Bilateral central retinal vein occlusion following COVID-19 vaccination: Cause or coincidence?

AIM

To report a case of sequential bilateral ischemic central retinal vein occlusion (CRVO) following the third dose of anti-COVID 19 vaccination.

METHODS

Observational case report.

RESULTS

A 73-year-old Caucasian male patient, with no known medical history, complained of sudden vision loss in his right eye (RE) 18 days following the third dose of Pfizer-BioNTech anti-COVID 19 vaccination. Ten days later, he suffered from sudden vision loss in his left eye (LE).Best-corrected visual acuity was limited to counting fingers at 50cm in both eyes.Fundus examination of both eyes revealed signs of ischemic central retinal vein occlusion (CRVO) with diffuse superficial and deep retinal hemorrhages in all four quadrants. Diagnosis was confirmed of fluorescein angiography.Optical coherent tomography (OCT) showed an ischemic hyperreflectivity and disorganization of the inner retinal layers in both eyes with significantly increased central macular thickness, associated to intraretinal fluid accumulation in LE.An urgent systemic assessment was requested. A mild hypertension was discovered and the rest of the work up was unremarkable.

CONCLUSION

To our knowledge, we report the first case of bilateral CRVO in a healthy patient after anti-COVID 19 vaccination. CRVO occurred few days following third shot of vaccine followed by a sequential CRVO in the fellow eye in a patient with recently diagnosed very mild hypertension and no thrombo-embolic risk factors, strongly suggesting a relationship between both events. Nowadays, CRVO should be kept in mind as a potential side effect of Covid-19 vaccination and should be added to the spectrum of their ophthalmic complications.

Efficacy, Safety, and Treatment Burden of Aflibercept 2 mg and Ranibizumab in Retinal Vein Occlusion: A Systematic Review and Meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to provide an updated evidence base for clinical decision-making by comparing the efficacy and safety of aflibercept 2 mg and ranibizumab in treating retinal vein occlusion (RVO).

METHODS

A systematic search was conducted using eight databases up to December 2021. Randomized controlled trials (RCTs) and real-world studies (RWSs) comparing aflibercept and ranibizumab in patients with RVO were evaluated. The primary outcomes assessed were efficacy, number of injections administered, and adverse events.

RESULTS

Three RCTs (424 patients) and 11 RWSs (1415 patients) were included. For central RVO (CRVO), RCTs demonstrated a comparable efficacy, whereas RWSs showed that mean changes from baseline in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were significantly greater with aflibercept compared to ranibizumab; the number of injections of aflibercept was fewer than that of ranibizumab in RCTs, but similar in RWSs. For branch RVO (BRVO), no statistically significant difference in efficacy between the two drugs in RCTs/RWSs was observed, with fewer injections of aflibercept at 12 months in RWSs. The safety profiles of both drugs were similar for both CRVO and BRVO.

CONCLUSIONS

For CRVO, aflibercept had similar efficacy and safety profile but with fewer injections versus ranibizumab in RCTs; RWSs showed greater BCVA improvement and CRT reduction with aflibercept than ranibizumab. For BRVO, RCTs showed similar in efficacy, safety, and injection numbers for both drugs, while RWSs demonstrated that aflibercept required fewer injections at 12 months of follow-up. Overall, this study provides updated evidence for clinical decision-making in the treatment of RVO.

Foveal Thickness Fluctuations in Anti-VEGF Treatment for Central Retinal Vein Occlusion

Purpose

The aim of this study was to examine the effects of foveal thickness (FT) fluctuation (FTF) on 2-year visual and morphological outcomes of eyes with central retinal vein occlusion (CRVO) undergoing anti-VEGF treatment for recurrent macular edema (ME) based on a pro re nata regimen.

Design

Retrospective, observational case series.

Participants

We analyzed 141 treatment-naive patients (141 eyes) with CRVO-ME at a multicenter retinal practice.

Methods

We assessed FT using OCT at each study visit. Patients were divided into groups 0, 1, 2, and 3 according to increasing FTF.

Main Outcome Measures

We evaluated the logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA), the length of the foveal ellipsoid zone (EZ) band defect measured using OCT, and the association of FTF with VA and EZ band defect length.

Results

The mean baseline logMAR BCVA and FT were 0.65 ± 0.52 (Snellen equivalent range: 20/20-20/2000) and 661.1 ± 257.4 μm, respectively. The mean number of anti-VEGF injections administered was 5.6 ± 3.6. At the final examination, the mean logMAR BCVA and FT values were significantly improved relative to the baseline values (both P < 0.01). During the observation, BCVA longitudinally improved in Groups 0 and 1, remained unchanged in Group 2, and worsened in Group 3. Likewise, the length of the foveal EZ band defect did not increase in Group 0; however, it gradually increased in Groups 1, 2, and 3. Foveal thickness fluctuation was significantly and positively associated with the logMAR BCVA and length of the foveal EZ band defect at the final examination (P < 0.01). The final logMAR BCVA of patients developing neovascular complications was 1.27 ± 0.72 (Snellen equivalent range: 20/50-counting fingers), which was significantly poorer than that of patients without complications (P < 0.001). There was no significant difference in the neovascular complication rate among the FTF groups (P = 0.106, Fisher exact test).

Conclusions

In eyes receiving anti-VEGF treatment for CRVO-ME, FTF can longitudinally impair the visual acuity and foveal photoreceptor status during the observation period, thus influencing the final outcomes. However, neovascular complications, which would also lead to a poor visual prognosis, may not be associated with FTF.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

A Multicentric Cross-Sectional Observational Study to Analyze the Effects of Moderate High Altitude on Ocular Health

Objectives

Prolonged exposure to hypoxia at high altitudes can affect the eyes through various mechanisms, culminating in reduced vision. Multiple studies on this subject have focused on the ocular effects of high altitude on intraocular pressure (IOP), corneal thickness, and the retina. However, there is a lack of literature on the effects of 'moderate high altitude (2000-3000 m)' on the eyes. Hence, we designed our study to determine the impact of moderate high altitude on the eyes.

Methods

We recruited two age and gender-matched groups of 250 research participants, each at moderate high altitude (Group A) and plains (Group B), respectively, to determine the effects of moderate high altitude on ocular health, if any.

Results

We found a statistically significant increase in dry eye in Group A. We also found four cases of central serous retinopathy and one case of central retinal vein occlusion in Group A. There was no statistically significant change in visual acuity, IOP, or central corneal thickness.

Conclusion

There is a vast lacuna in the literature on this particular altitude range, and further studies are required to confirm our findings. It is also recommended that lubricant eye drops be advised as a standard prophylactic measure for all individuals traveling and staying at moderate high altitude.

Acute onset of decreased vision after violently vomiting: A case report

PURPOSE

Reported cases of central retinal vein occlusion (CRVO) associated with violent vomiting are scarce all over the world. In this case, we reported a male patient with an acute decreased vision right after violently vomiting.

METHODS

A 55-year-old male patient found himself with a sudden, painless decline in visual acuity in his left eye (LE) after violently vomiting due to alcohol consumption for 1 day. His best corrected visual acuity (BCVA) was 20/2000 in the LE. He has a history of moderate myopia in both eyes and well-controlled hypertension. After evaluating multimodal images, non-ischemic CRVO retinopathy was diagnosed.

RESULTS

During the follow-up period, the patient's BCVA in the LE improved to 20/40 and the ocular examination data confirmed that the previous abnormal performances were nearly back to normal without any treatment.

CONCLUSION

Non-ischemic CRVO retinopathy following violent vomiting suggests that vomiting-related mechanisms like Valsalva maneuvers and dehydration may contribute to CRVO through effects on ocular blood flow and thrombosis.

Real-world effectiveness of intravitreal dexamethasone implants - Comparison between eyes eligible and ineligible for clinical trials and their associated outcomes

BACKGROUND

Concerns about the generalizability of pivotal randomized controlled trials (pRCTs) findings have been raised. We aimed to compare intravitreal dexamethasone implants' (IDIs) effectiveness for diabetic macular edema (DME) and central retinal vein occlusion (CRVO), between eyes eligible and ineligible for pRCTs.

METHODS

This retrospective cohort study analyzed Taiwan's Chang Gung Research Database, including DME or CRVO eyes initiating IDIs during 2015-2020. We classified all treated eyes as eligible or ineligible for pRCTs following major selection criteria of the MEAD and GENEVA trials, and evaluated three-, six-, and twelve-month changes in central retinal thickness (CRT) and visual acuity (VA) after initiating IDIs.

