The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch retinal vein occlusion

Improving blood flow in occluded veins to reduce anti-vascular endothelial growth factor injections for branch retinal vein occlusion

Purpose

To assess the relationship between improving blood flow via arteriovenous (AV) sheathotomy without vitrectomy and the total number of anti-vascular endothelial growth factor injections (VEGF) required to treat branch retinal vein occlusion (BRVO).

Methods

In this prospective, clinical case series, 16 eyes of 16 patients at the Toho University Sakura Medical Center with best-corrected visual acuity (BCVA) of 20/40 or worse due to macular edema associated with BRVO were analyzed for 12 months. AV sheathotomy was performed without vitrectomy for all cases. On the second day after surgery, anti-VEGF was injected into the operated eye. During the 12-month follow-up after surgery, pro re nata injections were administered when changes in foveal exudation and BCVA were evident. The blood flow of the occluded vein was assessed before and after AV sheathotomy during the operation using laser speckle flowgraphy. The total number of anti-VEGF injections, central retinal thickness (CRT), and BCVA 12 months after surgery were examined.

Results

The changes in CRT and BCVA from baseline to month 12 were statistically significant (P < 0.01). No additional anti-VEGF injections were required for nine of 16 eyes (56.3%) during the 12 months. The total number of anti-VEGF injections for 12 months correlated with the change rate of blood flow in an occluded vein before and after AV sheathotomy (r = -2.816, P = 0.022).

Conclusions and Importance

Improved blood flow in occluded vein may reduce the need for anti-VEGF injections in BRVO.

Vitrectomy for macular edema due to retinal vein occlusion

Purpose: To determine the long-term outcomes of vitrectomy for the macular edema associated with a retinal vein occlusion (RVO).

Methods: This was a retrospective, consecutive, interventional case series. The intraoperative procedures included internal limiting membrane peeling, arteriovenous sheathotomy, radial optic neurotomy, and intravitreal triamcinolone acetonide injection at the end of the surgery. The main outcome was the best-corrected visual acuity (BCVA).

Results: Eight hundred and fifty-four eyes of 854 patients were studied. The eyes consisted of 602 with branch RVO (BRVO), 74 with hemi-central RVO (hemi-CRVO), 87 with nonischemic central retinal vein occlusion (CRVO), and 91 with ischemic CRVO. The mean follow-up period was 68.6 months with a range of 12 to 262 months. The mean BCVA was significantly improved at the final visit (P<0.0001 to 0.0016). The final BCVA improved in 74.4% of the BRVO eyes, in 58.1% of the hemi-CRVO eyes, in 57.4% of the nonischemic CRVO eyes, and in 51.6% of the ischemic CRVO eyes. Multiple regression analysis showed there was no significant relationship between the intraoperative combined procedures and the final BCVA.

Conclusions: The results indicate that the type of RVO is significantly associated with the final BCVA, and vitrectomy is a treatment option to improve and maintain BCVA for a long term.

[Management of macular edema secondary to retinal vein occlusion]

BACKGROUND

In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO.

METHODS

A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article.

RESULTS

The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters.

DISCUSSION

Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

Long-term outcome after vitrectomy for macular edema with retinal vein occlusion dividing into the occlusion site

Purpose. To investigate the efficacy of treatment for macular edema secondary to retinal vein occlusion (RVO) with vitrectomy. Methods. This retrospective study identified patients with macular edema associated with RVO between January 2004 and April 2006. Inclusion criteria were eyes with (1) preoperative visual acuity (VA) of 20/40 or worse, (2) a central foveal thickness (CFT) greater than 250 μm, and (3) vitrectomy with internal limiting membrane and intravitreal triamcinolone acetonide. Each patient had their RVO classified as a major or macular BRVO or hemispheric RVO (HSRVO). Results. Forty-six eyes with major BRVO, 18 eyes with macular BRVO, and 17 eyes with HSRVO were investigated. VA was significantly improved at 24 months after surgery for each group (P < 0.05). Vision in the macular BRVO group 24 months after surgery was significantly better than that in other groups (P < 0.05). For each group, a concomitant reduction of CFT was noted at every time point when compared to preoperative values (P < 0.001). Conclusions. In macular BRVO, the postoperative vision 24 months after surgery was significantly better than the other groups. These findings suggest that additional and earlier treatments might be more important for patients with major BRVO and HSRVO than for those with macular BRVO.

Matched control study of visual outcomes after arteriovenous sheathotomy for branch retinal vein occlusion

Background

The purpose of this study was to evaluate visual outcomes of arteriovenous sheathotomy for macular edema due to branch retinal vein occlusion (BRVO).

Methods

The medical records of 45 eyes from 45 patients who had undergone vitrectomy surgery with arteriovenous sheathotomy for BRVO were studied. Forty-five eyes of 45 patients with a BRVO but without intervention were studied as the control group. The best-corrected visual acuity and central macular thickness were compared between the two groups at baseline and at 1, 3, 6, and 12 months postoperatively.

Results

Improvement of best-corrected visual acuity was 0.42 logarithm of the minimum angle of resolution (logMAR) units in the sheathotomy group and 0.22 logMAR units in the control group (P=0.007). The mean postoperative central macular thickness was significantly thinner in the sheathotomy group at 1 month (P=0.01), but not at 3, 6, and 12 months (P=0.75, P=0.81, and P=0.46, respectively). Improvement of best-corrected visual acuity at 12 months was significantly correlated with baseline best-corrected visual acuity, age, duration of symptoms, and sheathotomy (P<0.05).

