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.
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- 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