RESULTS

We included 177 IDI-treated eyes (DME: 72.3%; CRVO: 27.7%), of which 39.8% and 55.1% were ineligible for DME and CRVO pRCTs, respectively. LogMAR-VA and CRT changes at different times were comparable in DME eyes eligible (LogMAR-VA difference: 0.11 to 0.16; CRT difference: -32.7 to -96.9 μm) and ineligible (LogMAR-VA difference: -0.01 to 0.15; CRT difference: -54.5 to -109.3 μm) for the MEAD trial. By contrast, CRVO eyes ineligible for the GENEVA trial had greater LogMAR-VA changes (0.37 ~ 0.50) than those eligible (0.05 ~ 0.13), with comparable CRT reductions (eligible eyes: -72.3 to -106.4 μm; ineligible eyes: -61.8 to -110.7 μm) (all p-values <0.05 of the mean differences between eligible and ineligible CRVO eyes for all follow-ups).

CONCLUSIONS

IDIs had similar VA and CRT outcomes among DME eyes, regardless of pRCT-eligibility. However, among CRVO eyes, those ineligible for pRCTs showed greater deterioration in VA than those eligible.

Real-World Management of Macular Edema Secondary to Retinal Vein Occlusion with Intravitreal Aflibercept: 24-month Results from the AURIGA Observational Study

INTRODUCTION

AURIGA is the largest real-world study to date to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema or macular edema secondary to retinal vein occlusion (RVO) in routine clinical practice. Here, we report the 24-month outcomes in the RVO cohort from France, Germany, Italy, and Taiwan.

METHODS

AURIGA (NCT03161912) was a prospective observational study. Eligible patients with RVO were enrolled for whom the decision to treat with IVT-AFL had already been made by the attending physician. Patients were treated with IVT-AFL for up to 24 months at physician discretion according to local practice. The primary endpoint was mean change in visual acuity (VA; Early Treatment Diabetic Retinopathy Study [ETDRS] letters) from baseline to month (M) 12. All statistical analyses were descriptive.

RESULTS

In 554 treatment-naïve and 65 previously treated patients with RVO, the respective mean (95% confidence interval) change in VA from baseline was + 12.5 (10.8, 14.3) and + 7.9 (3.3, 12.6) letters by M12 and + 11.4 (9.4, 13.3) and + 4.4 (- 0.6, 9.5) letters by M24 (baseline mean ± standard deviation: 51.0 ± 21.9 and 51.9 ± 20.4 letters); 44.0% of treatment-naïve and 27.9% of previously treated patients reported ≥ 15-letter gains by M24. By M24, the mean change in central retinal thickness from baseline was - 247 (- 267, - 227) µm in treatment-naïve patients and - 147 (- 192, - 102) µm in previously treated patients. From baseline to M6, M12, and M24, treatment-naïve patients received a total of 4.0 ± 1.3, 5.5 ± 2.5, and 6.9 ± 4.2 injections, respectively, and previously treated patients received 3.8 ± 1.5, 5.0 ± 2.2, and 6.3 ± 3.7 injections, respectively. The safety profile of IVT-AFL was consistent with that of previous studies.

CONCLUSIONS

In AURIGA, patients with RVO experienced clinically relevant functional and anatomic improvements following IVT-AFL treatment in routine clinical practice. These improvements were largely maintained in treatment-naïve patients over the 24-month study despite the decreasing treatment frequency, suggesting long-term durability of IVT-AFL treatment outcomes. Infographic available for this article.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03161912 (May 19, 2017). INFOGRAPHIC.

From Hair Loss to Vision Loss: Minoxidil-Associated CRVO in a Young Female

Introduction

Central retinal vein occlusion (CRVO) is a common retinal vascular disorder that is most often seen in older adults and individuals with vascular risk factors.

Case Presentation

We report a case of CRVO with cystoid macular edema (CME) in a young, otherwise healthy patient taking minoxidil for hair loss. The patient had no known vascular risk factors, and a comprehensive coagulability workup was negative. The CRVO with CME resolved without intervention upon cessation of minoxidil.

Conclusion

Possible mechanisms for minoxidil-associated retinal vascular disorders are explored. Thorough medication histories and the consideration of possible adverse drug events in patients without traditional risk factors are recommended.

Anterior chamber fluorescein leakage in a child with intraocular pressure elevation and vitreous hemorrhage

Purpose

To report a case of a child with neovascular and ghost cell glaucoma in the setting of previously treated vitreous hemorrhage with unique fluorescein leakage from abnormal iris vessels ultimately preventing successful fluorescein angiography.

Observations

A 3-year-9-month-old female with a medical history of very high-risk B-cell acute lymphoblastic leukemia presented with eye pain and was noted to have a complete vitreous hemorrhage and intraocular pressure elevation in the right eye which was refractory to maximum medical therapy and vitrectomy. Following vitreous hemorrhage resolution, an examination under anesthesia with fluorescein angiography was found to have diffuse leakage of fluorescein into the anterior chamber, presumably due to the active iris neovascularization. This anterior chamber fluorescein signal prevented visualization of the retinal vasculature. The patient was diagnosed with mixed mechanism glaucoma (neovascular and ghost cell) due to a resolved vitreous hemorrhage in the setting of a presumed prior ischemic event.

Conclusions and Importance

We report a case of an unsuccessful fluorescein angiogram in the setting of anterior chamber fluorescein leakage due to active iris neovascularization, and review considerations for the differential diagnosis and useful diagnostic tests in this clinical scenario.

Real-world outcomes of intravitreal bevacizumab treat-and-extend for cystoid macular oedema secondary to central retinal vein occlusion

INTRODUCTION

The purpose of this study was to report the real-world treatment outcomes using a treat-and-extend intravitreal bevacizumab protocol in cystoid macular oedema (CMO) secondary to central retinal vein occlusion (CRVO).

METHODS

We conducted a retrospective case series of consecutive adult patients with CMO secondary to CRVO who presented between 1st January 2019 and 31st December 2021. All included patients were treated with bevacizumab using a treat-and-extend protocol, were followed up for a minimum of 6 months and had a clinical examination including best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) at every visit. The primary outcome measure was mean change in BCVA.

RESULTS

Thirty-three eyes of 33 patients were included in the study. The mean change in BCVA from baseline was + 24.5 (Median 18, SD 21.5) letters, with a mean follow-up duration of 18.5 (SD 8.9) months. The mean number of injections was 9.5 (SD 1.9) in year 1 and 7.8 (SD 2.8) in year 2. 87.9% of patients were still requiring active treatment, with a maximum interval achieved of 4-weekly in 18.2%, 6-weekly in 42.4%, 8-weekly in 6.1%, 10-weekly in 15.2%, and 12-weekly in 6.1%. The mean maximum interval achieved of those requiring ongoing treatment was 6.8 (SD 2.4) weeks. Multiple regression analyses showed that a higher baseline BCVA was negatively associated with mean visual acuity gain (P < 0.001) and positively associated with final BCVA (P < 0.001).

CONCLUSION

The use of intravitreal bevacizumab in a treat-and-extend regimen is effective in treating CMO secondary to CRVO, in a real-world setting.

SCORE2 Report 24: Nonlinear Relationship of Retinal Thickness and Visual Acuity in Central Retinal and Hemiretinal Vein Occlusion

PURPOSE

To investigate whether a nonlinear association between central subfield thickness (CST) on spectral-domain OCT and concurrent visual acuity letter score (VALS) exists in eyes treated initially with aflibercept or bevacizumab for macular edema associated with central retinal vein occlusion (CRVO) or hemiretinal vein occlusion (HRVO) in the Study of Comparative Treatments for Retinal Vein Occlusion 2 (SCORE2).

DESIGN

Long-term follow-up after a randomized clinical trial from 64 centers in the United States.

PARTICIPANTS

Participants were followed up to 60 months and treated at investigator discretion after completing the 12-month treatment protocol.

METHODS

Two-segment linear regression models were compared with simple linear regression models of VALS on CST. Pearson correlation coefficients were calculated to assess strength of CST and VALS associations.

MAIN OUTCOME MEASURES

Central subfield thickness was measured by OCT and VALS by the electronic Early Treatment Diabetic Retinopathy Study methodology.

