Branch retinal vein occlusion is a common retinal vascular disease of the elderly. It is caused by the occlusion of one of the branches of

central retinal vein The central retinal vein (retinal vein) is a vein that drains the retina of the eye. It travels backwards through the centre of the optic nerve accompanied by the central retinal artery before exiting the optic nerve together with the central re ...

Signs and symptoms

Patients with branch retinal vein occlusion usually have a sudden onset of blurred vision or a central visual field defect. The eye examination findings of acute branch retinal vein occlusion include superficial hemorrhages, retinal edema, and often cotton-wool spots in a sector of retina drained by the affected vein. The obstructed vein is dilated and tortuous. The quadrant most commonly affected is the superotemporal (63%). Retinal neovascularization occurs in 20% of cases within the first 6–12 months of occlusion and depends on the area of retinal nonperfusion. Neovascularization is more likely to occur if more than five disc diameters of nonperfusion are present and

vitreous hemorrhage Vitreous hemorrhage is the extravasation, or leakage, of blood into the areas in and around the vitreous humor of the eye. The vitreous humor is the clear gel that fills the space between the lens and the retina of the eye. A variety of conditio ...

can ensue.

Risk factors

Studies have identified the following abnormalities as risk factors for the development of branch retinal vein occlusion: *

hypertension Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...

cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, h ...

obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...

glaucoma Glaucoma is a group of eye diseases that result in damage to the optic nerve (or retina) and cause vision loss. The most common type is open-angle (wide angle, chronic simple) glaucoma, in which the drainage angle for fluid within the eye rem ...

Diabetes mellitus Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...

was not a major independent risk factor.

Diagnosis

Branch retinal vein occlusion revealed by laser Doppler imaging

The diagnosis of branch retinal vein occlusion is made clinically by finding retinal hemorrhages in the distribution of an obstructed retinal vein. *

Fluorescein angiography Fluorescein angiography (FA), fluorescent angiography (FAG), or fundus fluorescein angiography (FFA) is a technique for examining the circulation of the retina and choroid (parts of the fundus) using a fluorescent dye and a specialized camera. S ...

is a helpful adjunct. Findings include delayed venous filling, hypofluorescence caused by hemorrhage and capillary nonperfusion, dilation and tortuosity of veins, leakage due to neovascularization and macular edema. *

Optical coherence tomography Optical coherence tomography (OCT) is an imaging technique that uses low-coherence light to capture micrometer-resolution, two- and three-dimensional images from within optical scattering media (e.g., biological tissue). It is used for medical ...

is an adjunctive test in branch retinal vein occlusion. Macular edema is commonly seen on optical coherence tomography exams. Serial optical coherence tomograph is used as a rapid and noninvasive way of monitoring the macular edema. *

Laser Doppler imaging Laser Doppler imaging (LDI) is an imaging method that uses a laser beam to scan live tissue. When the laser light reaches the tissue, the moving blood cells generate doppler components in the reflected ( backscattered) light. The light that comes ...

reveals dynamic

hemodynamics Hemodynamics or haemodynamics are the dynamics of blood flow. The circulatory system is controlled by homeostatic mechanisms of autoregulation, just as hydraulic circuits are controlled by control systems. The hemodynamic response continuously m ...

discrepancies between branch arteries and veins, from local

vascular resistance Vascular resistance is the resistance that must be overcome to push blood through the circulatory system and create flow. The resistance offered by the systemic circulation is known as the systemic vascular resistance (SVR) or may sometimes be ca ...

increase by the venous occlusion.

Treatment

Several options exist for the treatment of branch retinal vein occlusion. These treatments aim for the two of the most significant complications, namely

macular edema Macular edema occurs when fluid and protein deposits collect on or under the macula of the eye (a yellow central area of the retina) and causes it to thicken and swell ( edema). The swelling may distort a person's central vision, because the macu ...

and

neovascularization Neovascularization is the natural formation of new blood vessels ('' neo-'' + '' vascular'' + '' -ization''), usually in the form of functional microvascular networks, capable of perfusion by red blood cells, that form to serve as collateral circu ...

. * Systemic treatment with oral aspirin, subcutaneous Heparin, or intravenous thrombolysis have not been shown to be effective treatments for

central retinal vein occlusion Central retinal vein occlusion, also CRVO, is when the central retinal vein becomes occluded, usually through thrombosis. The central retinal vein is the venous equivalent of the central retinal artery and both may become occluded. Since the centra ...

and for branch retinal vein occlusion no reliable clinical trial has been published. * Laser treatment of the macular area to reduce macular edema is indicated in patients who have 20/40 or worse vision and did not spontaneously improve for at least 3 months (to permit the maximum spontaneous resolution) after the development of the vein occlusion. It is typically administered with the

argon laser An ion laser is a gas laser that uses an ionized gas as its lasing medium. Like other gas lasers, ion lasers feature a sealed cavity containing the laser medium and mirrors forming a Fabry–Pérot resonator. Unlike helium–neon lasers, the ...

