Retinal venous occlusive disease
- 1. Retinal Venous OcclusiveRetinal Venous Occlusive DiseaseDisease presentation : Dr.Ali Maaroufpresentation : Dr.Ali Maarouf supervision : Dr.Reem Moustafasupervision : Dr.Reem Moustafa
- 2. DefinitionDefinition the second most prevalent retinalthe second most prevalent retinal vascular disorder following diabeticvascular disorder following diabetic retinopathyretinopathy and is often associated with vision loss .and is often associated with vision loss . Partial or Complete obstruction .Partial or Complete obstruction . Varying degrees of retinal vascularVarying degrees of retinal vascular leakageleakage leading to : - macular edemaleading to : - macular edema
- 3. PrevalencePrevalence Age :Age : > 40 y> 40 y 66thth - 7- 7thth decadesdecades < 40 y relatively uncommon< 40 y relatively uncommon 3.1 - 4.6 % of population3.1 - 4.6 % of population BRVOs 6-7 times more than CRVOsBRVOs 6-7 times more than CRVOs ocuurence in fellow eye is 7 % within 4ocuurence in fellow eye is 7 % within 4 yy
- 4. predisposing factorspredisposing factors • systemic :systemic : ( vessel-wall dysfunction )( vessel-wall dysfunction ) - Advanced age- Advanced age - HTN :- HTN : - especially in not well treated patiens- especially in not well treated patiens - 63.6 % of RVO vs. 36.2 % of controls- 63.6 % of RVO vs. 36.2 % of controls - DM :- DM : - significantly more frequent in CRVO- significantly more frequent in CRVO - Hyperlipidemia- Hyperlipidemia - Smoking- Smoking - OCCs- OCCs - Homocysteinemia : >>- Homocysteinemia : >> - Coagulation disorders : >>- Coagulation disorders : >> proteins C & S deficiencies , antiphospholipid synproteins C & S deficiencies , antiphospholipid syn in young patients
- 5. perdisposing factorsperdisposing factors • local :local : - Glaucoma :- Glaucoma : occlusion at disc rimocclusion at disc rim - Hypermetropia- Hypermetropia
- 6. pathogenesispathogenesis • Diseases of both Veins & ArteriesDiseases of both Veins & Arteries arteriosclerosis :arteriosclerosis : small arteries andsmall arteries and arteriolesarterioles important in BRVOimportant in BRVO atherosclerosis :atherosclerosis : large & medium sizedlarge & medium sized arteriesarteries important in CRVOimportant in CRVO
- 7. pathogenesispathogenesis • endothelial cell loss , stagnationendothelial cell loss , stagnation thrombus formationthrombus formation >>> Occlusion>>> Occlusion
- 8. pathogenesispathogenesis hypoxia ↑ Vein & Capillary pressure & stagnation occlusion endothelial damage & extravasation of constituents ↑ tissue pressure
- 9. Signs & SymptomsSigns & Symptoms • Vision Loss :Vision Loss : - macular ischemia or edema- macular ischemia or edema - retinal hemorrhages- retinal hemorrhages • Slit Lamp Test & Fundus Examination :Slit Lamp Test & Fundus Examination : - vitreous hemorrhage- vitreous hemorrhage - epiretinal membrane formation- epiretinal membrane formation - rubeosis iridis- rubeosis iridis - neovascular glaucoma- neovascular glaucoma
- 10. ClassificationClassification - Central Retinal Vein Occlusion ( CRVO )- Central Retinal Vein Occlusion ( CRVO ) at or posterior to optic nerve headat or posterior to optic nerve head - Branch Retinal Vein Occlusion- Branch Retinal Vein Occlusion ( BRVO )( BRVO ) at a branch or tributary of CRVat a branch or tributary of CRV
- 11. CRVOCRVO
- 12. CRVOCRVO
- 13. CRVOCRVO • Variable visual lossVariable visual loss • Fundus : - retinal hemorrhagesFundus : - retinal hemorrhages - dilated tortuous retinal veins- dilated tortuous retinal veins - macular edema- macular edema - optic disc edema- optic disc edema - cotton wool spots- cotton wool spots
- 14. CRVO - scattered hemorrhagesCRVO - scattered hemorrhages
- 15. CRVOCRVO Important investigations :Important investigations : - FFA- FFA - OCT- OCT
- 16. CRVOCRVO
- 17. CRVOCRVO • Complications :Complications : - Macular edema- Macular edema - Neovascularisation :- Neovascularisation : NVDNVD NVENVE NVINVI
- 18. CRVOCRVO significant disc edema - dilated tortuos veins -significant disc edema - dilated tortuos veins - scattered hemorrhagesscattered hemorrhages
- 19. CRVOCRVO same patient - leakage from disc - staining of veinssame patient - leakage from disc - staining of veins
- 20. CRVOCRVO