Conclusion

Arteriovenous sheathotomy for BRVO improves best-corrected visual acuity significantly more than the natural course of the BRVO disease process.

Branch retinal vein occlusion: treatment modalities: an update of the literature

BACKGROUND

Retinal vein occlusion is the second most common retinal vascular disorder after diabetic retinopathy and is considered to be an important cause of visual loss. In this review, our purpose is to update the literature about the treatment alternatives for branch retinal vein occlusion.

METHODS

Eligible papers were identified by a comprehensive literature search of PubMed, using the terms "branch retinal vein occlusion," "therapy," "intervention," "treatment," "vitrectomy," "sheathotomy," "laser," "anti-VEGF," "pegaptanib," "bevacizumab," "ranibizumab," "triamcinolone," "dexamethasone," "corticosteroids," "non-steroids," "diclofenac," "hemodilution," "fibrinolysis," "tPA," and "BRVO." Additional papers were also selected from reference lists of papers identified by the electronic database search.

RESULTS

Treatment modalities were analyzed.

CONCLUSIONS

There are several treatment modalities for branch retinal vein occlusion and specifically for its complications, such as macular edema, vitreous hemorrhage, retinal neovascularization, and retinal detachment, including anti-aggregative therapy and fibrinolysis, isovolemic hemodilution, vitrectomy with or without sheathotomy, peripheral scatter and macular grid retinal laser therapy, non-steroid agents, intravitreal steroids, and intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Prospective comparisons of intravitreal injections of triamcinolone acetonide and bevacizumab for macular oedema due to branch retinal vein occlusion

PURPOSE

To compare the efficacy of intravitreal injections of triamcinolone acetonide (TA) and that of bevacizumab for macular oedema because of branch retinal vein occlusion (BRVO).

DESIGN

Prospective, comparative, randomized, interventional clinical trial.

METHODS

Forty-three eyes of 43 patients with macular oedema because of BRVO were randomly assigned to 4-mg intravitreal injections of TA (IVTA)(21 patients, IVTA group) or 1.25-mg intravitreal injections of bevacizumab (IVB) (22 patients, IVB group) and followed for 12 months. No additional treatments were administered for 3 months after the initial injection; additional injections were administered when macular oedema recurred between 3 and 12 months after the initial injection. The best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) were measured at baseline and monthly. The main outcome measures were changes in the logarithm of the minimal angle of resolution BCVA and CRT from baseline to 12 months.

RESULTS

Eighteen eyes of 18 patients in the IVTA group and 18 eyes of 18 patients in the IVB group completed follow-up at 12 months. The mean improvements in BCVA from baseline to 12 months were 0.12 in the IVTA group and 0.33 in the IVB group, which was significantly (p = 0.032) higher than in the IVTA group. There was no significant difference between the two groups in the mean reduction in CRT from baseline to 12 months after the initial injection. Two eyes in the IVTA group required intraocular pressure-lowering medications.

CONCLUSION

Intravitreal injection of bevacizumab may be of greater benefit than that of TA for macular oedema because of BRVO.

Optic disk analysis with heidelberg retina tomography in patients with branch retinal vein occlusion

PURPOSE

To investigate the optic disk topography parameters of patients with branch retinal vein occlusion (BRVO) in a controlled study by using Heidelberg retinal tomography.

METHODS

This prospective study included 35 eyes of 30 patients with BRVO who were followed-up at the Retina Clinic of the Ankara Ulucanlar Eye Education and Research Hospital, and 30 normal subjects (60 eyes). All patients and control subjects underwent complete ophthalmologic evaluation. The optic nerve heads of all subjects were imaged with the Heidelberg retinal tomography III (software 3.01a-M). The following stereometric parameters were calculated for each patient: disk area, cup area, cup-to-disk ratio, rim area, cup volume, rim volume, mean cup depth, maximum cup depth, and cup shape measure. Differences between the two groups were evaluated by the nonparametric independent sample t-test.

RESULTS

The mean cup volume, rim volume, cup area, disk area, rim area, and cup depth in BRVO group were found to be statistically significantly smaller than those in the control group (P < 0.05). Significant differences in the same parameters were also noted between the unaffected and affected eyes in patients with BRVO (P < 0.05). No significant differences were found between the groups in terms of the other stereometric parameters (P > 0.05).

CONCLUSION

Based on the results that were obtained in this series, a relationship was found between BRVO and various optic disk topography parameters determined by Heidelberg retinal tomography. Anatomical features of the optic disk may play a role in the pathogenesis of BRVO.

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.

Long-term study of vascular perfusion effects following arteriovenous sheathotomy for branch retinal vein occlusion

PURPOSE

To evaluate the perfusion effects and long-term visual outcome of pars plana vitrectomy (PPV) combined with arteriovenous sheathotomy (AVS) with or without triamcinolone for nonischaemic branch retinal vein occlusion (NI-BRVO).

