The 10-Year Incidence and Risk Factors of Retinal Vein Occlusion

Retinal Vein Occlusion-Background Knowledge and Foreground Knowledge Prospects-A Review

Thrombosis of retinal veins is one of the most common retinal vascular diseases that may lead to vascular blindness. The latest epidemiological data leave no illusions that the burden on the healthcare system, as impacted by patients with this diagnosis, will increase worldwide. This obliges scientists to search for new therapeutic and diagnostic options. In the 21st century, there has been tremendous progress in retinal imaging techniques, which has facilitated a better understanding of the mechanisms related to the development of retinal vein occlusion (RVO) and its complications, and consequently has enabled the introduction of new treatment methods. Moreover, artificial intelligence (AI) is likely to assist in selecting the best treatment option for patients in the near future. The aim of this comprehensive review is to re-evaluate the old but still relevant data on the RVO and confront them with new studies. The paper will provide a detailed overview of diagnosis, current treatment, prevention, and future therapeutic possibilities regarding RVO, as well as clarifying the mechanism of macular edema in this disease entity.

Prevalence and risk factors of retinal vein occlusion in individuals with diabetes: The kailuan eye study

PURPOSE

The aim of this study was to analyze the incidence of retinal vein occlusion (RVO) in patients with and without diabetes in the population and compare the influencing factors.

METHOD

The community-based Kailuan Eye Study included 14,440 participants (9835 male, 4605 female) with a mean age of 54.0 ± 13.3 years (range, 20-110 years). They underwent a systemic and ophthalmologic examination. RVO were diagnosed on fundus photographs.

RESULT

By matching for age and gender, we included a total of 2767 patients each with diabetes and non-diabetes. The prevalence of RVO among patients with and without diabetes was 1.5% and 0.8%, respectively. The prevalence of RVO was higher in patients with diabetes than in patients without diabetes in all age groups. Multifactorial regression analysis showed that only fasting blood glucose levels were significantly different between patients with RVO with or without DM. The occurrence of RVO in the group with diabetes was mainly associated with higher fasting glucose and systolic blood pressure; in the group without diabetes, RVO was mainly associated with higher diastolic blood pressure, Body Mass Index, and lower low-density lipoprotein cholesterol levels.

CONCLUSION

We found that patients with diabetes have increased risks of RVO. In addition to blood pressure control, we recommend educating patients with diabetes about RVO, to prevent its subsequent occurrence.

Deep Learning based Retinal Vessel Caliber Measurement and the Association with Hypertension

PURPOSE

To develop a highly efficient and fully automated method that measures retinal vessel caliber using digital retinal photographs and evaluate the association between retinal vessel caliber and hypertension.

METHODS

The subjects of this study were from two sources in Beijing, China, a hypertension case-control study from Tongren Hospital (Tongren study) and a community-based atherosclerosis cohort from Peking University First Hospital (Shougang study). Retinal vessel segmentation and arteriovenous classification were achieved simultaneously by a customized deep learning model. Two experienced ophthalmologists evaluated whether retinal vessels were correctly segmented and classified. The ratio of incorrectly segmented and classified retinal vessels was used to measure the accuracy of the model's recognition. Central retinal artery equivalents, central retinal vein equivalents and arteriolar-to-venular diameter ratio were computed to analyze the association between retinal vessel caliber and the risk of hypertension. The association was then compared to that derived from the widely used semi-automated software (Integrative Vessel Analysis).

RESULTS

The deep learning model achieved an arterial recognition error rate of 1.26%, a vein recognition error rate of 0.79%, and a total error rate of 1.03%. Central retinal artery equivalents and arteriolar-to-venular diameter ratio measured by both Integrative Vessel Analysis and deep learning methods were inversely associated with the odds of hypertension in both Tongren and Shougang studies. The comparisons of areas under the receiver operating characteristic curves from the proposed deep learning method and Integrative Vessel Analysis were all not significantly different (p > .05).

CONCLUSION

The proposed deep learning method showed a comparable diagnostic value to Integrative Vessel Analysis software. Compared with semi-automatic software, our deep learning model has significant advantage in efficiency and can be applied to population screening and risk evaluation.

VITRECTOMY FOR VITREOUS HEMORRHAGE ASSOCIATED WITH RETINAL VEIN OCCLUSION: Visual Outcomes, Prognostic Factors, and Sequelae

PURPOSE

To report the outcomes of pars plana vitrectomy for vitreous hemorrhage (VH) associated with retinal vein occlusion and to identify prognostic indicators.

METHODS

Interventional, retrospective consecutive case series between 2015 and 2021.

RESULTS

The study included 138 eyes of 138 patients (64 female and 74 male); 81 patients had branch retinal vein occlusion and 57 had central retinal vein occlusion. The mean age was 69.8 years. The mean duration between the diagnosis of VH and surgery was 79.6 ± 115.3 (range, 1-572) days. The mean follow-up was 27.2 months. The logarithm of the minimum angle of resolution visual acuity significantly improved from 1.95 ± 0.72 (Snellen equivalent, 20/1782) to 0.99 ± 0.87 (20/195) at 6 months and to 1.06 ± 0.96 (20/230) at the final visit (both P < 0.001). The visual acuity at 6 months improved by three or more lines in 103 eyes (75%). Postoperative complications during follow-up included recurrent VH in 16 eyes (12%) (of which 8 eyes underwent reoperations), rhegmatogenous retinal detachment in six eyes (4%), and new neovascular glaucoma in three eyes (2%). Worse final visual acuity was significantly associated with older age ( P = 0.007), concurrent neovascular glaucoma ( P < 0.001), central retinal vein occlusion ( P < 0.001), worse preoperative visual acuity ( P < 0.001), postoperative new neovascular glaucoma ( P = 0.021), and postoperative retinal detachment ( P < 0.001). The duration of VH was not associated with visual outcomes ( P = 0.684). Preoperative antivascular endothelial growth factor injections and tamponade did not prevent postoperative recurrent VH.

CONCLUSION

Pars plana vitrectomy is effective for VH associated with retinal vein occlusion, regardless of the duration of hemorrhage. However, pre-existing risk factors and postoperative sequelae may limit visual recovery.

Association between retinal vein occlusion and early-stage hypertension: A propensity score analysis using a large claims database

BACKGROUNDS/OBJECTIVES

The threshold of hypertension was lowered from systolic blood pressure (SBP)/diastolic blood pressure (DBP) 140/90 mmHg to 130/80 mmHg by the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline. Thus, we investigated the association between retinal vein occlusion (RVO) occurrence and early-stage hypertension.

SUBJECTS/METHODS

This retrospective cohort study used the JMDC Claims Database (JMDC Inc., Tokyo, Japan) between 2005 and 2020. Individuals undergoing health checkups who had data on BP and did not take antihypertensive medications were included. They were classified into four BP groups: normal BP (SBP < 120 mmHg and DBP < 80 mmHg), elevated BP (SBP 120-129 mmHg and DBP < 80 mmHg), stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg), and stage 2 hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). Date of RVO occurrence was defined as the first date of diagnosis. We estimated adjusted hazard ratios for RVO and central RVO using weighted Cox regression to adjust for potential confounders.

RESULTS

A total of 2,703,264 individuals were eligible. During a mean follow-up of 1,091 days, 3,526 RVO and 828 central RVO events occurred. The adjusted hazard ratios (95% confidence intervals) were 1.37 (1.19-1.57), 1.95 (1.75-2.18), and 3.33 (2.95-3.76) for RVO and 1.44 (1.07-1.93), 2.17 (1.72-2.73), and 3.76 (2.91-4.86) for central RVO in the elevated BP, stage 1 hypertension, and stage 2 hypertension groups, respectively, compared with the normal BP group.

CONCLUSIONS

Even individuals with early-stage hypertension showed higher risks for RVO and central RVO than individuals with normal BP.

Impact of anti-VEGF therapy on distinctive retina layers in patients with macular edema secondary to branch retinal vein occlusion

BACKGROUND

To explore the impact of anti-vascular epithelial growth factor (ant-VEGF) on the thickness of each retinal layer in patients with macular edema (ME) secondary to the branch retinal vein occlusion (BRVO).

METHODS

This retrospective study included patients with ME secondary to monocular BRVO who received anti-VEGF therapy in Ningxia Eye Hospital between January-December 2020.

