What is the recommended treatment for a patient with a known retinal vein occlusion?

Treatment of Retinal Vein Occlusion

Intravitreal anti-VEGF agents (ranibizumab or aflibercept) are the first-line treatment for macular edema associated with retinal vein occlusion, providing superior visual outcomes compared to all other treatment modalities. 1, 2

Initial Treatment Algorithm for Macular Edema

First-Line: Anti-VEGF Therapy

• Begin with intravitreal anti-VEGF injections immediately for any patient with vision loss from macular edema secondary to either branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO). 2, 3

• FDA-approved options include ranibizumab 0.5 mg or aflibercept 2 mg administered intravitreally, with bevacizumab used off-label. 2, 4

• Start with 3 monthly loading injections, then transition to pro-re-nata (PRN) or treat-and-extend regimens based on OCT findings rather than visual acuity alone. 5

• Early treatment is critical—delays lead to suboptimal visual outcomes and permanent vision loss. 2, 5

• The BRAVO trial demonstrated that monthly ranibizumab resulted in 16-18 letter gains compared to only 7.3 letters with sham injections at 6 months. 2

Second-Line: Intravitreal Corticosteroids

• Reserve intravitreal corticosteroids (dexamethasone implant or triamcinolone) for patients with contraindications to anti-VEGF therapy. 2, 3, 5

• These agents are effective but carry significant risks including secondary glaucoma and cataract formation. 2

• Consider as an alternative when monthly follow-up for anti-VEGF injections is not feasible. 5

Third-Line: Laser Photocoagulation

• Grid laser photocoagulation is no longer recommended as initial therapy because recent trials (BRIGHTER and RETAIN) showed that adding laser to ranibizumab provided no additional benefit. 1, 2

• The CVOS demonstrated no value of focal photocoagulation for macular edema in CRVO patients. 1

• Laser may be considered only for patients who cannot receive injections or maintain follow-up. 1

Treatment of Neovascular Complications

For BRVO with Neovascularization

• Perform sectoral panretinal photocoagulation (PRP) when complications such as vitreous hemorrhage or iris neovascularization occur. 1, 2

For CRVO with Neovascularization

• Perform immediate and complete peripheral PRP for any iris or angle neovascularization. 1, 2, 3

• Consider initial anti-VEGF injection as adjunctive therapy to facilitate complete laser delivery and provide immediate benefit, though this is off-label without phase 3 trial evidence. 1, 3

• PRP prevents progression to neovascular glaucoma, a vision-threatening complication. 2

Critical Monitoring Protocol

First 6 Months (Monthly Visits)

• Perform monthly examinations for the first 6 months in all CRVO patients and ischemic CRVO patients after discontinuing anti-VEGF to detect neovascularization early. 1, 2, 3

• At each visit, assess:

  • Visual acuity 1, 3
  • Undilated gonioscopy before dilation to detect angle neovascularization 1, 3
  • Slit-lamp biomicroscopy with careful iris examination 1, 3
  • Intraocular pressure measurement 1, 3
  • Pupillary assessment for relative afferent pupillary defect 1
  • OCT imaging to monitor macular edema and guide re-treatment decisions 1, 3, 5
  • Dilated fundus examination of posterior pole and peripheral retina 1

Fluorescein Angiography

• Obtain fluorescein angiography before starting treatment and during follow-up to assess retinal ischemia and capillary nonperfusion. 3, 5

• Significant retinal ischemia increases risk for proliferative complications requiring laser treatment. 5

Systemic Evaluation and Risk Factor Management

• Immediately refer all RVO patients to their primary care physician for cardiovascular risk factor optimization, as RVO is associated with increased stroke and myocardial infarction risk. 1, 2, 3

• Communicate the following to the primary care provider:

  • Need for control of hypertension, diabetes, and hyperlipidemia 1, 3
  • Risk to the fellow eye 1
  • Smoking cessation counseling 3
  • Treatment of obesity and obstructive sleep apnea 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for spontaneous improvement—early intervention is essential for optimal outcomes. 2, 5

• Do not skip gonioscopy before dilation—angle neovascularization can be missed if pupils are dilated first. 3

• Do not add laser photocoagulation to anti-VEGF therapy expecting better outcomes—this has been proven ineffective. 1, 2

• Do not use visual acuity alone to guide re-treatment decisions—OCT findings are more reliable for detecting persistent or recurrent macular edema. 5

• Do not discontinue monitoring after 6 months in ischemic CRVO—neovascular complications can develop later. 1

Special Considerations

• Anti-VEGF therapy in RVO patients carries a small risk of arterial thromboembolic events, with stroke rates of 0.2% in the ranibizumab group versus 0.4% in controls at 6 months. 4

• All treatment modalities (anti-VEGF, laser, and intravitreal steroids) are cost-effective, with dollars per quality-adjusted life year ranging from $800-$26,000 for BRVO and $1,400-$16,000 for CRVO. 1, 2

• Patients who fail to respond to treatment should be referred for vision rehabilitation and social services. 1