1 mm³. No eyes had uveitis, cataract progression, intraocular pressure (IOP) elevations, or systemic adverse events.

Conclusions and importance

Ziv-aflibercept achieves favorable intermediate-term functional and structural outcomes in macular edema secondary to CRVO. No safety concerns were raised. Low-cost ziv-aflibercept may thus be useful for CRVO in resource-poor countries. Further prospective studies in larger cohorts are needed further establish the efficacy and safety of this agent.

Disorganization of the Retinal Inner Layers as a Predictor of Visual Acuity in Eyes With Macular Edema Secondary to Vein Occlusion

PURPOSE

To determine whether spectral-domain optical coherence tomography (SD-OCT) disorganization of the retinal inner layers (DRIL) is predictive of best-corrected visual acuity (BCVA) in retinal vein occlusion macular edema (RVO-ME).

DESIGN

Retrospective cohort study.

METHODS

Setting: Two tertiary centers.

PATIENTS

Treatment-naïve RVO-ME receiving monthly intravitreal bevacizumab.

OBSERVATION PROCEDURES

Spectral-domain optical coherence tomography (SD-OCT) images from baseline, 4-month, and 8-month visits. The DRIL extent and additional parameters were evaluated in the 1-mm-wide foveal centered area.

MAIN OUTCOME MEASURES

BCVA at each visit.

RESULTS

A total of 136 eyes were included in this study. Greater DRIL extent at baseline correlated with worse baseline BCVA (point estimate, 0.04; 95% CI, 0.01-0.07 per 100 μm, P = .003). In multivariate analysis extent of DRIL (P = .03) and ellipsoid zone disruption (P < .001) correlated with baseline BCVA. Four-month DRIL reduction was associated with 8-month BCVA improvement (point estimate, 0.02; 95% CI, 0.01-0.04, P = .01), with only DRIL remaining significant in multivariate analysis (P = .02). Baseline DRIL predicted 8-month improvement in BCVA (point estimate, 0.03; 95% CI, 0.01-0.05, P = .04), with only DRIL remaining significant in multivariate analysis (P = .006). Eight-month DRIL change was associated with 8-month BCVA change (point estimate, 0.03, 95% CI 0.01-0.05, P = .001), with only DRIL remaining significant in multivariate analysis (P = .002).

CONCLUSIONS

The change of the DRIL extent following the first 3 monthly injections identifies eyes with a high likelihood of subsequent BCVA improvement or decline. Therefore, the extent of DRIL before and after treatment is an additional SD-OCT parameter that may serve as a biomarker for patients with RVO-ME.

Mystery of Retinal Vein Occlusion: Vasoactivity of the Vein and Possible Involvement of Endothelin-1

Retinal vein occlusion (RVO) is a common vascular disease of retina; however, the pathomechanism leading to RVO is not yet clear. In general, increasing age, hypertension, arteriosclerosis, diabetes mellitus, dyslipidemia, cardiovascular disorder, and cerebral stroke are systemic risk factors of RVO. However, RVO often occur in the unilateral eye and sometimes develop in young subjects who have no arteriosclerosis. In addition, RVO show different variations on the degrees of severity; some RVO are resolved without any treatment and others develop vision-threatening complications such as macular edema, combined retinal artery occlusion, vitreous hemorrhage, and glaucoma. Clinical conditions leading to RVO are still open to question. In this review, we discuss how to treat RVO in practice by presenting some RVO cases. We also deliver possible pathomechanisms of RVO through our clinical experience and animal experiments.

Ultrafast Ultrasound Imaging of Ocular Anatomy and Blood Flow

Purpose

Ophthalmic ultrasound imaging is currently performed with mechanically scanned single-element probes. These probes have limited capabilities overall and lack the ability to image blood flow. Linear-array systems are able to detect blood flow, but these systems exceed ophthalmic acoustic intensity safety guidelines. Our aim was to implement and evaluate a new linear-array–based technology, compound coherent plane-wave ultrasound, which offers ultrafast imaging and depiction of blood flow at safe acoustic intensity levels.

Methods

We compared acoustic intensity generated by a 128-element, 18-MHz linear array operated in conventionally focused and plane-wave modes and characterized signal-to-noise ratio (SNR) and lateral resolution. We developed plane-wave B-mode, real-time color-flow, and high-resolution depiction of slow flow in postprocessed data collected continuously at a rate of 20,000 frames/s. We acquired in vivo images of the posterior pole of the eye by compounding plane-wave images acquired over ±10° and produced images depicting orbital and choroidal blood flow.

Results

With the array operated conventionally, Doppler modes exceeded Food and Drug Administration safety guidelines, but plane-wave modalities were well within guidelines. Plane-wave data allowed generation of high-quality compound B-mode images, with SNR increasing with the number of compounded frames. Real-time color-flow Doppler readily visualized orbital blood flow. Postprocessing of continuously acquired data blocks of 1.6-second duration allowed high-resolution depiction of orbital and choroidal flow over the cardiac cycle.

Conclusions

Newly developed high-frequency linear arrays in combination with plane-wave techniques present opportunities for the evaluation of ocular anatomy and blood flow, as well as visualization and analysis of other transient phenomena such as vessel wall motion over the cardiac cycle and saccade-induced vitreous motion.

