Transcript rvox

Response to questions
 Laboratory tests
 Ophthalmic test
 Ophthalmic treatments
 Prognosis
 How to fallow up
CRVO EVALUATION
SYSTEMIC VASCULAR DISEASE:diabetes mellitus
Hypertension, carotid insufficincy.
 OCULAR DISEASES:open angle glacuma,
Ischmic optic neuropathy,pseudotumor cerebri
Tilted optic nerve head,optic nerve head drusen
 HEMATOLOGIC ALTERATION:hyperviscosity
Multiple myeloma,blood dyscrasias,anemia&…
 INFLAMMATORY/AUTOIMMUNE VASCULITIS:
SLE
 MEDICATIONS:oral contraceptives,duretics,
Hepatitis B vaccine,
 INFECTIOUS VASCULITIS:HIV,syphilis,herpes zoster
 OTHER:retrobulbar block,dehydration,pregnancy
CRVO EVALUATION
 SYSTEMIC WORKUP is not indicated in person
older than60 years of age with known systemic
Vascular risk factors for CRVO.
younger patient are more likely to have predispoIng conditions resulting in thrombotic disease.
• A limited systemic workup may be considered in
those with prior occlusion in the fellow eye,
prior systemic thrombotic disease,family history
of thrombosis,hematologic or rheumatologic .
CRVO EVALUATION:LAB.tests
 CBC,ESR,FBS,ANA,ANTIPHOSPHOLIPID Ab
fasting plasma homocysteine level.
 In bilateral,simaltaneous CRVO or mixed-type
retinal vascular occlusions should have detailed
evaluation for a hypercogulable condition, as these
persons may be at risk for future,non-Ocular
thrombotic events.
OPHTHALMIC TEST IN CRVO
 Wide-angle FA 30 second after Iv injection of
Sodium fluorescein.
 classification:perfused[less than 10 disc areas of
capillary nonperfusion]non perfused[10 or more disc
areas of retinal capillary nonperfusion] indeterminate
[intraretinal hemorrhage prevent angiographic
determination of perfusion status].
 OCT
THERAPEUTIC OPTIONS IN CRVO
MACULAR EDEMA
 Observation
 Corticosteroid therapy
 Intravitreal anti-VEGF therapy
NEOVASCULARIZATION
 Laser photocoagulation
 Medical therapy
 ALTERNATIVE TREATMEHTS
 Chorioretinal venous anastomosis
 Tissue plasminogen activator
 Surgical treatments:vitrectomy,radial optic neurotomy,
MACULAR EDEMA
OBSERVATION
Widespread damage to the
perifovealcapillary
netwrk has been
hypothesized to
contribute to the lack of
visual recovery.
MACULAR EDEMA
CORTICOSTEROID THERAPY
 It is believed that corticosteroid maintain anti-Inflammatory
effects with modulation of production of cytokines and growth
factor including VEGF.steroid are also stabilize blood
retinal barrier with reduction in vascular permeability.
 Eyes were treated with 1-mg IVTA every 4month for 1 year
and observed significant improvement in visual acuity
compared to observation.
 Primary ocular advers events included cataract formation and
elevated Intraocular pressure.
 In chronic refractory CME sustained –release intravitreal
dexamethasone delivery system,OZURDEX,was approved .
MACULAR EDEMA
 Intravitreal anti-VEGF therapy
 Combined anti-VEGF and corticosteroid
OCULAR NEOVASCULARIZATION
 Laser phothcoagulation
 CVOS recommended that PRP be delivered
promptly after the development of NVI/NVA but
not in eyes with nonperfused crvo.
 Prophylactic PRP may be done in special risk
factors for developing NVI/NVA[male gender,
short duration of CRVO,extensive retinal
nonperusion,and extensive retinal hemorrhage]
Optociliary shunt
SYSTEMIC MEDICAL CONDITION
 Treatment of systemic vascular risk factors,
coordination with the internist is strongly recommended
 Systemic anticoagulation such as asprin or heparin,cannot
prevent or alter the natural history of CRVO but may help
prevent nonocular thrombotic events ,especially in individuals
with known systemic vascular disease.
 Oral pentoxifylline is a potent vasodilator usedin systemic
vascular diseases to improve perfusionto occluded vessels and
enhance the development ofcollateral circulation.this drug
reduct macular thickening but not change in VA or perfusion
status.
 Hemodilation increased oxigen supply to the retina.
Hemodilution is likely not appropriate for patient with
anemia,renal insufficiency ,or pulmonary insuffcieny.
