Shivani V. Reddy, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
6/5/2014

Patient Presentation
CC: Blurry vision OS x 1month
HPI: 52 y/o AAF presenting to the eye clinic for her first diabetic exam c/o occasional blurry vision OS x 1 month.
Denies flashes, floaters, scotomas or episodes of vision loss.

none
Medical History
POHx:
PMH: DMII (diagnosed 3 months prior, A1c: 8.9%)
HTN with HTN urgency episode in 2012 secondary to cocaine abuse
Meds: metformin, lantus insulin, norvasc, gabapentin
Allergies: NKDA

Exam
BCVA
20/20 -1 (sc)
20/60-2 (-1.00+1.00x180)
P
3 ->2mm
(-) RAPD
3 ->2mm
14
T
TP
17
EOM: Full OU
CVF: Full OU
Anterior Segment: mild NS cataracts OU, otherwise WNL

OCT Photos

OCT
OD
OS
OS: retinal thickening with cystic spaces temporal to fovea, subfoveal disruption of ELM and ellipsoid region lines

Autofluorescence OS
OD: Area of central hyperautofluorescence , hypoautofluorescense concentrated superiorly

FA Photo OS
00:19:53
Arterial phase : normal arterial filling

FA Photo OS
00:23:28
Mid AV phase : delayed superotemporal venous arcade filling, scattered areas of hypofluorescence, pinpoint hyperfluorescent areas

FA Photo OS
00:30:33
Late AV phase: persistent filling defect in superior temporal arcade, prominent macular collateral vessel, hypofluoresent ares scattered throughout the sup-temp segment

FA Photo OS
00:38:65
Venous Phase: Late filling of superotemporal venous arcade, increasing hyperfluorescence surrounding original pinpoint areas with persistent intervening hypofluorescent regions, hyperfluorescence temporal to the fovea, appearance of venous collaterals

FA Photo OS
01:44:39
Recirculation phase: increasing hyperfluoresnce around pinpoint leakages, decreasing fluorescence of collateral vessels. Increasing hyperfluorescence temporal and superior to the fovea

FA Photo OS
02:24:13 02:39:10

Assessment and Plan

A: 52 yo AAF with CME OS secondary to old branch retinal vein occlusion.

P: Avastin OS, follow-up pending

Branch Retinal Vein Occlusion

Vein occlusion that occurs most commonly at an AV crossing

Mean age of presentation: 7 th decade

Risk factors



HTN
Cardiovascular disease
Glaucoma history

Increased BMI at age 20

Most commonly effected area: supero-temporal quadrant

Branch Retinal Vein Occlusion

Acute Phase


Segmental intraretinal hemorrhage with apex near obstructed vein
Subretinal hemorrhages less common


Cotton wool spots scattered throughout the occluded segment
CME with layering intraretinal heme within the cysts

If CME present, round yellow spot can occur centrally that later disappears

Branch Retinal Vein Occlusion


Resolution of subretinal heme at 9-12 months

Underlying retinal vascular abnormalities seen on FA

Collateral vessel formation around blockage site

Capillary telangiectasia

Capillary non-perfusion areas within involved segment

Branch Retinal Vein Occlusion
Branch Vein Occlusion Study (BVOS)
Questions asked:



Can scatter laser prevent neovascularization?
Can peripheral scatter laser prevent vitreous hemorrhage?.
Can grid laser improve visual acuity in eyes with macular edema with vision <20/40?
Conclusions:


Grid laser is beneficial for macular edema with vision <20/40 for 3 months
Scatter laser is beneficial for prevention of vitreous hemorrhage
The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol.
1984;98(3):271-282. 2001;21:416-434.

Branch Retinal Vein Occlusion

SCORE (BRVO) Study
Question asked:

Is triamcinolone beneficial in the treatment of macular edema when compared to standard of care?

