on Branch Retinal Vein Occlusion Sarita M. Registered Nurse - - PowerPoint PPT Presentation

Clinical Case Presentation

• n

Branch Retinal Vein Occlusion

Sarita M. Registered Nurse Whangarei Base Hospital

Content

• Introduction
• Case Study
• Pathogenesis
• Clinical Features
• Investigations
• Treatment
• Follow-up
• Nurses’ Role
• Reference

Retinal Vein Occlusion

• 2nd most common retinal vascular disorder
• 2 main types: Central Retinal Vein Occlusion (CRVO)

Branch Retinal Vein Occlusion (BRVO)

• one of the most common cause of sudden painless

unilateral vision loss

History and Presentation

• Mrs. X, 72 y.o, healthy, fit and active

>hx of distortion L eye for 1 yr > 1st clinic visit : Va R6/6 L6/24 IOP R15 L14 O/E: CMO left superotemporal area, R macula: normal

Plan:

Bevacizumab x 2 doses Review + OCT 4/52

Clinic review after 2nd dose of Bevacizumab

> VA 6/6 6/15-1 IOPs: normal O/E: slight blot hrge left ST macula Plan: Bevacizumab x2 Review + OCT OCT: persistent L superior macular oedema

Review after 4x doses of Bevacizumab

VA: L 6/9 O/E: L old hrge or a small area of pigmentation Plan: 2 months f/u + OCT OCT: nil swelling

2/12 clinic review:

VA : L 6/9 IOP: normal O/E: recurrence of L mac oedema Plan: 5th dose Avastin Review 6/52 + OCT OCT: recurrence of CMO

Review after 5x doses Bevacizumab

VA: L 6/7.5+1 O/E: stable, no oedema noted Plan: 2 months f/u + OCT OCT: nil CMO

Clinic review 2/12

2/12 VA: L 6/7.5 O/E: some collaterals ST macula OCT: Slight thickening of RPE Plan: Discharge 2/12 VA: L 6/7.5 O/E: some collaterals ST macula

Final Diagnosis: Left BRVO

• defined as a segmental intraretinal haemorrhage
• 4x more than CRVO
• Affects males and females equally
• Usually unilateral, 9% bilateral
• Risk factors:

advancing age “Classic trio” : HTN, hyperlipidaemia, DM 50% of BRVO are hypertensive

Pathophysiology

Usually occur at the arteriovenous (AV) junction arterial compression to adjacent vein -->partial obstruction → inc intraluminal pressure → transudation of blood to retina Mac

• edema

Dec capillary tissue perfusion Tissue ischaemia release of VEGF → inc vascular permeability

Hypoxia Ischaemia

Clinical Features

Symptoms: Sudden onset of painless unilateral distortion or loss of vision Occasionally, floaters from vitreous haemorrhage Signs: Wedge-shape distribution of retinal haemorrhage retinal thickening & oedema cotton wool spots and hard exudates dilated and tortuous veins

Investigations:

Optical Coherence Tomography

• Best method
• Measures macular oedema, and monitor the response to treatment
• Findings

Cystoid macular oedema, serous macular detachment, subretinal fluid

OCT angiography - newer technology can measure vascular density can observe the superficial and deep capillary networks, non flow areas, vascular dilation,and intraretinal oedema

Investigations:

Fundal Fluorescein Angiography- information on the extent and location of the disease to study the choroidal and retinal vascular filling Findings

• delayed venous filling in the area of occlusion
• capillary nonperfusion
• Dye extravasation from macular oedema or retinal

neovascularization

Treatment:

is address to limit damage and progression of the disease Main purpose : is the resolution of the macular oedema before the foveal photoreceptor layer is damaged Treat the BRVO complications eg macular oedema, retinal neovascularization, vitreous hrge, and tractional retinal detachment

Treatment

• 1. Anti -VEGFs - treatment of choice for mac oedema and choroidal

neovascularization Bevacizumab Ranibizumab Aflibercept

Treatment

• 2. Laser photocoagulation

Treatment

Mechanism:

Destruction of photoreceptor of the ischaemic retina Decrease oxygen demand Increase oxygen influx Arteriolar constriction and inc resistance Dec capillary hydrostatic pressure Less transudation of fluid Less oedema

Treatment

Corticosteroids

Triamcinolone acetate Anti-inflammatory effect Antiangiogenic properties Inhibition of VEGF and other inflammatory cytokines Complications: inc IOP and cataract formation.

Treatment

Surgery Arteriovenous sheathotomy (AVS) Pars plana vitrectomy + AVS Vitrectomy Retinal artery bypass

Treatment

Medical Anti-platelet treatments

• Ticlopidine
• Beraprost
• Heparin
• Tissue plasminogen activator

Follow-up

Initially, followed closely every month or 2 months to monitor macular

• edema and neovascularization

Anti-VEGF treatment with or without laser should be started if without spontaneous improvement With stable or resolved macular oedema, follow-up interval can be 3-6 months or even longer for stable chronic cases.

Northland DHB: Monthly intravitreal injections

Nurses’ Role

Triage and history taking Monitor and assess stable BRVO cases Administer IV anti-VEGF injection Education

References:

[1] Jaulim,A.,Ahmed,B.,Khanam,T.,Chatziralli,I. (2013): Branch retinal vein occlusion:Epidemiology,pathogenesis,risk factors, clinical features,diagnosis, and complications. An update of the literature. Retina,33(5), 901-910. doi: 10.1097/IAE.0b013e3182870c15 [2] Patel, M., Prisant, L., & Marcus, D. (2003). Branch Retinal Vein Occlusion. The Journal of Clinical Hypertension, 5(4), 295-297. doi: 10.1111/j.1524-6175.2003.02469.x [3] Karia, N. (2010). Retinal vein occlusion: pathophysiology and treatment options. Clinical ophthalmology, 4, 809-816. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915868/ [4] Chatziralli, I., Nicholson, L., Sivaprasad, S., & Hykin, P. (2015). Intravitreal steroid and anti-vascular endothelial growth agents for the management

• f

retinal vein

• cclusion:

Evidence from randomized

• trials. Expert Opinion on

Biological Therapy.,15(12),1685-1697. http://dx.doi.org/10.1517/14712598.2015.1086744 [5] Duker, J., Waheed, N., & Goldman, D. (2014). Handbook of retinal OCT : Optical coherence

• tomography. Retrieved from

https://www-clinicalkey-com-au.ezproxy.auckland.ac.nz:9443/#!/content/book/3-s2.0-B978032318884500032X [6] Biousse, V., & Newman, N. (2009). Neuro-ophthalmology Illustrated. New York, NY: Thieme Medical Publishers, Inc. [7] Lattanzio, R., Torres Gimeno, A., Battaglia Parodi, M., & Bandello, F. (2011). Retinal Vein Occlusion: Current Treatment. Ophthalmologica, 225(3), 135-143. doi:10.1159/000314718) Li, J., Paulus, Y. M., Shuai, Y., Fang, W., Liu, Q., & Yuan, S. (2017). New Developments in the Classification, Pathogenesis, Risk Factors, Natural History, and Treatment of Branch Retinal Vein Occlusion. Journal of Ophthalmology, 2017.