Download Retinal Vein Occlusion: Do I Work

R. Doug Davis, M.D.
Scott & White Eye Institute
2013 Veirs Conference
2/27/2013
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What to Remember:
• 1) A annual general health assessment is
reasonable advice whether or not the patient has a
retinal vein occlusion.
• 2) If the patient is young and without known
systemic risk factors, it is potentially worthwhile to
evaluate for systemic processes.
o
Possibile entities include elevated serum
homocysteine levels or anti-phospholipid
antibody syndrome.
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What to Remember:
• 3) Patients with bilateral, simultaneous CRVO should
undergo careful medical and hematologic
evaluation assessing various blood rheologic
parameters.
o For most of us, this involves consultation with
other physicians outside of Ophthalmology.
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Definitions
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Branch Retinal Vein
Occlusion (BRVO)
• Disruption of blood flow in a tributary of the central
retinal vein invariably at an arteriovenous crossing.
• Defined as Ischemic if 5 or more disc areas of
capillary non-perfusion are identified on the FA.
• Findings:
o Intra-retinal hemorrhage
o venous dilation and tortuosity
o cotton-wool spots in the involved region
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Hemi- Retinal Vein
Occlusion (HRVO)
• Approximately 20% of eyes have been found to
have retinal drainage through a dual-trunked
central retinal vein (superior and inferior systems).
• Disruption of blood flow through one of these trunks
results in the clinical picture termed an HRVO.
• These straddle the BRVO and CRVO clinical
appearance. Progression to CRVO is possible.
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Central Retinal Vein
Occlusion (CRVO)
• Examination of enucleated eyes with this clinical picture
has demonstrated interruption of blood flow at the
lamina cribrosa.
• Defined as Ischemic if 10 or more disc areas of capillary
non-perfusion are demonstrated on FA.
• Characteristics of Ischemic cases includes:
o
o
o
o
Visual acuity of < 20/400
Presence of APD
Extensive intra-retinal hemorrhage (Blood and Thunder)
Anterior segment neovascularization
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Retinal Venous Occlusion
(RVO)
• Five population – based studies with incidence data
out to as much as 10 years are in the literature:
• 1) Beaver Dam Eye Study (BDES)
• 2) Eye Disease Case – Control Study (EDCCS)
• 3) Atherosclerosis Risk in Communities Study &
Cardiovascular Health Study (ARIC / CHS)
• 4) Blue Mountains Eye Study (BMES)
• 5) Ocular Vascular Clinic at University of Iowa case
series (Hayreh)
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Retinal Venous Occlusion
(RVO)
• Advanced Age and presence of Glaucoma are
definite common risk factors
• Second most common retinal vascular disorder
behind Diabetic Retinopathy
• Incidence of any RVO - 5.2 / 1000
• Incidence of CRVO - 0.8 / 1000
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Systemic Risk Factors for
BRVO
• Hypertension – significant risk factor in 4 out of the 5
studies
• Diabetes - significant to a limited extent in only 2 of
the 5 studies
• Hx of CVD or MI – No significant association
demonstrated
• Tobacco use – Significant in only 1 of the 5
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Ocular Risk Factors for
BRVO
• Arterio-venous nicking - significant association
• Focal arteriolar narrowing – significant association
• Perfusion pressure – limited association
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Systemic Risk Factors for
CRVO
• Hypertension – odds ratio in the EDCCS was 2.9
(95% CI of 1.6 – 5.3)
• Diabetes - odds ratio in the EDCCS was 2.4 (95% CI
of 1.2 – 4.8)
• Elevated ESR - odds ratio in EDCCS was 1.9 (95% CI
of 1.1 - 3.4)
• Estrogens, Alcohol, and increased activity - all
found in the EDCCS to have a reduced OR (0.3 –
0.5)
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Effect of Systemic Factors
on Risk
RISK FACTOR
BRVO
CRVO
HTN
Worse
Worse
Diabetes
Equivocal
Worse
MI / CVD
Equivocal
No change
Stroke Hx
Equivocal
No change
ESR elevation
No change
Worse
BMI / Obesity
Equivocal
No change
Tobacco
Equivocal
No change
Alcohol
Equivocal
Better
Activity
No change
Better
Estrogens
No change
Better
Renal disease
Worse
Worse
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Primary Thrombophilia
Examples
• Hyperhomocysteinemia (> 15 micro- mol / liter)
o 9.5% of young CRVO patients (Lahey)
o 5 – 10 % of Caucasians
o RVO OR 3.76 (95% CI of 1.06 – 13.4) noted in BMES
o May be managed with vitamin supplementation (Folate)
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Primary Thrombophilia
Examples
• Antiphospholipid Antibody syndrome
o Lupus anticoagulant
o Anticardiolipin antibodies
o 10.8 % of young CVO patients (Lahey)
o 2 – 4 % of the population
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Perspectives on Disease
Associations
• Systemic Diseases which are common in the
populations at risk are, likewise, commonly seen in
the case populations reported in the long term
studies.
