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IN THE NAME OF GODRVO EVALUATION&TREATMENT

ETESAMPOOR MD vitroretinal flowshipResponse to questionsLaboratory testsOphthalmic testOphthalmic treatmentsPrognosisHow to fallow up

CRVO EVALUATIONSYSTEMIC VASCULAR DISEASE:diabetes mellitusHypertension, carotid insufficincy.OCULAR DISEASES:open angle glacuma,Ischmic optic neuropathy,pseudotumor cerebriTilted optic nerve head,optic nerve head drusenHEMATOLOGIC ALTERATION:hyperviscosityMultiple myeloma,blood dyscrasias,anemia&INFLAMMATORY/AUTOIMMUNE VASCULITIS:SLEMEDICATIONS:oral contraceptives,duretics,Hepatitis B vaccine,INFECTIOUS VASCULITIS:HIV,syphilis,herpes zosterOTHER:retrobulbar block,dehydration,pregnancyCRVO EVALUATIONSYSTEMIC WORKUP is not indicated in personolder than60 years of age with known systemic Vascular risk factors for CRVO.younger patient are more likely to have predispo-Ing conditions resulting in thrombotic disease.A limited systemic workup may be considered inthose with prior occlusion in the fellow eye,prior systemic thrombotic disease,family historyof thrombosis,hematologic or rheumatologic .

CRVO EVALUATION:LAB.testsCBC,ESR,FBS,ANA,ANTIPHOSPHOLIPID Abfasting plasma homocysteine level.In bilateral,simaltaneous CRVO or mixed-typeretinal vascular occlusions should have detailedevaluation for a hypercogulable condition, as these persons may be at risk for future,non-Ocular thrombotic events.OPHTHALMIC TEST IN CRVOWide-angle FA 30 second after Iv injection ofSodium fluorescein.classification:perfused[less than 10 disc areas of capillary nonperfusion]non perfused[10 or more disc areas of retinal capillary nonperfusion] indeterminate [intraretinal hemorrhage prevent angiographic determination of perfusion status].OCT

THERAPEUTIC OPTIONS IN CRVOMACULAR EDEMAObservationCorticosteroid therapyIntravitreal anti-VEGF therapyNEOVASCULARIZATIONLaser photocoagulationMedical therapyALTERNATIVE TREATMEHTSChorioretinal venous anastomosisTissue plasminogen activatorSurgical treatments:vitrectomy,radial optic neurotomy,MACULAR EDEMAOBSERVATIONWidespread damage to the perifovealcapillary netwrk has been hypothesized to contribute to the lack of visual recovery.

MACULAR EDEMACORTICOSTEROID THERAPYIt is believed that corticosteroid maintain anti-Inflammatory effects with modulation of production of cytokines and growth factor including VEGF.steroid are also stabilize bloodretinal barrier with reduction in vascular permeability.Eyes were treated with 1-mg IVTA every 4month for 1 yearand observed significant improvement in visual acuitycompared to observation.Primary ocular advers events included cataract formation and elevated Intraocular pressure.In chronic refractory CME sustained release intravitreal dexamethasone delivery system,OZURDEX,was approved .

MACULAR EDEMAIntravitreal anti-VEGF therapyCombined anti-VEGF and corticosteroid

OCULAR NEOVASCULARIZATIONLaser phothcoagulationCVOS recommended that PRP be deliveredpromptly after the development of NVI/NVA butnot in eyes with nonperfused crvo.Prophylactic PRP may be done in special risk factors for developing NVI/NVA[male gender,short duration of CRVO,extensive retinal nonperusion,and extensive retinal hemorrhage]

Optociliary shunt

SYSTEMIC MEDICAL CONDITIONTreatment of systemic vascular risk factors,coordination with the internist is strongly recommendedSystemic anticoagulation such as asprin or heparin,cannot prevent or alter the natural history of CRVO but may help prevent nonocular thrombotic events ,especially in individuals with known systemic vascular disease.Oral pentoxifylline is a potent vasodilator usedin systemic vascular diseases to improve perfusionto occluded vessels and enhance the development ofcollateral circulation.this drug reduct macular thickening but not change in VA or perfusion status.Hemodilation increased oxigen supply to the retina.Hemodilution is likely not appropriate for patient with anemia,renal insufficiency ,or pulmonary insuffcieny.

