eMedicine Specialties > Ophthalmology > Retina

Central Retinal Vein Occlusion: Differential Diagnoses & Workup

Author: Lakshmana M Kooragayala, MD, Vitreo-retinal Surgeon, Marietta Eye Clinic
Contributor Information and Disclosures

Updated: May 26, 2009

Differential Diagnoses

Branch Retinal Vein Occlusion
Ocular Ischemic Syndrome

Other Problems to Be Considered

Hypertensive retinopathy
Retinopathy due to anemia
Retinopathy due to thrombocytosis

Workup

Laboratory Studies

  • No laboratory studies are routinely indicated in the diagnosis of central retinal vein occlusion (CRVO).
  • In older patients, laboratory testing should be directed toward identifying systemic vascular problems.
  • In young patients, laboratory testing may be tailored depending upon individual findings, to include the following:
    • Complete blood cell (CBC) count
    • Glucose tolerance test
    • Lipid profile
    • Serum protein electrophoresis
    • Chemistry profile
    • Hematologic tests
    • Syphilis serology
    • In addition, thrombophilic screening, activated protein C resistance, lupus anticoagulant, anticardiolipin antibodies, protein C, protein S, and antithrombin III may be completed.

Imaging Studies

  • Color Doppler imaging is a noninvasive quantitative method of assessing the retrobulbar circulation. Detection of low venous velocities has been used to predict the onset of iris neovascularization. At present, this is performed as an investigational procedure in large facilities.11
  • Optical coherence tomography12
    • Optical coherence tomography (OCT) scanning is a noninvasive, noncontact, transpupillary imaging technology that can image retinal structures in vivo with a resolution of 10-17 µm. OCT quantitatively measures the retina in micrometers in situ and in real time.
    • OCT can detect even subtle macular edema in the presence of significant hemorrhages, which is not evident by fluorescein angiography because of blockage from hemorrhage.
    • OCT is useful in quantitatively monitoring the development of macular edema and resolution with treatment.13,12

Other Tests

  • Fluorescein angiography is the most useful test for the evaluation of retinal capillary nonperfusion, posterior segment neovascularization, and macular edema.2
    • Fluorescein angiography is one of the tests used in the classification of CRVO. Areas of capillary nonperfusion are visualized as hypofluorescence, but hemorrhages can block fluorescence and give a similar picture. Therefore, in the early stages of the disease process, due to extensive hemorrhages, fluorescein angiography gives little information regarding the perfusion status of the retina. Once the hemorrhages clear, areas of capillary nonperfusion can be detected as hypofluorescence in the fluorescein angiography.
    • Various studies have reported different criteria for defining ischemic CRVO versus nonischemic CRVO based on the extent of capillary nonperfusion of the retina. The amount of retinal nonperfusion ranges from 10-30 disc areas.
    • In addition, fluorescein angiography may show delayed arteriovenous transit, staining along the retinal veins, microaneurysms, arteriovenous collaterals, NVD, NVE, and dilated optic nerve head capillaries.
    • In a nonischemic central retinal vein obstruction, angiography may show minimal or absent retinal capillary nonperfusion, staining along the retinal veins, microaneurysms, and dilated optic nerve head capillaries. Resolved CRVO may be completely normal.
    • Macular edema may be detected as leakage from perifoveal capillaries, leakage from microaneurysms, or diffuse leakage on fluorescein angiography. If extensive edema is present, fluorescein angiography may show pooling of dye in large cystoid spaces. In addition, capillary nonperfusion around the fovea may indicate macular ischemia. If macular edema persists, pigmentary changes become evident.
  • Electroretinography (ERG) is another useful test to evaluate the functional status of the retina and to classify CRVO.14,12,15
    • In ERG waveform, b-wave and a-wave are produced by the inner retina and the outer retina, respectively.
    • In central retinal vein obstruction, perfusion of the inner retina is affected, so that the amplitude of the b-wave is decreased relative to the a-wave; the b-to-a ratio has been shown to be reduced. Some studies indicate that a b-to-a ratio of less than 1 suggests an ischemic central retinal vein obstruction.

Histologic Findings

Not many histopathologic reports exist in the literature. A report of histologic sections of 29 eyes with central retinal vein obstruction showed a fresh or recanalized thrombus at or just posterior to the lamina cribrosa. Within the thrombi, a mild lymphocytic infiltration with prominent endothelial cells was seen. Loss of the inner retinal layers consistent with inner retinal ischemia also was seen.16

More on Central Retinal Vein Occlusion

Overview: Central Retinal Vein Occlusion
Differential Diagnoses & Workup: Central Retinal Vein Occlusion
Treatment & Medication: Central Retinal Vein Occlusion
Follow-up: Central Retinal Vein Occlusion
Multimedia: Central Retinal Vein Occlusion
References
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References

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Further Reading

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Keywords

central retinal vein occlusion, CRVO, nonischemic central vein occlusion, venous stasis retinopathy, ischemic central vein occlusion, retinal vascular disorder

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Contributor Information and Disclosures

Author

Lakshmana M Kooragayala, MD, Vitreo-retinal Surgeon, Marietta Eye Clinic
Lakshmana M Kooragayala, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, and Medical Association of Georgia
Disclosure: Nothing to disclose.

Medical Editor

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center
V Al Pakalnis, MD, PhD 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

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
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; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest 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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