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Central retinal vein occlusion and anti-VEGF treatment

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Julian Lovell
BOptom(Hons) MBA PGCO
Hobart TAS

CASE REPORT

CC, a 59-year-old Caucasian male, presented with a five-day history of right visual symptoms. He complained of ‘patchy and sort of splotchy vision’ with ‘some scattered areas of vision loss’. He was not concerned as his ‘central vision seemed fine’. His general health was good with no history of trauma or past ophthalmic issues. He had no family history of any ocular or cardiovascular health problems and was not on medications. His blood pressure was 126/78.

His uncorrected acuity was R 6/12 L 6/12. He was astigmatic and presbyopic. His spectacle prescription was: R plano/-1.50 x 155  6/7.5  L plano/-1.75 x 45  6/6  Add +1.75 N5.

His pupil reactions were normal with no relative afferent pupil defect. IOP was R 11 mmHg L 11 mmHg at 10:00 am

His fundus examination showed features consistent with a right central retinal vein occlusion (CRVO). The left fundus was unremarkable. His right fundus (Figure 1) shows extensive haemorrhages, slight swelling of his optic nerve head and an area of central macular oedema. It is important to note that his acuity was still good at this stage (6/7.5) with very little ischaemic damage since the occlusion occurred five days earlier.

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Figure 1. Fundus photo five days post CRVO showing extensive retinal haemorrhages

The patient was referred to a retinal specialist ophthalmologist and was seen 48 hours later. At this stage, his right acuity had decreased to 6/12 and he was now very aware of the decrease in his vision levels.

His Spectralis OCT scan (Figure 2) showed marked central macular oedema. The wide-field fluorescein angiogram (Figures 3-5) showed some leakage at the optic nerve, leakage of vessels at the macula and extensive peripheral retinocapillary drop-out.

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Figure 2. Spectralis macular OCT scan showing marked macular oedema and thickening

The decision was made to treat CC with anti-VEGF therapy. At this stage he was injected with 0.05 mL (1.25 mg) of Avastin (bevacizumab) in his right eye and booked for review in one month. He was referred for a full blood examination, which showed his HDL and LDL cholesterol levels to be within normal limits. There were no abnormalities of his clotting factors and his ESR, serum homocysteine and blood glucose levels were normal.

At one month post-treatment, his right acuity had returned to 6/6 and he had no visual problems. His IOP was R 12 mmHg  L 13 mmHg. His Spectralis OCT scan (Figure 6) showed that his macular oedema had completely resolved and his fundus photo (Figure 7) showed that his retinal haemorrhages were starting to resolve. He will be reviewed again in another month to check for further macular oedema and may need further anti-VEGF treatment.

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Figures 3-5. Wide-field fluorescein angiography showing macular and optic disc
leakage and leakage of the peripheral retinal capillaries

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Figure 6. Spectralis macular OCT scan showing normal macular thickness one month post-treatment with complete resolution of the macular oedema

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Figure 7. Fundus photo one month post-treatment showing resolution of the macular oedema and haemorrhages

Discussion

This case illustrates the importance of prompt, timely treatment of CRVO with anti-VEGF therapy. If treatment is initiated prior to ischaemic changes developing, then the prognosis for visual recovery is very good. Initial presentation acuity can be a good indicator for the likelihood of ischaemia and hence visual prognosis.1,2

Non-ischaemic CRVO cases can still deteriorate and become ischaemic so they need to be closely monitored after treatment. CRVO has a higher association with glaucoma and post-treatment patients need to have monitoring of their IOP and optic discs. Risk factors for CRVO include age, hypertension, hyperlipidaemia, diabetes, oral contraception,3 elevated serum homocysteine,4 low vitamin B12 levels,4 raised IOP and smoking. In this case the only risk factor was age.

  1. Hayreh SS. Ocular vascular occlusive disorders: natural history of visual outcome. Prog Retin Eye Res 2014; 41: 1-25.
  2. Thapa R, Poudyal G. Short term results of intra-vitreal bevacizumab for the treatment of macular edema secondary to retinal vein occlusion. Nepal J Ophthalmol 2013; 5: 1: 63-68.
  3. Aggarwal RS, Mishra VV, Aggarwal SV. Oral contraceptive pills: A risk factor for retinal vascular occlusion in in vitro fertilization patients. J Hum Reprod Sci 2013; 6: 1: 79-81.
  4. Minniti G, Calevo MG, Giannattasio A, Camicione P, Armani U, Lorini R, Piana G. Plasma homocysteine in patients with retinal vein occlusion. Eur J Ophthalmol 2014; 24: 5: 735-743.


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