RESULTS

Estimated inflection points, reflecting turning points at which the CST and VALS association changes from positive to negative, calculated at 7 postbaseline visits, range from 217 to 256 μm. A strongly positive correlation exists to the left of each estimated inflection point, ranging from 0.29 (P < 0.01 at month 60) to 0.50 (P < 0.01 at month 12), and a strongly negative correlation exists to the right of each estimated inflection point, ranging from -0.43 (P < 0.01 at month 1) to -0.74 (P < 0.01 at month 24). Randomization statistical tests showed that 2-segment models are favored over 1-segment models for all postbaseline months (P < 0.001 for all tests performed).

CONCLUSIONS

The relationship between CST and VALS in eyes with CRVO or HRVO after treatment with anti-vascular endothelial growth factor (VEGF) therapy is not simply linear. The usually modest correlations between OCT-measured CST and visual acuity belie strong left and right correlations present in 2-segment models. Post-treatment CST close to the estimated inflection points showed the best expected VALS. The SCORE2 participants with a post-treatment CST after treatment close to the estimated inflection points of 217 to 256 μm showed the best VALS. In patients treated with anti-VEGF for macular edema associated with CRVO or HRVO, a thinner retina is not always associated with better VALS.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Central retinal vein and artery occlusion associated with sildenafil: a case report and review of the literature

BACKGROUND

Sildenafil is a selective phosphodiesterase type 5 inhibitor used for the treatment of erectile dysfunction and pulmonary hypertension. It is available over the counter in many countries. While there have been a few reports of retinal vascular occlusion following sildenafil consumption, most cases have other comorbidities as risk factors for the disease, and the exact causal role of this drug in these conditions remains unclear.

CASE PRESENTATION

We present the case of a healthy 32-year-old Iranian man who developed combined central retinal vein occlusion and retinal artery occlusion following sildenafil exposure. The patient underwent a hypercoagulative state workup for possible underlying risk factors. Additionally, we conducted a literature search on PubMed using the keywords: retinal vein occlusion AND Sildenafil OR Viagra, retinal artery occlusion AND Sildenafil OR Viagra, retinal vascular occlusion AND Sildenafil OR Viagra. To obtain more objective results in the reviews, we employed an adverse drug reaction possibility algorithm. The patient was found to be otherwise healthy, and ancillary tests were unremarkable. A literature review identified seven reports of retinal vascular occlusion following sildenafil use. In most of these cases, the role of sildenafil was not clearly established. To the best of our knowledge, our case achieved the highest score based on the algorithm compared with previous reports.

CONCLUSION

Sildenafil may be associated with severe retinal vascular accidents in otherwise healthy young individuals.

Henle fiber layer hemorrhage associated with combined central retinal vein occlusion and cilioretinal artery occlusion: a case report

BACKGROUND

The purpose of this study is to describe a patient who experienced simultaneous central retinal vein and cilioretinal artery occlusions, as well as perifoveal hemorrhage in the Henle fiber.

CASE PRESENTATION

A 67-year-old Iranian woman presented with a 3-day history of reduced vision in her left eye. Venous tortuosity and retinal hemorrhage were observed in the retina, together with whitened regions around the fovea, consistent with the diagnosis of central retinal vein occlusion in conjunction with cilioretinal artery occlusion. In structural and en face optical coherence tomography, star-shaped hemorrhages were observed around the fovea, which looked hyperreflective in the Henle fiber layer.

CONCLUSIONS

We present a case of central retinal vein occlusion exacerbated by cilioretinal occlusion and hemorrhage in the Henle fiber layer. The hemorrhage is most likely the result of increased intraluminal pressure in the deep capillary plexus.

Are inner nuclear layer ischemic lesions hidden indicators of retinal vein occlusion risk? A case-control study

PURPOSE

To investigate the association between retinal vein occlusion (RVO) and evidence of previous, unnoticed inner nuclear layer (INL) infarction in the fellow eye.

METHODS

This prospective case-control study compared the prevalence of INL lesions in the fellow eye of consecutive people with hypertension (PwHTN) with unilateral RVO versus a randomly chosen eye of an age-matched control group of PwHTN without RVO. En face slabs above the outer plexiform layer (OPL) were generated from 6 × 6 fovea-centered optical coherence tomography scans. Cross-sectional scans and en face slabs were surveyed for evidence of active/resolved ischemic INL lesions.

RESULTS

69 PwHTN were included and assigned to two groups, i.e., the RVO group (n = 37; 22 BRVO and 15 CRVO) and the control group (n = 32). There was no inter-group difference regarding age, gender distribution, and background diseases. Resolved INL lesions were more frequent in the RVO group (n = 26) than in the control group (n = 4) (70.3% vs. 12.5%, p < 0.001). BRVO and CRVO cases had similar prevalence of INL lesions in their fellow eyes. Unlike diabetes, ischemic heart disease, and gender, INL lesions were associated with RVO (in the fellow eye) with an odds ratio of 15.7 (95%CI: 4.17-76.73, p < 0.001).

CONCLUSION

We identified a substantially higher prevalence of INL lesions in PwHTN with RVO compared to PwHTN without RVO. The atrophic appearance of lesions suggests they may serve as early markers of increased RVO risk in individuals with systemic or cardiovascular predisposing factors.

Effects of Intravitreal Ranibizumab Injection to Treat Macular Edema due to Central Retinal Vein Occlusion on Choroidal Findings and Functional-Morphological Parameters

INTRODUCTION

Little research has examined the effects of anti-vascular endothelial growth factor therapy on subfoveal choroidal thickness (SCT), choroidal blood flow, aqueous flare, and humor levels of growth and inflammatory factors in patients with macular edema due to central retinal vein occlusion (CRVO).

METHODS

In 58 patients with macular edema due to CRVO treated by intravitreal ranibizumab injection (IRI), we retrospectively assessed best-corrected visual acuity (BCVA, assessed as the logarithm of the minimum angle of resolution [logMAR]), 8 aqueous factors (by suspension array), mean blur rate (MBR; estimated by laser speckle flowgraphy as a measure of choroidal blood flow), aqueous flare (with a laser flare meter), and SCT and central macular thickness (CMT; by optical coherence tomography).

RESULTS

After 4 weeks, IRI resulted in a significant improvement in BCVA and CMT and a significant reduction in SCT, choroidal MBR, and aqueous flare. SCT was significantly positively correlated with placental growth factor and significantly negatively correlated with platelet-derived growth factor-AA, and change in SCT was significantly negatively correlated with change in BCVA (logMAR). Aqueous flare was significantly negatively correlated with SCT.

CONCLUSION

Growth and inflammatory factors may be associated with SCT, and changes in SCT may be associated with changes in BCVA after IRI to treat macular edema due to CRVO.

Combined central retinal vein occlusion and cilioretinal artery occlusion as the initial presentation of frosted branch angiitis: a case report and literature review

PURPOSE

To report a case of combined central retinal vein occlusion (CRVO) with cilioretinal artery occlusion (CLRAO) that heralded the development of frosted branch angiitis (FBA).

CASE REPORT

A 25-year-old healthy male presented with sudden painless visual loss in his left eye with a visual acuity (VA) of 20/300. Fundus exam and fluorescein angiography showed signs of combined CRVO and CLRAO. Without treatment, his vision gradually improved until it reached 20/30 within four months. Five months after initial presentation, he returned with severe visual loss (20/400) in the same eye and a clinical picture of severe occlusive periphlebitis resembling a frosted branch angiitis pattern associated with severe macular edema. This was promptly and successfully treated with systemic steroids and immunosuppressive medications.

CONCLUSION

CRVO in young population can have an unusual course and one should carefully rule out underlying uveitic etiologies in each visit. Clinical suspicion and close follow‑up are required for early detection and timely management of FBA.

Central retinal vein occlusion associated with Bartonella henselae infection

PURPOSE

To report the clinical features and treatment course of a case of central retinal vein occlusion (CRVO) as the initial sign of ocular Bartonella henselae (B. henselae) infection.

OBSERVATION

A 36-year-old male was evaluated for unilateral vision loss. He denied prodromal symptoms but reported prior exposure to fleas. Best corrected visual acuity (BCVA) was 20/400 in the left eye. Clinical examination revealed a CRVO with atypical features including significant peripapillary exudates and peripheral vascular sheathing. Laboratory testing revealed elevated B. henselae IgG titers (1:512) with no abnormalities on hypercoagulability testing. The patient was treated with doxycycline and aflibercept with an excellent clinical response and improvement in BCVA to 20/25 in the left eye two months later.

CONCLUSION

CRVO is a rare but sight-threatening complication of ocular bartonellosis and can be the presenting sign of infection, even in the absence of cat exposure or prodromal symptoms.