RESULTS

Forty-three patients (25 males) were included, with 31 showed > 25% reduction in central retinal thickness (CRT) after anti-VEGF therapy (response group), and the others showed a ≤25% reduction in CRT (no-response group). The response group showed significantly smaller mean changes in the ganglion cell layer (GCL) (after 2 months) and inner plexiform layer (IPL) (after 1, 2, and 3 months) and significantly greater mean changes in the inner nuclear layer (INL) (after 2 and 3 months), outer plexiform layer (OPL) (after 3 months), outer nuclear layer (ONL) (after 2 and 3 months), and CRT (after 1 and 2 months) (all P < 0.05) as compared to the no-response group. The mean change in the thickness of each retinal layer IPL (P = 0.006) between the two groups was significantly different after controlling for a time and with a significant time trend (P < 0.001). Additionally, patients in the response group were more likely to have an improvement in IPL (43.68 ± 6.01 at 1 month and 41.52 ± 5.45 at 2 months vs. 39.9 ± 6.86 at baseline) after anti-VEGF therapy, while those in no response group might show improvement in GCL (45.75 ± 8.24 at 1 month, 40.00 ± 8.92 at 2 months, and 38.83 ± 9.93 at 3 months vs. 49.67 ± 6.83 at baseline).

CONCLUSIONS

Anti-VEGF therapy might help restore the retinal structure and function in patients with ME secondary to BRVO, and those who have a response after anti-VEGF therapy are more likely to improve IPL, while those having no response might show improvement in GCL.

Acetazolamide and bevacizumab combination therapy versus bevacizumab monotherapy in macular edema secondary to retinal vein occlusion

PURPOSE

To determine and compare the efficacy of intravitreal bevacizumab (IVB) and oral acetazolamide (OA) combination therapy versus IVB monotherapy in patients with macular edema secondary to retinal vein occlusion (RVO).

METHODS

This randomized clinical trial included 54 eyes of 52 patients with RVO central macular thickness (CMT) of more than 300μm, and best corrected visual acuity (BCVA) between 20/400 and 20/40. Eligible patients were randomly assigned to two groups: (I) IVB and OA (250mg twice daily) combination therapy or (II) IVB monotherapy. Ocular injections were repeated monthly for up to three months; BCVA and CMT were measured monthly.

RESULTS

Both regimens resulted in significant reduction in CMT (534±150μm to 352±90μm in the IVB+OA group, P<0.001; and 580±175μm to 362±90μm in the IVB group, P<0.001); neither showed superiority in this regard. Likewise, BCVA showed significant improvement in both groups (0.87±0.56 to 0.53±0.28 LogMAR in the IVB+OA group, P=0.001; and 0.85±0.62 to 0.46±0.4 LogMAR in the IVB group, P<0.001), with no intergroup difference.

CONCLUSION

Addition of oral acetazolamide to IVB in eyes with macular edema secondary to RVO may not result in additional short-term benefits regarding functional and anatomical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05290948, registered on March 22, 2022. https://clinicaltrials.gov/ct2/show/NCT05290948.

Mechanisms of macular edema

Macular edema is the pathological accumulation of fluid in the central retina. It is a complication of many retinal diseases, including diabetic retinopathy, retinal vascular occlusions and uveitis, among others. Macular edema causes decreased visual acuity and, when chronic or refractory, can cause severe and permanent visual impairment and blindness. In most instances, it develops due to dysregulation of the blood-retinal barrier which permits infiltration of the retinal tissue by proteins and other solutes that are normally retained in the blood. The increase in osmotic pressure in the tissue drives fluid accumulation. Current treatments include vascular endothelial growth factor blockers, corticosteroids, and non-steroidal anti-inflammatory drugs. These treatments target vasoactive and inflammatory mediators that cause disruption to the blood-retinal barrier. In this review, a clinical overview of macular edema is provided, mechanisms of disease are discussed, highlighting processes targeted by current treatments, and areas of opportunity for future research are identified.

Prevalence and factors associated with visual impairment in middle-aged and older Chinese population

OBJECTIVE

This study aimed to estimate the prevalence of visual impairment and to identify the factors associated with it in China.

METHODS

Data for this cross-sectional study were retrieved from the China Health and Retirement Longitudinal Study (CHARLS) for a total of 16,480 subjects who completed the questionnaire between June 2011 and March 2012. The prevalence of visual impairment was estimated considering the complex survey design and response rate. Associated factors were identified using the weighted logistic regression analysis.

RESULTS

The overall prevalence of visual impairment among middle-aged and older Chinese adults was 6.22%. Regionally, Qinghai and Gansu provinces showed the highest prevalence of visual impairment, whereas Shanghai showed the lowest prevalence of visual impairment in China. Older age (OR = 1.888; 95% CI: 1.537-2.467) was correlated with a higher likelihood of visual impairment, whereas a non-alcohol intake (OR = 0.072; 95% CI: 0.018-0.246) was correlated with a lower likelihood of visual impairment. Hypertension (OR = 1.299; 95% CI: 1.189-1.467), diabetes (OR = 2.000; 95% CI: 1.163-3.765), lung diseases (OR = 1.795; 95% CI: 1.067-3.019), liver diseases (OR = 1.270; 95% CI: 1.221-2.876), stroke (OR = 1.135; 95% CI: 1.107-3.528), and heart disease (OR = 1.350; 95% CI: 1.104-1.708) were significantly associated with visual impairment.

CONCLUSION

Geographical variations in the prevalence of visual impairment in China were defined, indicating that such variations do exist in China. Age, alcohol intake, hypertension, diabetes, lung diseases, liver diseases, stroke, and heart disease were factors associated with visual impairment.

Analysis of the Cytokine Expression in the Aqueous Humor of Individuals with BRVO-Associated Macular Edema

Purpose

This study aimed to determine the expression levels of vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) in the aqueous humor of patients with macular edema (ME) caused by branch retinal vein occlusion (BRVO), as well as to investigate the relationship between the cytokines as mentioned earlier and best-corrected visual acuity (BCVA), ME, and the degree of ME from the molecular level.

Methods

In a prospective observational study, fluorescein fundus angiography (FFA) and optical coherence tomography (OCT) were used to classify 58 patients with non-ischemic BRVO-ME into three groups according to the degree of ME: 14-mild, 17-moderate, and 27-severe. The specific concentration of IL-6, VEGF, ICAM-1, and VCAM-1 in the aqueous humor was detected using the BD CSCanto™ II Flow Cytometer (US). Spearman or Pearson correlation analysis was used to test the correlation between the levels of BCVA and severity of ME and the expression levels of IL-6, VEGF, ICAM-1, and VCAM-1 in the aqueous humor.

Results

According to the obtained data, BCVA did not correlate with the severity of ME, and these four cytokines expression levels in patients' aqueous humor (P > 0.05). Moreover, BCVA did not correlate with mild, moderate, or severe ME as well (P > 0.05). However, the levels of these four cytokines were correlated with the severity of the ME. These underlined cytokines were linked to the mild, moderate, and severe degrees of ME. VEGF was also significantly correlated (r > 0.8, P < 0.0001) with the severity of ME.

Conclusions

This study suggests that the severity of ME in BRVO-ME patients is significantly correlated with the expression levels of IL-6, VEGF, ICAM-1, and VCAM-1 in the aqueous humor. Lowering the level of disease-associated cytokines may potentially reduce the degree of ME. Therefore, an in-depth study of the levels and the relationship may provide some evidence for the pathogenesis, treatment, and prevention of BRVO-ME.

Association between Retinal Vein Occlusion and Life's Simple 7 Cardiovascular Health Metrics: A Large Claims Database Study

PURPOSE

Cardiovascular diseases and retinal vein occlusion (RVO) have many risk factors in common. We aimed to investigate the associations between RVO occurrence and each of the cardiovascular health (CVH) metrics known as Life's Simple 7, which are indicators of an unhealthy lifestyle.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Individuals in the JMDC Claims Database (JMDC Inc) who underwent health checkups between 2005 and 2020.

METHODS

We set the following exposures: (1) each component of the CVH metrics (body mass index, blood pressure [BP], fasting blood glucose, total cholesterol, smoking, dietary habits, and physical activity) and (2) the number of nonideal CVH metrics (nonideal CVH score, ranging from 0 [healthiest] to 7 [unhealthiest]). The study outcomes were RVO and central RVO (CRVO) occurrence, which were identified on the first date of diagnosis. We performed Cox regression analyses, with covariates including age, sex, and glaucoma.

