What is the diagnosis and treatment for Branch Retinal Vein Occlusion (BRVO)?

From the Guidelines

Branch retinal vein occlusion (BRVO) should be treated with intravitreal anti-VEGF injections, such as ranibizumab, as the first-line therapy, due to its efficacy in improving visual acuity and reducing macular edema, as demonstrated in the BRAVO trial 1. The treatment of BRVO focuses on managing complications like macular edema and neovascularization.

• The use of intravitreal anti-VEGF injections, such as ranibizumab, aflibercept, or bevacizumab, is recommended as the first-line therapy 1.
• These injections are typically administered monthly initially, then as needed based on response.
• The BRAVO trial demonstrated the efficacy of monthly intravitreal ranibizumab injections in improving visual acuity, with a gain of 16 to 18 letters compared to a gain of 7.3 letters in the sham group at month 6 1.
• The benefits of ranibizumab were generally maintained by month 12, and approximately half of the eyes achieved resolution of edema and 80% had visual acuity of better than or equal to 20/40 in the HORIZON trial 1.
• Intravitreal steroid implants, like dexamethasone, may be used as alternative or adjunctive therapy, but are not recommended as the first-line treatment due to the risk of intraocular pressure elevations 1.
• Laser photocoagulation, including grid laser and scatter photocoagulation, remains an important treatment option for persistent macular edema and neovascularization 1.
• Patients should monitor their vision at home with an Amsler grid and maintain regular follow-up appointments, typically every 4-6 weeks initially.
• Controlling systemic risk factors, such as hypertension, diabetes, and hyperlipidemia, is crucial for preventing recurrence and involvement of the other eye 1.

From the FDA Drug Label

The safety and efficacy of ranibizumab were assessed in two randomized, double-masked, 1-year studies in patients with macular edema following RVO. In Study RVO-1, patients with macular edema following branch or hemi-RVO, received monthly ranibizumab 0.3 mg or 0. 5 mg intravitreal injections or monthly sham injections for 6 months. At Month 6, after monthly treatment with 0. 5 mg ranibizumab, the following clinical results were observed: Table 5 Visual Acuity Outcomes at Month 6 in Study RVO-1 and Study RVO-2 Outcome MeasureStudy*ShamRanibizumab 0.5 mg Estimated Difference (95% CI)†

• RVO-1: Sham, n=131; ranibizumab 0.5 mg, n=132 Gain of ≥15 letters in visual acuity (%) RVO-1 29% 61% 31% (20%, 43%) Figure 5 Mean Change in Visual Acuity from Baseline to Month 6 in Study RVO-1 and Study RVO-2

The branch retinal vein occlusion (BRVO) treatment with ranibizumab resulted in a significant improvement in visual acuity, with 61% of patients gaining ≥15 letters in visual acuity at Month 6, compared to 29% in the sham group, with an estimated difference of 31% (20%, 43%) 2.

• Key points:
  • Ranibizumab 0.5 mg was administered monthly for 6 months.
  • Visual acuity improved significantly in the ranibizumab group.
  • The study results suggest that ranibizumab is effective in treating macular edema following BRVO.

From the Research

Branch Retinal Vein Occlusion (BRVO) Treatment

• BRVO is a frequent cause of visual loss with currently insufficient treatment options 3
• The primary treatment against macular edema with BRVO has changed from laser photocoagulation to administration of intravitreal agents based on anti-vascular endothelial growth factor (VEGF) or anti-inflammatory strategies 4

Anti-Vascular Endothelial Growth Factor (Anti-VEGF) Treatment

• Anti-VEGF treatment such as ranibizumab, bevacizumab, or aflibercept improved vision by 13.9-16.2 letters (best-corrected visual acuity) after 12 months versus baseline in patients with macular edema secondary to BRVO 4
• Intravitreal anti-VEGF agents for preserving or improving vision in the treatment of macular edema secondary to BRVO have shown to be effective 5, 6
• Anti-VEGF intravitreal administration resulted in good vision in BRVO patients and is employed as a primary therapy 4

Comparison of Treatments

• Anti-VEGF treatment is recommended as first line treatment over intravitreal corticosteroid due to its effectiveness and lower rate of ocular adverse events 7
• Macular laser may have an adjunctive role in BRVO but not central retinal vein occlusion 7
• There was no significant difference between standard care and intravitreal triamcinolone groups in BRVO, and increased intraocular pressure and cataract progression occurred frequently in the triamcinolone group 4

Outcome Measures

• The primary outcome was the proportion of participants with an improvement from baseline in best-corrected visual acuity of greater than or equal to 15 letters (3 lines) on the Early Treatment in Diabetic Retinopathy Study (ETDRS) Chart at six months and 12 months of follow-up 5, 6
• Mean visual acuity (VA) change at six and 12 months, as well as the change in central retinal thickness (CRT) on optical coherence tomography from baseline at six and 12 months were also measured 5, 6