Download Darcy Sczepanik

Darcy Sczepanik, O.D., Resident
[email protected]
Claudia Pezzia, O.D., Resident
[email protected]
Vitreous Hemorrhage Secondary to Branch Retinal Vein Occlusion with
Neovascularization Elsewhere
Eye Center of Texas
Bellaire, TX
Abstract
 A 47-year-old Indian male presents with vitreous hemorrhage secondary to branch
retinal vein occlusion with neovascularization elsewhere. Once the blood clears,
sectoral photocoagulation is applied to the areas of neovascularization. Disease
presentation, treatment, and current research are presented here.
1. Case History
 Demographics: 47-year-old emmetropic Indian male
 Chief Complaint: Sudden decrease in vision OD x 1 day with increase in floaters.
Patient reports no flashes.
 Ocular Hx: Previous superior temporal BRVO OD with self-resolved macular
edema 1 year prior. No intravitreal injections, corticosteroids, or focal grid used.
 Medical Hx: Diabetes Mellitus Type 2 x 10 years with fluctuating fasting blood
sugar from 180 mg/dL to 250 mg/dL.
 Medications: Metformin of unknown dosage.
2. Pertinent Findings
 1st Exam (Day 1)
o BCVA: 20/25 OD, 20/15 OS
o Pupils and EOMs unremarkable OU.
o IOP with Tono-Pen: 14mmHg OD, 14mmHg OS
o Anterior segment: Unremarkable OU. No NVI OU.
o Posterior segment: Diffuse vitreous hemorrhage OD with poor central
views. Superior views appear flat with no retinal holes or tears. Undilated
view OS appears unremarkable.
 2nd Exam (Day 4)
o BCVA: 20/25 OD, 20/15 OS
o Pupils and EOMs unremarkable OU.
o IOP with Tono-Pen: 14mmHg OD, 14mmHg OS
o Anterior segment: Unremarkable OU. No NVI OU.
o Posterior segment: Resolving vitreous hemorrhage OD with poor central
views. Superior views appear flat with no retinal holes or tears. No
diabetic or hypertensive changes OS through dilated examination.
 3rd Exam (Day 10)
o BCVA: 20/25 OD, 20/15 OS
o
o
o
o


Pupils and EOMs unremarkable OU.
IOP with Tono-Pen: 13mmHg OD, 11mmHg OS
Anterior segment: Unremarkable OU. No NVI OU.
Posterior segment: Resolving vitreous hemorrhage OD with poor central
views. Superior views appear flat with no retinal holes or tears. OS not
observed.
th
4 Exam (Day 19)
o BCVA: 20/25 OD, 20/15 OS
o Pupils and EOMs unremarkable OU.
o IOP with Tono-Pen: 13mmHg OD, 14mmHg OS
o Anterior segment: Unremarkable OU. No NVI OU.
o Posterior segment: Resolving vitreous hemorrhage OD with improved
views. Neovascularization appears superior temporal along the arcades.
No tears or holes seen. OS not observed. Sectoral laser applied to the
areas of neovascularization. Patient is to return in three weeks for further
evaluation and possible treatment if macular edema present.
Imaging
Image 1 - Fundus photo of posterior
pole of the right eye.
Image 2 - Fundus photo of superior
temporal arcade showing
neovascularization elsewhere as
indicated in the rectangle.
Image 3 – Late phase fluorescein
angiography shows leakage from the
neovascularization (black arrow)
above an area of ischemia (red arrow).
3. Differential Diagnoses
 Vitreous hemorrhage secondary to:
o Primary:
 Proliferative diabetic retinopathy
 Posterior vitreous detachment with/without retinal hole/tear
o Secondary:
 Proliferative sickle-cell retinopathy
 Macroaneurysm
4. Diagnosis & Discussion
 Etiology and pathophysiology: Branch retinal vein occlusions (BRVO) are
blockages of the branching vessels that drain the blood from the retina as a result
of atherosclerotic changes. Vasculopathic conditions like hypertension, coronary
artery disease, and diabetes cause the arteries to stiffen and become rigid, leading
to the formation of thrombi and compression and occlusion of the accompanying
veins via their shared adventitial sheaths. BRVOs occur most commonly in the
superior temporal quadrant (60% of cases).1

Epidemiology: BRVO is the second most common ocular
vasculopathy behind diabetic retinopathy with a prevalence and five-year
incidence of 0.6 percent.1 BRVO usually affects patients 50 to 70 years of age and
is linked to hypertension 60 percent of the time. BRVOs are primarily nonischemic events (resulting in <5 disc diameters of capillary non-perfusion) twothirds of time. As a result, BRVO rarely leads to neovascularization (22% to
36%), but is often associated with macular edema (50%), particularly in superior
BRVOs (60%).2