MAIN OUTCOME MEASURES

The hazard ratios for RVO and CRVO occurrence for (1) each component of the CVH metrics and (2) the nonideal CVH score.

RESULTS

We included 2 093 536 individuals. During a mean follow-up period of 1070 ± 884 days, there were 3265 RVO and 789 CRVO events. An increased risk of RVO occurrence was most strongly associated with a nonideal BP (hazard ratio [HR], 2.25; 95% confidence interval [CI], 2.06-2.46), followed by a nonideal body mass index (HR, 1.31; 95% CI, 1.21-1.41). Individuals with nonimprovement in BP within 1 year showed a higher risk of RVO occurrence than those with improvement (HR, 2.07; 95% CI, 1.70-2.52). The adjusted HRs of the groups with nonideal CVH scores of 6 to 7, 5, 4, 3, 2, and 1 were 3.76 (2.66-5.30), 2.87 (2.06-4.00), 2.57 (1.85-3.57), 2.22 (1.60-3.08), 1.79 (1.29-2.48), and 1.39 (0.99-1.95), respectively, compared with the group with a score of 0. Similar results were observed for CRVO.

CONCLUSIONS

The strongest risk factor for RVO was nonideal BP, followed by nonideal body mass index. There was a dose-dependent positive association between a nonideal CVH score and RVO occurrence. These findings are important with respect to the identification of individuals at higher risk of RVO.

Retinal vascular occlusion and SARS-CoV-2 vaccination

PURPOSE

To assess the clinical and retinal imaging features of patients in whom retinal vascular occlusion (VO) had developed in temporal associations with COVID-19 vaccination.

METHODS

In this retrospective case series, all consecutive adult patients with new onset VO within 6 weeks of vaccination against COVID-19 were included in the study between May 1 and October 31, 2021. All patients had a systemic medical health assessment, full ophthalmic evaluation, and complete fundus imaging.

RESULTS

Fifteen eyes of VO (14 patients) after COVID-19 vaccinations were identified. The median time between vaccination and symptoms onset was 14 days (range 7-42 days). The mean best-corrected visual acuity (BCVA) was 20/55 with a range of 20/20 to 20/200. Eleven of 15 eyes (73.3%) had visual acuity improvement after intravitreal treatment at 60-90 days (range, 45-105 days) from the presentation. Four of 5 cases without systemic risk factors for VO had a mean BCVA > 20/32 at presentation and > 20/25 at the latest evaluation. Between May 1 and October 31, 2021, a temporal association was found between the 15 reported cases and COVID-19 vaccination out of a total of 29 VO (p = 0.05). The incidence of VO was higher in the considered period compared to the equivalent 6-month period in 2019 (1.17% vs 0.52%, respectively; p = 0.0134).

CONCLUSIONS

Retinal vascular occlusion with different grades of severity are reported in temporal association with COVID-19 vaccination. The exact pathogenic mechanism needs to be further studied. No certain causal relationship can be established from this case series.

Association between proteinuria and retinal vein occlusion in individuals with preserved renal function: a retrospective cohort study

PURPOSE

To investigate the association between proteinuria and the incidence of retinal vein occlusion (RVO) in individuals with preserved renal function.

METHODS

We conducted a retrospective cohort study from 2005 to 2020 using the JMDC Claims Database, a large database of health check-ups and administrative claims in Japan. Individuals who underwent annual health check-ups were included. Participants were classified into three groups based on the protein concentration in their urine: negative (≤10 mg/dl), trace (10-30 mg/dl) and positive (≥30 mg/dl). We estimated hazard ratios (HRs) for the development of RVO using Cox regression analyses with adjustment for baseline characteristics by the matching weights calculated from the multiple propensity scores. The cumulative incidence of RVO between the weighted groups was calculated using the Kaplan-Meier estimator.

RESULTS

There were 1 635 212 eligible participants, among whom 2360 developed RVO. The mean follow-up period was 1036 ± 951 days. The adjusted HRs for RVO were 1.10 (95% confidence interval 0.92-1.33) and 1.46 (1.19-1.78) in the groups with trace and positive proteinuria compared with negative proteinuria respectively. The cumulative incidence rates of RVO at 7 years were 0.40%, 0.43% and 0.55% in the groups with negative, trace and positive proteinuria, respectively.

CONCLUSION

Positive proteinuria was independently associated with an increased incidence of RVO in individuals with preserved renal function. Proteinuria may be a novel risk factor for RVO development.

Changes of Optical Coherence Tomography Biomarkers in Macular Edema Secondary to Retinal Vein Occlusion After Anti-VEGF and Anti-Inflammatory Therapies

Purpose

Patients and Methods

Results

Conclusion

Novel Association between Opioid Use and Increased Risk of Retinal Vein Occlusion Using the National Institutes of Health All of Us Research Program

Purpose

To assess for risk factors for retinal vein occlusion (RVO) among participants in the National Institutes of Health All of Us database, particularly social risk factors that have not been well studied, including substance use.

Design

Retrospective, case-control study.

Participants

Data were extracted for 380 adult participants with branch retinal vein occlusion (BRVO), 311 adult participants with central retinal vein occlusion (CRVO), and 1520 controls sampled among 311 640 adult participants in the All of Us database.

Methods

Data were extracted regarding demographics, comorbidities, income, housing, insurance, and substance use. Opioid use was defined by relevant diagnosis and prescription codes, with prescription use > 30 days. Controls were sampled at a 4:1 control to case ratio from a pool of individuals aged > 18 years without a diagnosis of RVO and proportionally matched to the demographic distribution of the 2019 U.S. census. Multivariable logistic regression identified medical and social determinants significantly associated with BRVO or CRVO. Statistical significance was defined as P < 0.05.

Main Outcome Measure

Development of BRVO or CRVO based on diagnosis codes.

Results

Among patients with BRVO, the mean (standard deviation) age was 70.1 (10.5) years. The majority (53.7%) were female. Cases were diverse; 23.7% identified as Black, and 18.4% identified as Hispanic or Latino. Medical risk factors including glaucoma (odds ratio [OR], 3.29; 95% confidence interval [CI], 2.22-4.90; P < 0.001), hypertension (OR, 2.15; 95% CI, 1.49-3.11; P < 0.001), and diabetes mellitus (OR, 1.68; 95% CI, 1.18-2.38; P = 0.004) were re-demonstrated to be associated with BRVO. Black race (OR, 2.64; 95% CI, 1.22-6.05; P = 0.017) was found to be associated with increased risk of BRVO. Past marijuana use (OR, 0.68; 95% CI, 0.50-0.92; P = 0.013) was associated with decreased risk of BRVO; however, opioid use (OR, 1.98; 95% CI, 1.41-2.78; P < 0.001) was associated with a significantly increased risk of BRVO. Similar associations were found for CRVO.

Conclusions

Understanding RVO risk factors is important for primary prevention and improvement in visual outcomes. This study capitalizes on the diversity and scale of a novel nationwide database to elucidate a previously uncharacterized association between RVO and opioid use.

Retinal vein occlusion with cerebral infarction in a preterm neonate: a case report

BACKGROUND

Retinal vein occlusion (RVO) is a common disease that causes blindness in elderly patients, and cerebral infarction is also a severe disorder impairing the health of individuals. Both diseases are not common in neonates and are related to thrombosis. To date, only one case of simultaneous occurrence of RVO with intracranial haemorrhage in a full-term neonate has been reported.

CASE PRESENTATION

A preterm neonate was diagnosed with cerebral infarction and RVO. Retinal haemorrhage and macular oedema were detected in the left eye after the onset of ipsilateral stroke. Although the retinal conditions in this case resolved spontaneously without ocular treatment, the long-term effect on visual function is still unknown.

CONCLUSIONS

Given that ocular fundus examinations are rarely performed in paediatric stroke patients, a screening fundus examination in these newborns with stroke might be worth considering.

Hypertension as a risk factor for retinal vein occlusion in menopausal women: A nationwide Korean population-based study

Retinal vein occlusion (RVO) is an important cause of blindness. Hypertension is a well-known risk factor for RVO. Although the prevalence of hypertension increases in women after menopause, the relationship between blood pressure and RVO in women before and after menopause has not been studied in detail.We retrospectively analyzed 2,619,206 patients from the Korean National Health Insurance System database. A Cox proportional hazard regression model was used to evaluate the independent association between blood pressure and the risk of RVO development and identify differences between premenopausal and postmenopausal women.The incidence of RVO was higher among postmenopausal women than in premenopausal women. In the model adjusted for socioeconomic and clinical variables, there was an association between blood pressure and RVO development in premenopausal and postmenopausal women; however, this was stronger than premenopausal women.Both systolic and diastolic blood pressure are associated with an increased risk of RVO, and their effects are more potent in premenopausal women than postmenopausal women. Thus, comprehensive management of hypertension in premenopausal women is essential to reduce the risk of RVO.

