Surgical Care

Branch retinal vein occlusions (BRVOs) have a relatively benign course. Nevertheless, certain complications that lead to visual loss may occur. These complications include macular edema and the sequelae from retinal neovascularization (eg, vitreous hemorrhage, tractional retinal detachment, neovascular glaucoma). Several surgical and laser techniques are available to deal with these situations.

Macular grid laser photocoagulation o Macular grid laser photocoagulation was mildly effective in the treatment of macular edema in a small prospective trial, the BVOS.
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The current recommendation is to wait 3 months to see if the patient's vision spontaneously improves. If no improvement occurs and if the hemorrhages have mostly cleared from the macular area, a fluorescein angiogram is obtained. If the angiogram shows leakage in the macular area that is responsible for the decrease in vision, treatment with a macular grid laser is recommended. After 3 years of follow-up care, 63% of laser treated eyes improved by 2 or more lines of vision compared with 36% of control eyes.[15] Despite macular photocoagulation, eyes gained on average 1.33 lines of vision with respect to baseline. At the 3-year follow-up, 40% of eyes had a visual acuity of less than 20/40 and 12% of eyes had a visual acuity of less than 20/200.[15] If the fluorescein angiogram reveals macular nonperfusion, laser therapy is not warranted, and observation is recommended. Finkelstein reported that eyes with macular nonperfusion have a good visual prognosis.[33] In his series, the median visual acuity was 20/30. Macular grid laser photocoagulation remains the criterion standard treatment of eyes with perfused macular edema secondary to BRVO.

Scatter photocoagulation
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The BVOS also demonstrated that scatter photocoagulation reduces the prevalence of neovascularization from 40% to 20%. However, if all eyes with nonperfusion were treated, 60% of patients who would never develop neovascularization would be treated. If only the eyes that develop neovascularization were treated, the events of vitreous hemorrhage would decrease from 60% to 30%. Therefore, the recommendation is to wait until neovascularization actually develops before scatter photocoagulation is considered.

Laser-induced chorioretinal anastomosis

Bypass of the normal retinal venous drainage channels is attempted by creating a communication between the obstructed vessel and the choroid. Problems with this technique are the lack of reliability in creating an anastomosis (most groups report a 30-50% success rate) and its complications. Complications from the procedure include tractional retinal detachment and vitreous hemorrhage.

Vitrectomy and arteriovenous decompression

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Virtually all cases of BRVO occur at arteriovenous crossings. Because arterial compression is believed to be the major cause of this condition, some have recommended lifting the artery from the underlying vein to relieve the compression. Several small, uncontrolled series have shown good results in improving macular edema and macular perfusion. However, others have reported a lack of efficacy of this procedure. Planning of a multicenter controlled trial is currently underway.

Several surgeons have reported resolution of macular edema secondary to BRVO after vitrectomy with or without peeling of the internal limiting membrane. Vitrectomy and posterior hyaloid separation improved the visual acuity in eyes with macular edema secondary to BRVO. The addition of intravitreal triamcinolone had no additional benefit.[34] A number of eyes may develop a transient postoperative increase in macular edema following vitrectomy. The edema resolves spontaneously and does not appear to have an effect on visual acuity.[35] Pars plana vitrectomy techniques with or without scleral buckling may be necessary in eyes with tractional and rhegmatogenous retinal detachments.