Branch Retinal Vein Occlusion, Macular Ischemia, and Intravitreal Anti-VEGF Therapy

PURPOSE

To report a case with ischemic macular edema (ME) due to an acute branch retinal vein occlusion (BRVO) which was treated with repeated intravitreal anti-VEGF injections.

METHODS

Retrospective case presentation.

RESULTS

A 66-year-old female patient was treated with repeated intravitreal anti-VEGF injections due to ischemic ME following an acute BRVO. Over a period of 2.5 years best corrected visual acuity increased from 0.06 to 0.6 (decimal notation) accompanied by a reduction in central retinal thickness from 546 to 292 µm. Overall 17 anti-VEGF injections were administered to treat repeated recurrence of ME. Macular ischemia did not worsen during this profound intravitreal anti-VEGF therapy.

CONCLUSION

Intravitreal anti-VEGF therapy can be a beneficial treatment strategy even in ischemic ME following an acute BRVO.

Branch retinal vein occlusion: the importance of the topographical distribution of retinal vessels among risk factors

PurposeTo investigate the role of the topographical distribution of temporal retinal vessels in anatomical predisposition to branch retinal vein occlusion (BRVO).Patients and methodsSixty patients with BRVO and 60 control subjects were included in this retrospective-observational study. The fundus images of the individuals were classified into four topographical vessel positions: P1, the superior and inferior temporal retinal veins were closer to the foveal center; P2, the superior and inferior temporal retinal arteries were closer to the foveal center; and P3 and P4, the superior temporal retinal vein and inferior temporal retinal artery were closer to the foveal center or vice versa. The groups were compared in terms of demographics and topographical vessel positions.ResultsThere were no significant differences between the groups in terms of age and gender (P>0.05). The topographical distribution of temporal retinal vessels among the BRVO and control eyes were significant (P<0.001). P1 was less common in BRVO eyes (5%) when compared with control eyes (33.3%); however, P2 was more common in BRVO eyes (46.7 vs 20%). There were no significant differences in terms of the distribution of P3 and P4 vessel positions in the BRVO and control groups (P>0.05). A logistic regression test revealed that the risk of BRVO increases 15-fold in P2, 6-fold in P3, and 8-fold in P4 when compared with eyes having P1.ConclusionP1 eyes are less likely to be affected by BRVO. Therefore, the topographical distribution of retinal vessels can be assessed as a risk factor for BRVO.

Retinal vein occlusion and paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder associated with increased risk for thrombosis and reduced life expectancy. Retinal vein occlusion (RVO) is a frequent cause of vision loss but its relationship with PNH has not been studied systematically. Patients followed up for RVO in our ophthalmology department were screened for the presence of a PNH clone in peripheral blood by means of flow cytometry. The presence of other well-documented risk factors for RVO was also analyzed. In a series of 110 patients (54 males, median age of 67) we found no evidence of PNH. Most patients (97/110) had cardiovascular risk factors and/or hyperhomocysteinemia (67/110). Inherited thrombophilias were rare (three confirmed cases). Therefore, PNH does not appear to play a role in the development of RVO. However, this finding does not necessarily apply to young patients and/or those with no conventional risk factors for RVO, due to the low number of patients in these subgroups in our population.

Optic disk hemorrhage in health and disease

Optic disk hemorrhage occurs in all age groups from neonates to the elderly. Optic disk hemorrhage is best known for its association with visual field loss and progression in patients with glaucoma; however, it may occur in conjunction with other ocular or systemic conditions as well as in healthy individuals. It may also be the first sign of a sight-threatening condition. Variations in the shape, location, and size of the optic disk hemorrhage, as well as associated ocular and systemic signs or symptoms, may help determine the underlying pathology. We address the epidemiology, demographics, pathophysiology, clinical presentations and implications, differential diagnoses, and management of eyes with optic disk hemorrhage in diseased and healthy subjects.

Ranibizumab versus aflibercept for macular edema due to central retinal vein occlusion: 18-month results in real-life data

PURPOSE

The objective of this study was to compare the anatomical and functional outcomes of ranibizumab versus aflibercept for the treatment of macular edema due to central retinal vein occlusion (CRVO) in routine clinical practice.

METHODS

Participants in this observational study included 62 treatment-naïve patients with CRVO who received intravitreal injections of either ranibizumab or aflibercept. The demographic data, best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) characteristics were evaluated at baseline and at months 1, 2, 3, 6, 12 and 18 post-treatment.

RESULTS

At month 18, the mean BCVA of ranibizumab-treated eyes increased 7.9 letters, compared to 7.4 letters for eyes receiving aflibercept, with a similar number of injections. There was no statistically significant difference between the two groups in letters or in central subfield thickness at month 18. At the end of the follow-up, 50% of patients in the ranibizumab group and 42.9% in the aflibercept group showed complete resolution of macular edema.

CONCLUSIONS

Ranibizumab and aflibercept demonstrated similar anatomical and functional outcomes over 18-month follow-up in patients with macular edema due to CRVO, with a similar number of injections.

Poor outcomes despite aspirin or statin use in high-risk patients with retinal vein occlusion

PURPOSE

Since atherosclerosis contributes to the pathophysiology of retinal vein occlusion (RVO), we aimed to assess the effects of aspirin and statins on the visual outcomes of RVO in high-risk patients, whom we define to have hypertension and open-angle glaucoma prior to RVO.