and is focused on edematous retina within the arcades drained by the obstructed vein and avoiding the foveal avascular zone. Leaking microvascular abnormalities may be treated directly, but prominent collateral vessels should be avoided. In a Cochrane Review comparing laser treatment to other treatments, grid laser was found to be preferable to no laser. Due to quality of evidence it is uncertain whether bevacizumab injections or subthreshold diode were preferable to grid laser treatments. * The second indication of laser treatment is in case of neovascularization. Retinal photocoagulation is applied to the involved retina to cover the entire involved segment, extending from the arcade out to the periphery. Ischemia alone is not an indication for treatment provided that follow-up could be maintained. * Preservative-free, nondispersive

Triamcinolone acetonide Triamcinolone acetonide, sold under the brand name Kenalog among others, is a synthetic corticosteroid medication used topically to treat various skin conditions, to relieve the discomfort of mouth sores, and by injection into joints to trea ...

in 1 or 4 mg dosage may be injected into the vitreous to treat macular edema but has complications including elevated

intraocular pressure Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine this. IOP is an important aspect in the evaluation of patients at risk of glaucoma. Most tonometers are calibrated to ...

and development of

cataract A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colors, blurry or double vision, halos around light, trouble w ...

. Triamcinolone injection is shown to have similar effect on visual acuity when compared with standard care (Laser therapy), However, the rates of elevated intraocular pressure and cataract formation is much higher with the triamcinolone injection, especially the higher dosage. Intravitreal injection of

Dexamethasone Dexamethasone is a glucocorticoid medication used to treat rheumatic problems, a number of skin diseases, severe allergies, asthma, chronic obstructive lung disease, croup, brain swelling, eye pain following eye surgery, superior vena cav ...

implant (Ozurdex; 700,350 μg) is being studied, its effect may last for 180 days. The injection may be repeated however with less pronounced effect. Although the implant was designed to cause less complications, pressure rise and cataract formation is noted with this treatment too. * Anti-

vascular endothelial growth factor Vascular endothelial growth factor (VEGF, ), originally known as vascular permeability factor (VPF), is a signal protein produced by many cells that stimulates the formation of blood vessels. To be specific, VEGF is a sub-family of growth factors, ...

(VEGF) drugs such as

bevacizumab Bevacizumab, sold under the brand name Avastin among others, is a medication used to treat a number of types of cancers and a specific eye disease. For cancer, it is given by slow injection into a vein (intravenous) and used for colon cancer, l ...

(Avastin; 1.25 -2.5 mg in 0.05ml) and

ranibizumab Ranibizumab, sold under the brand name Lucentis among others, is a monoclonal antibody fragment ( Fab) created from the same parent mouse antibody as bevacizumab. It is an anti-angiogenic that is approved to treat the "wet" type of age-related ...

(Lucentis) injections are widely used and there is good evidence of improved visual and anatomic outcomes with these agents. Intravitreal anti-VEGF drugs have a low incidence of adverse side effects compared with intravitreal steroids, but are often requiring repeated injections. They are the treatment of choice for macular edema or neovascularization. The mechanism of action and duration of anti-VEGF effect on macular edema is currently unknown. The intraocular levels of VEGF are increased in eyes with macular edema secondary to branch retinal vein occlusion and the elevated VEGF levels are correlated to the degree and severity of the areas of capillary nonperfusion and macular edema. * Surgery is employed occasionally for longstanding

and other serious complications such as

epiretinal membrane Epiretinal membrane or macular pucker is a disease of the eye in response to changes in the vitreous humor or more rarely, diabetes. Sometimes, as a result of immune system response to protect the retina, cells converge in the macular area as t ...

and

retinal detachment Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment the entire retina may detach, leading to vision loss and blin ...

. * Arteriovenous sheathotomy has been reported in small, uncontrolled series of patients with branch retinal vein occlusion. Branch retinal vein occlusiontypically occurs at arteriovenous crossings, where the artery and vein share a common adventitial sheath. In arteriovenous sheathotomy an incision is made in the adventitial sheath adjacent to the arteriovenous crossing and is extended along the membrane that holds the blood vessels in position to the point where they cross, the overlying artery is then separated from the vein.

Prognosis

In general, branch retinal vein occlusion has a good prognosis: after 1 year 50–60% of eyes have been reported to have a final visual acuity of 20/40 or better even without any treatment. With time the dramatic picture of an acute branch retinal vein occlusion becomes more subtle, hemorrhages fade so that the retina can look almost normal. Collateral vessels develop to help drain the affected area.

Epidemiology

*branch retinal vein occlusion is four times more common than central retinal vein occlusion. *Usual age of onset is 60–70 years. *An analysis of population from several countries estimates that approximately 16 million people worldwide may have retinal vein occlusion.

References

External links

{{Medical resources , ICD10 = , ICD9 = , ICDO = , OMIM = , DiseasesDB = , MedlinePlus = , eMedicineSubj = article , eMedicineTopic = 1223498 , MeSH = , GeneReviewsNBK = , GeneReviewsName = , Orphanet = Disorders of choroid and retina