Peripapillary retinal nerve fiber layer thickness in patients with unilateral retinal vein occlusion

This study evaluated longitudinal changes in peripapillary retinal nerve fiber layer (pRNFL) thickness in eyes affected with branch and central retinal vein occlusion (BRVO and CRVO, respectively) and fellow eyes. This retrospective case-control study included patients with newly diagnosed unilateral BRVO (46 patients) or unilateral CRVO (27 patients). The control group included 48 patients without abnormal findings on the fundus examination. Global and all-sector pRNFL thicknesses were greater in eyes with BRVO and CRVO than in fellow eyes at baseline; however, at 24 months, this difference remained only in the temporal sector of eyes affected with CRVO. Although the global pRNFL thicknesses of the fellow eyes in the BRVO and CRVO groups decreased significantly at 24 months compared to baseline (p = 0.001 and p = 0.011, respectively), there was no significant difference in the normal control group (p = 0.824). The global, inferior temporal, and inferior nasal pRNFL thicknesses at 12 and 24 months were significantly lower in the fellow eyes of the CRVO group than in those of the BRVO and normal control groups. The fellow eyes of patients with BRVO and CRVO suffered a significant reduction in pRNFL thickness compared to normal controls, indicating that they are susceptible to pRNFL damage.

Characteristics of Branch Retinal Vein Occlusion in African American Patients

BACKGROUND AND OBJECTIVES

To describe the presentation, management, and clinical outcomes of branch retinal vein occlusion (BRVO) in African American patients compared to patients of other racial or ethnic backgrounds.

PATIENTS AND METHODS

This retrospective cohort study included eyes diagnosed with BRVO and macular edema at a tertiary referral center. Presenting features, treatment, and outcomes were compared based on racial or ethnic backgrounds.

RESULTS

The study included 285 eyes: 21.8% African American, 78.2% other. African American patients were more likely to have comorbid diabetes (P = .012), open-angle glaucoma (P < .001), and to present with subretinal fluid (P = .049); multivariate analysis showed race and ethnicity alone may not fully explain presenting subretinal fluid (odds ratio = 2.807; 95% CI, 0.997 to 7.903; P = .051). There was no difference in other comparisons of clinical outcomes or treatment burden, including visual acuity, duration, or treatment method.

CONCLUSIONS

Despite significant differences at presentation, the management and outcomes of BRVO did not differ significantly between African American patients and patients of other racial and ethnic backgrounds. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:492-497.].

Cataract Surgery Is Not Associated with Decreased Risk of Retinal Vein Occlusion

Purpose

Design

Participants

Methods

Main Outcome Measure

Results

Conclusions

Treatment Patterns and Clinical Outcomes for Branch Retinal Vein Occlusion: An 8-Year Experience at a Tertiary Eye Center

Purpose:

This work aims to investigate real-world treatment patterns and outcomes in eyes with branch retinal vein occlusion in the antivascular endothelial growth factor (anti-VEGF) era.

Methods:

A retrospective, nonrandomized, comparative study was conducted on eyes diagnosed with branch retinal vein occlusion at a single tertiary center between 2009 and 2017. Medical history, treatment patterns, and visual acuity outcomes were examined. Subanalysis was performed for eyes that met the eligibility criteria for the BRAVO (Ranibizumab for the Treatment of Macular Edema Following Branch Retinal Vein Occlusion) trial.

Results:

A total of 315 eyes were included, of which 244 were treatment naive. In all eyes, the most common first treatment was the following: intravitreal bevacizumab (38.4%), aflibercept (15.1%), ranibizumab (8.1%), sectoral scatter laser (6.2%), and triamcinolone (3.1%). At 1 year, treatment-naive eyes had received an average of 2.43 anti-VEGF injections. During follow-up, treatment-naive eyes gained an average of 0.21 Early Treatment Diabetic Retinopathy Study lines. Forty eyes that met BRAVO trial criteria received an average of 5.05 anti-VEGF injections in the first year and gained an average of 1.83 Early Treatment Diabetic Retinopathy Study lines.

Conclusions:

This real-world cohort received fewer anti-VEGF injections at year 1 and experienced less improvement in visual acuity during the course of treatment than clinical trial participants. Trial-eligible patients received more injections and had greater visual gains than those who would not have been eligible for the trial.

Clinical significance of subclinical atherosclerosis in retinal vein occlusion

Retinal vein occlusion (RVO) is associated with atherosclerotic cardiovascular risk factors; however, its association with the specific markers of subclinical atherosclerosis has not yet been established. To investigate this association, we compared 70 patients with RVO to 70 age- and sex-matched patients without RVO. Low-density lipoprotein cholesterol (LDL-C) levels and brachial-ankle pulse wave velocity (baPWV) were significantly higher in the RVO group than in the control group. Carotid plaques (54.3% vs. 28.6%, p = 0.004) were more frequent in the RVO group. Multivariate logistic regression analysis showed that the presence of carotid plaques (odds ratio [OR]: 3.15, 95% confidence interval [CI] 1.38–7.16, p = 0.006), as well as smoking, LDL-C level, and baPWV were associated with RVO. Additionally, a multinomial logistic regression model showed that the presence of carotid plaques (OR: 3.94, 95% CI 1.65–9.41, p = 0.002) and LDL-C level were associated with branch RVO, whereas smoking and baPWV were associated with central RVO. In conclusion, RVO was associated with subclinical atherosclerosis markers, including carotid plaques and baPWV. These results support the hypothesis that atherosclerosis contributes to the etiology of RVO and suggest the evaluation of subclinical atherosclerosis in patients with RVO.

SERUM LEVELS OF ANTIBODIES AGAINST OXIDATION-SPECIFIC EPITOPES ARE DECREASED IN PATIENTS WITH RETINAL VEIN OCCLUSION

PURPOSE

Oxidative stress and inflammation have been implicated in the development of retinal vein occlusion (RVO). Oxidation-specific epitopes (OSEs) represent products of oxidative stress that can trigger vascular inflammation and thrombosis. Natural occurring antibodies have been shown to bind oxidation-specific epitopes thereby inhibiting their inflammatory potential and promoting their removal.

METHODS

This prospective cross-sectional study included 270 patients with RVO and 81 in-hospital control patients. We measured three types of serum levels of oxidation-specific epitope-specific immunoglobulin M and immunoglobulin G antibodies (anti-copper-oxidized LDL [CuOx-LDL], antiphosphocholine [PC], anti-malondialdehyde-modified LDL [MDA-LDL]). History of arterial hypertension, hyperlipidemia, myocardial infarction, diabetes mellitus, stroke, smoking status, and several laboratory parameters were determined to control for potential confounders.

RESULTS

Compared with controls, patients with RVO had significantly lower levels of immunoglobulin M and immunoglobulin G antibodies against CuOx-LDL and PC, and significantly lower levels of immunoglobulin G but not immunoglobulin M antibodies against MDA-LDL. The association between RVO patients and lower levels of these antibodies prevailed upon multivariable adjustment.

CONCLUSION

These prospective data show that antibodies against oxidation-specific epitope are lower in patients with RVO compared with control patients and support the concept that oxidative stress and inflammation play key roles in the development and subsequent complications in RVO.

Central Retinal Vessel Trunk Caliber Changes After Short-term Intraocular Pressure Elevation

PRECIS

After a short-term intraocular pressure (IOP) elevation, the central retinal vein caliber may be widened at lower IOP rise levels, while be compressed at higher IOP rise values.

PURPOSE

The purpose of this study was to investigate changes in the calibers of the central retinal vein trunk (CRVT) and central retinal artery trunk (CRAT) trunk during a short-term elevation of IOP.

METHODS

A prospective observational study. Acute primary angle-closure suspects underwent a dark room prone provocative test (DRPPT) for 2 hours. Before and at the end of the test, tonometry, swept-source optical coherence tomography, and nonmydriatic fundus photography were performed. The calibers of the CRVT and CRAT were measured on the fundus photos taken at baseline and at the end of the DRPPT.

