Arterial and Venous Occlusive Disease of the Retina

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Arterial and Venous Occlusive Disease of the
Retina
Dr.M NAQEEB Assistant
professor Um Al-Qura university
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Objective

• Central retinal artery occlusion
• Branch retinal artery occlusion
• Branch retinal vein occlusion
• Central retinal vein occlusion

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retinal artery obstructions

• 57 of obstructions involved the central retinal
  artery
• 38 involved one of the branch retinal arteries
• 5 involved the cilioretinal artery

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Central Artery Obstruction

• Characteristics
• Sudden severe visual loss
• Painless
• Retinal appearance
• Opaque and edematous
• Most prominent in posterior pole
• Thickest ganglion cell layer
• Cherry-red spot
• Visible intact choroidal vasculature beneath the
  foveola

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Central Artery Obstruction

• Characteristics
• With time
• Artery re-canalizes
• Edema clears
• Visual loss is devastating and permanent
• Irreversible damage to neural tissue after 90
  minutes

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Intravenous fluorescein angiography
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Central Artery Obstruction

• Prognosis
• 20/400 or worse 2/3 of eyes
• 20/40 or better 1/6 eyes
• Intact cilioretinal artery
• Vision of NLP
• Implies ophthalmic artery occlusion
• Choroidal ischemia as well

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Central Artery Obstruction

• Pathogenesis
• Majority
• atherosclerosis-related thrombosis
• At the level of the lamina cribrosa
• Other causes
• Arterial spasm
• Dissecting aneurysm
• GIANT CELL ARTERITIS
• 1 of cases
• Check ESR in elderly patients!
• Start high does steroids if suspicious

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Central Artery Obstruction

• Management
• No good therapy exists, all treatments
  questionable
• Ocular message
• Anterior chamber paracentesis
• Attempt to acutely reduce IOP
• Dislodge thrombosis
• Inhalation therapy
• 95O2, 5CO2
• Stimulate vasodilatation
• Iris neovascularization
• Occurs in 18 of eyes
• 1-12 weeks later (usually 3-4 weeks later)
• Full PRP treatment required

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Branch Retinal Artery Obstruction

• Characteristics
• Vision loss
• Visual filed defect
• Within hours/days
• Edematous opacification of the retina
• In the distribution of the affected vessel

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Branch Retinal Artery Obstruction

• Pathogenesis
• Embolization or thrombosis of vessel
• Three types of emboli
• Cholesterol
• Hollenhorst plaques
• Arise from carotid
• Platelet-fibrin
• Associated with arteriosclerosis
• Calcific
• Diseased cardiac valves

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Retinal Embolization

• Hollenhorst plaque
• Glistening cholesterol emboli
• Found within retinal arteriole
• Typically lodge at bifurcations
• Arise in carotid arteries

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Retinal Embolization

• Hollenhorst plaque
• Glistening cholesterol emboli
• Found within retinal arteriole
• Typically lodge at bifurcations
• Arise in carotid arteries

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Branch Retinal Artery Obstruction

• Other causes of BRVO
• Migraine
• Particularly in smokers
• Trauma
• Coagulation disorders
• Sickle cell disease
• Oral contraceptive use
• Smoking, older women
• Mitral valve prolapse
• Infections
• Toxoplasmosis, syphilis
• Giant cell arteritis
• Check ESR in elderly patients
• Good prognosis

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Workup

• ESR,CBC and C-reactive protein
• Fasting blood sugar
• Glycosylated hemoglobin
• Doppler US for carotid artery
• ECG, echocardiogram
• Refer for haematology

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Mortality/Morbidity

• Further emboli to the brain resulting in CVA
• 55 death over 10 years
• 27 age matched population
• Further emboli to same or contralateral eye
  resulting in further visual loss
• Progression of temporal arteritis

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Venous Occlusive Disease
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Central Retinal Vein Occlusion

• Findings
• Dilated and tortuous retinal veins
• Swollen optic disc
• Intra-retinal hemorrhages
• Retinal edema

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Central Retinal Vein Occlusion

• Classification
• Based on amount of non-profusion on fluorescein
  angiography
• Ischemic
• 10 disk areas

• Non-ischemic
• lt 10 disk areas
• Indeterminate
• Too much hemorrhage to tell
• 80 progress to ischemic

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Central Retinal Vein Occlusion

• Pathogenesis
• Thrombosis of the central retinal vein
• At or posterior to the lamina cribrosa
• Atherosclerotic central retinal artery
• Impinges on central retinal vein
• Turbulent flow ? thrombus

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Central Retinal Vein Occlusion

• Non-ischemic CRVO
• Less dilation and vascular tortuosity
• Dot and flame hemorrhages in all quadrants
• Less or no disk swelling
• Angiogram shows
• Delayed A-V transit time
• Leakage
• Minimal capillary dropout
• Neovascularization is rare