Real-World Outcomes of Ranibizumab Treatment in French Patients with Visual Impairment due to Macular Edema Secondary to Retinal Vein Occlusion: 24-Month Results from the BOREAL-RVO Study

INTRODUCTION

Information about real-world ranibizumab use is needed to optimize treatment of macular edema secondary to retinal vein occlusion (RVO). The BOREAL-RVO study assessed treatment use, effectiveness, and safety of 24-month treatment with ranibizumab 0.5 mg in patients with visual impairment due to macular edema secondary to RVO in a real-world setting.

METHODS

This was a multicenter, post-authorization, observational study in France, including patients starting ranibizumab for RVO. Primary endpoint was mean change from baseline in best-corrected visual acuity (BCVA) at month 6. Secondary endpoints were mean changes from baseline in BCVA at month 24 and central retinal thickness (CRT) at months 6 and 24, and treatment use in real-world setting.

RESULTS

226 branch RVO (BRVO) and 196 central RVO (CRVO) patients were enrolled; 71.7% and 70.9% completed the 24-month follow-up, respectively. In BRVO, mean (SD) baseline BCVA was 55.2 (18.7) letters, with gains of 14.3 (13.7), 14.1 (16.5), 13.0 (17.5), and 11.4 (20.1) letters at months 3, 6, 12, and 24, respectively. In CRVO, mean (SD) baseline BCVA was 40.4 (25.6) letters, with gains of 16.0 (21.2), 9.5 (25.4), 9.2 (27.7), and 8.3 (23.8) letters at months 3, 6, 12, and 24, respectively. At month 24, 52% of BRVO and 41% of CRVO patients had gains of 15 or more letters. In BRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 550 (175), 315 (104), 343 (122), 335 (137), and 340 (105) μm. In CRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 643 (217), 327 (152), 400 (203), 379 (175), and 348 (161) μm. On average, BRVO patients had 3.8 injections for 6.9 visits by month 6, and 7.2 injections for 19.7 visits by month 24. CRVO patients had 2.7 injections for 4.2 visits by month 6 and 7.1 injections for 21.1 visits by month 24. Factors predictive of better BCVA gain at month 6 were age under 60 at baseline, lower baseline BCVA and BCVA gain at month 3. There were no new safety findings.

CONCLUSION

Major improvements in BCVA and CRT were observed at month 3 after the induction phase and then were sustained up to month 24, with a slight decrease, probably due to under-treatment. This study demonstrated ranibizumab to be a safe and effective treatment for BRVO and CRVO in the real-world setting, although more regular or proactive treatment could further improve outcomes.

Multiple sclerosis and glatiramer acetate: Risk factors for central retinal vein occlusion?

Multiple sclerosis may present an increased risk for venous thromboembolism. Ophthalmological symptoms include loss of vision, visual field loss, changes in color vision, diplopia and nystagmus. First-line treatments for multiple sclerosis are beta-interferon, glatiramer acetate, dimethyl fumarate and teriflunomide. To the best of our knowledge, no ophthalmologic side effects have been reported with glatiramer acetate. We present a woman with multiple sclerosis on glatiramer acetate therapy with a central retinal vein occlusion in the absence of other risk factors.

Emerging applications of bioinformatics and artificial intelligence in the analysis of biofluid markers involved in retinal occlusive diseases: a systematic review

PURPOSE

To review the literature on the application of bioinformatics and artificial intelligence (AI) for analysis of biofluid biomarkers in retinal vein occlusion (RVO) and their potential utility in clinical decision-making.

METHODS

We systematically searched MEDLINE, Embase, Cochrane, and Web of Science databases for articles reporting on AI or bioinformatics in RVO involving biofluids from inception to August 2021. Simple AI was categorized as logistics regressions of any type. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Among 10,264 studies screened, 14 eligible articles, encompassing 578 RVO patients, met the inclusion criteria. The use and reporting of AI and bioinformatics was heterogenous. Four articles performed proteomic analyses, two of which integrated AI tools such as discriminant analysis, probabilistic clustering, and string pathway analysis. A metabolomic study used AI tools for clustering, classification, and predictive modeling such as orthogonal partial least squares discriminant analysis. However, most studies used simple AI (n = 9). Vitreous humor sample levels of interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), and aqueous humor levels of intercellular adhesion molecule-1 and IL-8 were implicated in the pathogenesis of branch RVO with macular edema. IL-6 and VEGF may predict visual acuity after intravitreal injections or vitrectomy, respectively. Metabolomics and Kyoto Encyclopedia of Genes and Genomes enrichment analysis identified the metabolic signature of central RVO to be related to lower aqueous humor concentration of carbohydrates and amino acids. Risk of bias was low or moderate for included studies.

CONCLUSION

Bioinformatics has applications for analysis of proteomics and metabolomics present in biofluids in RVO with AI for clinical decision-making and advancing the future of RVO precision medicine. However, multiple limitations such as simple AI use, small sample volume, inconsistent feasibility of office-based sampling, lack of longitudinal follow-up, lack of sampling before and after RVO, and lack of healthy controls must be addressed in future studies.

Vision-related quality of life and subscale items following intravitreal ranibizumab injections for central retinal vein occlusion

PURPOSE

To evaluate the vision-related quality of life (VR-QOL) before and after intravitreal ranibizumab injections (IVR) for central retinal vein occlusion (CRVO) and to investigate subscale items of VR-QOL in detail.

STUDY DESIGN

A multicenter, open-label, prospective and comparative study.

METHODS

Twenty-three patients with treatment naïve CRVO and 22 age-matched normal controls were included. VR-QOL was assessed by 25-Item Visual Function Questionnaire (VFQ-25) before and up to 12 months post-treatment. The VFQ-25 composite score and 12 subscales were compared between CRVO patients and normal controls.

RESULTS

The VFQ-25 composite scores of CRVO patients showed significant improvement throughout the treatment period compared with baseline. The VFQ-25 composite scores both before and after treatment for CRVO were significantly lower than in normal controls. The subscale items, including general health, general vision, near activities, social functioning, mental health, role difficulties, dependency, and peripheral vision in CRVO, were significantly lower than in the normal controls even after treatment.

CONCLUSION

Vision-related QOL was low in patients with CRVO before treatment and improved with IVR. In spite of the improvements, several subscale items remained lower than in normal controls following treatment. Attention should be paid to the patients with CRVO and their decreased visual, social and psychological QOL.

Central Retinal Vein Occlusion after mRNA COVID-19 Vaccination

A 47-year-old man presented with visual loss in the right eye 8 h after the first dose of a coronavirus disease 2019 (COVID-19) vaccine developed by Pfizer/BioNTech (BNT162b2). The best corrected visual acuity (BCVA) was 20/200. Fundus examination showed dilated and tortuous retinal veins at the posterior pole, retinal hemorrhages throughout the fundus, and macular edema. Fluorescein angiography showed multiple hypofluorescent spots that appeared to be fluorescent block due to retinal hemorrhages and hyperfluorescent leakage from the retinal veins. The eye was diagnosed with central retinal vein occlusion (CRVO). For the treatment of macular edema, intravitreal injection of aflibercept (IVA) was administered and treated with one plus pro re nata regimen. Five IVAs were performed over a 10-month follow-up period, with resolution of macular edema, and the BCVA recovered to 20/20. The patient was young and had no history of diabetes mellitus, hypertension, or atherosclerotic diseases, and his blood tests showed no abnormal findings. Both antigen test and polymerase chain reaction test for COVID-19 were negative, and the antibody test was positive due to vaccination. The development of CRVO in this patient may have been related to COVID-19 vaccination, and the appropriate IVA treatment resulted in a good visual prognosis.

Bilateral Simultaneous Central Retinal Vein Occlusion Secondary to COVID-19: A Case Report

Herein, we report a case of bilateral simultaneous central retinal vein occlusion (CRVO) secondary to coronavirus disease 2019 (COVID-19). A 48-year-old man, with hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease, diagnosed with COVID-19 1 month ago presented to the ophthalmology department with blurred vision in both eyes for 2 weeks. Ocular examination revealed a classic clinical presentation of CRVO in both eyes. Optical coherence tomography revealed increased central macular thickness with intraretinal and subretinal fluid in both eyes. Laboratory data revealed elevated D-dimer and C-reactive protein (CRP) levels. The levels of other hypercoagulability markers were normal. The patient received intravitreal anti-vascular endothelial growth factor therapy in both eyes, followed by regular follow-up every month until complete resolution of symptoms and gradual improvement of the retinal vascular appearance. COVID-19 can cause a variety of coagulation abnormalities and thromboembolic complications such as bilateral simultaneous CRVO. Clinicians and patients should be aware of ocular symptoms and presentations that are probably associated with COVID-19.

