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RETINAL VEIN OCCLUSION Epidemiology 51% >65y 10-15% <45y ν Afro-caribbean and Asian descent in UK Pathogenesis Primary retinal venous disease/ endothelium Thrombus secondary event (Hypercoaguability) AETIOLOGICAL CONDITIONS COMMON SYSTEMIC 1. BP 2.Hyperlipidemia 3.DM 4.Smoking RARER 1.MM and Waldestrom 2.CRF 3.Vasculitis 4.Thrombotic disorders 5. Oral contraceptives (oestrogen)/ no HRT LOCAL Glaucoma Trauma Orbital lesions Oedema-drusen optic disc 6.Secondary causes of 1, 2, 3 such as acromegaly cushing, hypothyroidism DIAGNOSIS 1. Painless loss of vision- unilateral 2. Asymptomatic BRVO Arteriovenous crossings Macular branch (DD from diabetic maculopathy) ACUTE CHRONIC Haemorrhages Venous sheathing Retinal oedema Exudates Cotton wool spots Collaterals Tortuous veins CMO >5 dd non-perfusion: NVE CRVO ACUTE CHRONIC Dilated tortuous retinal veins Sheathing of veins Absorption of haemorrhage Disc collaterals Macular oedema Swollen optic disc Intraretinal haemorrhage Cotton wool spots Retinal oedema MECHANISMS OF VISUAL LOSS Ischaemic (direct- indirect) Exudative (macular oedema) 30% non-isch. Convert to ischaemic type first 4/12 Eyes at High Risc for Ischaemic Complications 1.RAPD 2. VA 3. FFA >10DD, 5-10 DD 4.Cotton wool spots >10, 5-10 5. Deep dark haem. (infarct) 6. Elderly ( rubeosis) DIFFERENTIAL DIAGNOSIS 1.Accelerated hypertension 2.DM 3.Slow-flow retinopathy 4.Peripapillary telangiectasia 5. AION 6.Lupus/ radiation retinopathy 7. CMV retinitis 8.Ocular ischaemic syndrome MEDICAL INVESTIGATIONS ALL PATIENTS FBC, ESR, U&E, LFT, GLC, Lipid profile Protein electrophoresis ECG TFT MORE SPECIALISED CXR Cardiolipin, Lupus anticoagulant CRP, ACE, FTA-ABS RF, ANA, DNA, ANCA MRI: orbit, brain MANAGEMENT OCULAR BRVO Argon laser for macular oedema if foveal vasculature intact (FFA), VA 6/12-6/60 3-6/12 after the initial event Sectoral PRP for proliferative complications or if areas of non-perfusion >5DD FU: 6/52, up to 2years after (collaterals) CRVO Prevention of neovascularisation Grid: no benefit FFA and Laser: haemorrhages sufficiently resolved Monthly FU/ total of 2years >40DD: PRP 10-40DD: no <10 (non-ischaemic): no Non-ischaemic cases convert to ischaemic 13%: 6/12 18%: 18/12 CHECK RAPD ALWAYS IN FU MEDICAL 1. Maximise visual outcome 2. cardiovascular morbidity/ mortality (risk factors) 3. Prevent recurrence to other eye (15% over 5 years) + Aspirin/ dipyridamole