METHODS

We conducted a retrospective case-control study of adults diagnosed with RVO between 2006 and 2014. To evaluate for a preventive effect of these medications, we compared the prevalence of aspirin or statin use (either separately or concomitantly) among high-risk patients who developed RVO and among those who did not during at least 2 years of follow-up. To evaluate for a therapeutic effect, we then compared the final follow-up visual acuity (VA) of high-risk RVO patients who had and who had not been taking a statin prior to the RVO.

RESULTS

We analyzed 43 eyes [23 central RVOs (CRVOs), 16 branch RVOs (BRVOs), and 4 hemi-RVOs (HRVOs)] from 42 high-risk patients, along with 129 high-risk controls. There was no significant difference (p = 0.47) in aspirin exposure between the control (60%) and RVO (67%) groups, and the increased statin exposure among controls (72% vs. 53% for the cases; p = 0.03) paralleled their higher prevalence of hyperlipidemia. The non-statin and statin RVO groups each had a mean VA of 20/800 at a mean 30 and 43 months of follow-up, respectively.

CONCLUSIONS

No preventive benefit of aspirin or statins, and no therapeutic benefit of statins, was found for RVO in high-risk patients. High-risk RVO patients suffer substantially worse outcomes than those reported in other studies not limited to such patients.

Retinal vascular occlusion: a window to diagnosis of familial and acquired thrombophilia and hypofibrinolysis, with important ramifications for pregnancy outcomes

Aim

Our specific aim was to document the pathoetiologic importance of thrombophilia among females presenting with severe ischemic retinal vein (RVO) or retinal artery (RAO) occlusion, without typical risk factors, and to emphasize that the ophthalmologists’ diagnosis of thrombophilia has important diagnostic and therapeutic downstream ramifications for nonocular thrombosis, including reproductive outcomes.

Methods

We evaluated familial and acquired thrombophilia in 60 females with RVO (central RVO, n=52; branch RVO, n=8) and 16 with RAO (central RAO, n=11; branch RAO, n=5). They were referred by retinologists, without typical risk factors for RVO/RAO and/or severe ocular ischemic presentation. We focused on extraocular thrombotic events, particularly pregnancy complications, including unexplained spontaneous abortion, pre-eclampsia–eclampsia. Thrombophilia measurements in the 76 females were compared with 62 healthy normal females without ocular vascular occlusions (OVOs).

Results

The 76 females with OVO were more likely than 62 normal female controls to have high homocysteine (24% vs 0%, P<0.0001), high anticardiolipin antibody (immunoglobulin M, 17% vs 3%, P=0.012), high (>150%) factor VIII (42% vs 11%, P<0.0001), and high (>150%) factor XI (22% vs 4%, P=0.004). Of the 76 females, 26 (34%) had ≥1 spontaneous abortion; 17 (22%) had ≥2 spontaneous abortions and/or pre-eclampsia–eclampsia. Compared to 62 healthy female controls, these 17 females with pregnancy complications had high homocysteine (29% vs 0%, P=0.0003), high anticardiolipin antibody immunoglobulin M (24% vs 3%, P=0.02), high factor VIII (38% vs 11%, P=0.02), and were marginally more likely to be heterozygous for the factor V Leiden mutation (19% vs 3%, P=0.058).

Conclusion

In females lacking typical risk factors for retinal vascular occlusion or severely ischemic presentation, by diagnosing thrombophilia as an etiology for OVO, the ophthalmologist opens a window to family screening and preventive therapy, with particular relevance to pregnancy outcomes and venous thromboembolism.

GENETIC ASSOCIATION BETWEEN ARTERIAL STIFFNESS-RELATED GENE POLYMORPHISMS IN BRVO AND CRVO PATIENTS IN A TURKISH POPULATION

PURPOSE

To investigate possible associations between five different single-nucleotide polymorphisms, from genes associated with arterial stiffness and branch retinal vein occlusion (BRVO), or central retinal vein occlusion.

METHODS

A total of 187 patients with retinal vein occlusion (133 with BRVO and 54 with central retinal vein occlusion), and 167 controls, were enrolled in this study. All subjects were screened for hypertension, diabetes, smoking status, body mass index, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, total cholesterol, and very low-density lipoprotein. The genotyping of adiponectin +276 G/T, ACE I/D, AGTR1 A1166C, eNOS E298D, and p22phox -242 C/T polymorphisms was performed using real-time polymerase chain reaction.

RESULTS

The percentage of the adiponectin +275 T allele carriers was significantly higher in the BRVO patients (37%) than in the controls (23%, P < 0.001). Similarly, the percentage of AGTR1 1166 C allele carriers was significantly higher in the BRVO patients (38%) than in the controls (24%, P < 0.001). At the multiple logistic regression analysis, the adiponectin +275 T allele carrier and AGTR1 1166 C allele carrier status were found to be associated with an increased risk of BRVO (TT vs. GG and TG: odds ratio = 2.278, P = 0.002, 95% confidence interval: 1.370-3.789; CC vs. AA and AC: odds ratio = 1.804, P = 0.025, 95% confidence interval: 1.079-3.017). The genotype distributions or allelic frequencies of ACE I/D, eNOS E298D, and p22phox -242 C/T did not significantly differ between the patients with BRVO and the control subjects. There was no significant difference between the central retinal vein occlusion patients and controls for the genotype or the allele frequency distributions of all evaluated single-nucleotide polymorphisms.