Central retinal vein occlusion as primary ocular manifestation of rhino-orbital-cerebral mucormycosis: A case report

Mucormycosis is a serious, rapidly progressing, life-threatening, and sight threatening fungal infection frequently seen in diabetics and immunocompromised patients. We report a rare occurrence of rhino-orbital mucormycosis presenting as unilateral central retinal vein occlusion (CRVO) and no other ocular signs of infection in a 65-year-old diabetic male. The definitive diagnosis was made by nasal biopsy which confirmed broad branching aseptate fungal hyphae. The patient was treated with amphotericin B for mucormycosis and intravitreal anti-vascular growth factor (anti-VEGF) drug for macular edema. To conclude, although ophthalmoplegia is the most common ocular presentation and retinal artery occlusion is the most common cause of visual loss in mucormycosis, it may have many varied presentations including CRVO. A high index of suspicion must be kept in diabetics and immunocompromised patients.

Optociliary Shunt Vessels or Neovascularisation of the Optic Disc: Fluorescein Angiography Versus Optical Coherence Tomography Angiography

A 56-year-old man with a history of gallbladder carcinoma, hypothyroidism and hypertension was examined by us after developing marked visual loss in his left eye. A left ischaemic type of central retinal vein occlusion (CRVO) with macular oedema was diagnosed. Three months later, a non-ischaemic type of CRVO with no macular oedema developed in his right eye. While the left eye received five intravitreal ranibizumab injections and panretinal photocoagulation, the right central retinal vein occlusion improved spontaneously without any treatment. Ten months after his first visit we noticed optociliary shunt vessel formation in the right eye and neovascularisation of the optic disc in the left eye. Fluorescein angiography and optical coherence tomography angiography were performed at the same visit. The place of fluorescein angiography and optical coherence tomography angiography in distinguishing the optociliary shunt vessel from neovascularisation of the optic disc is discussed.

[Retinal vein occlusion : Intravitreal pharmacotherapies and treatment strategies for the management of macular edema]

Intravitreal injection treatment for the management of macular edema as an expression of increased capillary permeability and leakage constitute the mainstay of treatment in retinal vein occlusion. In contrast to diabetic retinopathy or neovascular age-related macular degeneration, permanent and complete functional and morphological restoration can be achieved, as retinal vein occlusions are usually associated with risk factors, but do not represent the manifestation form of an underlying systemic or degenerative chronic disorder; however, successful long-term management of retinal vein occlusion -associated macular edema usually requires intensive and also long-term continued treatment with vascular endothelial growth factor (VEGF) inhibitors or with a less favorable side effect profile, dexamethasone. A functional treatment success can be maintained over the long term by both pro re nata (PRN) or treat and extend (T&E) regimens. In contrast, according to the currently available data, the combination of anti-VEGF administration and grid laser treatment has no additional benefit compared to monotherapy. In patients with recalcitrant macular edema, switching to another intravitreal agent may be considered during the course of treatment, although a true therapeutic benefit with respect to the development of visual acuity has not yet been proven. The current review summarizes the relevant aspects in the management of RVO-associated macular edema and provides the foundations for the application of successful treatment strategies.

Central corneal thickness, axial length, anterior chamber and optic disc structure in patients with central and branch retinal vein occlusion

PURPOSE

To compare the central corneal thickness (CCT), the structural properties of the anterior chamber and optic disc in patients with central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), and controls.

MATERIAL AND METHODS

In this prospective study, 31 eyes of 31 CRVO patients (group 1) (mean age: 65.7 ± 10.2 male/female:16/15), 42 eyes of 42 BRVO patients (group 2) (mean age: 61.5 ± 9.9, male/female: 21/21), and 41 controls (mean age: 61.2 ± 15.3, male/female:15/26) were enrolled. Intraocular pressure (IOP), corrected IOP (IOPcorr), central corneal thickness (CCT), anterior chamber depth & volume (ACD & ACV), iridocorneal angle (ICA), axial length (AL), retinal nerve fiber layer (RNFL) thickness, ganglion cell layer (GCL) thickness, cup to disc ratio (C/D), cup & rim volume, the scleral canal diameter (SCD), and mean & pattern deviation in visual field of the eyes with CRVO/BRVO, their fellow eyes and control eyes were evaluated.

RESULTS

There was no significant difference in IOP among groups (p:0.239), while IOPcorr was significantly higher in eyes with CRVO compared with eyes with BRVO (p:0.003). Central corneal thickness was significantly thinner in CRVO than both BRVO and controls (p:0.005, p:0.002 respectively). The difference in the RNFL thickness was significant among groups (p:0.019), and it was detected significant between CRVO eyes and controls (p:0.05). Anterior chamber volume was lower in eyes with BRVO than in normal eyes (p:0.009). There was no significant difference in AL, ACD, rim volume, cup volume, GCL thickness, C/D ratio, ICA, and PSD among groups.

CONCLUSION

The patients with CRVO tend to have thinner corneas, and the evaluation of IOP and CCT can be overlooked during retinal follow-up. Intraocular pressure values corrected with CCT should always be take into account to prevent possible optic nerve damage.

Clinical Features and Treatment Outcome of a Concurrent Central Retinal Vein Occlusion and Cilioretinal Artery Occlusion

We describe the clinical features and treatment outcome of a patient with combined central retinal vein occlusion and cilioretinal artery occlusion. A 52-year-old female presented to our clinic with decreased vision in the right eye for 4 days. Visual acuity and intraocular pressure were count fingers at 2&1/2M and 14 mm Hg in the right and 20/20 and 16 mm Hg in the left eye, respectively. Funduscopic exam and optical coherence tomography (OCT) of the right eye confirmed the diagnosis of concurrent cilioretinal artery occlusion and central retinal vein occlusion with segmental macular pallor in the territory of the cilioretinal artery, corresponding marked inner retina thickening on OCT and signs of vein occlusion. The patient received an intravitreal injection of bevacizumab and at 1-month follow-up, vision improved to 20/30 with corresponding anatomical improvement. It is very important to recognize combined central retinal vein occlusion and cilioretinal artery occlusion as they could be treated with intravitreal injections of anti-vascular endothelial growth factors with favorable treatment outcomes.

Possible COVID-19 MRNA Vaccine-Induced Case of Unilateral Central Retinal Vein Occlusion

PURPOSE

To report a case of a patient with central retinal vein occlusion (CRVO), 2 weeks after the first dose of a COVID-19 mRNA vaccine.

RESULTS

A 35-year-old man presented with decreased vision on his right eye, 2 weeks after receiving the first dose of COVID-19 mRNA vaccine. During examination, signs of right CRVO were found. We started general checkup of the patient, extended with laboratory tests specific for VIPIT. No exact cause of the thromboembolic episode could be documented. With the applied therapy, symptoms resolved completely.

CONCLUSION

CRVO after COVID-19 mRNA vaccination is reported only in one case in the literature. In our case, the young age of the patient, the close onset of the symptoms to the vaccination and the negative systemic, immunologic and hematologic tests are suggesting a vaccine-induced thrombotic mechanism. We propose further investigation of vaccine-induced thrombotic mechanisms and also close follow of the reported cases.

Consecutive central and branch retinal vein occlusions in the same eye of a young healthy COVID-19 patient: A unique case report

Purpose

To report a case of consecutive central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) in the same eye correlated with coronavirus disease (COVID-19) of the otherwise healthy patient.

Observations

A 39-year-old woman with the diagnosis of COVID-19 infection for two weeks presented with a nonischemic central retinal vein occlusion (CRVO) in her right eye. The patient was on low-dose aspirin for anticoagulant prophylaxis (100 mg/day) for a week when the CRVO occurred. She had no history of any systemic risk factors for retinal vein occlusion (RVO) and her systemic evaluation failed to identify an etiology for her unilateral CRVO. While she was on monthly follow-up with no additional treatment, she experienced sudden visual acuity decrease in the same eye four months after the first RVO incident and one month after the cessation of aspirin intake. Her best corrected visual acuity (BCVA) was decreased from 20/25+ to 20/63. Her fundoscopic examination revealed increased intraretinal hemorrhages, dilated tortuous veins in the upper hemifield and macular edema. The central macular thickness measurement by optic coherence tomography was increased from 234 μm to 700 μm. The patient refused to undergo a fundus fluorescein angiography. After the diagnosis of the branch retinal vein occlusion with cystoid macular edema was done, the aspirin prophylaxis was restarted, and she received three intravitreal antivascular endothelial growth factor one month apart for her macular edema. Her BCVA improved to 20/20, and macular edema disappeared without any recurrence during the 6-month follow-up.

