Classification

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Branch retinal vein occlusion (BRVO)
CLASSIFICATION
1) Major BRVO:  At the disc and/or away from the disc. 2) Macular BRVO:  Involving only a macular branch. 3) Peripheral BRVO:  Not involving the macular circulation.

DIAGNOSIS
Presentation:
It depends on the extent of macular circulation compromised by the occlusion.   Patients with macular involvement often present with the sudden onset of blurred vision and metamorphopsia, or a relative visual field defect. Patients with peripheral occlusions may be asymptomatic.

Visual Acuity (VA):
It is very variable and is principally dependent on the extent of macular involvement.

Fundus Examination:
   Dilatation and tortuosity of the affected venous segment. The site of occlusion is often identifiable as an arteriovenous crossing point. Flame-shaped and dot/blot haemorrhages, retinal edema, sometimes cotton wool spots affecting the sector of the retina drained by the obstructed vein.

Fluorescein Angiography (FA):
It shows variable delayed venous filling, blockage by blood, staining of the vessel wall, hypofluorescence due to capillary non-perfusion and ‘pruning’ of vessels in the ischemic areas.

Optical coherence tomography (OCT):
It demonstrates and allows quantification of the severity of macular edema and is a useful way of monitoring its course and the response to treatment.

Branch Retinal Vein Occlusion

Prognosis

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Course:
The acute features usually resolve within 6–12 months and may be replaced by the following:   Exudates, venous sheathing and sclerosis peripheral to the site of obstruction, collaterals and variable residual haemorrhage. Collateral are characterized by slightly tortuous veins that develop locally or across the horizontal raphe between the inferior and superior vascular arcades and are best detected on FA. The severity of residual signs is highly variable and they may be only subtle.

PROGNOSIS
  At 6 months about 50% of eyes achieve vision of 6/12 or better. Approximately 50% of untreated eyes with BRVO retain 6/12 or better whilst 25% will have vision of <6/60.

COMPLICATIONS:
The two main vision-threatening complications are:

Chronic macular edema:
It is the most common cause of persistent poor visual acuity after BRVO. Patients with visual acuity of 6/12 or worse may benefit from laser photocoagulation, provided the macula is not significantly ischemic.

Neovascularization:
Retinal neovascularization occurs in about 60% of eyes with more than 5 disc areas of nonperfusion and a third with less than 4 disc areas – about 40% overall. NVE are considerably more common than NVD. NVE usually develops at the border of the triangular sector of ischemic retina drained by the occluded vein. New vessels usually appear within 6–12 months but may develop at any time; they can lead to recurrent vitreous and pre-retinal haemorrhage, and occasionally tractional retinal detachment.

Branch Retinal Vein Occlusion

Management

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MANAGEMENT
Follow-up should be at about 3 months with FA: A) With good macular perfusion and improving visual acuity, no treatment is required. B) If macular edema is associated with good macular perfusion and visual acuity continues to be 6/12 or worse after 3–6 months, laser photocoagulation should be considered. Patients with visual acuity of less than 6/60 or those with symptoms for over a year are unlikely to benefit from laser. Prior to treatment, the FA should be studied carefully to identify leaking areas. C) If macular non-perfusion is present and visual acuity is poor, particularly if FA shows an incomplete foveal avascular zone (FAZ), laser treatment is unlikely to improve vision.

Treatment of macular edema
Grid laser photocoagulation

(50–100 µm, 0.1 second duration and spaced one burn width apart) to produce a gentle reaction in the area of leakage as identified on FA. The burns should extend no closer to the fovea than the edge of the FAZ and be no more peripheral than the major vascular arcades. Care should be taken to avoid treating over intraretinal haemorrhage. It is also very important to identify shunts/collaterals on FA, which do not leak fluorescein, because they must not be treated. Follow-up should take place after three months. If macular edema persists, retreatment may be considered although the results are frequently disappointing.
Intravitreal triamcinolone (IVT)

It is as effective as laser in eyes with macular edema, but may cause cataract and elevation of intraocular pressure. An average of 2 injections of 1 mg are given in the first year.
Periocular steroid injection

It is less invasive, although probably less effective, than the intravitreal route.
Intravitreal anti-VEGF agents.

Bevacizumab (Avastin) 0.05 mL/1.25 mg) in a regimen of 2–3 injections over 5–6 months has shown promising effects on macular edema and vision, including in patients resistant to laser.

Branch Retinal Vein Occlusion

Management

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Arteriovenous sheathotomy.

Some positive results have been reported both for sheathotomy and for vitrectomy alone; a randomized controlled trial showed similar benefit from IVT.

Treatment of neovascularization
Neovascularization is not normally treated unless vitreous haemorrhage occurs because early treatment does not appear to affect the visual prognosis. If appropriate, scatter laser photocoagulation (200–500 µm size, 0.05–0.1 s duration and spaced one burn width apart) is performed with sufficient energy to achieve a medium reaction covering the entire involved sector as defined by the colour photograph and FA. A quadrant usually requires 400–500 burns. Follow-up should be after 4–6 weeks. If neovascularization persists re-treatment can be considered, and is usually effective in inducing regression.

Branch Retinal Vein Occlusion