Medical and surgical management of central retinal vein occlusion

Investigation of choroidal structure changes after intravitreal anti-VEGF therapy for retinal vein occlusion

BACKGROUND

We aimed to investigate the effect of retinal vein occlusion (RVO) on the posterior segment structures of the eye and its changes with intravitreal anti-Vascular Endothelial Growth Factor (VEGF) treatment.

METHODS

This prospective longitudinal study included 29 eyes of 29 patients with RVO (17 males and 12 females) followed for 6 months. The best corrected visual acuity (BCVA), macula, choroid ticknesses and choroidal vascularity index (CVI) obtained by spectral-domain optical coherence tomography were recorded at baseline and the first, third, and sixth months after the first injection. Results were compared with fellow eyes (non-affected eyes) and age- and sex-matched controls.

RESULTS

BCVA increased significantly in the 6th month, more in the first month of injection (p < 0.05 for each). Central macular tickness, subfoveal choroid tickness, stromal and total area of choroid decreased significantly after injection (p < 0.05 for each). CVI values increased significantly, especially in the 1st month after injection (p < 0.05 for each). In eyes with Branch RVO, there was a significant decrease in the macular thickness of the occlusive areas with treatment, while there was no statistically significant change in the non-occlusive macular thickness.

CONCLUSION

Observation of changes in choroidal structure may be useful to assess the activity of RVO and predict the efficacy of anti-VEGF therapy.

Pathogenesis, prevention, diagnosis and management of retinal vein occlusion

Retinal vein occlusion (RVO) is the second vascular retinal cause of visual loss and defined by the occlusion of a retinal vein. It is divided into branch retinal vein occlusion or central retinal vein occlusion, depending on the location of occlusion. RVO has severe medical, financial and social implications on the patients. The diagnosis of the disease is easier nowadays with the use of spectral domain optical coherence tomography and fluorescein angiography. The treatment options for RVO have changed dramatically over the past few years with the introduction of the intravitreal injections of dexamethasone (Ozurdex), bevacizumab (Avastin), ranibizumab (Lucentis) and aflibercept (EYLEA), along with the panretinal laser photocoagulation, abandoning former treatment modalities and surgical solution. This manuscript is a review of current literature about RVO with emphasize on the pathophysiology, risk factors and prevention, diagnosis and sub-group categorization and treatments including medical and surgical. Since no official guidelines are available for the treatment of RVO patients, and considering the latest developments in the treatment options, and the variety of follow-up and treatment modalities, this manuscript aims to provide tools and knowledge to guide the physician in treating RVO patients, based on the latest publications from the literature and on several of the patients characteristics.

Practical management of retinal vein occlusions

Retinal vein occlusion (RVO) is the second most common cause of visual impairment due to retinal disease after diabetic retinopathy. Nowadays, the introduction of new, powerful diagnostic tools, such as spectral domain optical coherence tomography, and the widespread diffusion of intravitreal drugs, such as vascular endothelial grow factor inhibitors or implantable steroids, have dramatically changed the management and prognosis of RVO. The authors aim to summarize and review the main clinical, diagnostic, and therapeutic aspects of this condition. The authors conducted a review of the most relevant clinical trials and observational studies published within the last 30 years using a keyword search of MEDLINE, EMBASE, Current Contents, and Cochrane Library. Furthermore, for all treatments discussed, the level of evidence supporting its use, as per the US Preventive Task Force Ranking System, is provided.

Evaluation of ultrasound-assisted thrombolysis using custom liposomes in a model of retinal vein occlusion

PURPOSE

To study the potential efficacy of ultrasound (US) assisted by custom liposome (CLP) destruction as an innovative thrombolytic tool for the treatment of retinal vein occlusion (RVO).

METHODS

Experimental RVO was induced in the right eyes of 40 rabbits using laser photothrombosis; the US experiment took place 48 hours later. Rabbits were randomly divided into four equal groups: US+CLP group, US+saline group, CLP+sham US group, and no treatment group. The latter three groups acted as controls. Fundus fluorescein angiography and Doppler US were used to evaluate retinal blood flow.

RESULTS

CLP-assisted US thrombolysis resulted in restoration of flow in seven rabbits (70%). None of the control groups showed significant restoration of retinal venous blood flow.

CONCLUSIONS

US-assisted thrombolysis using liposomes resulted in a statistically significant reperfusion of retinal vessels in the rabbit experimental model of RVO. This approach might be promising in the treatment of RVO in humans. Further studies are needed to evaluate this approach in patients with RVO. Ultrasound assisted thrombolysis can be an innovative tool in management of retinal vein occlusion.