Conclusions and importance

To the best of our knowledge, this unique case is the first report of consecutive RVOs in the same eye of a healthy young patient associated with COVID-19. As our case report demonstrated, close follow-up and timely initiation of appropriate treatment could give rise to complete resolution of RVO.

Clinical Features of Central Retinal Vein Occlusion in Young Patients

Retinal vein occlusion (RVO) is the second most common retinal vascular disease. Central RVO (CRVO), in which obstruction occurs posterior to the lamina cribrosa due to various causes, manifests with extensive venous tortuosity, dilatation of blood vessels in the four quadrants, and retinal hemorrhage. The presence of macular edema decreases visual acuity in patients with CRVO, especially in elderly patients with hypertension, hyperlipidemia, and diabetes. In the last decade, treatment modalities for CRVO have improved, with anti-vascular endothelial growth factor agents being widely used as treatment. However, there are cases of refractory or recurrent macular edema. Moreover, CRVO also occurs in young patients. This article reviews previous studies and case reports and summarizes the differences in etiological factors, clinical manifestations, treatment, and prognosis between young and elderly patients. Due to the low incidence of CRVO in young patients, clinical data from these age groups are limited. Hence, further studies are warranted to explore the differences between age groups to improve individualization of treatment of young patients.

COVID-19 AdenoviralVector Vaccine and Central Retinal Vein Occlusion

PURPOSE

The purpose of this article is to report a case of sudden onset ischemic retinal central vein occlusion after a second dose of COVID-19 adenoviral vector vaccine.

CASE REPORT/OBSERVATIONS

A 54-year-old woman with systemic arterial hypertension developed ischemic central retinal vein occlusion in her right eye on day 2 after the second dose of COVID-19 adenoviral vector vaccine ChAdOx1 nCoV-19/ AZD1222, Oxford-AstraZeneca.

CONCLUSION

Adenoviral vector vaccine promotes both cellular and humoral immune responses, increasing the level of inflammatory cytokines. These cytokines are the same implied in the possible pathogenesis of central retinal vein occlusion. Subsequently, we recommend informing patients at risk of possible ocular adverse events, which require urgent evaluation.

Idiopathic combined retinal vessels occlusion in a pregnant woman: a case report

Background

Ocular vascular occlusion is an extremely rare event, especially in the young population. This diagnosis is always associated with active systemic diseases in young adults and needs thrombophilia workup. Nevertheless, we present the case of a pregnant woman suffering from idiopathic combined central retinal vein and cilioretinal artery occlusion.

Case presentation

A 36-year-old pregnant Iranian woman at the 36th week of her second pregnancy complained of subacute unilateral painless decreased vision of her left eye. She had experienced a transient vision loss that lasted several minutes, but attacks gradually became more frequent and finally persistent over a several-day period. Finally combined central retinal vein and cilioretinal artery occlusion was established. Her visual acuity improved to 4/10 in a month without any ocular intervention except for a short duration of prophylactic dose enoxaparin, and the acuity reached 8/10 without any complications in the third month follow-up visit. At 1 year follow-up, the visual acuity had not changed and no macular edema was seen.

Conclusions

Ocular vascular occlusion is extremely rare among young adults, and even rarer among pregnant women. According to this, any suspected retinal vascular event in this population should raise suspicion for underlying diseases such as hypertension, diabetes, autoimmune diseases, migraine, preeclampsia syndrome, and thrombophilia. However, as seen in this presented case, idiopathic ocular vascular occlusion events can occur also.

Comparison of each retinal layer thicknesses between eyes with CRVO and normal contralateral eyes

Purpose

To evaluate the difference in each retinal layer thickness in central retinal vein occlusion (CRVO) with resolved macular edema after intravitreal antivascular endothelial growth factor injection and normal contralateral eyes..

Methods

Patients with ischemic and nonischemic CRVO whose macular edema resolved after intravitreal antivascular endothelial growth factor injections and did not recur for at least 6 months, and a normal contralateral eye were enrolled. Each retinal layer thickness between CRVO and normal contralateral eyes was compared according to Early Treatment Diabetic Retinopathy Study subfields using spectral domain optical coherence tomography.

Results

The thicknesses of outer nuclear layer, photoreceptor layer, and retinal pigment epithelium in central ring, ganglion cell layer, inner plexiform layer, outer nuclear layer, and photoreceptor layer in the inner ring, and ganglion cell layer in the outer ring of CRVO eyes were significantly thinner than those of normal contralateral eyes (all p < 0.05). Whereas, inner nuclear layer and outer plexiform layer thicknesses in central ring of CRVO eyes were 23.86 ± 8.8 and 25.76 ± 7.6 μm, respectively, which was significantly thicker than those of normal contralateral eyes (19.52 ± 7.7 and 22.76 ± 6.5 μm; p = 0.019 and p = 0.043, respectively). Additionally, the mean best-corrected visual acuity of CRVO eyes were significantly correlated with photoreceptor layer thickness in central ring (p = 0.005).

Conclusions

In CRVO eyes with resolved macular edema, the outer retinal layers were thinner as well as inner retinal layers, whereas inner plexiform layer and outer nuclear layer were thicker than normal fellow eyes. Additionally, photoreceptor layer thickness in foveal area had a significant impact on visual acuity in CRVO.

SCORE2 Report 17: Macular thickness fluctuations in anti-VEGF-treated patients with central or hemiretinal vein occlusion

PURPOSE

To evaluate macular thickness fluctuations and their association with visual acuity outcome in eyes with macular edema (ME) secondary to central (CRVO) or hemiretinal vein occlusion (HRVO) treated initially with intravitreal aflibercept or bevacizumab.

METHODS

Post hoc analysis of 362 patients with ME secondary to CRVO or HRVO initially randomized to six monthly intravitreal injections of aflibercept or bevacizumab. Three spectral domain optical coherence tomography (SD-OCT) central subfield thickness (CST) fluctuation measures were investigated over Months 1-12: standard deviation (SD), number of turning points (T) for each participant, and a measure denoted as Zigzag reflecting the magnitude of alternating ups and downs in a participant's CST. Main outcome measure is Month 12 visual acuity letter score (VALS).

RESULTS

More fluctuations occurred in eyes randomized to bevacizumab than aflibercept: SD (59.98 vs 32.12; p < 0.0001), T (4.03 vs 3.53; p = 0.02) and Zigzag (24.91 vs 11.60; p = 0.0003). Month 12 VALS is significantly lower for the 4th (highest) quartile of the CST fluctuation measure than for the 1st (lowest) quartile for both SD (mean difference in VALS of 7.87; 95% confidence interval: 3.03, 12.70) and Zigzag (mean difference in VALS of 5.11; 95% confidence interval: 0.29, 9.93). SD and Zigzag quartiles were no longer significantly different after Month 1 VALS was added to the regression analysis.

CONCLUSIONS

Greater CST fluctuation as assessed by SD and Zigzag was negatively associated with Month 12 VALS. However, early post-treatment VALS is a stronger predictor of VALS outcomes than the CST fluctuation measures.

Optical coherence tomography biomarkers in patients with macular edema secondary to retinal vein occlusion treated with dexamethasone implant

Purpose

To evaluate the impact of optical coherence tomography (OCT) biomarkers on intravitreal dexamethasone (DEX) implant clinical outcomes in patients with macular edema secondary to retinal vein occlusion (RVO-ME).

Methods

Retrospective study conducted on a cohort of patients with RVO-ME, either naïve or previously treated, who underwent treatment with DEX implant and had a follow-up of 6 months. Anatomic success was defined as a central retinal thickness (CRT) < 250 μm or a relative reduction of CRT ≥10% from baseline. The primary endpoint was the mean change in CRT from baseline to month-6. Secondary end-points included changes in BCVA, the impact of baseline OCT biomarkers on functional and anatomic outcomes; and the impact of treatment on the different OCT biomarkers. OCT biomarkers associated with functional and anatomic outcomes were estimated using a logistic regression model.