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Central Retinal Vein Occlusion

• Ischemic CRVO
• Extensive hemorrhage
• Retinal edema
• Marked venous dilation
• Cotton-wool spots
• Angiogram show
• Widespread capillary nonprofusion
• Visual prognosis poor
• Only 10 have gt20/400 vision
• NVI
• As high as 60 of eyes
• Occurs 3-5 months post occlusion
• the three month glaucoma

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Central Retinal Vein Occlusion

• Risk Factors
• Eye Disease Case-Control Study
• Hypertension
• Diabetes
• Unlike BRVO
• Glaucoma
• Check and treat IOP!
• CRVO in young patients requires more extensive
  workup for cause

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CRVO In Young Patients Causes

• Systemic vascular disease
• Hypertension
• Diabetes mellitus
• Cardiovascular disease
• Blood dyscrasias
• Polycythemia vera
• Lymphoma
• Leukemia
• Clotting disorders
• Activated protein C resistance
• Lupus anticoagulant
• Anticardiolipin antibodies
• Protein C
• Protein S
• Antithrombin III

• Paraproteinemia and dysproteinemias
• Multiple myeloma
• Cryoglobulinemia
• Vasculitis
• Syphilis
• Sarcoidosis
• Autoimmune disease
• Systemic lupus erythematosus
• Oral contraceptive use in women
• Other rare associations
• Closed-head trauma
• Optic disc drusen
• Arteriovenous malformations of retina

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Central Retinal Vein Occlusion

• Management
• Family medical doctor to manage
• Hypertension
• Diabetes
• Elevated cholesterol

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Central Retinal Vein Occlusion

• Management
• Macular edema
• Central Vein Occlusion Study Group
• Grid laser treatment in the macula
• DOES reduce angiographic evidence of edema
• DOES NOT improve vision

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Central Retinal Vein Occlusion

• Management
• Macular edema
• Intravitreal trimcinolone/Avastin
• Capable of transiently improving vision
• Risks
• Glaucoma
• RD
• Cataract
• Endopthalmitis

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Central Retinal Vein Occlusion

• Management
• Iris neovascularization
• PRP to eyes prior to NVI
• NO benefit
• Even if very ischemic
• Once neovascularization detected
• Prompt PRP

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Central Retinal Vein Occlusion

• Outcome
• Most important predictor is initial visual
  acuity
• 20/40 or better
• Likely to remain unchanged
• 20/400 or less
• Likely to remain worse than 20/400
• 20/50-20/200
• 1/3 unchanged
• 1/3 improve
• 1/3 worse

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Branch Retinal Vein Occlusion

• Findings
• Within one sector of the retina
• Superficial hemorrhages
• Retinal edema
• Cotton-wool spots
• Dilated and tortuous vein
• Corresponding artery narrowed and sheathed

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Branch Retinal Vein Occlusion

• Findings
• Superotemporal quadrant most common
• 63
• Occurs at arteriovenous crossing
• Artery and vein bound together in a common sheath
• Arterial thickening compresses vein
• Turbulent flow ? thrombus formation

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Branch Retinal Vein Occlusion

• Risk factors
• Identified by the Eye Disease Case-Control Study
• Hypertension
• Cardiovascular disease
• Increased BMI at age 20
• Glaucoma
• Note Diabetes not an independent risk factor

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Branch Retinal Vein Occlusion

• Visual Loss
• Acute
• Macular hemorrhage
• Macular edema
• Capillary occlusion
• Chronic
• Macular ischemia
• CME
• Macular pigmentary changes
• Epiretinal membrane formation
• Subretinal fibrosis

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Branch Retinal Vein Occlusion

• Photocoagulation
• Used to treat
• Macular edema
• Requires intact foveal perfusion
• Neovascularization
• Macular edema
• Allow three months for improvement
• Vision 20/40 or worse
• Light grid pattern of laser spots to involved
  sector of retina
• Branch vein occlusion study
• Treated eyes more likely to gain 2 lines of
  vision
• Treated 65, untreated 37

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Branch Retinal Vein Occlusion

• Photocoagulation
• Neovascularization
• BVOS defined ischemic BRVO
• Area of non-profusion gt 5 disk diameters
• Large areas of non-profusion increase risk of
  neovascularization
• Apply scatter PRP to areas of retinal ischemia
• Only when neovascular complications develop
• NVI, NVE, NVD

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Branch Retinal Vein Occlusion

• Photocoagulation
• Must differentiate
• Neovascular tissue
• Leaks on fluorscein angiogram
• Collateral vessels
• Help to reduce vascular tissue
• Do not treat

Vascular Remodeling
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Thank you xoxo