METHODS

Prospective, interventional case series of eight patients with NI-BRVO and haemorrhagic macular oedema. Patients underwent PPV and AVS (n = 5), or PPV, AVS and intravitreal triamcinolone (IVT, n = 3). A masked grading technique assessed fundus photographs and fluorescein angiography (FFA) following surgery. Scanning laser ophthalmoscopy/optical coherence tomography (SLO/OCT) evaluated macular oedema and outer retinal architecture. Main outcomes examined included visual acuity (VA), retinal reperfusion, collateral vessel regression, vascular dilatation, cystoid macular oedema (CMO), and ocular neovascularization.

RESULTS

Seven of eight patients underwent uncomplicated surgery, with increased intraretinal perfusion and reduced engorgement of distal retinal veins. The mean pre-logMAR VA was 0.8 (SD 0.17) and did not improve significantly after surgery (post-logMAR 0.6, SD 0.38; p = 0.11, paired t-test). SLO/OCT showed persistent CMO in four patients, and subfoveal thinning of the photoreceptor layer. Collateral vessels disappeared at the blockage site post-AVS in 7/8 eyes, and this was associated with improved retinal perfusion. Six of eight patients developed epiretinal membrane. No patients developed ocular neovascularization. The average follow-up was 34.5 months.

CONCLUSIONS

PPV with AVS is a safe procedure, and adjunctive IVT had no additional effects on vascular perfusion. Successful decompressive surgery was followed by disappearance of collateral vessels at the BRVO blockage site and was a clinical marker for intravascular reperfusion. Long-term epiretinal gliosis and subfoveal photoreceptor atrophy limited functional and visual recovery.

Comparison of two doses of intravitreal bevacizumab as primary treatment for macular edema secondary to branch retinal vein occlusions: results of the Pan American Collaborative Retina Study Group at 24 months

PURPOSE

The purpose of this study was to compare the injection burden, central macular thickness (CMT), and change in best-corrected visual acuity (BCVA) after injecting 1.25 mg or 2.5 mg of bevacizumab as needed in patients with primary macular edema secondary to branch retinal vein occlusion.

METHODS

An interventional, retrospective, comparative multicenter study was conducted of 63 eyes with macular edema secondary to branch retinal vein occlusion that were treated primarily with intravitreal bevacizumab (38 eyes, 1.25 mg; 25 eyes, 2.5 mg). The main outcome measures were the CMT and the change of BCVA at 24 months.

RESULTS

All patients completed at least 24 months of follow-up. The mean number of injections per eye was 3.6 in the 1.25-mg group and 4.3 in the 2.5-mg group (P = 0.4770). At 24 months, in the 1.25-mg group, the logarithm of the minimum angle of resolution BCVA improved from baseline 0.38 +/- 0.63 (P < 0.0001) units to 0.64 +/- 0.6 units for the 2.5-mg group (P < 0.0001). In the 1.25-mg group, 26 (68%) eyes gained > or =3 of Early Treatment of Diabetic Retinopathy Study visual acuity and 2 (5%) eyes lost > or =3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity. In the 2.5-mg group, 18 (72%) eyes improved > or =3 of Early Treatment of Diabetic Retinopathy Study visual acuity, and none of the eyes lost > or =3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity. The CMT in the 1.25-mg group improved from 453 +/- 140 microm to 244 +/- 125 microm (P < 0.0001) versus 444 +/- 175 microm to 234 +/- 80 microm in the 2.5-mg group (P < 0.0001). There were no cases of endophthalmitis. No systemic adverse events were reported.

CONCLUSION

Intravitreal bevacizumab at doses up to 2.5 mg seems to be effective in improving BCVA and reducing CMT in macular edema secondary to branch retinal vein occlusion. No statistically significant differences were found between the two dose groups with regard to the number of injections, CMT, and change in BCVA.

Edaravone (MCI-186) is effective as a free radical scavenger following arteriovenous sheathotomy for treatment of macular oedema associated with branch retinal vein occlusion

Aims:

To determine whether edaravone (MCI-186), a free radical scavenger, can reduce macular oedema and improve the visual acuity after arteriovenous sheathotomy in eyes with a branch retinal vein occlusion (BRVO).

Methods:

Forty-seven eyes of 47 consecutive patients with a BRVO who were treated with arteriovenous sheathotomy were studied. The patients were assigned prospectively to either Group R who received 30 mg of edaravone (Radicut) systemically during the vitrectomy or Group N who did not receive any drugs. The postoperative visual acuity was measured before and 12 months after the operation.

Results:

At 12 months postoperatively, the best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR) units improved significantly from 0.22 to 0.56 logMAR units in Group R and from 0.20 to 0.27 units in Group N (p = 0.016). Twenty-three of 27 cases (85%) in Group R and four of 15 cases (27%) in Group N showed an improvement in BCVA of >0.2 logMAR units (p = 0.0025).

Conclusion:

The better visual acuity in patients given edaravone than those without endaravone during the arteriovenous sheathotomy suggests that edaravone improved the physiology of the retinal cells after the arteriovenous sheathotomy.

Long-term visual outcome of arteriovenous adventitial sheathotomy on branch retinal vein occlusion induced macular edema

Purpose

To evaluate long-term visual outcome of arteriovenous adventitial sheathotomy in BRVO-induced macular edema.

Methods

The visual outcomes of 8 patients following vitrectomy with arteriovenous adventitial sheathotomy for BVO-induced macular edema (surgery group) were retrospectively evaluated. The three year post-operative visual acuity of the surgery group was compared with that of the conservatively managed controls.

