From the Guidelines
The management of branch retinal vein occlusion (BRVO) should prioritize intravitreal anti-VEGF injections as first-line therapy, with agents like ranibizumab (0.5 mg), aflibercept (2 mg), or bevacizumab (1.25 mg) administered monthly initially, then as needed based on response, as demonstrated by the BRAVO trial 1. This approach is supported by the most recent and highest quality study, which showed that monthly intravitreal ranibizumab injections resulted in a gain of 16 to 18 letters compared with a gain of 7.3 letters in the sham group at month 6 1. Key considerations in the management of BRVO include:
- Addressing underlying risk factors such as hypertension, diabetes, and hyperlipidemia
- Using intravitreal corticosteroids such as dexamethasone implant (Ozurdex 0.7 mg) as second-line treatment, lasting 3-6 months but carrying risks of cataract formation and increased intraocular pressure
- Considering laser photocoagulation for persistent macular edema or areas of retinal ischemia, with grid laser for macular edema and scatter laser for neovascularization
- Regular monitoring with optical coherence tomography to assess treatment response
- Evaluating patients for complications like neovascularization, vitreous hemorrhage, and neovascular glaucoma The use of anti-VEGF therapy is supported by multiple studies, including the VIBRANT trial, which demonstrated the efficacy of aflibercept over grid laser treatment for macular edema in BRVO 1. Additionally, the HORIZON trial showed that approximately half of the eyes achieved resolution of edema and 80% had visual acuity of better than or equal to 20/40 with repeat injections of 0.5 mg ranibizumab 1. It is essential to note that the management of BRVO should be individualized, and treatment decisions should be based on the specific needs and circumstances of each patient, as recommended by the retinal vein occlusions preferred practice pattern guidelines 1.
From the Research
Management of Branch Retinal Vein Occlusion
The management of branch retinal vein occlusion (BRVO) can be directed at the underlying etiology or the resulting sequelae. Options include:
- Surgical intervention
- Laser photocoagulation
- Intravitreal pharmacotherapy
- Sustained drug delivery devices 2
Treatment Modalities
Various treatment modalities have been proposed for BRVO, including:
- Grid laser photocoagulation, which is an established treatment for macular edema in a particular group of patients with BRVO 3
- Intravitreal application of steroids or new vascular endothelial growth factor inhibitors, which have shown promising results for this condition 3
- Vitrectomy with or without arteriovenous sheathotomy combined with removal of the internal limiting membrane, which may improve vision in eyes with macular edema that are unresponsive to or ineligible for laser treatment 3
- Intravitreal ranibizumab, dexamethasone intravitreal implant, and intravitreal triamcinolone acetonide injections, which have been compared in terms of their long-term efficacy and safety results in macular edema due to BRVO 4
Long-term Results
A retrospective study compared the long-term efficacy and safety results of intravitreal ranibizumab, dexamethasone intravitreal implant, and intravitreal triamcinolone acetonide injections in macular edema due to BRVO, and found that:
- Best-corrected visual acuity increased significantly in the ranibizumab and dexamethasone groups at all visits
- Central macular thickness decreased significantly in all groups at the end of one year of follow-up
- Intraocular pressure increased significantly in none of the patients in the ranibizumab group, 18.8% of the patients in the dexamethasone group, and 30% of the patients in the triamcinolone group 4
Clinical Findings and Natural History
BRVO is characterized by sectoral intraretinal hemorrhages, retinal ischemia, retinal exudates, and macular edema, and is predisposed by various systemic and local factors 5 Complications of BRVO include macular edema, capillary nonperfusion, retinal neovascularization, vitreous hemorrhage, and tractional retinal detachments that often result in loss of vision 5