CONCLUSION

Adiponectin +276 G/T and AGTR1 A1166C single-nucleotide polymorphism are likely to be risk factors for BRVO.

Investigational drugs for retinal vein occlusion

INTRODUCTION

Retinal vein occlusion (RVO) is the second most common retinal vascular disorder. This multifactorial disease frequently leads to visual impairment. Some risk factors for RVO can be managed prophylactically. Given the complex physiopathology of RVO, most of the latest therapeutic strategies focus on secondary clinical features (such as macular oedema and neovascularization).

AREAS COVERED

This author reviews ongoing, prospective, open-label Phase I and Phase II clinical trials of novels treatments for RVO (primarily intravitreal steroids and anti-VEGF agents). Specifically, they review the pharmacokinetics, safety profile, study design and adverse events associated with innovative drugs in clinical development.

EXPERT OPINION

A number of innovative, early-phase clinical trials are based on combination therapy with an anti-VEGF agent and steroids. There is good evidence that early treatment of RVO has clinical benefits. Larger, randomized studies are now required for a better understanding of patient selection, treatment timing and dosing, and thus the optimized use of novel drugs and medical devices.

Human retinal microvascular imaging using adaptive optics scanning light ophthalmoscopy

BACKGROUND

Retinal microvascular imaging is an especially promising application of high resolution imaging since there are increasing options for therapeutic intervention and need for better structural and functional biomarkers to characterize ocular and systemic vascular diseases.

MAIN BODY

Adaptive optics scanning light ophthalmoscopy (AOSLO) is an emerging technology for improving in vivo imaging of the human retinal microvasculature, allowing unprecedented visualization of retinal microvascular structure, measurements of blood flow velocity, and microvascular network mapping. This high resolution imaging technique shows significant potential for studying physiological and pathological conditions of the retinal microvasculature noninvasively.

CONCLUSION

This review will briefly summarize the abilities of in vivo human retinal microvasculature imaging in healthy controls, as well as patients with diabetic retinopathy, retinal vein occlusion, and sickle cell retinopathy using AOSLO and discuss its potential contribution to scientific research and clinical applications.

Risk of Retinal Vein Occlusion Following End-Stage Renal Disease

The aim of the study was to investigate the risk of retinal vein occlusion (RVO) following end-stage renal disease (ESRD). The study was designed as a retrospective, nationwide, matched cohort study. The subjects were ESRD patients identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 585. The study cohort included 92,774 ESRD patients registered between January 2000 and December 2009 at the Taiwan National Health Insurance Research Database. An age- and sex-matched control group comprised 92,774 patients (case:control = 1:1) selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient was collected from the index date until December 2011. The incidence and risk of RVO were compared between the ESRD and control groups. The adjusted hazard ratio (HR) for RVO after adjustment for potential confounders was obtained by Cox proportional hazard regression analysis. Kaplan-Meier analysis was used to calculate the RVO cumulative incidence rate. The main outcome measure was the incidence of RVO following ESRD. In total, 904 ESRD patients (0.97%) and 410 controls (0.44%) had RVO (P < 0.0001) during the follow-up period, leading to a significantly elevated risk of RVO in the ESRD patients compared with controls (incidence rate ratio = 3.05, 95% confidence interval = 2.72-3.43). After adjustment for potential confounders including diabetes mellitus, hypertension, hyperlipidemia, congestive heart failure, and coronary artery disease, ESRD patients were 3.05 times more likely to develop RVO in the full cohort (adjusted hazard ratio = 3.05, 95% confidence interval = 2.64-3.51). In addition, hypertension patients showed high incidence rate of RVO in the ESRD group compared with controls (incidence rate ratio = 1.71, 95% confidence interval = 1.44-2.03) and maintained significant risk of RVO after adjustment for other confounders in the cohort (adjusted hazard ratio = 1.39, 95% confidence interval = 1.20-1.60). ESRD increases the risk of RVO. For ESRD patients, we recommend education regarding RVO in addition to blood pressure control to prevent subsequent RVO.

Study of retinal vessel oxygen saturation in ischemic and non-ischemic branch retinal vein occlusion

AIM

To explore how oxygen saturation in retinal blood vessels is altered in ischemic and non-ischemic branch retinal vein occlusion (BRVO).

METHODS

Fifty BRVO eyes were divided into ischemic (n=26) and non-ischemic (n=24) groups, based on fundus fluorescein angiography. Healthy individuals (n=52 and n=48, respectively) were also recruited as controls for the two groups. The mean oxygen saturations of the occluded vessels and central vessels were measured by oximetry in the BRVO and control groups.

RESULTS

In the ischemic BRVO group, the occluded arterioles oxygen saturation (SaO2-A, 106.0%±14.3%), instead of the occluded venule oxygen saturation (SaO2-V, 60.8%±9.4%), showed increases when compared with those in the same quadrant vessels (SaO2-A, 86.1%±16.5%) in the contralateral eyes (P<0.05). The oxygen saturations of the central vessels showed similar trends with those of the occluded vessels. In the non-ischemic BRVO group, the occluded and central SaO2-V and SaO2-A showed no significant changes. In both the ischemic and non-ischemic BRVOs, the central SaO2-A was significantly increased when compared to healthy individuals.