RESULTS

The study included 101 eyes (61 individuals; mean age: 54.8±9.3 y; range: 30 to 70 y) which showed an increase in IOP by 9.6±9.0 mm Hg (range: 2.3 to 46.7 mm Hg). From baseline to the end of the DRPPT, the mean CRVT caliber increased from 101.8±25.9 to 107.7±26.6 μm (P<0.001), while the CRAT caliber did not differ significantly (110.3±24.2 vs. 109.7±21.5 μm; P=0.54) during the test. The CRVT widening was larger in the subgroup with IOP rise of <6 mm Hg than in the subgroup with an IOP rise of 6 to 15 mm Hg, while in the subgroup with an IOP rise of >15 mm Hg the CRVT caliber did not change significantly (P=0.20) during the test.

CONCLUSIONS

A physiological short-term IOP rise at lower levels of IOP elevation led to a widening of the CRVT, while at higher IOP values, the further IOP-rise may have compressed the retinal vein. Because of higher intraluminal pressure values, the retinal artery diameters were not affected by the IOP-rise.

Correlations between choroidal thickness and renal function in patients with retinal vein occlusion

The purpose of this study was to analyze the correlation of renal function indices with sub-foveal choroidal thickness (SFChT) in treatment-naïve (naïve) eyes with retinal vein occlusion (RVO) using swept-source optical coherence tomography (SS-OCT) and systemic workup. Retrospective chart review was performed from Dec 2016 to Sep 2019 in patients newly diagnosed with treatment-naïve unilateral RVO. Ocular parameters, including SFChT, and systemic profiles, including renal function indices, were reviewed. Simple and multiple linear regression analyses were performed to check if there was a correlation between renal profiles and SFChT. A total of 56 patients were included in the study; 34 of them were branch RVO and 22 were central RVO patients. Multiple linear regression analysis revealed that SFChT was positively correlated with estimated glomerular filtration rate (eGFR) (P < 0.001). SFChT showed significant correlation with renal function indices. In addition, choroidal thickness may be considered as systemic biomarkers for renal function.

Ocular microcirculation changes, measured with laser speckle flowgraphy and optical coherence tomography angiography, in branch retinal vein occlusion with macular edema treated by ranibizumab

PURPOSE

This study searched for early predictive vascular biomarkers for visual outcomes in eyes with macular edema caused by branch retinal vein occlusion (BRVOME).

METHODS

Twenty-four eyes of 24 subjects with BRVOME were treated with the intravitreal injection of ranibizumab (IVR) for at least 6 months. We measured mean blur rate (MBR) in the optic nerve head (ONH) and vessel density (VD) in the macula with laser speckle flowgraphy and optical coherence tomography angiography, respectively.

RESULTS

Six-month post-IVR best-corrected visual acuity (BCVA) was correlated positively with age, pre-IVR BCVA, 1-month post-IVR BCVA, 3-month post-IVR BCVA and pre-IVR systolic blood pressure (P < 0.001, P < 0.001, P < 0.001, P < 0.001 and P = 0.02, respectively) and negatively with pre-IVR overall MBR, 1-month post-IVR overall MBR, 6-month post-IVR overall MBR, 3-month post-IVR deep retinal capillary plexus (DCP) VD and 6-month post-IVR DCP VD (P = 0.03, P = 0.03, P = 0.02, P = 0.01 and P = 0.005, respectively). Furthermore, a multiple regression analysis showed that pre-IVR overall MBR (β =  - 0.67, P = 0.009) was among independent prognostic factors predicting 6-month post-IVR BCVA. Six-month post-IVR DCP VD was also correlated with overall MBR at all time points.

CONCLUSION

ONH blood flow may be a pre-IVR biomarker of both visual outcomes and post-IVR deep macular microcirculation in eyes with BRVOME.

POSTERIOR FUNDUS HEMORRHAGES: Frequency and Associated Factors: The Beijing Eye Study

PURPOSE

To examine frequency and associations of retinal hemorrhages.

METHODS

The population-based Beijing Eye Study included 3,468 individuals. Monoscopic fundus photographs were examined for hemorrhages.

RESULTS

Retinal hemorrhages were detected in 515 eyes (429 individuals) (prevalence: 7.6%; 95% confidence interval [CI]: 7.0-8.0 per eye; 12.7%; 95% CI: 11.7-13.7 per person). Higher prevalence of retinal hemorrhages was correlated (multivariate analysis) with higher systolic blood pressure (P < 0.001; odds ratio: 1.02; 95% CI: 1.01-1.03), higher prevalence of diabetic retinopathy (P < 0.001; odds ratio: 121; 95% CI: 61-240), and higher prevalence of retinal vein occlusions (P < 0.001; odds ratio: 27; 95% CI: 17-42). Retinal hemorrhages were due to diabetic retinopathy (189 [36.7%] eyes), retinal vein occlusions (n = 65 [12.6%]), posterior vitreous detachment (n = 23 [4.5%]), glaucoma (n = 14 [2.7%]), exudative age-related macular degeneration (n = 8 [1.6%]), hypertensive retinopathy (n = 10 [1.9%]), and exudative myopic maculopathy (n = 1 [0.2%]). Retinal hemorrhages without evident ocular cause ("NOH") were detected in 204 (3.0%) eyes (or 39.6% of all retinal hemorrhages). Higher prevalence of NOHs was correlated with higher systolic blood pressure (P < 0.001; odds ratio: 1.02; 95% CI: 1.01-1.03) after adjusting for blood glucose concentration and prevalence of cortical cataract.

CONCLUSION

In a population-based recruited cohort of individuals aged 50+ years, prevalence of any fundus hemorrhage was about 8% per eye and 13% per individual. Approximately 60% of the hemorrhages were due to ocular reasons, mainly diabetic retinopathy, retinal vein occlusions, and posterior vitreous detachment, whereas 40% of the bleedings were not evidently associated with ophthalmologic causes but strongly with elevated systolic blood pressure.

Differential effect of obesity on the incidence of retinal vein occlusion with and without diabetes: a Korean nationwide cohort study

We aimed to evaluate the association between obesity and the incidence of retinal vein occlusion (RVO) with and without diabetes mellitus (DM).This is a retrospective cohort study using Korean National Health Insurance System data. The participants were 23,061,531 adults older than 20 years who received a health examination at least once between 2009 and 2012, and all patients were observed for RVO development until 2015. We used a multivariate adjusted Cox regression analysis to evaluate the association between RVO and body mass index (BMI) with and without DM. The analysis were evaluated via a hazard ratio (HR) and 95% confidence interval (CI). The age-, sex-, and multivariable-adjusted HRs for RVO were stratified by BMI. This population-based study revealed evidence that obesity has a different effect on the incidence of RVO in the presence and absence of DM.In people with DM, a lower BMI was associated with an increased risk of RVO, and a higher BMI was associated with a lower risk for RVO. In people without DM, the correlation was reversed: a lower BMI was associated with a lower risk for RVO and vice versa.

Topical Triamcinolone Acetonide-Loaded Liposomes as Primary Therapy for Macular Edema Secondary to Branch Retinal Vein Occlusion: A Pilot Study

Purpose: To explore safety and therapeutic efficacy of a topical ophthalmic triamcinolone acetonide-loaded liposome formulation (TA-LF) as primary therapy in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods: Twelve eyes of 12 patients with ME secondary to BRVO were exposed to a topical instillation of 1 drop of TA-LF (TA 0.2%) 6 times a day for 12 weeks to evaluate safety and efficacy. Best corrected visual acuity (BCVA) intraocular pressure (IOP), slit lamp examination, and central foveal thickness (CFT) were analyzed at every visit. In addition, the morphology of TA-LF was analyzed using scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Results: Patients presented a significant improvement of BCVA and CFT without significant IOP modification (P = 0.94). Treated eyes showed BCVA improvement from 40 ± 12.05 to 64.83 ± 15.97 letters and CFT reduction from 682.91 ± 278.60 to 271.58 ± 57.66 μm after 12 weeks of TA-LF therapy (P < 0.001). No adverse events, including IOP rising, were registered. SEM analysis of liposomal formulations showed that liposome (LP) size depends on its concentration. As the concentration of TA increased, the average size of LPs and the number of larger particles increased as well. TEM study displayed that LP formulation efficiently solubilizes TA crystals in nanoparticles and encapsulates them. Conclusion: LPs can function as nanocarriers of TA and they could be used as topical ophthalmic primary therapy instead of intravitreal drugs in patients with ME secondary to BRVO.

