Management of Retinal Venous Thrombosis
The management of retinal vein occlusion (RVO) should focus on anti-VEGF agents as first-line treatment for macular edema, with intravitreal corticosteroids as second-line therapy, while aggressively managing underlying systemic risk factors to prevent recurrence and fellow eye involvement. 1
Diagnosis and Initial Assessment
- Comprehensive ocular examination to distinguish between Branch Retinal Vein Occlusion (BRVO) and Central Retinal Vein Occlusion (CRVO)
- Imaging studies:
- Optical Coherence Tomography (OCT) to evaluate macular edema
- Fluorescein angiography to assess retinal ischemia and detect neovascularization
- Additional assessments:
- Pupillary assessment for relative afferent pupillary defect (indicates level of ischemia)
- Gonioscopy to evaluate for neovascularization of the angle
- Careful examination for iris neovascularization
- Intraocular pressure measurement
Treatment Algorithm
1. Management of Macular Edema
First-line treatment:
- Anti-VEGF intravitreal injections 2, 1
- FDA-approved: ranibizumab, aflibercept
- Off-label: bevacizumab
- Typical dosing: Monthly injections initially, then as needed based on OCT findings
Second-line treatment:
- Intravitreal corticosteroids 2
- Triamcinolone acetonide
- Dexamethasone implant
- Note: Limited by side effects including glaucoma and cataract formation
Alternative treatment:
- Grid laser photocoagulation for persistent macular edema in BRVO cases 2
2. Management of Neovascularization
For BRVO with retinal neovascularization:
- Laser photocoagulation to areas of retinal nonperfusion 2
For CRVO with iris/retinal neovascularization:
- Extensive and complete peripheral panretinal photocoagulation (PRP) 2
- Consider initial anti-VEGF treatment for immediate benefit and to improve ability to deliver complete laser treatment 2
3. Systemic Risk Factor Management
- Aggressive control of hypertension, diabetes, and hyperlipidemia 2, 1
- Coordinate care with primary care physician or internist 2
- Consider systemic evaluation for less common causes in select high-risk patients 2:
- Hypercoagulable states
- Paradoxical emboli
- Septic emboli
4. Prevention of Recurrence
Antithrombotic therapy options:
- Anticoagulants may be more effective than antiplatelet therapy for improving visual acuity and reducing recurrence (7% vs 15% recurrence rate) 3
- Antiplatelet options:
- Other options:
Special Considerations
Central Retinal Artery Occlusion (CRAO)
- Requires immediate emergency department referral 2
- Consider intravenous tissue plasminogen activator (tPA) for patients presenting within 4.5 hours of symptom onset 2
- Historical strategies (anterior chamber paracentesis, ocular massage, hemodilution) are not beneficial for visual outcomes 2
Arteritic CRAO
- Screen for giant cell arteritis in patients over 50 2
- Immediate steroid therapy indicated to preserve vision in the contralateral eye 2
Follow-up and Monitoring
- Regular OCT imaging to monitor macular edema
- Careful examination for development of neovascularization
- Ongoing assessment of visual acuity
- Regular monitoring of intraocular pressure, especially with corticosteroid treatment
- Coordination with primary care for management of systemic risk factors
Potential Complications and Pitfalls
- Delayed treatment may result in reduced vision gain
- Failure to detect early neovascularization can lead to vitreous hemorrhage and neovascular glaucoma 1
- Inadequate systemic evaluation increases risk of recurrence and fellow eye involvement 1
- Overlooking giant cell arteritis in older patients can lead to delayed diagnosis and treatment 1
- Intravitreal corticosteroids can cause significant ocular side effects (secondary glaucoma, cataract formation) 2
By following this structured approach to the management of retinal vein occlusion, clinicians can optimize visual outcomes, reduce complications, and minimize the risk of recurrence.