CONCLUSION

Obvious changes in the occluded and central SaO2-A were found in the ischemic BRVO group, indicating that disorders of oxygen metabolism in the arterioles may participate in the pathogenesis of ischemic BRVO.

Factors correlated with the resolution of macular oedema after one dose injection of intravitreal triamcinolone acetonide treatment in branch retinal vein occlusion

Objective

To investigate the predictive baseline factors for a successful outcome following one dose of intravitreal triamcinolone acetonide (IVTA) in patients with macular oedema (ME) caused by branch retinal vein occlusion (BRVO).

Methods

This retrospective study enrolled patients with ME (macular retinal thickness [MRT] ≥ 300 µm) due to BRVO who still had ME 3 months after grid laser photocoagulation. Patients were divided according to treatment into an IVTA group and a laser-only group. The resolution of ME was documented at months 3 and 6.

Results

A total of 154 eyes with ME were investigated: IVTA group (90 eyes) and laser-only group (64 eyes). Predictive factors for successful IVTA treatment were younger age, shorter duration of ME, initial onset ME, accompanied by serous retinal detachment, few concomitant systemic diseases and nonischaemic BRVO. A broken foveal capillary ring was related to a poor treatment outcome. Eyes with cystoid spaces in the outer plexiform layer were more likely to have a good treatment response.

Conclusion

IVTA is effective for resolving ME due to BRVO after grid laser photocoagulation treatment.

Optical Coherence Tomography Angiography in Retinal Vein Occlusion: Evaluation of Superficial and Deep Capillary Plexa

PURPOSE

To evaluate the optical coherence tomography angiography (OCT angiography) appearance of the superficial and deep capillary plexa in eyes with retinal vein occlusion (RVO) and to compare these findings with those of fluorescein angiography (FA) and spectral-domain optical coherence tomography (SD OCT).

DESIGN

Retrospective observational case series.

METHODS

Patients presenting with RVO to Creteil University Eye Clinic were retrospectively evaluated. All patients had undergone a comprehensive ophthalmic examination including FA, SD OCT, and OCT angiography.

RESULTS

There were 54 (31 male, 57%) RVO patients with a mean age of 70 years. The perifoveal capillary arcade was visible in 52 of 54 eyes (96%) on OCT angiography and in 45 eyes (83%) on FA; this arcade was disrupted in 48 eyes (92%) and 39 eyes (72%) on OCT angiography and FA, respectively (P = .002). Perifoveal capillary arcade disruption was correlated with peripheral retinal ischemia (P = .025). Intraretinal cystoid spaces were observed in 34 eyes (68%) using FA, in 40 eyes (76%) using SD OCT, and in 49 eyes (90%) using OCT angiography (P = .008 for OCT angiography vs SD OCT and P = .001 for OCT angiography vs FA). Retinal capillary network abnormalities were observed in all patients in both superficial capillary plexus and deep capillary plexus on OCT angiography. Nonperfusion grayish areas were more frequent in the deep capillary plexus (43 eyes, 84%) than in the superficial capillary plexus (30 eyes, 59%, P < .001).

CONCLUSION

OCT angiography can simultaneously evaluate both macular perfusion and edema. For the first time, an imaging technique enables the evaluation of the deep capillary plexus, which appears to be more severely affected than the superficial capillary plexus in RVO.

Systematic study of retinal vein occlusion in young patients. Case report and review of the literature

PURPOSE

To report the case of a young woman with retinal vein occlusion and prothrombin heterozygous mutation, and to review the current evidence on the systematic study in cases of retinal vein occlusion (RVO) in young patients.

METHODS

Eligible articles were identified using a comprehensive literature search of PubMed.

CONCLUSION

RVO risk factors may have different relevance depending on each age group. In the systematic study of cases in young patients, it is recommended to look for "emerging" risk factors, bilateral involvement, or absence of "classic" risk factors.

Optic disc morphology in unilateral branch retinal vein occlusion using spectral domain optical coherence tomography

Background

The aim of this study was to evaluate the association between optic nerve head (ONH) parameters and branch retinal vein occlusion (BRVO) using spectral domain optical coherence tomography (SD-OCT).

Methods

Both eyes of 40 patients with unilateral BRVO (mean age: 67.4 ± 11.4 years, male: female - 18:22) were enrolled in this study. Control group consisted of randomly selected single healthy eyes of 40 age and gender matched volunteers (mean age: 64.7 ± 15.4 years, male: female - 16:24). ONH parameters (including optic disc area, optic cup area, neuroretinal rim area, cup volume, rim volume, cup-disc area ratio, horizontal and vertical cup-disc ratio, average retinal nerve fiber layer) were measured by SD-OCT. Axial length (AL) of the eyes was measured by non-contact optical low coherence reflectometry. The ONH parameters of eyes with BRVO were compared with those of fellow eyes using mixed model, one-way between-groups analysis of covariance was conducted to compare the ONH parameters of affected and unaffected fellow eyes in BRVO patients with those of the control eyes keeping confounding factors, including AL, age and gender under control in the statistical analysis.