Results

All patients were followed for a minimum of 36 months. Mean BCVA (logMAR) in the surgery group changed from 1.10± 0.34 to 1.19±0.70 and to 0.80±0.36 at 12 and 36 months, respectively (p=0.959 at 12 months, p=0.018 at 36 months). In the control group, visual acuity improved from 1.15±0.43 to 0.43±0.44 and to 0.43±0.39 at 12 and 36 months, respectively (p=0.015 at 12 months, at p=0.003 at 36 months). A strong trend toward better visual acuity at 12 months and final examination was observed for controls. (surgery vs. control group, p=0.052 at 12 months, p=0.066 at 36 months).

Conclusions

Considering the favorable natural course of BVO and the unproven effect of reperfusion on macular edema, surgical efficacy of arteriovenous adventitial sheathotomy requires further evaluation.

Comparison of two doses of intravitreal bevacizumab (Avastin) for treatment of macular edema secondary to branch retinal vein occlusion: results from the Pan-American Collaborative Retina Study Group at 6 months of follow-up

PURPOSE

To report the 6-month anatomical and visual outcomes after injecting two different doses of intravitreal bevacizumab in patients with macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

An interventional, retrospective multicenter study of 45 eyes that were treated with at least one intravitreal injection (24 eyes, 1.25 mg; 21 eyes, 2.5 mg) of bevacizumab is reported. The main outcome measures were the central 1-mm macular thickness (CMT) and the change in ETDRS lines of best-corrected visual acuity (BCVA) at 6 months.

RESULTS

Forty-five eyes were injected on average 26.1 months (range, 3-86 months) after the diagnosis. The average follow-up was 35.2 weeks (range, 24-52 weeks). All patients completed at least 6 months of follow-up. In the 1.25-mg dose group, at 1 month, there was an average gain of 4.5 lines of BCVA; at 3 months, 5.1 lines of BCVA; and at 6 months, 5.1 lines of BCVA (P < 0.005). In the 2.5-mg dose group, at 1 month, there was an average gain of 2.3 lines of BCVA; at 3 months, 3.8 lines of BCVA; and at 6 months, 4.8 lines of BCVA (P = 0.05). In the 1.25-mg dose group, the mean CMT +/- SD decreased from 461 +/- 211 microm at baseline to 321 +/- 152 microm at 1 month, 273 +/- 99 microm at 3 months, and 277 +/- 114 microm at 6 months (P = 0.0002). In the 2.5-mg group, the mean CMT +/- SD decreased from 385 +/- 168 microm at baseline to 279 +/- 111 microm at 1 month, 249 +/- 97 microm at 3 months, and 240 +/- 93 microm at 6 months (P = 0.011).

CONCLUSION

There were no statistically significant differences between the two dose groups with regard to the number of injections and anatomical and functional outcomes. Intravitreal injection of bevacizumab at doses up to 2.5 mg appears to be effective in improving BCVA and reducing CMT in BRVO in the short term. Multiple injections are needed in a large number of eyes for continued control of macular edema and preservation of visual acuity in the short term. Longer studies are needed to determine what role if any intravitreal injection of bevacizumab may play in the long-term treatment of this condition.

Visual acuity and multifocal electroretinographic changes after arteriovenous crossing sheathotomy for macular edema associated with branch retinal vein occlusion

PURPOSE

To evaluate the influence of arteriovenous (AV) sheathotomy on retinal function with central multifocal electroretinography (mfERG) in eyes with macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

Fifteen patients (15 eyes) who underwent AV sheathotomy for macular edema secondary to BRVO were included in the study. Best-corrected visual acuity and mfERG responses from the most central seven hexagons were analyzed before and 6 months after the operation.

RESULTS

The mean preoperative Early Treatment Diabetic Retinopathy Study (ETDRS) score +/- SD was 34.1 +/- 12.7 letters (Snellen equivalent, 20/50) and significantly improved up to 40.5 +/- 10.9 letters (Snellen equivalent, 20/40) at 6 months after AV sheathotomy (P = 0.027, Wilcoxon signed rank test). The mean preoperative P1 amplitude +/- SD of the most central 7 hexagons was 39.30 +/- 10.86 nV/deg(2) for the affected eye versus 47.72 +/- 6.67 nV/deg(2) for the normal fellow (control) eye (P = 0.013, Mann-Whitney U test) and significantly increased up to 50.71 +/- 15.58 nV/deg at 6 months after the operation (P = 0.014, Wilcoxon signed rank test). Significant correlations between preoperative and postoperative ETDRS score and preoperative P1 amplitude were present (r = 0.929, P < 0.001; r = 0.768, P = 0.001; respectively [Spearman correlation]).

CONCLUSIONS

AV sheathotomy improved macular function and anatomical outcome as measured by ETDRS score and mfERG responses in patients with macular edema due to BRVO.

Arteriovenous crossing sheathotomy versus intravitreal triamcinolone acetonide injection for treatment of macular edema associated with branch retinal vein occlusion

PURPOSE

To compare the functional and anatomical outcomes of arteriovenous (AV) sheathotomy and intravitreal triamcinolone acetonide (IVTA) injection in the treatment of macular edema associated with branch retinal vein occlusion (BRVO).

METHODS

Forty eyes of 40 patients with macular edema secondary to BRVO were randomized into two treatment groups. A total of 20 patients received AV sheathotomy (sheathotomy group), and the second group of 20 patients was treated with IVTA (IVTA group). Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) score, total macular volume measured, and foveal thickness by 3rd generation optical coherence tomography (OCT3) were evaluated as main outcome measurements.