Results

Fifty-seven eyes were included in the study. Baseline CRT was significantly decreased from 567.6 ± 226.2 μm to 326.9 ± 141.0 μm at month-6 (p < 0.0001). Baseline BCVA was significantly lower in the eyes with disrupted external limiting membrane (ELM) (mean 40.3 ± 21.3 letters) than in those with non-disrupted (mean 68.6 ± 10.7 letters) or partially-disrupted ELM (mean 59.6 ± 13.2 letters), p = 0.0001 and p = 0.0011, respectively. Baseline BCVA was significantly lower in eyes with > 20 hyperreflective foci (HRF) than in those with < 10 HRF (p = 0.0388). The eyes with disorganization of the retinal inner layers (DRIL) had lower baseline BCVA than those without DRIL (Hodges-Lehmann median difference: − 12.0 letters, 95% CI: − 25.0 to − 5.0 letters, p = 0.0042). At month-6, 26 (45.6%); 24 (42.1%), and 20 (35.1%) eyes achieved a BCVA improvement ≥5, ≥10, and ≥ 15 letters respectively. Forty (70.2%) eyes were classified as anatomic success at month-6. Logistic regression analysis found none factor significantly associated with success in the multivariate analysis.

Conclusions

The results of this study suggested a positive impact of DEX on CRT and BCVA in eyes with RVO-ME. No OCT-biomarkers were identified as predictors of clinical-outcomes. Additionally, presence of DRIL, presence of HRF (> 20), or disrupted ELM were significantly associated with worse baseline BCVA.

Retinal vascular occlusion in pregnancy: three case reports and a review of the literature

Background

Retinal arterial occlusive events in young patients are rare. However, because of physiological multifactorial adaptations during pregnancy, retinal vascular occlusive disease may occur spontaneously. In addition, a patent foramen ovale is a risk factor for an ischemic thromboembolic event. Since fluorescein angiography, a central tool in the evaluation of these occlusions, should be avoided during pregnancy, optical coherence tomography angiography, a novel technique, offers a good opportunity for visualizing vascular perfusion of retinal tissue.

Case presentation

Here we present a case series of three patients (Caucasian, nonsmoker) who visited our clinic owing to acute visual impairment and central scotoma. Using regular optical coherence tomography and optical coherence tomography angiography, retinal vascular occlusions were detected, thus initiating the evaluation of systemic risk factors. We report two patients (30 and 32 years old) who developed cilioretinal artery occlusion but whose etiology differed: one was of thromboembolic origin associated with patent foramen ovale, while the other was caused by hemodynamic blockade secondary to central retinal vein occlusion. In both cases, optical coherence tomography angiography revealed reperfusion of the cilioretinal artery occlusion. However, transient ischemia led to retinal atrophy after a few weeks. In the third patient (32 years old), 8 weeks after onset of scotoma, optical coherence tomography angiography revealed atrophy of the middle layers and impaired perfusion in the deep capillary plexus, and thus a paracentral acute middle maculopathy was diagnosed. All patients regained normal visual acuity and had otherwise uncomplicated pregnancies, and laboratory blood tests did not reveal any defects or alterations.

Conclusions

As shown here, optical coherence tomography angiography enables risk-free imaging of retinal vessel perfusion during pregnancy. Together with regular optical coherence tomography, it allows one to predict functional outcome according to the existing retinal occlusion-related atrophy.

CRVO associated with COVID-19 and MTHFR mutation in a 15-year-old male

Purpose

To report a case of a central retinal vein occlusion (CRVO) associated with COVID-19 in a patient predisposed to clotting due to a genetic mutation in methylenetetrahydrofolate reductase (MTHFR).

Observations

A 15-year-old male presented with 1 day of painless blurry vision in the left eye. Exam disclosed trace anterior chamber cell, anterior vitreous cell, optic nerve head edema, temporally displaced macular star, dilated tortuous veins, and diffuse intraretinal hemorrhages. Exam and FA was consistent with CRVO, however the macular star and OCT were suggestive of a neuroretinitis.The patient then presented to a children's hospital for further evaluation. A routine screen for COVID-19 via nasopharyngeal swab was positive with a high viral load. He also had a known history of an MTHFR mutation. Extensive laboratory and neuroradiologic evaluation excluded other infectious, inflammatory, and coagulopathic etiologies.

Conclusions and Importance

This is a case of CRVO associated with COVID-19 infection and an underlying systemic hypercoagulable mutation, with an initial presentation that mimicked neuroretinitis. This case provides valuable diagnostic learning points and expands our knowledge of possible ocular complications of COVID-19.

Quality-adjusted life years in macular oedema due to age-related macular degeneration, diabetes and central retinal vein occlusion: the impact of anti-VEGF agents in a tertiary centre in Greece

INTRODUCTION

Neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), and macular oedema due to central retinal vein occlusion (CRVO) are leading causes of vision loss, currently managed with anti-vascular endothelial growth factor injections (anti-VEGF). The aim of this study was to calculate QALYs in patients with nAMD, DME, and CRVO treated with anti-VEGF agents (QALYs⁺) in a Greek tertiary hospital setting and compare them to theoretical QALYs that the patients would have without treatment (QALYs^-).

MATERIAL AND METHODS

The study included 143 treatment-naive patients with macular oedema due to nAMD (n = 79), DME (n = 57), and CRVO (n = 7), who received anti-VEGF injections as monotherapy according to the Treat-and-Extend (T&E) protocol. The anti-VEGF agents were ranibizumab and aflibercept in equivalent fractions. QALYs where calculated by the formula QALY = Utility Value × Time, where "Time" refers to the follow-up period of the study. For QALYs^-, we assumed that visual acuity remained unchanged during this period.

RESULTS

Mean follow-up time was 1.3 ± 1.2 years in the nAMD group, 1 ± 1.3 years in the DME group, and 0.5 ± 1 years in the CRVO group. There was no statistically significant difference between QALYs^- and QALYs⁺ in all three ocular pathologies for the study period (p > 0.05 for each of the three statistical tests performed).

DISCUSSION/CONCLUSION

Possible explanations for the lack of significant difference between QALYs - and QALYs + in nAMD, DME, and CRVO groups, may be the short time horizon used in this analysis, the inclusion of data from the better-seeing eye (BSE) and the specific socio-economic, geographical and health care characteristics of this rural Greek area.

Evaluation of augmentation index and pulse wave velocity measurements in central retinal vein occlusion patients with and without hypertension

PURPOSE

To evaluate arterial stiffness using the pulse wave velocity (PWV) and augmentation index (AI) in central retinal vein occlusion (CRVO) patients.

METHODS

Forty-two CRVO patients (i.e., CRVO group) and 54 healthy controls (i.e., control group) were included in this comparative and cross-sectional study. The PWV, AI and augmentation pressure were measured with a noninvasive, oscillometric method.

RESULTS

The mean PWV, AI and augmentation pressure values were significantly higher in CRVO patients than in controls (p = 0.024, p < 0.001 and p = 0.001, respectively). The mean augmentation pressure, AI and PWV measurements were not statistically significant between CRVO patients with and without hypertension (p = 0.856 and p < 0.526, p = 0.432, respectively). Age, presence of hypertension, AI and PWV were found to be as independent risk factors of CRVO development (OR = 2.21, 95% CI [1.44, 3.38] and OR = 2.40, 95% CI [1.50, 3.86], OR = 3.2, 95% CI [1.70, 5.60] and OR = 5.70, 95% CI [2.00, 18.50], respectively).

CONCLUSION

The AI and PWV values were significantly higher in CRVO patients than in controls. These results indicate that similar abnormalities in the arterial wall structure may play an important role in the pathogenesis of the CRVO and cardiovascular diseases. In addition, our findings show that each patient with RVO should be examined in terms of systemic vascular pathologies.

Central Retinal Vein Occlusion in patients with COVID-19 infection: A systematic review

This systematic review summarizes the evidence on patients diagnosed with central retinal vein occlusion (CRVO) secondary to COVID-19. We searched PubMed and Google Scholar from its inception till June 2021. From an initial 55 publications, 10 studies provided specific information on COVID-19 patients with CRVO. Studies described 10 patients, 60% were male and the mean age was 39.3 ± 11.6 years. Blurred vision (40%) and decreased vision (50%) were the most common presenting complain. Symptom onset ranged from 5 days to 6 weeks after initial complaint of fever. Laboratory results showed elevated inflammatory markers and D-dimers in 60% of patients included in our review. Common treatment options were intravitreal anti-VEGF injections, steroids, and anticoagulants. Traditional co-morbidities like diabetes mellites, hypertension, and morbid obesity (hyperlipidemia) were observed in only 3/10 patients. The prognosis was excellent as all patients saw improvement in their condition. Our findings highlight the importance of identifying CRVO as an important complication of COVID-19 infection. Thus, physicians should not overlook the likelihood of CRVO in patients with COVID-19 infection and offer prompt treatment.