Results

None of the investigated ONH parameters of affected BRVO eyes, unaffected fellow eyes and control eyes were statistically different after controlling for AL, age and gender.

Conclusion

Optic disc morphology might not be a potential anatomical predisposing factor for development of BRVO.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-015-0165-1) contains supplementary material, which is available to authorized users.

Intravitreal Aflibercept for Macular Edema Following Branch Retinal Vein Occlusion: 52-Week Results of the VIBRANT Study

PURPOSE

To determine week 52 efficacy and safety outcomes in eyes with macular edema after branch retinal vein occlusion (BRVO) treated with 2 mg intravitreal aflibercept injection (IAI) compared with grid laser.

DESIGN

VIBRANT was a double-masked, randomized, phase 3 trial.

PARTICIPANTS

Eyes randomized and treated in VIBRANT were followed to week 52.

METHODS

In the IAI group, eyes received IAI every 4 weeks through week 24 and IAI every 8 weeks through week 48 with rescue grid laser if needed at week 36. In the grid laser group, all eyes received grid laser at baseline and, if prespecified rescue criteria were met, 1 additional laser from week 12 to 20 and IAI every 8 weeks after 3 monthly doses from week 24 onward (the laser/IAI group).

MAIN OUTCOME MEASURES

The primary outcome measure was percentage of eyes with improvement from baseline best-corrected visual acuity (BCVA) letter score ≥15 at week 24. All outcome measures at week 52 were exploratory, and P values are considered nominal.

RESULTS

The percentage of eyes with improvement from baseline letter score ≥15 in the IAI and laser/IAI groups was 52.7% versus 26.7% (P = 0.0003) at week 24 and 57.1% versus 41.1% (P = 0.0296) at week 52. The corresponding mean change from baseline BCVA letter score was 17.0 versus 6.9 (P < 0.0001) at week 24 and 17.1 versus 12.2 (P = 0.0035) at week 52. The mean reduction from baseline central retinal thickness was 280.5 μm versus 128.0 μm (P < 0.0001) at week 24 and 283.9 μm versus 249.3 μm (P = 0.0218) at week 52. In the IAI group, 10.6% of eyes received rescue laser at week 36, and in the laser/IAI group, 80.7% received rescue IAI from week 24 to week 48. Traumatic cataract in 1 eye (1.1%) in the IAI group was the only ocular serious adverse event.

CONCLUSIONS

After 6 monthly IAI, injections every 8 weeks maintained control of macular edema and visual benefits through week 52. In the laser group, rescue IAI given from week 24 onward resulted in substantial visual improvements at week 52.

Fundus changes in branch retinal vein occlusion

PURPOSE

To investigate systematically the retinal changes in branch retinal vein occlusion (BRVO) and their natural history.

METHODS

The study comprised 214 consecutive patients with BRVO (144 major BRVO and 72 macular BRVO eyes) seen within 3 months of onset. Ophthalmic evaluation at initial and follow-up visits included recording visual acuity, visual fields, and detailed anterior segment and fundus examinations and fluorescein fundus angiography.

RESULTS

Initially, retinal hemorrhages were moderate to severe in the perifovea and macula in at least 65% in major and 52% in macular BRVO; at the fovea, it was 51% in major and 36% in macular BRVO. Initially, macular edema was more marked in major BRVO than in macular BRVO (P = 0.007). Major BRVO had a significantly higher rate of development of serous macular detachment (P = 0.002), epiretinal membrane (P = 0.008), serous retinal detachment (P = 0.002), perivenous sheathing (P < 0.0001), optic disk pallor (P < 0.0001), and lipid deposit (P < 0.0001) compared with macular BRVO. Retinal and disk neovascularization was seen only in major BRVO. The time to resolution of BRVO was significantly longer for major BRVO compared with macular BRVO (P = 0.0002).

CONCLUSION

Major and macular BRVOs are two distinct clinical entities. Initial and final fundus findings in the two types differ markedly.

Bilateral BRVO in a patient with recurrent prostate cancer

Bilateral cases of branch retinal vein occlusions (BRVO) are infrequent and often related to systemic disease. A 72-year-old man with biochemical recurrence of prostate cancer was referred for decreased vision in his left eye. Fundus examination and fluorescein angiography disclosed bilateral BRVO with patches of peripheral non-perfusion and macular oedema in the left eye. A systemic work up revealed elevated fibrinogen and reduced free protein S antigen, consistent with an underlying hypercoagulable state. Cancer is a well-known cause of hypercoagulability. We report the first case of bilateral BRVO related to biochemical recurrence of prostate cancer and a proven coagulation derangement.

RISK OF RETINAL VEIN OCCLUSION WITH CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To investigate the risk of retinal vein occlusion (RVO) after central serous chorioretinopathy (CSCR).

METHODS

The study included 2882 CSCR patients and 17,292 control patients matched by age, sex, number of visits to an ophthalmologist, diabetes mellitus, hypertension, and hyperlipidemia from January 2001 to December 2010 from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient was collected until December 2011. Cox proportional hazard regression analysis was used to obtain the adjusted hazard ratio for RVO. The RVO-free survival rate was calculated using Kaplan-Meier analysis.