RESULTS

The average changes in ETDRS scores, total macular volumes, and foveal thicknesses compared to baseline values, were significant 3 months and 6 months after treatment in both groups (P < 0.05, paired t-test), but only the IVTA group showed significant improvements 1 month after treatment. The between-group differences in average ETDRS score, total macular volume, and foveal thickness changes were significantly better at 1 month after treatment in the ITVA group (P = 0.026, P < 0.001, P = 0.001, respectively, Student's t-test), at which time IVTA patients had better vision and anatomical outcomes than did those in the sheathotomy group.

CONCLUSIONS

After either AV sheathotomy or IVTA treatment, patients with macular edema secondary to BRVO showed similar functional and anatomical outcomes 6 months later. When the cost and the risks of vitreoretinal surgery are considered, IVTA treatment may be a better treatment option, as the drug yields better short-term outcomes.

Sheathotomy in complicated cases of branch retinal vein occlusion

PURPOSE

To report the clinical experience and results of using a microsurgical technique to decompress the arteriovenous connection in complicated branch retinal vein occlusion (BRVO) combined with haemorrhage, oedema and ischaemia.

METHODS

We carried out a retrospective, non-randomized, interventional case study of the surgical sheathotomy decompression procedure. We enrolled 12 patients (seven women, five men; median age 64 years) with BRVO and decreased visual acuity (VA) caused by haemorrhage, oedema and ischaemia. The mean duration of thrombosis was 7 months (2-15 months). The patients were examined for pre- and postoperative best corrected VA (BCVA), intraocular pressure (IOP) and fundus photography. Ten patients were examined with fluorescein angiography and eight with ocular coherence tomography (OCT). Postoperative progression of cataract was recorded, as were other complications. The mean follow-up time was 20 months (8-39 months).

RESULTS

Best corrected VA had improved in nine patients, was unchanged in one patient and had deteriorated in two patients at the last follow-up. Noted complications were venous haemorrhage at surgery in five patients, retinal detachment in one patient and progression of cataract in four patients.

CONCLUSIONS

Microsurgical treatment with sheathotomy of BRVO is a technically feasible procedure with few complications. Postoperative increased reperfusion could explain the resolution of macular haemorrhage, oedema and ischaemia, and may improve visual function in patients with this common vascular eye disease.

Branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities

In branch retinal vein occlusion (BRVO), abnormal arteriovenous crossing with vein compression, degenerative changes of the vessel wall and abnormal hematological factors constitute the primary mechanism of vessel occlusion. In general, BRVO has a good prognosis: 50-60% of eyes are reported to have a final visual acuity (VA) of 20/40 or better even without treatment. One important prognostic factor for final VA appears to be the initial VA. Grid laser photocoagulation is an established treatment for macular edema in a particular group of patients with BRVO, while promising results for this condition are shown by intravitreal application of steroids or new vascular endothelial growth factor inhibitors. Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane may improve vision in eyes with macular edema which are unresponsive to or ineligible for laser treatment.

Intravitreous bevacizumab in the treatment of macular edema from branch retinal vein occlusion and hemisphere retinal vein occlusion (an AOS thesis)

PURPOSE

To compare intravitreous bevacizumab to other current treatments of branch retinal vein occlusion (BRVO) and hemisphere retinal vein occlusion (HRVO) with consideration to visual outcome, cost, convenience, and risk of treatment.

METHODS

This is a retrospective chart review from a large referral retina practice. The data comprise 56 patients with BRVO and HRVO treated by intravitreous bevacizumab, with and without intravitreous triamcinolone acetonide. Initial visual acuities at the time of first bevacizumab injection, best acuities through the follow-up time, final acuity at last visit before review, initial macular thickness, and final macular thickness were measured. Changes in vision and thickness were calculated, as were the percentage of eyes improving, stabilizing, and worsening.

RESULTS

The data were compared to composite data derived from several current treatments of BRVO. The subgroup of 39 eyes that received only bevacizumab without triamcinolone acetonide had the most improvement in vision. The median change in visual acuity was 1.5 lines (P = .012) over a mean follow-up of 8.8 months. Twenty-three eyes (59%) improved visually, with 20 eyes (51%) improving 2 or more lines. These results are similar to those for eyes that received argon grid laser and chorioretinal anastomosis, but are worse than in eyes that received arteriovenous adventitial sheathotomy, macular decompression surgery, and intravitreous triamcinolone acetonide.

CONCLUSIONS

Visual benefit from intravitreous bevacizumab compares well against laser treatments for BRVO and HRVO but not as well opposed to surgical techniques and intravitreous triamcinolone acetonide. Intravitreous bevacizumab injection has a risk, cost, and convenience profile that is favorable.

Long-term outcomes of vitrectomy with or without arteriovenous sheathotomy in branch retinal vein occlusion

PURPOSE

To evaluate the long-term effect of vitrectomy with or without arteriovenous sheathotomy for macular edema secondary to branch retinal vein occlusion (BRVO).

