What is the diagnosis and treatment for a plaque in the retinal vein of the eye?

Diagnosis and Treatment of Retinal Vein Plaque/Occlusion

The patient likely has a retinal vein occlusion (RVO), which requires immediate anti-VEGF intravitreal injections (ranibizumab or aflibercept) if macular edema with vision loss is present, along with urgent cardiovascular risk assessment within one week due to elevated stroke risk. 1, 2

Diagnostic Evaluation

The diagnosis is established through comprehensive ocular examination focusing on four critical features 1:

• Visual acuity testing is essential as baseline VA is the strongest prognostic factor for final visual outcome 1
• Pupillary assessment for relative afferent pupillary defect corresponds to ischemia severity and predicts neovascularization risk 1
• Retinal imaging (OCT and fluorescein angiography) to assess for macular edema, degree of ischemia, and neovascularization 1, 2
• Classification of RVO type: branch retinal vein occlusion (BRVO) versus central retinal vein occlusion (CRVO), as treatment algorithms differ 2, 3

Key Clinical Features to Document

• Duration and location of vision loss 1
• Cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, and smoking history 1, 4
• Retinal findings including hemorrhages, cotton-wool spots, dilated tortuous veins, and macular edema 5, 3
• Presence of neovascularization on iris, retina, or optic disc 2, 3

First-Line Treatment: Anti-VEGF Therapy

Anti-VEGF intravitreal injections are the first-line treatment for macular edema causing vision loss in RVO. 1, 2

• FDA-approved agents include ranibizumab 0.5 mg or aflibercept, with bevacizumab used off-label 2
• Evidence basis: The BRAVO trial demonstrated monthly ranibizumab resulted in 16-18 letter gains versus 7.3 letters with sham at 6 months 2
• Early treatment is crucial as delay leads to suboptimal visual outcomes 2
• Monthly monitoring for the first 6 months is essential to detect complications 1

Second-Line Treatment: Intravitreal Corticosteroids

Corticosteroids are reserved for patients with contraindications to anti-VEGF 1, 2:

• Options include triamcinolone or dexamethasone implant 1, 2
• Significant risks include secondary glaucoma and cataract formation 1, 2
• Use only when anti-VEGF therapy is contraindicated or ineffective 2

Treatment of Neovascular Complications

Panretinal photocoagulation (PRP) is indicated when neovascularization develops 6, 2:

• For BRVO: Sectoral laser photocoagulation to areas of nonperfusion prevents vitreous hemorrhage if retinal neovascularization is present 1, 2
• For CRVO: Dense peripheral PRP is the best treatment for iris or retinal neovascularization 2
• Anti-VEGF supplementation: Intravitreal anti-VEGF agents (off-label) may supplement or facilitate PRP treatment 6
• PRP decreases risk of progression to neovascular glaucoma 2

Critical Pitfall to Avoid

Grid laser photocoagulation was historically standard for BRVO macular edema, but recent trials (BRIGHTER and RETAIN) demonstrated that adding laser to ranibizumab did not improve visual outcomes or reduce treatment burden 2. Do not use laser as primary treatment for macular edema.

Urgent Systemic Evaluation Required

Patients with RVO must be referred for urgent cardiovascular evaluation within one week 6, 7:

• Stroke risk is highest within the first 7 days and remains elevated for 30 days 6, 7
• Up to 24% have concurrent cerebrovascular accident on diffusion-weighted MRI 6, 7
• Up to 70% have clinically significant carotid stenosis discovered on workup 6, 7
• Immediate referral to emergency department or stroke center for neurological evaluation is recommended 6, 7

Systemic Workup to Coordinate

• Cardiovascular risk factor optimization including control of hypertension, hyperlipidemia, and diabetes 1, 2, 4
• Vascular imaging to assess carotid artery status 7
• Brain MRI with diffusion-weighted imaging to detect silent infarctions 7
• Communication with primary care physician is essential for management of systemic risk factors 2, 7

Follow-Up Protocol

Monthly follow-up for 6 months is essential, particularly for CRVO and ischemic CRVO after discontinuing anti-VEGF to detect neovascularization 2:

• Visual acuity assessment 2
• Undilated slit-lamp biomicroscopy and gonioscopy with careful iris examination 2
• Intraocular pressure measurement 2
• Stereoscopic examination of posterior pole after pupil dilation 2
• OCT imaging when appropriate 2
• Peripheral retina and vitreous examination when indicated 2

Important Considerations

• Bilateral risk: Patients with RVO are at risk for developing RVO in the fellow eye 2
• Cardiovascular mortality: RVO patients have higher risk of cardiovascular disease and cerebrovascular accidents 2, 4
• Smoking cessation should be encouraged 6, 7
• No routine thrombophilia testing is recommended unless patient is young or has recurrent thrombotic events 3