Retinal vein occlusion: Treatment
- Douglas J Covert, MD, MPH
Douglas J Covert, MD, MPH
- Associated Retinal Consultants
- Traverse City, MI
- Dennis P Han, MD
Dennis P Han, MD
- Jack A. and Elaine D. Klieger Professor of Ophthalmology Director
- Vitreoretinal Section Medical College of Wisconsin
Retinal vein occlusion (RVO) is an important cause of visual loss among older adults throughout the world . RVO is the second most common cause of vision loss from retinal vascular disease, following diabetic retinopathy . Despite many proposed interventions, there are no treatments proven to reopen occluded retinal veins. Current treatment is directed at secondary complications of RVO that affect vision, including macular edema, retinal neovascularization, and anterior segment neovascularization. Effective treatment for macular capillary nonperfusion, a fourth cause of visual loss in RVO, is not available.
Treatment modalities, including medical therapies, laser photocoagulation, and other surgical therapies, will be discussed here. Epidemiology, pathophysiology, clinical manifestations, and diagnosis of RVO are discussed separately. (See "Retinal vein occlusion: Epidemiology, clinical manifestations, and diagnosis".)
OVERVIEW OF TREATMENT
There are two major anatomic types of retinal vein occlusion: branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). BRVO occurs when a vein in the distal retinal venous system is occluded, leading to hemorrhage along the distribution of a small vessel of the retina. CRVO occurs due to thrombus within the central retinal vein at the level of the lamina cribrosa of the optic nerve, leading to involvement of the entire retina. Less commonly, hemiretinal vein occlusion may occur when there is blockage of a vein draining the superior or inferior hemiretina. (See "Retinal vein occlusion: Epidemiology, clinical manifestations, and diagnosis", section on 'Classification'.)
Treatment for patients with retinal vein occlusion (RVO) is directed at eliminating macular edema, retinal neovascularization, and anterior segment neovascularization. Goals of treatment are to maintain central visual acuity by minimizing the effects of chronic macular edema, reducing the risk of bleeding into the vitreous cavity by producing regression of retinal neovascularization, and preventing neovascular glaucoma that can occur in eyes with severe disease. Treatment also involves management of predisposing risk factors, such as diabetes and hypertension. (See "Overview of medical care in adults with diabetes mellitus" and "Overview of hypertension in adults".)
Macular edema — Pharmacologic treatment with intravitreal anti-vascular endothelial growth factor (VEGF) agents is currently first-line therapy for macular edema [3-8]. Intravitreal glucocorticoid therapy is considered an alternative for patients with edema refractory to anti-VEGF monotherapy . Grid laser photocoagulation therapy is another distant alternative for treatment of BRVO , but has limited, if any, benefit in patients with CRVO. There is no established role for prophylactic therapy for macular edema with either anti-VEGF therapy or laser therapy.
- Rogers S, McIntosh RL, Cheung N, et al. The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia. Ophthalmology 2010; 117:313.
- Cugati S, Wang JJ, Rochtchina E, Mitchell P. Ten-year incidence of retinal vein occlusion in an older population: the Blue Mountains Eye Study. Arch Ophthalmol 2006; 124:726.
- Braithwaite T, Nanji AA, Greenberg PB. Anti-vascular endothelial growth factor for macular edema secondary to central retinal vein occlusion. Cochrane Database Syst Rev 2010; :CD007325.
- Brown DM, Campochiaro PA, Singh RP, et al. Ranibizumab for macular edema following central retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology 2010; 117:1124.
- Campochiaro PA, Brown DM, Awh CC, et al. Sustained benefits from ranibizumab for macular edema following central retinal vein occlusion: twelve-month outcomes of a phase III study. Ophthalmology 2011; 118:2041.
- Prasad AG, Schadlu R, Apte RS. Intravitreal pharmacotherapy: applications in retinal disease. Compr Ophthalmol Update 2007; 8:259.
- Wroblewski JJ, Wells JA 3rd, Adamis AP, et al. Pegaptanib sodium for macular edema secondary to central retinal vein occlusion. Arch Ophthalmol 2009; 127:374.
- Brown DM, Heier JS, Clark WL, et al. Intravitreal aflibercept injection for macular edema secondary to central retinal vein occlusion: 1-year results from the phase 3 COPERNICUS study. Am J Ophthalmol 2013; 155:429.
- Scott IU, Ip MS, VanVeldhuisen PC, et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol 2009; 127:1115.
- Argon laser photocoagulation for macular edema in branch vein occlusion. The Branch Vein Occlusion Study Group. Am J Ophthalmol 1984; 98:271.
- Argon laser scatter photocoagulation for prevention of neovascularization and vitreous hemorrhage in branch vein occlusion. A randomized clinical trial. Branch Vein Occlusion Study Group. Arch Ophthalmol 1986; 104:34.