RESULTS

There was a significantly higher risk of RVO in CSCR patients than in controls (incidence rate ratio = 3.07, 95% confidence interval = 1.86-5.07). After adjustment for potential confounders, the adjusted hazard ratio for developing RVO in the CSCR patients was 3.15 times higher than that of the controls (adjusted hazard ratio = 3.15, 95% confidence interval = 1.91-5.21).

CONCLUSION

Central serous chorioretinopathy increases the risk of RVO. For CSCR patients, the authors recommend thorough retinal vessel evaluation, regular follow-up, and education regarding RVO for patients with CSCR.

[Vitreous body and retinal vein occlusion]

PURPOSE

The aim of this study was to evaluate whether the adhesion status of the posterior vitreous cortex (PVC) towards the internal limiting membrane (ILM) has an impact on the development of retinal vein occlusion (RVO).

MATERIAL AND METHODS

In a retrospective analysis the operation protocols of 238 eyes receiving pars plana vitrectomy (ppV) and radial optic neurotomy (RON) for central retinal vein occlusion (CRVO) or ppV in combination with arteriovenous sheathotomy (AVS) for branch retinal vein occlusion (BRVO) were evaluated with respect to the intraoperative status of posterior vitreous body adhesion. The results were compared with age-matched healthy controls.

RESULTS

In this study 145 eyes (60.9 %) suffering from CRVO and 93 eyes (39.1 %) diagnosed with BRVO were included. In eyes with CRVO and BRVO the posterior vitreous cortex (PVC) was significantly more often attached (126 eyes, 86.9 % and 89 eyes, 95.7 %, respectively) than completely detached (19 eyes, 13.1 % and 4 eyes, 4.3 %, respectively, in each case p < 0.001). In the age groups between 70 and 79 years as well as between 80 and 89 years the PVC was significantly more often attached in both RVO entities in comparison to age-matched healthy controls (CRVO 70-79 years, p = 0.001 and 80-89 years, p = 0.002 and BRVO 70-79 years, p < 0.001, 80-89 years, p = 0.011). In eyes from the age group between 65 and 69 years (of age) the PVC was not significantly more often attached in comparison to healthy controls (CRVO p = 0.334 and BRVO p = 0.114).

CONCLUSION

According to these findings posterior vitreous adhesion is an independent risk factor for the development of retinal vein occlusion among patients aged 70 years or older.

Comparative analysis of the development of collateral vessels in macular edema due to branch retinal vein occlusion following grid laser or ranibizumab treatment

Purpose

To evaluate the differences in the development of collateral vessels in patients with macular edema due to branch retinal vein occlusion (BRVO) after treatment with either grid laser or ranibizumab (RNB).

Methods

Comparative study including patients with macular edema due to acute BRVO and best-corrected visual acuity (BCVA) between 20/40 and 20/200. The sample was divided into two groups according to the treatment applied: laser group, including eyes treated with Argon laser when retinal hemorrhages were sufficiently absorbed to perform the treatment, and RNB group, including patients treated initially with one monthly intravitreal injection for a period of 3 months of RNB and more injections according to need thereafter. Before treatment patients in both groups, received a complete ophthalmic examination, including BCVA, fundus examination, optical coherence tomography, fundus color photography, and fundus fluorescein angiography (FA). This same protocol of examination was repeated in every visit after treatment, except FA that was only repeated every 3 months. The detection of the collateral vessels was done by two experienced examiners based on the analysis of the early phase of the FA. If there was a discrepancy in their judgment, the criterion of a third examiner evaluating the FA was considered.

Results

Mean baseline BCVA was 0.86±0.26 and 0.82±0.25 (logMAR [logarithm of the minimum angle of resolution]) in the RNB and laser groups, respectively (P=0.83). At the end of the follow-up, mean BCVA was 0.38±0.18 and 0.64±0.33 (logMAR) in the RNB and laser groups, respectively. The difference in the final BCVA between both groups was statistically significant (P=0.002). Collaterals developed in both groups; 66.67% of patients (14 out of 21 patients) developed collaterals at a mean time of 6.14±2.60 months after diagnosis in the RNB group, and 68.18% (16 out of 22 patients) developed collaterals in the laser group at a mean time of 6.2±1.97 months after diagnosis. No statistically significant differences between groups were found in the number of cases developing collateral vessels (P=1.00) as well as in the time required for such development (P=0.947).

Conclusion

The use of RNB for the treatment of macular edema due to BRVO does not seem to alter the development of collateral vessels. Future studies with larger samples are required to confirm these outcomes.

Predictive factors for recurrence of macular edema after successful intravitreal bevacizumab therapy in branch retinal vein occlusion

PURPOSE

Our aim was to investigate predictive factors associated with efficacy and recurrence after intravitreal bevacizumab (IVB) therapy for macular edema (ME) in patients with branch retinal vein occlusion (BRVO).

METHODS

Fifty-two eyes of 52 patients who underwent IVB as a primary treatment against ME associated with BRVO were included retrospectively. Based on the postoperative central retinal thickness (CRT), the patients were classified into two groups: an effective group in which the CRT decreased to ≤250 µm within postoperative 3 months and an ineffective group in which the CRT remained >250 µm throughout the first 3 months. The effective group was then divided into two subgroups: a recurrent group in which ME had once resolved but recurred afterward, and a nonrecurrent group in which the resolution of ME was maintained throughout the follow-up period without additional injections. Preoperative factors such as age, gender, estimated elapsed time from disease onset to IVB, visual acuity, and CRT were compared between groups.