Five-year outcomes after intravitreal bevacizumab of treatment-naive eyes with macular edema secondary to CRVO in routine clinical practice: Results of the Pan-American Collaborative Retina Study (PACORES) group

PURPOSE

The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice.

METHODS

We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years.

RESULTS

At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p < 0.0001). At 5 years, 48 (47%) eyes had a gain of ≥ 3 lines, 41 (40.2%) eyes remained within 3 lines and 13 (12.7%) eyes had a loss of ≥ 3 lines of BCVA. The CMT improved from 740 ± 243 to 322 ± 179 µm (p < 0.0001). At 5 years, 59 (57.8%) eyes had a completely dry SD-OCT. Patients received a total of 10.6 ± 6.1 (range 6-27) injections. Baseline BCVA (p < 0.0001) and the duration of symptoms prior to initial anti-VEGF injection (p = 0.0274) were the only predictive factors for BCVA at 5 years.

CONCLUSIONS

After 5 years with an average of 10.6 injections, there was a mean gain of 0.22 logMAR. In addition, more eyes achieved a BCVA of ≥ 20/40, gained ≥ 3 lines and less patients had a BCVA ≤ 20/200. Eyes with a better baseline BCVA and a shorter duration of symptoms were more likely to achieve better BCVA at 5 years.

Retinal Blood Flow as a Predictor of Recurrence of Macular Edema after Intravitreal Ranibizumab Injection in Central Retinal Vein Occlusion

INTRODUCTION

To investigate the relationship between retinal blood flow and the presence or absence of macular edema (ME) recurrence after intravitreal ranibizumab injection (IRI) in patients with central retinal vein occlusion (CRVO).

METHODS

We reviewed the medical records of 16 eyes with ME associated with CRVO. All eyes had received pro re nata IRI. Repeat IRI was performed if the central macular thickness was ≥300 µm. At 12 months, patients without additional IRI in the past 6 months were assigned to the resolved group, and those with additional IRI, to the recurrence group. We used laser speckle flowgraphy (LSFG) to measure the mean blur rate (MBR) of the optic disc before and after IRI.

RESULTS

Ten of the 16 eyes were assigned to the resolved group, and the other 6 eyes to the recurrence group. At several visits in the 12 months after IRI, MBR was significantly higher in the resolved group than in the recurrence group. Percent change of MBR (%Δ MBR) from baseline was significantly higher in the resolved group than in the recurrence group at 1 month (initial %Δ MBR) and 11 and 12 months. Multivariate stepwise analysis showed that the initial %Δ MBR was significantly and negatively correlated with the number of IRIs.

DISCUSSION/CONCLUSION

These findings suggest that determining %Δ MBR in LSFG may be a useful way to determine the likelihood of ME recurrence in CRVO patients.

Central retinal vein occlusion secondary to varicella zoster retinal vasculitis in an immunocompetent individual during the COVID-19 pandemic - A case report

We report the occurrence of unilateral central retinal vein occlusion (CRVO) in a young yoga enthusiast who presented amidst the COVID-19 pandemic. Subtle signs of uveitis when systemically investigated revealed a multitude of causes, but ocular fluid polymerase chain reaction was positive for varicella zoster virus (VZV). The prompt initiation of antivirals resulted in a good visual outcome. Our case describes the rare presentation of VZV retinal vasculitis as CRVO in a young healthy individual and highlights the importance of early antiviral therapy for favorable outcomes.

Central Retinal Vein Occlusion in a 46-Year-Old Man with COVID-19: Case Report and Review of the Literature

A 46-year-old man with a history of well-controlled hypertension presented with a central retinal vein occlusion (CRVO) in his right eye, which was complicated by cystoid macular edema. When the patient noted new visual symptoms, he was also experiencing muscle aches and easy fatiguability. A standard hypercoagulability panel failed to identify an etiology for his CRVO. However, the patient underwent COVID-19 antibody testing, which returned positive. The patient received a series of aflibercept injections for his macular edema, and his vision improved. Further study is warranted to determine if there is any association between mild infection with COVID-19 and the development of CRVO.

Central retinal vein occlusion after laparoscopic sleeve gastrectomy in an 18-year-Old female

Purpose

To describe a case of central retinal vein occlusion (CRVO) in a young adult found to have elevated homocysteine after bariatric surgery and to review risk factors for CRVO in younger patients.

Observations

An 18-year-old female presented with a CRVO and severe cystoid macular edema (CME). She was normotensive, not on medications, and without known heritable hypercoagulable disease. Her medical history was notable for bariatric surgery and subsequently she was found to have nutritional deficiency, anemia, and elevated homocysteine. Her elevated homocysteine may have induced a hypercoaguable state that predisposed her to developing a CRVO. Treatment with bevacizumab dramatically improved her macular edema and visual acuity. Nutritional supplementation was initiated.

Conclusions

Elevated homocysteine in the setting of nutritional deficiency from prior bariatric surgery may cause a hypercoaguable state and is a potential risk factor for CRVO.

Importance

With the increasing prevalence of obesity and bariatric surgery, it is important to consider associated nutrient deficiency as a potential cause of induced hypercoagulability and increased risk for CRVO. Identification of these at-risk patients is especially important given this condition is easily treatable and may be present in younger individuals. To the best of our knowledge, this is the first reported case of a CRVO with elevated homocysteine in the setting of nutrient deficiencies from laparoscopic sleeve gastrectomy.

Central Retinal Vein Occlusion in a Young Healthy COVID-19 Patient: A Case Report and Literature Review

Coronavirus disease (COVID-19) has been declared by the World Health Organization as a pandemic on March 11, 2020. COVID-19 predispose patients to multisystem thromboembolic events, including pulmonary emboli and deep vein thrombosis. We report a 33-year-old previously healthy man, with previous history of COVID-19 infection presented with left eye central retinal vein occlusion (CRVO) with secondary macular edema. All possible risk factors for thromboembolic events were excluded. After a single dose of intravitreal injection of aflibercept (2 mg in 0.05 ml), gradual improvement in the clinical manifestation of CRVO with complete resolution of macular edema in the left eye was observed. To the best of our knowledge, this is the first report of CRVO post-COVID-19 in Oman.

Central retinal vein occlusion associated with creatine supplementation and dehydration

Purpose

Central retinal vein occlusions (CRVO) are relatively common; however, they are rare in young, otherwise healthy individuals. We report a case of CRVO associated with creatine supplementation and dehydration in a 25-year-old man.

Observations

A 25-year-old man developed a non-ischemic CRVO in the right eye. Comprehensive thrombophilia screening was unrevealing. Further questioning revealed that the patient was an avid weightlifter and had been taking creatine as a nutrition supplement daily for the past 5 years at a higher than recommended dose. At the time of CRVO onset, he was also restricting water intake in order to lose weight.

Conclusions and Importance

We conclude that the CRVO occurred in the context of creatine use and water restriction, leading to increased risk for thrombosis. Given the increased popularity for nutritional supplements to enhance fitness, it is important for individuals to recognize the association between CRVO, creatine supplementation, and hydration status.

Evaluation of non-exudative microcystoid macular abnormalities secondary to retinal vein occlusion

Purpose

We aimed to investigate non-exudative microcystoid macular abnormalities for visual and anatomical outcome in patients with retinal vein occlusion (RVO) with and without glaucomatous optic neuropathy (GON).

Methods

Medical records of 124 eyes (105 patients) with RVO were reviewed and analyzed. Eyes demonstrating microcystoid macular abnormalities were divided into 2 groups, those with evidence of glaucoma (group A) and those without glaucoma (group B). Best-corrected visual acuity (BCVA), the prevalence and number of microcystoid macular abnormalities, and number of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections were compared at baseline and follow-up.

Results

Seventy-one out of 105 eyes (67.6%) with RVO displayed microcystoid macular abnormalities. Thirty-eight out of 71 eyes (53.5%) presented with concomitant glaucoma (group A), while the remaining 33 eyes (42.6%) had no history of glaucoma (group B). At the end of the follow-up period, mean BCVA was worse in group A versus group B (20/80 versus 20/40, respectively; p = .003). The mean number of anti-VEGF injections was 10.1 ± 9.2 in group A versus 5.9 ± 6.9 in group B (p = .03).

Conclusion

Eyes with RVO and concomitant glaucoma exhibited a significantly higher number of microcystoid macular abnormalities and worse BCVA versus eyes with RVO without glaucoma.