• Presence of two uncommon diseases in one case is
not necessarily evidence for association.
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Perspectives on Disease
Associations
• Little evidence is available for Primary
Thrombophilia, Inflammatory disease, or other
Hypercoagulable states in the Majority of patients
with RVO.
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Anatomical Issues for
RVO
• Reports exist that document some patients have a
congenital anomaly of the retinal vasculature
(Kinky vein).
• This alone can predispose an individual to
experiencing an RVO.
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Testing Considerations
• High Frequency testing for uncommon disease
entities:
o Reduces the test’s positive predictive value
o Potentially results in unnecessary anxiety on the patients
part
o Likely is sub-optimal utilization of increasingly, limited
resources allocated for medical care.
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Patient Modification of
Risk Factors
• For known cardiovascular risk factors, this may be
an important component of their therapy. Examples
include:
o Diet selection
o Exercise appropriate for their current health status
o Medications known to favorably influence their
cardiovascular health
• May potentially reduce the progression from
perfused to ischemic RVO’s.
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Patient Modification of
Risk Factors
• May influence the likelihood for manifestation of the
RVO in the fellow eye as latency period between
the eyes may be significant.
• But, No proven Class I Rx benefit for efficacy.
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Patient Modification of
Risk Factors
• Current perspective for both the American Heart
and American Stroke Association:
o
the Only Factor of significant benefit to reduce an
individuals systemic stroke risk : Control of an individual’s
Hypertension.
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Take Home Points
• Increased age and Glaucoma are dominant risk
factors for RVO.
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Take Home Points
• Cardiovascular risk profile has strong predictive
attributes:
o Hypertension increases risk for BRVO or CRVO
o Diabetes increases risk for CRVO
o More physical activity decreases risk for CRVO
o Moderate alcohol decreases risk for CRVO
o Exogenous estrogens for post-menopausal women
decreases risk for CRVO.
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Take Home Points
• Hypercoagulability may play a role in limited cases:
o Patients < 60 years of age
o Bilateral, simultaneous CRVO cases
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Practice Guidelines to
Consider
• All patients with or without RVO should consider an
annual general health assessment
• Patients with bilateral, simultaneous CRVO:
o Request comprehensive medical and hematologic
evaluation
o Whole blood viscosity and other rheologic assessments
may be helpful
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Practice Guidelines to
Consider
• For patients without known risk factors:
o Additional history of systemic thrombosis, rheumatic or
inflammatory disease, and family history of thrombosis may
be used to guide medical consultation
o Medical consultation in young patients to assess for serum
homocysteine levels and assay for anti-phospholipid
antibody syndrome.
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Thanks to:
• Dr. Howard Ying, MD, PhD of the Wilmer Eye Institute
for some of the data and clinical correlations
presented today.
Footer Text
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References
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Klein et al., Tr Am Ophth Soc. 2000; 98 :133 – 143.
David et al., Ophthalmologica 1988; 197 : 69 – 74.
Mitchell et al., Arch Ophth 1996; 114 : 1243 – 1247.
Cugati et al., Arch. Ophth 2006; 124: 726 – 732.
The Eye Disease Case – Control Study Group, AJO
1993; 116: 286 – 296.
6. Klein et al., AJO 2006; 141 : 859 – 862.
7. Chua et al., AJO 2005; 139 : 181 – 182.
8. Hayreh et al., AJO 2001;131: 61 – 77.
9. Wong et al, Ophthalmology 2005; 112 : 540 – 547.
10. Lahey et al., Ophthalmology 2002; 109: 126 – 131.
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