clinical case presentation on branch retinal vein occlusion · clinical case presentation on branch...

Clinical Case Presentation

on

Branch Retinal Vein Occlusion

Sarita M.Registered NurseWhangarei Base Hospital

Content● Introduction● Case Study● Pathogenesis● Clinical Features● Investigations● Treatment● Follow-up● Nurses’ Role● Reference

Retinal Vein Occlusion

● 2nd most common retinal vascular disorder

● 2 main types: Central Retinal Vein Occlusion (CRVO)Branch Retinal Vein

Occlusion (BRVO)

● one of the most common cause of sudden painless unilateral vision loss

History and Presentation

Mrs. X, 72 y.o, healthy, fit and active

>hx of distortion L eye for 1 yr

> 1st clinic visit : Va R6/6 L6/24 IOP R15 L14

O/E: CMO left superotemporal area, R macula: normal

Plan:

Bevacizumab x 2 doses

Review + OCT 4/52

Clinic review after 2nd dose of Bevacizumab

> VA 6/6 6/15-1 IOPs: normal

O/E: slight blot hrge left ST macula

Plan: Bevacizumab x2

Review + OCT

OCT: persistent L superior macular oedema

Review after 4x doses of Bevacizumab

VA: L 6/9

O/E: L old hrge or a small area of pigmentation

Plan: 2 months f/u + OCT

OCT: nil swelling

2/12 clinic review:

VA : L 6/9

IOP: normal

O/E: recurrence of L mac oedema

Plan: 5th dose Avastin

Review 6/52 + OCT

OCT: recurrence of CMO

Review after 5x doses Bevacizumab

VA: L 6/7.5+1

O/E: stable, no oedema noted

Plan: 2 months f/u + OCT

OCT: nil CMO

Clinic review 2/12

2/12

VA: L 6/7.5

O/E: some collaterals ST macula

OCT: Slight thickening of RPE

Plan: Discharge

2/12

VA: L 6/7.5

O/E: some collaterals ST macula

Final Diagnosis: Left BRVO● defined as a segmental intraretinal haemorrhage ● 4x more than CRVO● Affects males and females equally ● Usually unilateral, 9% bilateral● Risk factors:

advancing age“Classic trio” : HTN, hyperlipidaemia, DM

50% of BRVO are hypertensive

PathophysiologyUsually occur at the arteriovenous (AV) junction

arterial compression to adjacent vein -->partial obstruction → inc intraluminal

pressure → transudation of blood to retina

Mac

oedema

Dec capillary tissue

perfusion

Tissue

ischaemia release of VEGF → inc vascular permeability

Hypoxia

Ischaemia

Clinical Features

Symptoms:

Sudden onset of painless unilateral distortion or loss of vision

Occasionally, floaters from vitreous haemorrhage

Signs:

Wedge-shape distribution of retinal haemorrhage

retinal thickening & oedema

cotton wool spots and hard exudates

dilated and tortuous veins

Investigations:

Optical Coherence Tomography

- Best method

- Measures macular oedema, and monitor the response to treatment

- Findings

Cystoid macular oedema, serous macular detachment, subretinal fluid

OCT angiography - newer technology

can measure vascular density

can observe the superficial and deep capillary networks, non flow areas, vascular dilation,and intraretinal oedema

Investigations:

Fundal Fluorescein Angiography-

information on the extent and location of the disease

to study the choroidal and retinal vascular filling

Findings

- delayed venous filling in the area of occlusion

- capillary nonperfusion

- Dye extravasation from macular oedema or retinal

neovascularization

Treatment:

is address to limit damage and progression of the disease

Main purpose : is the resolution of the macular oedema before the foveal

photoreceptor layer is damaged

Treat the BRVO complications eg macular oedema, retinal neovascularization,

vitreous hrge, and tractional retinal detachment

Treatment

1. Anti -VEGFs - treatment of choice for mac oedema and choroidal

neovascularization

Bevacizumab

Ranibizumab

Aflibercept

Treatment

2. Laser photocoagulation

TreatmentMechanism:

Destruction of photoreceptor of the ischaemic retina

Decrease oxygen demand

Increase oxygen influx

Arteriolar constriction and inc resistance

Dec capillary hydrostatic pressure

Less transudation of fluid

Less oedema

TreatmentCorticosteroids

Triamcinolone acetate

Anti-inflammatory effect

Antiangiogenic properties

Inhibition of VEGF and other inflammatory cytokines

Complications: inc IOP and cataract formation.

Treatment

Surgery

Arteriovenous sheathotomy (AVS)

Pars plana vitrectomy + AVS

Vitrectomy

Retinal artery bypass

Treatment

Medical

Anti-platelet treatments

- Ticlopidine

- Beraprost

- Heparin

- Tissue plasminogen activator

Follow-up

Initially, followed closely every month or 2 months to monitor macular

oedema and neovascularization

Anti-VEGF treatment with or without laser should be started if without

spontaneous improvement

With stable or resolved macular oedema, follow-up interval can be 3-6

months or even longer for stable chronic cases.

Northland DHB: Monthly intravitreal injections

Nurses’ Role

Triage and history taking

Monitor and assess stable BRVO cases

Administer IV anti-VEGF injection

Education

References:[1] Jaulim,A.,Ahmed,B.,Khanam,T.,Chatziralli,I. (2013): Branch retinal vein occlusion:Epidemiology,pathogenesis,risk factors, clinical

features,diagnosis, and complications. An update of the literature. Retina,33(5), 901-910. doi: 10.1097/IAE.0b013e3182870c15

[2] Patel, M., Prisant, L., & Marcus, D. (2003). Branch Retinal Vein Occlusion. The Journal of Clinical Hypertension, 5(4), 295-297. doi:

10.1111/j.1524-6175.2003.02469.x

[3] Karia, N. (2010). Retinal vein occlusion: pathophysiology and treatment options. Clinical ophthalmology, 4, 809-816. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915868/

[4] Chatziralli, I., Nicholson, L., Sivaprasad, S., & Hykin, P. (2015). Intravitreal steroid and anti-vascular endothelial growth agents for the

management of retinal vein occlusion: Evidence from randomized trials. Expert Opinion on Biological Therapy.,15(12),1685-1697.

http://dx.doi.org/10.1517/14712598.2015.1086744

[5] Duker, J., Waheed, N., & Goldman, D. (2014). Handbook of retinal OCT : Optical coherence

tomography. Retrieved from

https://www-clinicalkey-com-au.ezproxy.auckland.ac.nz:9443/#!/content/book/3-s2.0-B978032318884500032X

[6] Biousse, V., & Newman, N. (2009). Neuro-ophthalmology Illustrated. New York, NY: Thieme Medical Publishers, Inc.

[7] Lattanzio, R., Torres Gimeno, A., Battaglia Parodi, M., & Bandello, F. (2011). Retinal Vein Occlusion: Current Treatment. Ophthalmologica,

225(3), 135-143. doi:10.1159/000314718)

Li, J., Paulus, Y. M., Shuai, Y., Fang, W., Liu, Q., & Yuan, S. (2017). New Developments in the Classification, Pathogenesis, Risk Factors, Natural

History, and Treatment of Branch Retinal Vein Occlusion. Journal of Ophthalmology, 2017.