Patients were divided into 3 groups: grid laser, 4mg , 1mg group. Visual acuity changes were compared at 1 year

Conclusions:

3 groups with similar VA improvement BUT more complications in the steroid group. Therefore, Grid laser was the benchmark against which future treatments should be compared
Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report
6. Arch Ophthalmol. 2009;127(9):1115-1128.

Branch Retinal Vein Occlusion
BRAVO Study
Purpose: to determine the safety and efficacy of Lucentis in treating macular edema

Design:

3 groups – 0.3mg , 0.5mg ranibizumab and sham

Patients received monthly injections

Number of patients with >15 letters gained at 6 months:
0.5mg group: 61.1%, 0.3mg group: 55.2%, sham group: 28.8%

Conclusion: Intravitreal ranibizumab is effective for treatment of macular edema following BRVO
Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: sixmonth primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.

Branch Retinal Vein Occlusion
GENEVA Study

Purpose: to evaluate the efficacy and safety of Ozurdex for visual loss secondary to macular edema associated with BRVO

Design: patient injected with intravitreal implant 0.7mg, 0.35mg or sham

Conclusion: Dexamethasone intravitreal implant can reduce the risk of vision loss and improve speed and incidence of visual improvement
Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology.
2010;117(6):1134-1146.Epub 2010 Apr 24.

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusion
Francesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele
Pierluigi Iacono, Fondazione GB Bietti, Roma
Maurizio Parodi
Macula Society, 2014
Purpose: to evaluate the effects of dexamethsone implant for the treatment of macular edema secondary to ischemic retinal vein occlusions over a 12 month follow-up
Methods: - prospective, open-label, interventional, case series.
- each patient received a comprehensive exam, FA & OCT imaging followed by a dexamethasone implant
- retreatment based on presence of macular edema at month 4
primary outcome measure: ETDRS letter score
secondary outcome measure: CME, number of injections during followup

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusion
Francesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele
Pierluigi Iacono, Fondazione GB Bietti, Roma
Maurizio Parodi
Macula Society 2014
Results: 24 patients enrolled (11 CRVO, 13 BRVO)
- mean ETDRS letter score changed:
BRVO 75,3 to 95,6
CRVO 44,3 to 60,8
- CMT change
BRVO 544um to 321um
CRVO 776um to 444um
- mean #injections
BRVO: 1.7
CRVO: 1.8
Conclusions: Dexamethasone implant reduces ME in eyes with ischemic RVO’s, leading to a slight visual acuity improvement

The OMAR study: Comparison of Ozurdex and Triamcinolone
Acetonide for Refractory Cystoid Macular Edema in Retinal Vein
Occlusion
Ahmet Ozkok, M.D.,*Omar A Saleh, M.D.,* Douglas K. Sigford, M.D.James W Heroman, M.D.
Shlomit Schaal, M.D., Ph.D.

Purpose: To compare the risks and benefits of adding either intravitreal dexamethasone implant (DEX) or preservative free triamcinolone acetonide
(TA) to bevacizumab monotherapy in refractory CME due to RVO

Design: interventional, comparative study of
74 patients received bevacizumab, then later DEX (35) and TA (39) outcome measures: BCVA, CMT, frequency of injections

Results: no significant change in BCVA significant improvement in CMT significant decrease in number of injections per month, more so in
DEX group (from 0.66 to 0.26 inj/mo)

References
Retina-Vitreous Macula. Guyer, Yannuzzi, Chang, Shields, Green
BCSC. Chapter 12 Retina and Vitreous. 2012-2013:Chapter 6:121-127.
The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J
Ophthalmol. 1984;98(3):271-282. 2001;21:416-434.
Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch
Ophthalmol. 2009;127(9):1115-1128.
Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology.
2010;117(6):1134-1146.Epub 2010 Apr 24.
Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.
The Eye Disease Case-control Study Group. Risk factors for branch retinal vein occlusion. Am J Ophthalmol 1993;116(3):286-
96.