- A randomized clinical trial of early panretinal photocoagulation for ischemic central vein occlusion. The Central Vein Occlusion Study Group N report. Ophthalmology 1995; 102:1434.
- Yeh S, Kim SJ, Ho AC, et al. Therapies for macular edema associated with central retinal vein occlusion: a report by the American Academy of Ophthalmology. Ophthalmology 2015; 122:769.
- Aiello LP, Avery RL, Arrigg PG, et al. Vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. N Engl J Med 1994; 331:1480.
- Brown DM, Campochiaro PA, Bhisitkul RB, et al. Sustained benefits from ranibizumab for macular edema following branch retinal vein occlusion: 12-month outcomes of a phase III study. Ophthalmology 2011; 118:1594.
- Thach AB, Yau L, Hoang C, Tuomi L. Time to clinically significant visual acuity gains after ranibizumab treatment for retinal vein occlusion: BRAVO and CRUISE trials. Ophthalmology 2014; 121:1059.
- Campochiaro PA, Wykoff CC, Singer M, et al. Monthly versus as-needed ranibizumab injections in patients with retinal vein occlusion: the SHORE study. Ophthalmology 2014; 121:2432.
- Campochiaro PA, Heier JS, Feiner L, et al. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology 2010; 117:1102.
- Campochiaro PA, Sophie R, Pearlman J, et al. Long-term outcomes in patients with retinal vein occlusion treated with ranibizumab: the RETAIN study. Ophthalmology 2014; 121:209.
- Campochiaro PA, Clark WL, Boyer DS, et al. Intravitreal aflibercept for macular edema following branch retinal vein occlusion: the 24-week results of the VIBRANT study. Ophthalmology 2015; 122:538.
- Hikichi T, Higuchi M, Matsushita T, et al. Two-year outcomes of intravitreal bevacizumab therapy for macular oedema secondary to branch retinal vein occlusion. Br J Ophthalmol 2014; 98:195.
- Heier JS, Clark WL, Boyer DS, et al. Intravitreal aflibercept injection for macular edema due to central retinal vein occlusion: two-year results from the COPERNICUS study. Ophthalmology 2014; 121:1414.
- Ogura Y, Roider J, Korobelnik JF, et al. Intravitreal aflibercept for macular edema secondary to central retinal vein occlusion: 18-month results of the phase 3 GALILEO study. Am J Ophthalmol 2014; 158:1032.
- Ip MS, Scott IU, VanVeldhuisen PC, et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with observation to treat vision loss associated with macular edema secondary to central retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 5. Arch Ophthalmol 2009; 127:1101.
- Gewaily D, Muthuswamy K, Greenberg PB. Intravitreal steroids versus observation for macular edema secondary to central retinal vein occlusion. Cochrane Database Syst Rev 2015; 9:CD007324.
- Han DP, Heuer DK. Intravitreal corticosteroid therapy: putting the problem of glaucoma in perspective. Arch Ophthalmol 2012; 130:380.
- Haller JA, Bandello F, Belfort R Jr, et al. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology 2010; 117:1134.
- Kim M, Lee DH, Byeon SH, et al. Comparison of intravitreal bevacizumab and dexamethasone implant for the treatment of macula oedema associated with branch retinal vein occlusion. Br J Ophthalmol 2015; 99:1271.
- Squizzato A, Manfredi E, Bozzato S, et al. Antithrombotic and fibrinolytic drugs for retinal vein occlusion: a systematic review and a call for action. Thromb Haemost 2010; 103:271.
- Mohamed Q, McIntosh RL, Saw SM, Wong TY. Interventions for central retinal vein occlusion: an evidence-based systematic review. Ophthalmology 2007; 114:507.
- Chung EJ, Lee H, Koh HJ. Arteriovenous crossing sheathotomy versus intravitreal triamcinolone acetonide injection for treatment of macular edema associated with branch retinal vein occlusion. Graefes Arch Clin Exp Ophthalmol 2008; 246:967.
- Berker N, Batman C. Surgical treatment of central retinal vein occlusion. Acta Ophthalmol 2008; 86:245.
- OVERVIEW OF TREATMENT
- Macular edema
- Retinal neovascularization
- Anterior segment neovascularization
- MEDICAL THERAPY
- Vascular endothelial growth factor inhibitors
- - Evidence of effectiveness for BRVO
- - Evidence of effectiveness for CRVO
- - Intravitreal glucocorticoids
- - Effectiveness of intravitreal injection of triamcinolone
- - Effectiveness of glucocorticoid implant
- RETINAL LASER PHOTOCOAGULATION
- Antithrombotic and thrombolytic therapy
- SUMMARY AND RECOMMENDATIONS