eMedicine Specialties > Ophthalmology > Retina

Branch Retinal Vein Occlusion

Author: Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Coauthor(s): Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Contributor Information and Disclosures

Updated: Jul 20, 2007

Introduction

Background

Much confusion exists in the literature because central retinal vein occlusions and branch retinal vein occlusions (BRVOs) are often grouped and studied together. The natural history and the complication rate for each entity differ. The treatments and their results vary from one condition to the other. This article deals exclusively with BRVOs. Hemiretinal vein occlusions are probably variants of central retinal vein occlusions, and, as such, they are not included in this discussion.

Pathophysiology

Hypertensive, atherosclerotic, inflammatory, or thrombophilic conditions may lead to retinal endothelial vascular damage. In eyes with an anatomical predisposition, intravascular thrombus formation may occur. Eyes with arteriovenous crossings appear to be at risk for BRVO. In these eyes, the artery is anterior to the vein in most cases. The artery and the vein share a common adventitial sheath. Increased arterial stiffness may be a mechanical factor in the pathogenesis of BRVO.

Arterial compression of the vein is believed to be the main cause of BRVO. Compression of the vein may lead to turbulent flow in the vein. The turbulent flow in combination with the preexisting endothelial vascular damage from the different conditions creates a local environment favorable to intravascular thrombus formation. Up to two thirds of BRVOs occur in the supertemporal quadrant. This rate may be related to the increased number of arteriovenous crossings in this quadrant with respect to the rest. In addition, nasal BRVO often are asymptomatic; therefore, patients with this type of BRVO do not seek ophthalmic evaluation.

Frequency

United States

Retinal vein occlusions (branch and central) are the second most common retinal vascular diseases after diabetic retinopathy. The Beaver Dam Study reported a prevalence of 0.6% in patients older than 43 years.

International

In a population-based study from Australia, the Blue Mountains Eye Study, the prevalence of BRVO in the population older than 48 years was 1.1%.

Mortality/Morbidity

There is conflicting evidence regarding the mortality in patients with BRVO.

A 9-year follow-up study in the United Kingdom suggested a relationship between cardiovascular mortality and all retinal vein occlusions (including branch, central, and hemiretinal).

In another study, the 10-year risk of developing cardiovascular complications was higher in patients with BRVO than CRVO.

In a recent Danish study, the investigators did not find a significant difference in mortality between the patients with BRVO and the general population.

Race

No racial predilection for the disease is apparent.

Sex

No predilection for either sex is apparent.

Age

The patients who are affected are usually in their fifth or sixth decade of life.

Clinical

History

  • The Eye Disease Case-Control Study reported the following findings:
    • Systemic hypertension is a risk factor for BRVO.
    • Diabetes mellitus and open-angle glaucoma are not risk factors for BRVO.
    • Moderate alcohol consumption reduces the risk of BRVO.
  • Patients often complain of a sudden painless decrease of vision in the affected eye.
  • Some may complain of a scotoma.

Physical

  • In 1877, Leber first described the condition ophthalmoscopically. During the acute phase, intraretinal hemorrhages (usually flame shaped), retinal edema, and cotton-wool spots are seen in the distribution of a retinal vessel. The horizontal raphe is respected.
  • During the chronic stage, hemorrhages may be absent. Macular edema may be the only sign present. Telangiectatic vessels that extend across the horizontal raphe usually can be demonstrated angiographically.
  • In certain eyes with large areas of nonperfusion, retinal neovascularization may be seen.
    • Vitreous hemorrhage with tractional retinal detachments may ensue.
    • Further traction may create retinal breaks, creating combined rhegmatogenous and tractional retinal detachments.
    • Neovascular glaucoma and neovascularization at the disc are rare events with BRVO.

Causes

  • Most cases of BRVO are due to idiopathic factors. Usually, patients have an anatomical predisposing factor, such as an arteriovenous crossing where the artery compresses the vein. This compression leads to clot formation and subsequent BRVO.
  • Inflammatory conditions that affect the retinal veins may cause local damage that predisposes the individual to intravascular clot formation with subsequent BRVO. Some of the inflammatory conditions reported in the literature are the following:
    • Sarcoidosis
    • Lyme disease
    • Serpiginous choroiditis
  • Thrombophilic conditions, such as the following, may also be involved:
    • Protein S deficiency
    • Protein C deficiency
    • Resistance to activated protein C (factor V Leiden)
    • Antithrombin III deficiency
    • Antiphospholipid antibody syndrome
    • Lupus erythematosus
    • Gammopathies

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References
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Further Reading

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Keywords

BRVO, branch retinal vein obstruction, retinal tributary vein occlusion, retinal vein occlusions, retinal vascular diseases, retinal endothelial vascular damage, arterial compression, central retinal vein occlusions, hemiretinal vein occlusions

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Contributor Information and Disclosures

Author

Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Disclosure: Nothing to disclose.

Medical Editor

Vytautas A Pakainis, MD, Chief of Ophthalmology, Dorn Veterans Administration Medical Center, Professor of Ophthalmology, Ophthalmology, University of South Carolina School of Medicine
Vytautas A Pakainis, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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