RESULTS

There was no significant difference between effective (n = 37) and ineffective (n = 15) groups in all preoperative factors. Between recurrent (n = 26) and nonrecurrent (n = 11) groups, elapsed time was significantly different (29.7 ± 29.5 vs. 15.7 ± 8.9 weeks, respectively; P = 0.036), and there were no significant differences in the remaining factors.

CONCLUSIONS

Early IVB treatment against BRVO may suppress ME recurrence.

Choroidal Maps in Different Types of Macular Edema in Branch Retinal Vein Occlusion Using Swept-Source Optical Coherence Tomography

PURPOSE

To compare choroidal thickness maps of different types of macular edema secondary to branch retinal vein occlusion (BRVO) using swept-source optical coherence tomography (SS OCT).

DESIGN

Retrospective cross-sectional study.

METHODS

We generated choroidal thickness maps of 55 eyes of 55 patients with BRVO using the macular volumetric raster scan protocol of the SS OCT. The enrolled eyes were classified into 4 types of macular edema according to the captured OCT images: no macular edema (nME, 13 eyes), cystoid macular edema (CME, 15 eyes), serous retinal detachment (SRD, 12 eyes), and mixed type (CME + SRD, 15 eyes). The data from normal fellow eyes served as the control. Statistical analysis was performed to compare choroidal thickness maps according to the type of macular edema.

RESULTS

The mean choroidal thicknesses in the control, nME, CME, SRD, and mixed-type groups were 205.77 ± 41.65 μm, 211.56 ± 46.34 μm, 214.30 ± 49.21 μm, 249.18 ± 43.51 μm, and 248.05 ± 49.51 μm, respectively. No statistical difference in choroidal thickness was observed among the nME, CME, and control groups, while the SRD and mixed groups showed larger choroidal thickness values than the control group (P < .001). No topographic feature in the choroidal thickness was observed to vary according to the location of BRVO.

CONCLUSIONS

The results suggest the choroidal thickness in BRVO varies according to the type of macular edema. Among the macular edema groups, choroidal thickness was significantly increased in eyes with SRD relative to those without SRD, which suggests that increased choroidal thickness may influence the development of SRD in BRVO.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Efficacy and Safety of Dexamethasone Intravitreal Implant for Treatment of Refractory Macular Edema Secondary to Retinal Vein Occlusion in Taiwan

PURPOSE

To evaluate the long-term efficacy and safety of slow-release dexamethasone intravitreal implant (DEX implant) in patients with refractory macular edema (ME) secondary to retinal vein occlusion (RVO) in Taiwan.

METHODS

We conducted a retrospective chart review of patients with a diagnosis of ME secondary to RVO who received the DEX implant at Kaohsiung Veterans General Hospital from October 2010 to February 2014.

RESULTS

A total of 28 patients with an average age of 60.7 ± 11.1 years were examined. Of these patients, 17 were diagnosed with branch RVO (BRVO) and 11 were diagnosed with central RVO (CRVO). The mean maximal change in vision from the baseline after the final injection was an improvement of 1.7 ± 2.8 lines (equivalent to 8.5 ETDRS letters; p<0.0001). The response to the first injection was similar across both BRVO and CRVO groups, but patients with BRVO showed a more favorable response than those with CRVO after the second injection. The response in patients who had refractory ME after at least 3 previous interventions was similar to the whole group. Three patients (10.7%) had elevated intraocular pressure (IOP) that was well controlled by IOP-lowering medications. None of these patients required laser or glaucoma surgery. Five patients (17.9%) exhibited cataract progression during the observation period.

CONCLUSION

The DEX implant is an effective and safe treatment for ME, secondary to RVO, including refractory ME.

Investigation of retinal morphology alterations using spectral domain optical coherence tomography in a mouse model of retinal branch and central retinal vein occlusion

Retinal vein occlusion is a leading cause of visual impairment. Experimental models of this condition based on laser photocoagulation of retinal veins have been described and extensively exploited in mammals and larger rodents such as the rat. However, few reports exist on the use of this paradigm in the mouse. The objective of this study was to investigate a model of branch and central retinal vein occlusion in the mouse and characterize in vivo longitudinal retinal morphology alterations using spectral domain optical coherence tomography. Retinal veins were experimentally occluded using laser photocoagulation after intravenous application of Rose Bengal, a photo-activator dye enhancing thrombus formation. Depending on the number of veins occluded, variable amounts of capillary dropout were seen on fluorescein angiography. Vascular endothelial growth factor levels were markedly elevated early and peaked at day one. Retinal thickness measurements with spectral domain optical coherence tomography showed significant swelling (p<0.001) compared to baseline, followed by gradual thinning plateauing two weeks after the experimental intervention (p<0.001). Histological findings at day seven correlated with spectral domain optical coherence tomography imaging. The inner layers were predominantly affected by degeneration with the outer nuclear layer and the photoreceptor outer segments largely preserved. The application of this retinal vein occlusion model in the mouse carries several advantages over its use in other larger species, such as access to a vast range of genetically modified animals. Retinal changes after experimental retinal vein occlusion in this mouse model can be non-invasively quantified by spectral domain optical coherence tomography, and may be used to monitor effects of potential therapeutic interventions.