From the Guidelines
Intravitreal anti-VEGF injections, such as ranibizumab, aflibercept, or bevacizumab, are the first-line treatment for macular edema due to Central Retinal Vein Occlusion (CRVO), as they have been shown to improve visual acuity and reduce macular edema in multiple randomized controlled trials, including the CRUISE and COPERNICUS studies 1. The symptoms of CRVO typically include sudden, painless vision loss in one eye, and may also include blurred vision, floaters, and blind spots.
Treatment Options
- Intravitreal anti-VEGF injections, such as ranibizumab (0.5 mg), aflibercept (2 mg), or bevacizumab (1.25 mg), are recommended as first-line treatment for macular edema due to CRVO, with treatment typically given monthly initially then as needed based on response 1.
- Intravitreal steroid implants, such as dexamethasone (Ozurdex 0.7 mg), may be used as alternative or additional therapy, but their use is associated with risks of cataracts and glaucoma 1.
- For neovascular glaucoma, anti-VEGF injections and possibly panretinal photocoagulation are recommended.
Key Considerations
- Underlying risk factors, such as hypertension, diabetes, hyperlipidemia, must be addressed, and anticoagulation should be considered if appropriate.
- Regular follow-up is essential, initially every 4 weeks, to monitor for complications like macular edema, neovascularization, and glaucoma.
- Visual prognosis varies widely, with non-ischemic CRVO generally having better outcomes than ischemic CRVO, and early diagnosis and prompt treatment are crucial to preserve vision and prevent complications. Some studies, including the SCORE2 study, have compared the efficacy of different anti-VEGF agents, such as aflibercept and bevacizumab, and found them to be similar in terms of visual acuity outcomes 1. However, the choice of treatment should be individualized based on patient factors and response to treatment.
From the Research
Symptoms of Central Retinal Vein Occlusion (CRVO)
- Macular edema, which may develop and lead to a reduction in visual acuity 2, 3
- Retinal hypoxia with upregulation and release of vascular endothelial growth factor (VEGF) 4
- Impaired venous drainage leading to the breakdown of the blood-retinal barrier 4
- Visual acuity loss, with the visual prognosis being poor in a substantial proportion of patients, especially those with the ischemic subtype 3
Treatment Options for CRVO
- Anti-vascular endothelial growth factor (anti-VEGF) agents, which have been shown to improve visual outcomes in patients with macular edema due to CRVO 2, 3, 5, 4
- Intravitreal injections of anti-VEGF agents, such as aflibercept, bevacizumab, pegaptanib sodium, and ranibizumab 2, 3, 4
- Pro re nata (PRN) protocol for improving vision and maintaining gains over long-term follow-ups 5
- Laser therapy and switching between anti-VEGF agents and/or steroids for non or partially responding patients 5
- Intravitreal corticosteroids, which may be considered as an alternative treatment option 2
Efficacy of Treatment Options
- High-quality evidence from six trials revealed that participants receiving intravitreal anti-VEGF treatment were 2.71 times more likely to gain at least 15 letters of visual acuity at six months compared to participants treated with sham injections 2
- Treatment with anti-VEGF agents led to an improvement in visual acuity of ≥ 15 letters in 55.3% (COPERNICUS) and 60.2% of patients (GALILEO) 4
- Patients receiving anti-VEGF treatments experienced a significant reduction in central retinal thickness (CRT) compared to those receiving sham injections 2
Long-Term Outcomes
- Long-term follow-up demonstrated that patients responding poorly to anti-VEGFs tended to do so early in the course of treatment 5
- The SHORE study demonstrated that there were minimal differences in visual outcomes between patients receiving monthly injections and patients being treated PRN 5
- A seven-year follow-up study found that both CRVO and BRVO eyes experienced a significant visual acuity improvement secondary to anti-vascular endothelial growth factor/dexamethasone treatments 6