Symptoms and signs: Patients with BRVO often present with
unilateral, painless visual field loss of varying intensity.3 Many people will have
normal vision, particularly if the macula is not involved. Signs of BRVO are
dilated, tortuous veins with superficial hemorrhages and cotton-wool spots in a
wedge-shaped area radiating from the involved arterial-venule crossing.
Occlusions closer to the optic nerve usually involve more retina, leading to

subsequent complications like ischemia, macular edema, macroaneurysms and
possible neovascularization.
Prognosis: Fifty to fifty-five percent of all cases regain visual
acuity of 20/40 or better after 1 year. Risk of another BRVO in the same eye is
3% and 12% in the fellow eye.4
5. Management and Treatment

Management: Patients with BRVO should be
closely monitored with IOP measurements, careful slit-lamp evaluations,
gonioscopy to rule out neovascularization of iris and angle, and dilated fundus
examinations to evaluate edema, neovascularization, shunt vessels, and areas of
ischemia. Fluorescein angiographies can also help identify areas of nonperfusion
and neovascularization. OCT scans of the macular area are useful in identifying
and treating macular edema, secondary to BRVO. Depending upon the nature of
the episode, patients should be followed monthly for the first 3 to 6 months.
Naturally, those with ischemic episodes should be followed more closely as
secondary complications like neovascularization are more likely to occur in those
individuals.

Treatment:
o
Macular edema should be monitored for three
months to allow for self-resolution. If no resolution occurs, focal grid laser
photocoagulation or intravitreal anti-VEGF injections are indicated
according to the following studies:

Branch Retinal Vein Occlusion Study (BVOS) If after three months, macular edema persists or vision is worse
than 20/40, focal grid laser photocoagulation should be utilized to
improve visual outcome (up to 2 lines improvement).2

Standard Care v. Corticosteroid for Retinal
Vein Occlusion (SCORE) Study indicates intravitreal injection with
1 to 4mg of triamcinolone produces similar results to focal grid
photocoagulation but produces greater side effects and therefore is
not indicated in BRVO with ME.5

Branch Retinal Vein Occlusion Study (BRAVO)
shows significant visual improvement and reduction in macular
edema through a series of intravitreal injections of ranibizumab
(0.3mg and 0.5mg).6
o
Neovascularization of the iris (>2 clock hours),
angle neovascularization, and disc/retinal neovascularization should be
treated with sectoral photocoagulation to prevent/reduce subsequent
vitreous hemorrhage (VH), neovascular glaucoma, and tractional
detachments. Sectoral photocoagulation prior to the development of
neovascularization is not indicated according to BVOS. Non-clearing
VHs may require pars plana vitrectomy.
6. Conclusion and Clinical Pearls


In patients with vasculopathic conditions, clinicians often want to jump to the
most obvious conclusions – i.e. vitreous hemorrhage due to proliferative diabetic
retinopathy (PDR). Using the contralateral (uninvolved eye) as a control will help
guide clinicians to a more accurate synopsis. In the case of our patient with
uncontrolled blood sugar, one could have easily thought the VH was due to PDR,
but as dilation of the uninvolved eye revealed no diabetic retinopathy, we had to
explore other etiologies.
A good working knowledge of current treatment studies is essential in treating
retinal disease particularly in utilizing anti-VEGF agents.
7. References (preliminary)
1. Klein R, Klein BE, Moss SE, Meuer SM. The epidemiology of retinal vein
occlusion: the Beaver Dam Eye Study. Trans Am Ophthalmol Soc 2000; 98:13341.
2. The Branch Vein Occlusion Study Group. Argon laser photocoagulation for
macular edema in branch vein occlusion. Am J Ophthalmol. 1984 Sep 15;
98(3):271-82.
3. Ehlers, Justis et al. The Wills Eye Manual: Office and Emergency Room
Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott Williams and
Wilkins, 2008.
4. Yanoff, Myron et al. Ophthalmology. 2nd ed. St. Louis: Mosby, 2004.
5. SCORE Study Research Group. A randomized trial comparing the efficacy and
safety of intravitreal triamcinolone with observation to treat vision loss associated
with macular edema secondary to central retinal vein occlusion: the Standard Care
vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study report 5. Arch
Ophthalmol. 2009; 127:1101–1114.
6. Campochiaro PA. Safety and efficacy of intravitreal ranibizumab (Lucentis) in
patients with macular edema secondary to branch retinal vein occlusion. The
BRAVO Study. Paper presented at The American Society of Retina Specialists
Retina Congress, October 4, 2009; New York.