Response to questions BRVO
 Laboratory tests
 Ophthalmic test
 Ophthalmic treatments
 Prognosis
 How to fallow up
BRVO EVALUATION
 Systemic vascular diseases such as aterioscleros
Diabetis,smoking,hyperlipidemia,glaucoma,
and ocular inflammatory disease.
antiphosphlipid AB,elevated plasma homocystein level
and low serum folate.
 Short axial length
 In bilateral cases or cases involving young
patients,systemic manifestation of infectious
disease,inflammatory or autoimmune condition,
neoplasm,or hypercoagulable states may be present.
DIAGNOSTIC WORKUP
 PARTICULAR ATTENTION to the history of
glaucoma and sign of intraocular inflammation
 IN YOUNG:CBC,FBS,prothrombin time/partial
thromboplastin time,lipid panel,homocysteine
anticardiolipin AB,protein C/S
 IN OLDER than 60,additional workup isnot necessary
since the majority are idiopathic or due to
hypertension or atherosclerosis.
OPHTHALMIC TEST
 F/A
For delineate the retinal vascular caharacteristic That may have
prognostic significance :macular Leakage and edema,macular
ischemia,and large Segments of capillary nonperfusion that may
Portend neovascularization[ischemic BRVO>5 disc diameters
nonperfusion]
 In chronic cases ,when the hemorrhages have resolved,microvascular
changes on F/Amay provide the only clues of a previous BRVO.
 When we have leakage and edema with cystoid involvement of the
fovea,but no capillary nonperfusion, the macular edema is the cause of
vision loss.
 when macular edema is present within the first6 month after a BRVO
and there is little or no leakage on F/A,macular ischemia may be the
cause of the macular edema and almost always spontaneously resorbs
in the first year after occlusion,often with return of vision.
 OCT
Used to monitor the response to treatment of macular edema and has
been used in Place of F/A in some treatment trials for BRVO.
Chronic case of BRVO
TREATMENT OPTIONS IN BRVO
 MEDICAL TREATMENT
 LASER TREATMENT
 STEROID TREATMENT
 ANTI-VEGF TREATMENT
 FAVOR[ILUVIEN] STUDY
 SURGICAL MANAGEMENT[vitrectomy with or
Without sheathotomy]
Medical treatment
 In most cases anticoagulant therapy has not been
shown to be beneficial in either the prevention or the
management of BRVO.Since thes systemic
administration of anticoagulants can be associated
with systemic complication, and could,in
theory,increase the severity of intraretinal
hemorrhage occurring in the acute phase,such therapy
is not recommended.
Laser treatment
Steroid treatment
 Triamcinolone
Corticosteroid inhibit the expression of VEGF and reduce macular
edema.Significant side-effects,including cataract and Glaucoma.
1mg IVTA every 4 months reduced macular edema but not
recommended as first –line therapy and considered in patients
where macular grid laser or other therapies are ineffective,as the
treatment was found to be relatively safe,especially in
pseudophakic eyes.
 Dexamethasone implant.
 FAVOR[ILUVIEN] sustained-release non-erodable,intravitreal
implant for patients with macular edema due to BRVOorCRVO
of>3 months,duration in phase 2 trial.
prognosis
 BRVO:1/3 to1/2 of patients have return of vision to 20/40 or
better without any therapy.
31-41℅of patients with ischemic BRVO developed
neovascularization or vitreous hemmorrhage,compared
with11℅of patients With nonischemic BRVO.decreased
vision for over 1 year as a result of macular edema are much
less likely to regain vision spontaneously.
When macular edema is present within the first 6 months
after a BRVO and there is little or no leakage on FA,macular
ischemia may be the cause of the macular edema .this
edema always resorbs in the first year after the occlusion,
often with return of vision.
CRVO prognosis
 A perfused CRVO have better initial and final VA
 A nonperfused CRVO have poor VA and large areas of
retinal capillary nonperfusion were significant factors
associated with an increased risk of developing
NVI/NVA.
 Initial VA was highly correlated with degree of
nonperfusion and prognosis.
Follow up
 In CRVO eye with initial acuity of 20/40 or better were
generally examined every1-2 MO for 6 MO,then
annually if stable.
 Eye with initial acuity worse than 20/200 were
Seen monthly for the initial 6 MO,then bimonthly
For the next 6 MO.
 Eyes with 20/50 and20/200 have an intermediate risk
of developing NVI/NVA and were also typically
examined monthly for the first 6 MO.
BRVO FOLLOW UP
 In BRVO initially,patents followed closely every
MO or2 MO for macular edema and/or NVE.
 Once macular edema stabilized or resolved interval
can be extended to 3-6 MO or even longer for stable
chonic cases.
 Patients with previously untreated retinal
nonperfusion >5disc diameters followd at closer
intervals[3 months]due to the increased risk for
neovascular complication.