Characteristics of Central Retinal Vein Occlusion in African Americans

Purpose:

This article studies whether the characteristics and clinical course of African American patients with central retinal vein occlusion (CRVO) differ from other racial groups.

Methods:

This retrospective cohort study included consecutive patients diagnosed with CRVO at Duke Eye Center, Durham, North Carolina. Presenting characteristics, examination findings, treatment course, and functional and structural outcomes were compared based on patient-reported race.

Results:

A total of 479 patients with CRVO were included (64.7% white, 22.2% African American, 1.7% mixed race, and 11.4% other races). African American patients were older (68.1 vs 64.3 years, P = .049), more likely to be hypertensive ( P = .001) and diabetic ( P = .000), and had higher rates of open-angle glaucoma ( P < .000). Presenting visual acuity (VA) was worse in African Americans (logarithm of the minimum angle of resolution 1.25 vs 0.96, P = .010). There were no significant differences in the proportion of patients requiring panretinal photocoagulation, intravitreal antivascular endothelial growth factor (anti-VEGF), or intravitreal corticosteroid; however, analysis of treatment-naive individuals showed a higher number of anti-VEGF injections in the first year in African Americans. Final VA was not significantly different between groups, but African Americans had higher rates of neovascular sequelae (25.0% vs 11.8%, P = .019; odds ratio, 2.295, P = .088).

Conclusions:

African Americans with CRVO presented with more severe visual impairment and more systemic and ocular risk factors for CRVO. Treatment-naive African Americans had a greater treatment burden during the first year of follow-up.

Longitudinal changes in the peripapillary retinal nerve fiber layer thickness in the fellow eyes of unilateral retinal vein occlusion

To analyze longitudinal changes in peripapillary retinal nerve fiber layer (pRNFL) thicknesses over time in the fellow eyes of patients with unilateral retinal vein occlusion (RVO). A total of 47 patients with unilateral RVO and 47 healthy controls were enrolled. The mean and sectoral pRNFL thicknesses were measured using spectral domain-optical coherence tomography at 1 year intervals, and followed for 3 years. Linear mixed models were performed to calculate and compare the reduction rates of pRNFL thicknesses over time. The mean pRNFL thickness decreased significantly during the 3-year follow-up, with a significant decrease over time in both groups. The reduction rate in mean pRNFL thicknesses was -0.41 μm/year in the control group and -0.68 μm/year in the fellow eyes of RVO group, and the decrease was significantly higher in the fellow eyes of RVO group than in the control group (p < 0.001). Using a multivariate linear mixed model, age (estimate: -0.41, p = 0.011) and hypertension (HTN) (estimate: -6.51, p = 0.014) were significantly associated with the reduction in mean pRNFL thicknesses in fellow eyes of RVO group. The fellow eyes of RVO patients showed a greater reduction in pRNFL thickness over time than normal controls. Age and HTN should be considered as factors to decrease the pRNFL thickness over time in fellow eyes of RVO group.

Endothelial dysfunction and impaired arterial wall properties in patients with retinal vein occlusion

Retinal vein occlusion (RVO) is a common retinal vascular lesion, and a leading cause of visual impairment. Patients with RVO have an increased risk for cardiovascular disease and share multiple common risk factors. In this study, we investigated the endothelial function and arterial stiffness of patients with RVO compared to healthy-control (CL) subjects. We enrolled 40 consecutive patients with RVO and 40 CL subjects. RVO was diagnosed by an ophthalmologist, endothelial function was evaluated by flow mediated dilation (FMD) in the brachial artery, and carotid-femoral pulse wave velocity (PWV) and augmentation index (AIx) of the radial artery were measured to evaluate arterial stiffness and reflected waves, respectively. No significant differences were detected between the studied groups in sex, age, presence of hypertension or dyslipidemia, body mass index, systolic and diastolic blood pressure levels, total cholesterol levels, and smoking habits (p > 0.05 for all). However, patients with RVO had impaired FMD (p = 0.002) and increased PWV (p = 0.004), even after adjustment for several confounders. Both FMD and PWV were also significantly and independently associated with the development of RVO. Furthermore, a significant and positive correlation between PWV and systolic blood pressure existed only in the CL group. Therefore, we have shown that RVO is associated with significant endothelial dysfunction and increased arterial stiffness. Our results strengthen the vascular theory, according to which, systemic endothelial dysfunction and arteriosclerosis play a significant role in the pathogenesis of RVO.

One-year efficacy of intravitreal conbercept injection for macular oedema secondary to central retinal vein occlusion in Chinese patients

PURPOSE

To evaluate intravitreal conbercept injection for treatment of macular oedema secondary to central retinal vein occlusion (CRVO) in Chinese patients during 1-year follow-up in the real-world setting.

METHODS

Twenty-seven eyes of 27 patients with macular oedema associated with CRVO were retrospectively reviewed. The eyes received monthly intravitreal conbercept injection (0.5 mg in 50 µl) for 3 months. From then on, the patients were followed up every month and received injection pro re nata (PRN) up to 12 months. The primary outcome measurements included changes of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline to month 3 and month 12. Other outcome measurements included proportion of patients gaining ≥15 letters in BCVA at month 3 and 12, the mean number of injections and safety concerns.

RESULTS

The mean BCVA gain from baseline was 12.7 ± 7.6 letters at month 3 and 14.8 ± 9.6 letters at month 12. The mean CRT reduction from baseline was 374.5 ± 280.7 μm at month 3 and 428.2 ± 241.3 μm at month 12. The proportion of patients who gained ≥15 letters in BCVA was 45.1% at month 3 and 52.9% at month 12. The mean number of injections was 7.6 ± 1.5. No severe local and systemic complications occurred following injection.

CONCLUSIONS

Intravitreal conbercept injection by three monthly loading doses followed by PRN treatment regimen was safe and efficacious for patients with macular oedema secondary to CRVO through 1-year follow-up.

Ranibizumab and aflibercept intravitreal injection for treatment naïve and refractory macular oedema in branch retinal vein occlusion

BACKGROUND

Branch retinal vein occlusion complicated by macular oedema is a common disease treated with intravitreal injection of anti-vascular endothelial growth factor. Controversy exists surrounding anti-vascular endothelial growth factor selection for both treatment naïve and refractory cases.

METHODS

A retrospective electronic medical record review at a single UK centre generated a cohort of 259 treatment naïve eyes from 258 patients receiving ranibizumab, aflibercept or a combination (n = 83, 97 and 79, respectively) from 2013 to 2018 with ⩾6 months follow-up. Number of intravitreal injections, visual acuity and macular oedema presence were noted at 3, 6, 12, 24, 36 and 48 months. A subgroup analysis examined refractory cases switched from ranibizumab to aflibercept (n = 77) or maintained on ranibizumab (n = 35).

RESULTS

Eyes receiving ranibizumab or aflibercept had equivocal vision gain at 1 year, 8.0 (95% CI 5.0-11.0) and 9.6 (7.2-12.1) Early Treatment of Diabetic Retinopathy Study letters, respectively. About 35.6% had no macular oedema at 12 months with ranibizumab compared with 50.0% with aflibercept (p = 0.07) following 5.1 (4.7-5.6) and 6.0 (5.6-6.4) intravitreal injections, respectively. Visual prognosis declined significantly as treatment delay extended (p = 0.003) which was only apparent with ⩾3 months delay. Eyes with refractory macular oedema also had equivocal functional and anatomical outcomes whether they were maintained on ranibizumab or switched to aflibercept.

CONCLUSION

These real world data demonstrate more modest clinical improvements from anti-vascular endothelial growth factor treatment than reported in clinical trials. The functional outcomes of ranibizumab and aflibercept in both treatment naïve and refractory cases were equivocal while the anatomical outcomes of aflibercept may be superior.