METHODS

The study was a prospective, randomized, comparative, interventional case series of 36 patients (36 eyes) who underwent pars plana vitrectomy with or without arteriovenous sheathotomy for macular edema due to BRVO of <or=8 weeks' duration of symptoms. Eighteen eyes with arteriovenous sheathotomy (sheathotomy group) were compared with 18 eyes without sheathotomy (vitrectomy group). Main outcomes measures were best-corrected visual acuity and central foveal thickness as evaluated by optical coherence tomography.

RESULTS

Baseline demographic characteristics of the groups were similar. Postoperative follow-up period ranged from 12 months to 45 months (31 months). Median best-corrected visual acuity significantly improved from 0.4 at baseline to 1.0 at the final visit in both groups, and there was no significant difference in best-corrected visual acuity at any postoperative period between the groups. Of 16 patients with duration of symptoms of <4 weeks, those with arteriovenous sheathotomy had a tendency toward better visual outcomes than those without arteriovenous sheathotomy (P = 0.064). The central foveal thickness also significantly decreased after surgery in both groups, but the differences were not significant for the two groups at each time point. No patients had severe intraoperative and/or postoperative complications.

CONCLUSIONS

Our findings suggest that vitrectomy with or without arteriovenous sheathotomy may improve the long-term functional and tomographic outcomes for patients with macular edema secondary to BRVO. Although additional arteriovenous sheathotomy did not lead to a distinct functional benefit in this series, early surgical intervention may result in better visual outcomes.

Preoperative visual acuity as a prognostic indicator for laser treatment of macular edema due to branch retinal vein occlusion

BACKGROUND AND OBJECTIVE

To determine the visual outcome of laser treatments for macular edema due to branch retinal vein occlusion (BRVO) in patients with a preoperative visual acuity (VA) of 20/200 or worse compared to patients with a preoperative VA of better than 20/200.

PATIENTS AND METHODS

Records of 88 patients with macular edema secondary to BRVO undergoing laser treatment from 1984 to 2003 were reviewed. Mean VA was measured before and after each treatment and after the final treatment.

RESULTS

All patients received between one and five laser treatments. Preoperative VA was better than 20/200 in 56 patients (group 1) and 20/200 or worse in 32 patients (group 2). Patients in group 1 had a mean improvement of 0.48 lines and 57% had a final VA of 20/40 or better. Patients in group 2 had a mean improvement of 1.69 lines and 20% had a final VA of 20/40 or better.

CONCLUSIONS

Patients with poor VA (20/200 or worse) secondary to macular edema due to BRVO responded positively to laser treatment. The level of preoperative VA can be a useful predictor of visual outcome. These patients should consider laser treatment before alternative, more aggressive approaches.

Arteriovenous adventitial sheathotomy for branch retinal vein occlusion: report of a case with longterm follow-up

PURPOSE

To report the longterm follow-up of a case of branch retinal vein occlusion (BRVO) treated with vitrectomy and adventitial sheathotomy.

METHODS

A three-port vitrectomy was performed in a 55-year-old man with symptoms of BRVO of about 3 months' duration. After a core vitrectomy, the adventitial sheath of the affected arteriovenous crossing was dissected so that the anterior surface of the arteriole was freely exposed.

RESULTS

On the second postoperative day, visual acuity (VA) in the affected left eye had increased from preoperative 0.3 to 0.6. Within 6 months the fundus had almost normalized and vision improved to 1.0. Cataract surgery was performed about 2 years after the vitrectomy. At a follow-up 4 years and 11 months after the sheathotomy, VA was 1.0 and no signs of recurrence were seen.

CONCLUSIONS

Adventitial sheathotomy may improve vision in selected cases of BRVO. Further studies are necessary to determine the role of sheathotomy in the management of cases with BRVO.

Evaluation of arteriovenous crossing sheathotomy for decompression of branch retinal vein occlusion

PURPOSE

To report the effects of arteriovenous adventitial sheathotomy on anatomical and functional improvements in patients with macular oedema due to branch retinal vein occlusion (BRVO).

METHODS

Pars plana vitrectomy and arteriovenous sheathotomy was performed on 11 patients with BRVO who had vision loss due to macular oedema. Ten patients with macular oedema due to BRVO and who have been treated with grid laser photocoagulation were included in the control group. The measurement of visual acuity with ETDRS chart was taken preoperatively and at 1, 3, 6, and 9 months follow-up in the study group and at 1, 3, 6, and 9 months after grid laser in the control group.

RESULTS

The mean preoperative logMAR visual acuity was 0.84+/-0.3 in the surgical group and 1.06+/-0.4 in the control group. The postoperative mean logMAR visual acuity was 0.41+/-0.2, 0.40+/-0.2, 0.40+/-0.3, and 0.36+/-0.3 at 1, 3, 6, and 9 months follow-up, respectively. In the control group the postlaser mean logMAR visual acuity was 0.92+/-0.3, 0.87+/-0.4, 0.85+/-0.3, and 0.82+/-0.3 at 1, 3, 6, and 9 months follow-up, respectively. The improvements of visual acuity in both groups were statistically significant when compared to pretreatment (P=0.003 and P=0.007 at 9 months in the study and control group, respectively).

CONCLUSION

Arteriovenous sheathotomy for decompression of BRVO in patients who have vision loss due to macular oedema was safe and effective for anatomical and functional improvement and resulted in significantly better visual outcomes than a matched control group of laser-treated eyes.

