Central Retinal Vein Occlusion

and Branch Retinal Vein

Occlusion
(Retinal Vein Occlusion)
by Sunir J. Garg, MD, FACS

Central retinal vein occlusion is a blockage of the central retinal

vein by a thrombus. It causes painless vision loss, ranging from
mild to severe, and usually occurs suddenly. Diagnosis is by
funduscopy. Treatments can include antivascular endothelial
growth factor drugs (eg, ranibizumab, pegaptanib, bevacizumab),
intraocular injection of a dexamethasone implant or triamcinolone,
and laser photocoagulation.

Etiology
Major risk factors include
Hypertension
Age
Other risk factors include
Glaucoma
Diabetes
Increased blood viscosity

Occlusion may also be idiopathic. The condition is uncommon among young

people. Occlusion may affect a branch of the retinal vein or the central retinal
vein.
Neovascularization (abnormal new vessel formation) of the retina or iris
(rubeosis iridis) occurs in about 16% of patients with central retinal vein
occlusion and can result in secondary (neovascular) glaucoma, which can
occur weeks to months after occlusion. Vitreous hemorrhage may result from
retinal neovascularization.

Symptoms and Signs

Painless vision loss is usually sudden but it can also occur gradually over a
period of days to weeks. Funduscopy reveals hemorrhages throughout the
retina, engorged (dilated) and tortuous retinal veins, and, usually, significant
retinal edema. These changes are typically diffuse if obstruction involves the
central retinal vein and are limited to one quadrant if obstruction involves only
a branch of the central retinal vein.

Occlusion

Diagnosis

Central Retinal Vein

 Funduscopy
Color fundus photography
Fluorescein angiography
Optical coherence tomography
The diagnosis is suspected in patients with painless vision loss, particularly
those with risk factors. Funduscopy, color photography, and fluorescein
angiography confirm the diagnosis. Optical coherence tomography is used to
determine the degree of macular edema and its response to treatment.
Patients with a central retinal vein occlusion are evaluated for hypertension
and glaucoma and tested for diabetes. Young patients are tested for increased
blood viscosity (with a CBC and other coagulable factors as deemed
necessary).

Prognosis
Most patients have some visual deficit. In mild cases, there can be
spontaneous improvement to near-normal vision over a variable period of
time. Visual acuity at presentation is a good indicator of final vision. If visual
acuity is at least 20/40, visual acuity will likely remain good, occasionally near
normal. If visual acuity is worse than 20/200, it will remain at that level or
worsen in 80% of patients. Central retinal vein occlusions rarely recur.

Treatment
For macular edema, intraocular injection of antivascular endothelial
growth factor (anti-VEGF) drugs, dexamethasone implant,
and/or triamcinolone acetonide
For some cases of macular edema with branch retinal vein occlusion,
focal laser photocoagulation

 Panretinal laser photocoagulation if neovascularization develops

Treatment for branch retinal vein occlusion in patients with macular edema
that involves the fovea is usually intraocular injection of an anti-VEGF drug
(eg, ranibizumab, bevacizumab) or intraocular injection of a slowrelease dexamethasone implant. These treatments, in addition to another antiVEGF drug called aflibercept, can also be used to treat central retinal vein
occlusion in patients with macular edema whose premorbid visual acuity was
better than 20/400. Patients with central retinal vein occlusion whose
premorbid visual acuity was better than 20/400 can also be treated with
intraocular triamcinolone injection. With these treatments, vision improves
significantly in 30 to 40% of patients.
Focal laser photocoagulation can be used for branch retinal vein occlusion
with macular edema but is less effective than intraocular injection of an antiVEGF drug or a dexamethasone implant. Focal laser photocoagulation is
typically not effective for the treatment of macular edema due to a central
retinal vein occlusion.
If retinal or anterior segment neovascularization develops secondary to central
or branch retinal vein occlusion, panretinal laser photocoagulation should be
done promptly to decrease vitreous hemorrhage and prevent neovascular
glaucoma.

Key Points
Retinal vein occlusion involves blockage by a thrombus.
Patients have painless loss of vision that is typically sudden and may
have risk factors (eg, older age, hypertension).
Fundoscopy characteristically demonstrates macular edema with dilated
veins and hemorrhages; additional tests include color fundus
photography, fluorescein angiography, and optical coherence
tomography.

 Treat patients who have macular edema with an intraocular injection of

an anti-VEGF drug (ranibizumab, pegaptanib, bevacizumab, or, for
central retinal vein occlusion, possibly aflibercept) or intraocular injection
of a dexamethasone implant or triamcinolone.
Focal laser photocoagulation is useful in some cases of macular edema
secondary to a branch retinal vein occlusion, and panretinal laser
photocoagulation should be done for retinal or anterior segment
neovascularization.
Last full review/revision September 2014 by Sunir J. Garg, MD, FACS