Distinguishing Urgent vs. Monitorable Retinal Vein Occlusion

ReachMD Announcer:
You’re listening to Eye on Ocular Health on ReachMD. On this episode, we’ll hear from Dr. Ashkan Abbey, who’s the Director of Clinical Research at Texas Retina Associates in Dallas. He’ll be exploring how to determine whether a patient with retinal vein occlusion, or RVO, needs immediate intervention.

Here’s Dr. Abbey now.

Dr. Abbey:
When I evaluate a new retinal vein occlusion, I start by separating out two urgent decisions in terms of whether they need to be treated right away.

One is going to be, is there treatable macular edema that's actually threatening the vision today—mostly center-involving macular edema? And then number two is, is this eye a high or near-term risk for anterior segment neovascularization, particularly in a CRVO patient? So, when you break it down a little bit more, you're going to favor immediate intervention in patients who have center-involving macular edema, whether that's with a BRVO or CRVO, with reduced vision and OCT evidence of intraretinal and subretinal fluid.

Then, also, there's the ischemic features that we would look for, specifically when you're doing an fluorescein angiogram or an OCT angiogram. You can look specifically at the amount of ischemia using one or both of those modalities. So, when we see ischemic features, and when we see a lot of non-perfusion, you'll tend to think that there's going to be a higher VEGF drive. And so, when that is occurring, and we see, say, a lot of ischemia on the FA, poor-presenting vision, extensive hemorrhages, and cotton wool spots, that's when I think we almost immediately need to treat those kinds of patients. I think that's where we see that there's a really strong VEGF drive going on, because of all the ischemia, and we need to treat them immediately.

Finally, when we're talking about neovascularization, we need to pay close attention on our exam to the iris to look for any neovascularization of the iris. And you may even go as far as to get out—you know as retina specialists, we don't do this very often—but it wouldn't be necessarily a bad idea to consider doing a gonioscopy on a patient who has an ischemic CRVO in particular that's presenting to you for the first time, just to check the angle to see if there is any neovascularization of the angle as well. Sometimes, we may miss that just by looking at the anterior segment alone without gonioscopy. So if we do see neovascularization—either of the iris, of the angle, or even neovascularization in the retina specifically on that day, which can be picked up very well with widefield angiography as well—I think that's an immediate sign that we need to treat that patient with anti-VEGF injection.

Now, for the patients who can be monitored, I think that you can look at the patients who present with no center-involving edema and good vision, or they really aren't noticing much of a vision problem. And when we look at those patients, you can certainly watch those closely. Or if the edema is minimal and not center-involving, that's also part of it where I think you can watch. Also, a mild BRVO that has limited hemorrhage, and good visual acuity, and really minimal ischemia, I think, is a good one in those situations to probably watch.

In those cases where we are going to be monitoring them, occasionally, if there's just a trace amount of edema, I will consider using a topical NSAID, just to see if we can improve the edema a little bit more, just for a more conservative approach, just with drops. Even if the patient has almost no edema, then I usually will have them come back in roughly about six to eight weeks—maybe sometimes four to six weeks, depending on if there's more edema that's present. And just kind of watch them a little bit more closely over the course of several months to make sure we don't see more edema occurring, which can certainly happen, and that could lead to more vision loss. 

ReachMD Announcer:
That was Dr. Ashkan Abbey talking about ways to differentiate RVO patients that need immediate intervention and those who can be safely monitored. To access this and other episodes in our series, visit Eye on Ocular Health on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!