Intravitreal Triamcinolone Acetonide for Patients with Macular Edema due to Branch Retinal Vein Occlusion

We designed a case series study to evaluate the outcome of intravitreal triamcinolone acetonide for the treatment of macular edema due to branch retinal vein occlusion (BRVO). The prospective comparative nonrandomized clinical interventional study included 27 patients (27 eyes) with macular edema due to BRVO. The study group consisted of 16 patients who had accepted an intravitreal injection (IVI) of 4 mg triamcinolone acetonide. The control group included 11 patients without IVI of triamcinolone acetonide. The mean follow-up was 103.00 +/- 36.24 days in the study group and 94.55 +/- 36.31 days in the control group. In the study group, visual acuity measurements improved significantly (p < 0.001) from 0.77 +/- 0.43 logarithm of minimal angle of resolution (logMAR) preoperatively to a best postoperative visual acuity of 0.44 +/- 0.43 logMAR. Fourteen eyes (87.5%) gained improvement in visual acuity, with 10 eyes (62.5%) showing an increase in visual acuity of at least two Snellen lines. All 16 patients showed significant macular edema resolution in optical coherence tomography examination (p < 0.001) and perivascular leakage decrease in fluorescein angiography post-IVI. In the control group, baseline best-corrected visual acuity and best-corrected visual acuity during the follow-up did not vary significantly (p = 0.294). In conclusion, IVI of triamcinolone acetonide can lead to an increase in visual acuity and a resolution of macular edema in patients with BRVO.

The management of retinal vein occlusion: is interventional ophthalmology the way forward?

Retinal vein occlusions (RVO) are the second commonest sight threatening vascular disorder. Despite its frequency treatments for RVO are unsatisfactory and include several that have not been tested by large, well designed, prospective, randomised controlled trials. There is also the lack of long term follow up in many of the available small uncontrolled studies, and the timings of interventions are haphazard. This review aims to evaluate the current knowledge relating to the pathogenesis, suggested treatments for the different types of RVO, and their complications. Isovolaemic haemodilution is of limited benefit and should be avoided in patients with concurrent cardiovascular, renal, or pulmonary morbidity. Evidence to date does not support any therapeutic benefit from radial optic neurotomy, optic nerve decompression, or arteriovenous crossing sheathotomy on its own. Vitrectomy combined with intravenous thrombolysis may offer promise for central RVO. Similarly, vitrectomy combined with arteriovenous sheathotomy intravenous tissue plasminogen activator may offer benefits for branch RVO. RVOs occur at significantly high frequency to allow future prospective randomised controlled studies to be conducted to evaluate the role of different therapeutic modalities singly or in combination.

Arterio-venous dissection after isovolaemic haemodilution in branch retinal vein occlusion: a non-randomised prospective study

PURPOSE

The rationale for this pilot study was to add arterio-venous dissection (AVD) after unsuccessful medical treatment in a well-defined group of patients with branch retinal vein occlusion (BRVO).

METHODS

In this prospective, interventional case series 35 consecutive patients with a visual acuity (VA) of 0.4 (logMar) or worse were scheduled for surgery within the first 3 months of the onset of BRVO. The study endpoint was VA 1 year after AVD. Secondary study endpoints were: correlation of VA and successful vessel dissection; complication rate; and number of additional surgical procedures within the first year of AVD.

RESULTS

Preoperative VA (logMar) was 0.82+/-0.05 (range 0.2-1.6). VA 6 weeks postoperatively was 0.54+/-0.06 (range 0-1.6), 3 months postoperatively 0.61+/-0.07 (0-1.56), 6 months postoperatively 0.74+/-0.08 (range 0-2) and 12 months postoperatively 0.55+/-0.07 (range 0.1-1.5). VA improved 1 year after AVD (p=0.0004). An improvement in VA did not depend on successful separation of the artery and the vein. Four patients had a retinal detachment, 19 patients needed cataract surgery within the first year of AVD. A total of 24 additional surgical procedures were needed.

CONCLUSIONS

Patients with BRVO may profit from AVD compared with a historical control group. Visual improvement was found irrespective of the successful dissection of vessels. The cataract formation rate and additional surgery was a shortcoming of the AVD procedure.

TRIAMCINOLONE ACETONIDE WITH VITRECTOMY FOR TREATMENT OF MACULAR EDEMA ASSOCIATED WITH BRANCH RETINAL VEIN OCCLUSION

PURPOSE

To review the efficacy of a combination of triamcinolone acetonide (TA) injection and pars plana vitrectomy (PPV) for the treatment of macular edema associated with branch retinal vein occlusion (BRVO).

METHODS

Seventeen eyes with macular edema associated with BRVO underwent PPV with an intraoperative injection of TA (10 mg) into the vitreous cavity. Residual or recurrent macular edema was treated with postoperative sub-Tenon capsule injections of TA (20 mg).

RESULTS

With PPV and an intraoperative injection of TA, 82% of eyes showed rapid reduction of macular edema; foveal thickness decreased from 507 +/- 115 microm preoperatively to 261 +/- 123 microm 2 months after surgery (P = 0.0041). However, 59% of eyes showed recurrence of macular edema during the follow-up period. Twelve eyes with residual or recurrent macular edema received sub-Tenon capsule injections of TA; of these eyes, 9 showed substantial reduction of macular edema. Foveal thickness decreased from 381 +/- 102 microm to 256 +/- 56 microm (P = 0.0076) 2 weeks after postoperative injections of TA. At the final visit, visual acuity (logMAR) improved from 0.74 +/- 0.40 preoperatively to 0.40 +/- 0.34 (P = 0.010).