Retinal vein occlusion: beyond the acute event

Retinal vein occlusion is a major cause of vision loss. We provide an overview of the clinical features, pathogenesis, natural history, and management of both branch retinal vein occlusion and central retinal vein occlusion. Several recent multicenter randomized clinical trials have been completed which have changed the approach to this disorder. Management of retinal vein occlusions can be directed at the underlying etiology or the resulting sequelae. Options include surgical intervention, laser photocoagulation, intravitreal pharmacotherapy, and sustained drug delivery devices.

Management of retinal vein occlusion--consensus document

Retinal vein occlusion (RVO) can have severe consequences for the people affected by the disease, including visual loss with costly social repercussions. Currently, there is no European consensus with regard to the management of RVO. Following a careful review of the medical literature as well as the data from several clinical trials, a collaborative group of retina specialists put forth practical recommendations based on the best available scientific evidence for the clinical approach to RVO. Taking into consideration the recent advances in diagnostic tools and management options, the present document aims to provide the European ophthalmologists with guidelines for clinical practice to the benefit of their patients.

Intravitreal injection of bevacizumab alone or with triamcinolone acetonide for treatment of macular edema caused by central retinal vein occlusion

AIM

To compare the efficacy and safety of intravitreal bevacizumab alone versus bevacizumab combined with triamcinolone acetonide in eyes with macular edema caused by central retinal vein occlusion (CRVO) in Chinese patients.

METHODS

Seventy-five eyes of 75 patients were enrolled in this prospective, randomized, consecutive study. Thirty-six patients in group 1 were treated with an intravitreal injection of bevacizumab (1.25mg/0.05mL), and 39 patients in group 2 were treated with intravitreal bevacizumab (1.25mg/0.05mL) combined with triamcinolone acetonide (2mg/0.05mL). The main outcomes of the mean best corrected visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP) were measured.

RESULTS

In group 1, the mean BCVA improved from 37.78±6.14 (baseline) to 48.06±3.86, 46.48±4.77 and 44.18±5.78 at four, six and twelve weeks post-injection, respectively (P<0.01, P=0.03, P=0.04). In group 2, the mean BCVA improved from 35.92±6.20 (baseline) to 50.69±4.22, 48.76±5.59 and 45.70±6.56 at the same time points (P<0.01 each). However, there was no significant differences in the mean BCVA (F=0.043, P=0.836) and CRT (F=0.374, P=0.544) between these two groups. During the follow-up, five patients in group 1 and six patients in group 2 with high IOP were controlled with anti-glaucoma drugs.

CONCLUSION

Intravitreal injection of bevacizumab alone or combined with triamcinolone acetonide has a short beneficial effect in Chinese patients with macular edema caused by CRVO, but there is no significant difference between the two groups.

Visual outcomes in five different approaches for treatment of central retinal vein occlusion

BACKGROUND AND OBJECTIVE

Four treatment methods for central retinal vein occlusion were compared with its natural course.

PATIENTS AND METHODS

In this partially prospective, comparative, interventional case series on 63 eyes with central retinal vein occlusion, five approaches were compared: intravitreal triamcinolone injection; radial optic neurotomy; combined radial optic neurotomy and intraocular triamcinolone injection; combined internal limiting membrane peeling, radial optic neurotomy, and intraocular triamcinolone; and observation.

RESULTS

Final visual acuity in the intravitreal triamcinolone group was better compared with the observation (P = .025), radial optic neurotomy (P = .037), combined radial optic neurotomy/intraocular triamcinolone injection (P = .401), and combined internal limiting membrane peeling, radial optic neurotomy, and intraocular triamcinolone injection (P = .023) groups. However, after adjustment for baseline visual acuity, the only treatment method with significant visual acuity improvement in relation to the observation group was the combined radial optic neurotomy/intraocular triamcinolone injection (P = .025, .023, and .054 at 1, 3, and 6 months, respectively).

CONCLUSION

Among the five different approaches analyzed in this study, combined radial optic neurotomy and intraocular triamcinolone injection may provide a better visual outcome in the management of central retinal vein occlusion.

Surgical treatment of central retinal vein occlusion

The treatment of central retinal vein occlusion (CRVO) is still a subject of debate. Medical therapy efforts, as well as retinal laser photocoagulation, have mostly dealt with management of the sequelae of CRVO, and have shown limited success in improving visual acuity. The unsatisfactory results of such therapeutic efforts led to the development of new treatment strategies focused on the surgical treatment of the occluded retinal vein. The purpose of this review is to summarize the outcomes of commonly reported surgical treatment strategies and to review different opinions on the various surgical approaches to the treatment of CRVO.