How should I manage a patient with a superotemporal retinal vein occlusion who has hypertension, diabetes mellitus, and hyperlipidaemia?

Management of Superotemporal Branch Retinal Vein Occlusion

Initiate monthly intravitreal anti-VEGF therapy (ranibizumab 0.5 mg or aflibercept 2 mg) immediately if macular edema is causing vision loss, and simultaneously refer the patient to their internist for aggressive optimization of hypertension, diabetes, and hyperlipidemia control. 1

Immediate Ophthalmic Assessment

Your initial evaluation must document these specific parameters that drive treatment decisions:

• Visual acuity measurement – this is the single strongest prognostic factor for final visual outcome 2, 3
• Relative afferent pupillary defect (RAPD) testing – predicts ischemia severity and neovascularization risk 1, 3
• Slit-lamp examination – specifically inspect for fine abnormal iris vessels indicating early neovascularization 3
• Intraocular pressure measurement – baseline IOP is essential before initiating any therapy 3
• Dilated fundus examination – assess for hemorrhages, cotton wool spots, venous dilation/tortuosity, and hard exudates in the superotemporal quadrant 1
• Optical coherence tomography (OCT) – quantify macular edema and establish baseline retinal thickness 3
• Fluorescein angiography – define areas of capillary non-perfusion and differentiate ischemic from non-ischemic BRVO 1, 3

First-Line Treatment: Anti-VEGF Therapy

Anti-VEGF agents are the safest and most effective first-line therapy for macular edema causing vision loss in BRVO. 1, 2

Specific Regimens:

• Ranibizumab 0.5 mg intravitreally every 4 weeks – the BRAVO trial demonstrated 16-18 letter gains at 6 months versus 7.3 letters with sham 2, 4
• Aflibercept 2 mg intravitreally every 4 weeks – the VIBRANT trial showed 52.7% of patients gained ≥15 letters versus 26.7% with laser at 24 weeks 2
• Bevacizumab remains off-label but is commonly used in clinical practice 1

Critical Timing:

Do not delay anti-VEGF treatment awaiting spontaneous improvement; early therapy is essential for optimal visual outcomes. 4

Second-Line Treatment: Intravitreal Corticosteroids

Reserve corticosteroids only after ≥6 months of inadequate response to anti-VEGF therapy, when anti-VEGF is contraindicated, or as rescue therapy. 2, 4

• Triamcinolone acetonide and dexamethasone intravitreal implant are available options 1, 2
• The SCORE-BRVO trial showed approximately one-third of eyes in each treatment arm (laser, triamcinolone 1 mg, triamcinolone 4 mg) gained ≥15 letters at 12 months 1
• Major caveat: Corticosteroids carry significant risks of secondary glaucoma (requiring IOP monitoring at every visit) and cataract formation 1, 2

Management of Neovascular Complications

If retinal neovascularization or vitreous hemorrhage develops:

• Perform sectoral panretinal photocoagulation (PRP) to areas of non-perfusion – this decreases vitreous hemorrhage risk 1, 2, 4
• Anti-VEGF agents can be used adjunctively when PRP alone is insufficient to control angiogenesis or to facilitate complete laser delivery 1, 2

Important Distinction:

Grid laser photocoagulation added to ranibizumab provides no additional visual benefit or reduction in treatment burden (BRIGHTER and RETAIN trials). 4 Laser is now reserved exclusively for neovascular complications, not macular edema. 2, 4

Mandatory Systemic Risk Factor Management

Immediate referral to an internist is non-negotiable because BRVO is strongly associated with systemic vascular disease. 1

Evidence for Systemic Associations:

• 48% of RVO is attributable to hypertension 1, 4
• 20% to hyperlipidemia 1, 4
• 5% to diabetes mellitus 1, 4
• Patients with RVO have higher risk of cardiovascular disease and cerebrovascular accidents 1, 4
• 1% annual risk of developing RVO in the fellow eye 4

Coordination of Care:

Direct communication with the primary care physician is mandatory to optimize blood pressure control, glycemic control (HbA1c targets), and lipid management. 1 Document end-organ damage (retinal vascular occlusion) in your communication to emphasize urgency. 1

Follow-Up Protocol

Monthly monitoring for the first 6 months is essential and must include: 2, 4

• Visual acuity assessment 4
• Intraocular pressure measurement (especially if using corticosteroids) 4
• Slit-lamp examination with careful iris inspection 4
• OCT imaging to guide re-injection decisions 3, 4
• Dilated fundus examination to detect neovascularization 4
• Gonioscopy if elevated IOP or neovascularization risk is present 3

After the initial 6 months, if macular edema resolves and no neovascularization develops, transition to a PRN (as-needed) schedule with visits every 6-8 weeks. 4

Prognosis and Patient Counseling

• Approximately 50-60% of BRVO eyes achieve final visual acuity of 20/40 or better 2
• Initial visual acuity is the most important prognostic factor – eyes presenting with better baseline vision have better final outcomes 2, 3
• The severity of occlusion and extent of ischemia (assessed by fluorescein angiography) are critical determinants of final visual outcome 2

Common Pitfalls to Avoid

• Do not use corticosteroids as first-line therapy – the risk of IOP elevation and cataract formation makes anti-VEGF the safer initial choice 1, 4
• Do not perform macular grid laser photocoagulation – recent trials show no benefit when combined with anti-VEGF 4
• Do not neglect systemic evaluation – BRVO serves as a marker of underlying systemic vascular disease requiring aggressive risk-factor modification 1, 4
• Do not miss neovascularization – monthly dilated examinations during the first 6 months are required to detect this vision-threatening complication early 2, 4