Diabetes mellitus as a risk factor for retinal vein occlusion: A meta-analysis

Retinal vein occlusion (RVO) is the second most common etiology for vision loss. There is contrasting evidence on the association between diabetes mellitus (DM) and the risk of RVO. We performed a meta-analysis of published articles before October 31, 2019, to estimate a pooled odds ratio for the association between DM and RVO, including central and branch RVO by a fixed or random effects model. We identified 37 publications from 38 studies (1 publication was from 2 studies), published between 1985 and 2019. In total, 148,654 cases and 23,768,820 controls were included in this meta-analysis. The results of pooled analysis for all 37 publications (or 38 studies) showed a significant association between DM and the risk of RVO (OR = 1.68, 95% CI: 1.43-1.99). Subgroup analysis indicated that DM was significantly associated with CRVO (OR = 1.98, 95% CI: 1.29-3.03, I = 67.9%), but not significantly associated with BRVO (OR = 1.22, 95% CI: 0.95-1.56, I = 64.1%). In conclusion, the result of present meta-analysis suggested that DM is a risk factor for RVO. More well-designed studies on the relationship between RVO and DM should be undertaken in the future.

Spectrum of Eye Disease in Diabetes (SPEED) in India: A prospective facility-based study. Report # 3. Retinal vascular occlusion in patients with type 2 diabetes mellitus

Purpose

To determine the proportion of people with type 2 diabetes mellitus (T2DM) attending large eye care facilities across India who have retinal vascular occlusion (RVO).

Methods

A 6-month descriptive, multicenter, observational hospital-based study of people was being presented to the 14 eye care facilities in India. The retina-specific component of comprehensive eye examination included stereoscopic biomicroscopy, binocular indirect ophthalmoscopy, and fundus fluorescein angiography, and optical coherence tomography was also available when needed. Data recording of the duration of diabetes, hypertension (HTN), stroke, and other variables was obtained from the medical history. The statistical analysis included frequencies, mean, and standard deviations for continuous variables. Odds ratio (OR) and multivariate analysis were undertaken to assess the associations between risk factors and RVO.

Results

The study recruited 11,182 consecutive patients (22,364 eyes) with T2DM. About 59.0% (n = 6697) were male. The mean age was 58.2 ± 10.6 years. In this cohort, RVO was detected in 3.4% (n = 380) of patients; 67.6% (n = 257) of them had branch retinal vein occlusion (BRVO) and the remaining 32.4% (n = 123) had central retinal vein occlusion (CRVO). The frequency of unilateral BRVO (n = 220, 85.6%) and unilateral CRVO (n = 106, 86.18%) was much common. Unilateral RVO was more frequent (n = 326, 85.8%) than bilateral diseases (n = 54, 14.2%) (χ2 = 126.95, P < 0.001). Ischemic CRVO was more common (n = 103, 73.6%) than nonischemic CRVO (n = 37, 26.4%). Macula-involving BRVO was found in 58.5% (n = 172) of cases, suggesting more than 50% of cases in RVO carries a risk of severe vision loss. The duration of diabetes apparently had no influence on the occurrence of RVO. On the multivariate analysis, a history of HTN [OR: 1.7; 95% confidence interval (CI): 1.3-2.1; P = 0.001) and stroke (OR: 5.1; 95% CI: 2.1-12.4; P < 0.001) was associated with RVO.

Conclusion

RVO is a frequent finding in people with T2DM. History of stroke carries the highest risk followed by HTN. The management of people with T2DM and RVO must also include comanagement of all associated systemic conditions.

Investigation of clinical profile of Behçet's syndrome-related versus idiopathic branch retinal vein occlusion

Purpose:

To compare the long-term results of the patients with branch retinal vein occlusion (BRVO) secondary to Behçet's syndrome (BS) with the patients with unknown etiology.

Methods:

Medical records and optical coherence tomography (OCT) imaging results of the patients with BRVO secondary to BS and with unknown etiology were reviewed retrospectively between 2016 and 2018 at a single center. The anatomical location of the BRVO, involvement of the macula, application of laser photocoagulation, and intravitreal injection were evaluated.

Results:

Twenty-eight eyes of 23 patients with BRVO secondary to BS as the study group and 22 eyes of 19 idiopathic BRVO patients as the control group were included in the study. The mean duration of follow-up after the development of BRVO was 74.6 ± 57.4 months in the study group and 63.6 ± 59 months in the control group. The rate of bilaterality, macular involvement, and application of laser photocoagulation was not statistically significantly different between the groups. However, the frequency of injection requirement was significantly lower in the patients with BRVO secondary to BS in comparison to the control group (P = 0.009).

Conclusion:

Although the treatment of BRVO is laser photocoagulation and intravitreal injection of anti-VEGF agents or dexamethasone implant, the patients with BS might respond very well to systemic immunomodulatory agents in case of BRVO. Thus, rearrangement of the immunomodulatory treatment before starting intravitreal injections should be considered in the patients with BRVO secondary to BS.

Thrombophilic risk factors for retinal vein occlusion

The aim is to study risk factors for retinal vein occlusion (RVO), such as thrombophilic and cardiovascular risk factors (CRF). A retrospective consecutive case series of 60 patients with RVO was made, tested for CRF, hyperhomocysteinemia, lupic anticoagulant, antiphospholipid antibody and 5 gene variants: factor V (FV) Leiden (G1691A), factor II (PT G20210A), 5,1-methylenetetra-hydrofolate reductase (MTHFR; 677 C > T and 1298 A > C), plasminogen activator inhibitor 1 (PAI-1; 4 G/5 G). More than 1 CRF were present in 36 patients (60%), which had a significantly higher mean age at diagnosis (66.7 ± 12.9 versus 59.5 ± 13.7 with ≤1 CRF, [t(57) = −2.05, p = 0.045, d = 0.54). Patients with thermolabile MTHFR forms with decreased enzyme activity (T677T or C677T/A1298C) had a significant lower mean age [57.6 ± 15.1; t (58) = 3.32; p = 0.002; d = 0.846] than patients with normal MTHFR enzyme activity (68.5 ± 10.2). Regarding CRF and thermolabile forms of MTHFR, the mean age at diagnosis could be significantly predicted [F(2,56) = 7.18; p = 0.002] by the equation: 64.8 − 10.3 × (thermolabile MTHFR) − 5.31 × ( ≤ 1CRF). Screening of MTHFR polymorphisms may be useful in younger RVO patients, particularly when multiple CRF are absent.

Association of glaucoma with risk of retinal vein occlusion: A meta-analysis

To summarize epidemiological evidences on the association between glaucoma and the risk of retinal vein occlusion (RVO). Relevant studies were identified by searching in PubMed, EMBASE and Cochrane until February 2018. Fifteen eligible observational studies were aggregated in this analysis. All results were analysed and pooled using random effects models with 95% confidence intervals (CI). In all studies, the odds ratio (OR) of glaucoma as a risk factor for RVO was 4.01 (95% CI: 3.28-4.91). In RVO subtype-differentiated subgroup analyses (six studies), the pooled OR showed that glaucoma was associated with central retinal vein occlusion (CRVO) (OR: 6.21; 95% CI: 4.64-8.31), branch retinal vein occlusion (BRVO) (OR: 2.38; 95% CI: 1.77-3.19) and hemiretinal vein occlusion (HRVO) (OR: 4.60; 95% CI: 2.26-9.35). In glaucoma-classified subgroup analyses (five studies), primary open-angle glaucoma (POAG) (OR: 5.03; 95% CI: 3.97-6.37) and chronic open-angle glaucoma (COAG) (OR: 2.36; 95% CI: 1.39-4.02) were significant risk factors for RVO development. There was a plausible relationship between primary angle closure glaucoma (PACG) and RVO risk (OR: 1.85; 95% CI: 0.41-8.35); to be precise, the OR was 5.3 in PACG and CRVO risk (95% CI: 1.04-26.95; p = 0.045), while the OR was 0.65 in PACG and BRVO risk (95% CI: 0.07-6.27; p = 0.707). To sum up, this meta-analysis shows that glaucoma is associated with the risk of RVO. Glaucoma should be kept in mind when investigating patients with RVO in the clinic.

Efficacy and Safety of Ranibizumab in Asian Patients with Branch Retinal Vein Occlusion: Results from the Randomized BLOSSOM Study

PURPOSE

To assess the efficacy and safety profile of intravitreal ranibizumab 0.5 mg in Asian patients with visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO).

DESIGN

A 12-month, phase III, double-masked study.

PARTICIPANTS

A total of 283 patients with BRVO.

METHODS

Patients aged ≥18 years were randomized (2:1) to receive ranibizumab 0.5 mg or sham. The ranibizumab group received a minimum of 3 monthly intravitreal injections until stable maximal visual acuity (VA) was achieved followed by an individualized VA stabilization criteria-driven pro re nata (PRN) regimen. Patients in the sham group received sham injections up to month 5 and could receive ranibizumab 0.5 mg PRN from month 6.