Response to questions BRVOLaboratory testsOphthalmic testOphthalmic treatmentsPrognosisHow to fallow up

BRVO EVALUATIONSystemic vascular diseases such as ateriosclerosDiabetis,smoking,hyperlipidemia,glaucoma,and ocular inflammatory disease.antiphosphlipid AB,elevated plasma homocystein level and low serum folate.Short axial lengthIn bilateral cases or cases involving young patients,systemic manifestation of infectiousdisease,inflammatory or autoimmune condition,neoplasm,or hypercoagulable states may be present.DIAGNOSTIC WORKUPPARTICULAR ATTENTION to the history of glaucoma and sign of intraocular inflammationIN YOUNG:CBC,FBS,prothrombin time/partial thromboplastin time,lipid panel,homocysteineanticardiolipin AB,protein C/SIN OLDER than 60,additional workup isnot necessary since the majority are idiopathic or due to hypertension or atherosclerosis.OPHTHALMIC TESTF/AFor delineate the retinal vascular caharacteristic That may have prognostic significance :macular Leakage and edema,macular ischemia,and large Segments of capillary nonperfusion that may Portend neovascularization[ischemic BRVO>5 disc diameters nonperfusion]In chronic cases ,when the hemorrhages have resolved,microvascular changes on F/Amay provide the only clues of a previous BRVO.When we have leakage and edema with cystoid involvement of the fovea,but no capillary nonperfusion, the macular edema is the cause of vision loss. when macular edema is present within the first6 month after a BRVO and there is little or no leakage on F/A,macular ischemia may be the cause of the macular edema and almost always spontaneously resorbs in the first year after occlusion,often with return of vision.OCT Used to monitor the response to treatment of macular edema and has been used in Place of F/A in some treatment trials for BRVO.

Chronic case of BRVO

TREATMENT OPTIONS IN BRVOMEDICAL TREATMENTLASER TREATMENTSTEROID TREATMENTANTI-VEGF TREATMENTFAVOR[ILUVIEN] STUDYSURGICAL MANAGEMENT[vitrectomy with orWithout sheathotomy]Medical treatmentIn most cases anticoagulant therapy has not been shown to be beneficial in either the prevention or the management of BRVO.Since thes systemic administration of anticoagulants can be associated with systemic complication, and could,in theory,increase the severity of intraretinal hemorrhage occurring in the acute phase,such therapy is not recommended.Laser treatment

Steroid treatmentTriamcinoloneCorticosteroid inhibit the expression of VEGF and reduce macular edema.Significant side-effects,including cataract and Glaucoma.1mg IVTA every 4 months reduced macular edema but not recommended as first line therapy and considered in patients where macular grid laser or other therapies are ineffective,as the treatment was found to be relatively safe,especially in pseudophakic eyes.Dexamethasone implant.FAVOR[ILUVIEN] sustained-release non-erodable,intravitreal implant for patients with macular edema due to BRVOorCRVO of>3 months,duration in phase 2 trial.prognosisBRVO:1/3 to1/2 of patients have return of vision to 20/40 or better without any therapy.31-41of patients with ischemic BRVO developed neovascularization or vitreous hemmorrhage,compared with11of patients With nonischemic BRVO.decreased vision for over 1 year as a result of macular edema are much less likely to regain vision spontaneously.When macular edema is present within the first 6 months after a BRVO and there is little or no leakage on FA,macular ischemia may be the cause of the macular edema .this edema always resorbs in the first year after the occlusion,often with return of vision.CRVO prognosisA perfused CRVO have better initial and final VAA nonperfused CRVO have poor VA and large areas of retinal capillary nonperfusion were significant factors associated with an increased risk of developing NVI/NVA.Initial VA was highly correlated with degree ofnonperfusion and prognosis.Follow upIn CRVO eye with initial acuity of 20/40 or better were generally examined every1-2 MO for 6 MO,then annually if stable.Eye with initial acuity worse than 20/200 wereSeen monthly for the initial 6 MO,then bimonthlyFor the next 6 MO.Eyes with 20/50 and20/200 have an intermediate risk of developing NVI/NVA and were also typically examined monthly for the first 6 MO.BRVO FOLLOW UPIn BRVO initially,patents followed closely everyMO or2 MO for macular edema and/or NVE.Once macular edema stabilized or resolved interval can be extended to 3-6 MO or even longer for stable chonic cases.Patients with previously untreated retinal nonperfusion >5disc diameters followd at closer intervals[3 months]due to the increased risk for neovascular complication.

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