Clinical Case Presentation on Branch Retinal Vein Occlusion · Clinical Case Presentation on Branch...
Transcript of Clinical Case Presentation on Branch Retinal Vein Occlusion · Clinical Case Presentation on Branch...
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Clinical Case Presentation
on
Branch Retinal Vein Occlusion
Sarita M.Registered NurseWhangarei Base Hospital
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Content● Introduction● Case Study● Pathogenesis● Clinical Features● Investigations● Treatment● Follow-up● Nurses’ Role● Reference
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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
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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
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Plan:
Bevacizumab x 2 doses
Review + OCT 4/52
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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
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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
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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
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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
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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
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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
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PathophysiologyUsually occur at the arteriovenous (AV) junction
arterial compression to adjacent vein -->partial obstruction → inc intraluminal
pressure → transudation of blood to retina
Mac
oedema
Dec capillary tissue
perfusion
Tissue
ischaemia release of VEGF → inc vascular permeability
Hypoxia
Ischaemia
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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
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Investigations:
Optical Coherence Tomography
- Best method
- Measures macular oedema, and monitor the response to treatment
- Findings
Cystoid macular oedema, serous macular detachment, subretinal fluid
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OCT angiography - newer technology
can measure vascular density
can observe the superficial and deep capillary networks, non flow areas, vascular dilation,and intraretinal oedema
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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
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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
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Treatment
1. Anti -VEGFs - treatment of choice for mac oedema and choroidal
neovascularization
Bevacizumab
Ranibizumab
Aflibercept
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Treatment
2. Laser photocoagulation
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TreatmentMechanism:
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
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TreatmentCorticosteroids
Triamcinolone acetate
Anti-inflammatory effect
Antiangiogenic properties
Inhibition of VEGF and other inflammatory cytokines
Complications: inc IOP and cataract formation.
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Treatment
Surgery
Arteriovenous sheathotomy (AVS)
Pars plana vitrectomy + AVS
Vitrectomy
Retinal artery bypass
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Treatment
Medical
Anti-platelet treatments
- Ticlopidine
- Beraprost
- Heparin
- Tissue plasminogen activator
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Follow-up
Initially, followed closely every month or 2 months to monitor macular
oedema 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.
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Northland DHB: Monthly intravitreal injections
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Nurses’ Role
Triage and history taking
Monitor and assess stable BRVO cases
Administer IV anti-VEGF injection
Education
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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 of retinal vein occlusion: 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.