CONCLUSION

An intraoperative injection of TA in combination with PPV has the potential to facilitate the absorption of macular edema associated with BRVO. In addition, residual or recurrent macular edema can be treated with additional sub-Tenon capsule injections of TA.

Intravitreal versus retrobulbar injections of triamcinolone for macular edema associated with branch retinal vein occlusion

PURPOSE

To compare the short-term effect of intravitreal versus retrobulbar injection of triamcinolone acetonide for the treatment of macular edema caused by branch retinal vein occlusion.

DESIGN

Randomized clinical trial.

METHODS

Sixty eyes of 60 patients who had macular edema associated with branch retinal vein occlusion were randomly assigned to receive a single intravitreal injection (4 mg) or repeated retrobulbar injections (40 mg, three times) of triamcinolone. These injections (first injection in the retrobulbar group) were given approximately 1 week after focal laser photocoagulation. Using optical coherence tomography, the central retinal (foveal) thickness and total macular volume were measured before and at 1 and 3 months after injection. Visual acuity, intraocular pressure, and the incidence of reinjection were also examined. Fifty-two patients (86.7%) completed the 3-month follow-up.

RESULTS

The mean foveal thickness and total macular volume decreased significantly after either intravitreal or repeated retrobulbar triamcinolone injections. Foveal thickness and macular volume were significantly less after intravitreal injection than after repeated retrobulbar injections, although there had been no significant differences at baseline. The percent reductions in foveal thickness and macular volume were also greater after intravitreal injection than after retrobulbar injections. Improvement in visual acuity was significantly better after intravitreal injection than after the retrobulbar injections. The incidence of intraocular pressure rise (to > or =20 mm Hg) was greater in the intravitreal group than in the retrobulbar group, but this was readily controlled by the use of antiglaucoma medications. After completion of the 3-month follow-up, 24 patients (46.2%) underwent reinjection. The need for reinjections was significantly greater in the retrobulbar group than in the intravitreal group (P = .0001).

CONCLUSIONS

A single intravitreal injection of triamcinolone is significantly more effective than are repeated retrobulbar injections in reducing macular edema associated with branch retinal vein occlusion, and leads to greater improvement in visual acuity.

Multiple laser treatments for macular edema attributable to branch retinal vein occlusion

PURPOSE

To report the visual outcome of multiple laser treatments for macular edema attributable to branch retinal vein occlusions (BRVO) and to determine if any prognostic factors exist for improvement.

DESIGN

Retrospective chart review.

METHODS

A private practice with four vitreoretinal surgeons performed laser treatments on 88 eyes of 88 patients with macular edema secondary to BRVO from 1984 to 2003. Mean preoperative and postoperative visual acuities were collected after each laser treatment. Final visual acuities were also documented.

RESULTS

All 88 patients received at least one laser treatment, and 46 patients of the initial 88 underwent multiple treatments. Overall, forty-one (46.6%) of the total 88 patients improved by 2 or more lines, whereas 33 patients (37.5%) were within 1 line of the preoperative vision, and 14 patients (15.9%) worsened by 2 or more lines. The mean final visual improvement was 0.92 lines for all 88 patients. The group of patients that responded favorably to the first laser treatment (n = 37) showed an overall improvement of 3.5 lines. However, patients who responded poorly to the first laser treatment resulted in an overall worsening of vision by 0.96 lines.

CONCLUSIONS

Our study found that multiple laser treatments can improve visual acuity and resolve macular edema and that each additional laser treatment gives a patient a modest chance of visual improvement. A positive or stable visual response to first laser treatment portends a favorable prognosis with subsequent laser treatments.

Vitrectomy with or without arteriovenous adventitial sheathotomy for macular edema associated with branch retinal vein occlusion

PURPOSE

compare the results of vitrectomy with or without arteriovenous (AV) crossing sheathotomy for macular edema associated with branch retinal vein occlusion (BRVO).

DESIGN

Interventional case series.

METHODS

A retrospective study of 36 eyes with BRVO-associated macular edema. Twenty eyes underwent AV sheathotomy (AS group), and 16 eyes underwent posterior vitreous detachment (PVD group). Best-corrected visual acuity (BCVA), fluorescein angiography (FA), and optical coherence tomography to determine foveal thickness were conducted preoperatively and at 12 months postoperatively.

RESULTS

The mean postoperative BCVAs were significantly better in both the AS and the PVD group (P = .008 and P = .001, respectively). Foveal thickness decreased significantly 1 month after surgery in both groups (P = .002 and P = .007) and continued to decrease up to 12 months. The postoperative mean BCVA and improvement of BCVA and foveal thickness were not significantly different for the two groups at any postoperative period. Postoperative FA showed reperfusion of the occluded vein in 10 eyes in the AS group and 2 eyes in the PVD group, and formation of shunt vessels at the AV crossing site or around the macular region in all of the other eyes of both groups.

CONCLUSIONS

Both AV sheathotomy and simple PVD significantly reduced macular edema associated with BRVO. However, there was no significant difference in the improvement of macular function following either procedure. Postoperative improvement of retinal circulation by either reperfusion of the occluded vein or collateral vessel formation was found. This accounted for functional and morphologic improvements.