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

From the Guidelines

Branch retinal vein occlusion (BRVO) should be treated with anti-VEGF injections, such as ranibizumab, aflibercept, or bevacizumab, as first-line therapy for macular edema, due to their proven efficacy in improving visual acuity and reducing edema. The diagnosis of BRVO typically involves a comprehensive eye examination, including optical coherence tomography (OCT) and fluorescein angiography (FA), to assess the extent of the occlusion and the presence of macular edema.

Treatment Options

• Anti-VEGF injections, such as ranibizumab (Lucentis), aflibercept (Eylea), or bevacizumab (Avastin), are the preferred initial treatment for macular edema associated with BRVO, as demonstrated by the BRAVO trial 1 and the VIBRANT trial.
• Intravitreal steroid implants, like dexamethasone (Ozurdex), may be considered as alternative or adjunctive therapy, but their use is limited by potential side effects such as glaucoma and cataract formation.
• Laser photocoagulation, including grid laser and sectoral panretinal photocoagulation (PRP), may be recommended for persistent macular edema or areas of retinal ischemia, but its use is generally reserved for cases where anti-VEGF therapy is contraindicated or ineffective.

Management and Follow-up

• Regular monitoring with OCT is essential to track macular edema and adjust treatment as needed.
• Patients should be advised to control systemic risk factors, such as hypertension, diabetes, and hyperlipidemia, to prevent recurrence or worsening of the condition.
• The use of topical povidone iodine is recommended before all intravitreal injections, while the use of routine antibiotic eye drops is not recommended 1.

Prognosis

• Visual prognosis varies but is generally favorable with prompt treatment, though some patients may experience permanent vision loss in the affected area despite intervention.
• Delaying treatment can be deleterious, as demonstrated by the BRAVO trial, which showed that eyes randomized to initial sham injection and then eligible for ranibizumab 0.5 mg after 6 months did not achieve the same level of vision gain as those eyes that were randomized to ranibizumab initially 1.

From the FDA Drug Label

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 † Adjusted estimate based on stratified model; p < 0. 01 Gain of ≥15 letters in visual acuity (%) RVO-1 29% 61% 31% (20%, 43%)

The diagnosis of Branch Retinal Vein Occlusion (BRVO) is not explicitly stated in the provided text, but it can be inferred that it is a condition characterized by macular edema following retinal vein occlusion. The treatment for BRVO is intravitreal injections of ranibizumab, with a dose of 0.3 mg or 0.5 mg, administered monthly for 6 months, as shown in Study RVO-1. Key points about the treatment include:

• Visual acuity outcomes: Patients treated with 0.5 mg ranibizumab showed a gain of ≥15 letters in visual acuity in 61% of cases, compared to 29% in the sham group.
• Treatment duration: The treatment was administered for 6 months.
• Dosing regimen: The dose of ranibizumab was 0.3 mg or 0.5 mg, administered monthly. 2

From the Research

Diagnosis of Branch Retinal Vein Occlusion (BRVO)

• BRVO is one of the most commonly occurring retinal vascular abnormalities, with the most common cause of visual loss being macular oedema (MO) 3, 4
• Diagnosis can be supported by multimodal evaluation, including color, blue filter, and red-free fundus photography, fluorescein angiography, fundus autofluorescence, and spectral-domain optical coherence tomography (SD-OCT) B and C scan imaging 5
• Characteristic findings on multimodal evaluation can include hard exudates, mild venous engorgement, and diffuse macular intraretinal hemorrhages 5

Treatment of BRVO

• Anti-vascular endothelial growth factor (anti-VEGF) agents, such as bevacizumab and ranibizumab, have been shown to be effective in treating MO secondary to BRVO 3, 6, 4
• Grid or focal laser photocoagulation has also been shown to reduce the risk of visual loss and improve visual acuity (VA) in up to two thirds of individuals with MO secondary to BRVO 3, 4
• Anti-VEGF treatment has been associated with improved visual and anatomical outcomes at six and 12 months, including increased visual acuity and reduced central retinal thickness 3, 6
• The frequency of re-treatment with anti-VEGF agents has not yet been determined, and the impact of prior or combined treatment with laser photocoagulation on the primary outcome is unclear 4

Treatment Outcomes

• Studies have shown that anti-VEGF treatment can lead to significant improvements in visual acuity and reduction in central retinal thickness 3, 6
• The proportion of eyes gaining 15 or more ETDRS letters was greater in the anti-VEGF group at six months and 12 months 3
• Mean visual acuity was better in the anti-VEGF group at six months and 12 months compared with control or laser treatment 3, 6
• Quality of life outcomes were also improved in patients treated with anti-VEGF agents 3, 6