MAIN OUTCOME MEASURES

Mean average change in best-corrected VA (BCVA) from baseline to month 1 through month 6 and safety up to month 12.

RESULTS

At baseline, patients' mean (standard deviation [SD]) BCVA and central subfield thickness (CSFT) were 57.4 (11.7) letters and 525 (193.4) μm, respectively. Compared with sham, ranibizumab treatment resulted in superior VA gains. The least squares (LS) mean average change in BCVA from baseline to month 1 to month 6 in ranibizumab and sham groups was +12.5 and +5.0 letters, respectively (LS mean difference between ranibizumab vs. sham: +7.5 letters [95% confidence interval, 5.5-9.5], 1-sided P < 0.001). The LS mean change from baseline at month 12 in the ranibizumab versus sham groups in BCVA was +16.4 (14.9-17.8) versus +11.4 (9.3-13.5) letters and in CSFT was -280.0 (-291.6 to -268.4) versus -269.7 (-286.2 to -253.1) μm. The mean (SD) number of injections over 12 months was 7.0 (2.55) in the ranibizumab group and 3.6 (1.60) in the sham with ranibizumab group. No new safety findings were reported.

CONCLUSIONS

In Asian patients with BRVO, individualized PRN ranibizumab treatment was statistically superior to sham at month 6 and led to early visual gains that were maintained up to 12 months. Results from the sham group indicate the importance of early treatment in achieving optimal visual outcomes in BRVO. The safety of ranibizumab in this study was consistent with the well-established safety profile of ranibizumab.

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.

RETINAL MICROVASCULATURE AND VISUAL ACUITY AFTER INTRAVITREAL AFLIBERCEPT IN EYES WITH CENTRAL RETINAL VEIN OCCLUSION: An Optical Coherence Tomography Angiography Study

PURPOSE

To investigate vascular perfusion and foveal avascular zone area in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) after intravitreal aflibercept therapy in central retinal vein occlusion eyes and their association with best-corrected visual acuity.

METHODS

Thirty-five subjects with central retinal vein occlusion and macular edema were evaluated. After macular edema resolution following intravitreal aflibercept, subjects underwent optical coherence tomography angiography to measure SCP and DCP perfusion and the foveal avascular zone within a 3 × 3-mm area. Correlations between best-corrected visual acuity and optical coherence tomography angiography measurements were examined.

RESULTS

After intravitreal aflibercept therapy, mean retinal vascular area was 3.41 ± 0.74 mm in the SCP and 3.25 ± 0.91 mm in the DCP. Foveal avascular zone area was 1.03 ± 1.04 mm in the SCP and 1.78 ± 1.73 mm in the DCP. Improved best-corrected visual acuity was significantly associated with better SCP and DCP perfusion (both P < 0.001) and with smaller SCP and DCP foveal avascular zone areas (both P < 0.001). Additionally, SCP and DCP perfusion were negatively correlated with macular edema before treatment (P < 0.05) and ischemia (determined via pretreatment fluorescein angiography, P < 0.05), and positively correlated with photoreceptor integrity (P < 0.001).

CONCLUSION

Patients with better retinal perfusion and less retinal ischemia are associated with better visual outcomes after aflibercept in eyes with central retinal vein occlusion.

Management of the open angle glaucoma in patients with central/hemicentral retinal vein occlusions

AIM

To prospectively assess the cumulative prevalence and management of open angle glaucoma (OAG), including primary open angle glaucoma (POAG) with high and normal-pressure, as well as pseudoexfoliative glaucoma (PEXG), in patients with central/hemicentral retinal vein occlusions (RVOs) over a 3-year follow-up period.

METHODS

The study encompassed 57 patients with unilateral acute central/hemicentral RVOs. A complete ophthalmic examination of both eyes was undertaken for all patients. Patients with OAGs associated with central/hemicentral RVOs were treated with the current ocular hypotensive medications used worldwide and/or surgery and aimed to reduce the intraocular pressure (IOP) by 30% from baseline values for the 3 OAG forms existing in our series. The cumulative prevalence of OAG and the efficacy of treatment were evaluated.

RESULTS

OAG was observed in 3 clinical forms, namely, POAG with increased IOP in 4 patients, POAG with normal IOP in 3 patients, and PEXG in 3 patients. The cumulative prevalence of OAG was 19.6% (95%CI: 8.7-30.5). Using available ocular hypotensive medications (8 patients) and trabeculectomy (2 patients), the IOP decreased significantly from 24.3±4.36 mm Hg to 16.55±2.85 mm Hg, a reduction of 31.89% compared with baseline values. Glaucoma progression was not detected in any of the cases.

CONCLUSION

The high value of the cumulative prevalence of OAG is a risk factor for the development of venous occlusion. The treatment of glaucoma prevented its progression over a follow-up period of 3y.

Changes in Retinal Microvasculature and Visual Acuity After Antivascular Endothelial Growth Factor Therapy in Retinal Vein Occlusion

Purpose

To investigate the changes in the retinal microvasculature during the course of anti-VEGF therapy in eyes with macular edema due to retinal vein occlusion (RVO) and their association with visual outcomes.

Methods

The vessel density (VD) and foveal avascular zone (FAZ) area in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were quantitatively measured by optical coherence tomography angiography (OCTA) in 48 consecutive eyes with RVO before and 1, 3, 6, 9, and 12 months after anti-VEGF therapy. Anti-VEGF therapy was performed either with ranibizumab or aflibercept following a pro re nata (PRN) regimen. The correlation between post-treatment best-corrected visual acuity (BCVA) and changes in the retinal microvasculature evaluated by OCTA were assessed.

Results

The BCVA improved significantly at 12 months (P < 0.001). Better BCVA at 12 months was significantly associated with a better VD in the SCP and DCP both at baseline (R2 = 0.524, P < 0.001 and R2 = 0.457, P < 0.001, respectively) and at 12 months (R2 = 0.521, P < 0.001 and R2 = 0.662, P < 0.001, respectively). Overall, both VD and FAZ did not change significantly during the 12 months. However, the progression of nonperfusion was observed in the SCP in 6 (13%) eyes and in the DCP in 10 (21%) eyes. The number of macular edema recurrence was significantly associated with a decrease in the VD (P = 0.006 [SCP] and P < 0.001 [DCP]) and less visual gain (P = 0.02) after treatment.

Conclusions

Anti-VEGF therapy maintains retinal perfusion in most patients with RVO. Preserving retinal perfusion is crucial for better visual outcomes.

Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT

Non-graft-versus-host disease (non-GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT), but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We have summarized incidence, risk factors, screening, prevention and treatment of individual complications and generated evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical symptoms, signs and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplant physicians and ophthalmologists should be knowledgeable of non-GVHD ocular complications and provide comprehensive collaborative team care.

Histopathological Changes of the Retina After Nd: YAG Laser Thrombolysis in Branch Retinal Vein Occlusion: An Experimental Study

Introduction: The efficacy of many therapeutics techniques for treatment of branch retinal vein occlusion (BRVO) has been the subject of many investigations. The aim of the present work is to evaluate the transluminal Nd: YAG laser thrombolysis as a new therapeutic approach used for treatment of BRVO in rabbits as an experimental model. Methods: Four rabbits were considered as a control (n=8 eyes); occlusion of the branch retinal veins was performed by using a dye enhancing thrombus formation in right eyes of 10 rabbits (n=10 eyes). Thrombi in the retinal veins were induced by intravenous injection of rose bengal solution as a photosensitizer immediately before the argon laser application with a power of 1200 mW, a spot size of 100 µm, and a duration of 20 ms. One week later, transluminal Nd: YAG laser thrombolysis (30 mJ, 3 pulses/4 ns) was employed to the site of occluded veins, until the thrombi were partially or completely shattered. The rabbits were followed up after 4 days, 1 week and 2 weeks for slit lamp fundus examination and the treated retinas were isolated for histopathological examination. Results: Argon laser photothrombosis induced complete BRVO with some vitreous hemorrhage, destruction, and necrosis in the surrounding retinal layers. Moreover, one week later, Nd: YAG laser thrombolysis showed complete venous flow, minimal vitreous hemorrhage, reperfused retina, complete veins improvement. Follow up after 2 weeks revealed more improvement of all retinal layers. Conclusion: Treatment with transluminal Nd: YAG laser thrombolysis represented a novel therapeutic modality in BRVO.