- 21. CRVO - FFACRVO - FFA dilated tortuos veins - leakage into macula - cystoid patterndilated tortuos veins - leakage into macula - cystoid pattern
- 22. CRVO - FFACRVO - FFA perifoveal capillary leakage - cystoid pattern - late phaseperifoveal capillary leakage - cystoid pattern - late phase
- 23. CRVO - FFACRVO - FFA perifoveal leakage - cystoid patternperifoveal leakage - cystoid pattern
- 24. CRVO Non-IschemicCRVO Non-Ischemic perifoveal leakage - Arteriovenous phaseperifoveal leakage - Arteriovenous phase
- 25. CRVOCRVO resolving NVD - PRP spotsresolving NVD - PRP spots
- 26. CRVOCRVO optociliary shunt vesselsoptociliary shunt vessels
- 27. CRVOCRVO • impending :impending : uncommon , poorly describeduncommon , poorly described • non-ischemic :non-ischemic : ~75%~75% Afferent pupillary defect (APD) : absent or mild .Afferent pupillary defect (APD) : absent or mild . delay in AV transit time -good capillary perfusion -delay in AV transit time -good capillary perfusion - late leakagelate leakage prognosis : reasonably good , related to inital VAprognosis : reasonably good , related to inital VA • ischemic :ischemic : APD : markedAPD : marked marked delay in AV transit time ( > 20 S )marked delay in AV transit time ( > 20 S ) extensive areas of capillary non-perfusionextensive areas of capillary non-perfusion prognosis : extremely poor .prognosis : extremely poor .
- 31. BRVOBRVO • Occurs typically at A-V crossing pointOccurs typically at A-V crossing point ( commom adventitial sheath )( commom adventitial sheath ) • more common detected in the superiormore common detected in the superior temporal quadranttemporal quadrant
- 33. BRVOBRVO
- 34. BRVO - FFABRVO - FFA
- 35. BRVO - FFABRVO - FFA
- 36. investigationsinvestigations • All patients :All patients : - VA , Slit Lamp Exam- VA , Slit Lamp Exam - OCT , FFA- OCT , FFA - Laboratory Tests :- Laboratory Tests : BP , CBC , Random BG , Fasting BG , ESRBP , CBC , Random BG , Fasting BG , ESR ECG , Cholesterol and Lipids , Plasma protein electrophoresisECG , Cholesterol and Lipids , Plasma protein electrophoresis Urea , Creatinine , Electrolytes ,Thyroid tests .Urea , Creatinine , Electrolytes ,Thyroid tests . • Selected patients :Selected patients : - Thrombophilia screen , CRP , Autoantibodies , Fasting- Thrombophilia screen , CRP , Autoantibodies , Fasting Plasma Homocystein levelPlasma Homocystein level - CXR , ACE ,- CXR , ACE , - Treponemal serology , Carotid duplex imaging .- Treponemal serology , Carotid duplex imaging .
- 37. ComplicationsComplications • Macular Edema :Macular Edema : the most important factor for reducedthe most important factor for reduced VA after RVOVA after RVO • Neovascularisation :Neovascularisation : vitreous hemorrhagevitreous hemorrhage tractional RDtractional RD neovascular glaucomaneovascular glaucoma
- 38. TreatmentTreatment • Anti VEGFAnti VEGF • F/G LaserF/G Laser • Sectoral LaserSectoral Laser • VitrectomyVitrectomy • Treatment of underlying diseaseTreatment of underlying disease
- 39. a clinical case presentationa clinical case presentation • a 50-year-old woman diagnosed with HTNa 50-year-old woman diagnosed with HTN 1 month ago , HTN treatment has been1 month ago , HTN treatment has been stopped on patient’s own after 2 w ofstopped on patient’s own after 2 w of treatment .treatment . • FH : HTN , DM .FH : HTN , DM . • BP : 19-18 / ? mmHg .BP : 19-18 / ? mmHg . • FBS : W.N.LsFBS : W.N.Ls
- 40. presentation : reduced visual acuity OS with a sudden partial- field Vision Loss one week ago + chronic headache treated with analgesics . VA : - OS : CF . vision field : superiomedial quadrant - OD : 10/10 slit lamp examination : inferior archade BRVO
- 41. clinical case
- 44. ReferencesReferences • American Academy of OphthalmologyAmerican Academy of Ophthalmology publicationspublications • emedicine-Medscapeemedicine-Medscape • Charité Einblick-AusblickCharité Einblick-Ausblick Fachpublikation Band 2Fachpublikation Band 2 • Ophthalmic photographer’s societyOphthalmic photographer’s society • Kanski’s clinical ophthalmology 7Kanski’s clinical ophthalmology 7thth editionedition
- 45. Presented atPresented at :: Eye Surgical Hospital ,Eye Surgical Hospital , Damascus , Syria .Damascus , Syria . 18/1/201618/1/2016