eMedicine Specialties > Ophthalmology > Retina

Central Retinal Vein Occlusion: Treatment & Medication

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

Updated: May 26, 2009

Treatment

Medical Care

No known effective medical treatment is available for either the prevention of or the treatment of central retinal vein occlusion (CRVO). Identifying and treating any systemic medical problems to reduce further complications is important. Because the exact pathogenesis of the CRVO is not known, various medical modalities of treatment have been advocated by multiple authors with varying success in preventing complications and in preserving vision.

  • Advocated treatments are as follows: 
    • Aspirin
    • Anti-inflammatory agents
    • Isovolemic hemodilution
    • Plasmapheresis
    • Systemic anticoagulation with warfarin, heparin, and alteplase
    • Fibrinolytic agents
    • Systemic corticosteroids
    • Local anticoagulation with intravitreal injection of alteplase
  • Intravitreal injection of triamcinolone17,18,19,20,21
    • In patients with macular edema, injection of triamcinolone (0.1 mL/4 mg) into the vitreous cavity through pars plana has been shown to be effective not only in resolving the edema but also in corresponding improvement in vision.
    • Even though the exact mechanism of action of intravitreal injections of corticosteroids is not known, the triamcinolone crystals in the vitreous cavity probably reduce VEGF concentrations in the vitreous cavity. This leads to a reduction in capillary permeability and macular edema. The main drawback of an injection of triamcinolone was posttreatment recurrences of macular edema, requiring repeat triamcinolone injections, typically every 3-6 months.
    • In addition, significant complications reported due to the injection of triamcinolone include cataract, glaucoma, retinal detachment, vitreous hemorrhage, and endophthalmitis.
    • Because most of the data available for the use of triamcinolone injection is from multiple short-term follow-up studies, a large controlled, randomized clinical trial called the SCORE (Standard Care vs Corticosteroid for Retinal Vein Occlusion) Study is now underway in about 90 centers throughout the United States. This study is funded by the National Eye Institute (NEI) to evaluate the use of intravitreal triamcinolone for macular edema in about 1,200 patients with CRVO or branch retinal vein occlusion (BRVO). All patients are being randomized to either 1 mg or 4 mg of triamcinolone versus standard care therapy (eg, observation in CRVO, laser photocoagulation in BRVO). Patients will be followed for up to 3 years to measure long-term treatment efficacy and safety; reinjections (if needed) will be performed beginning at 4 months after the initial therapy.
  •   Intravitreal injection of bevacizumab22,23,24,12,25
    • In patients with macular edema, injection of bevacizumab (0.05 mL/1.25 mg) into the vitreous cavity through pars plana has been shown to be effective not only in resolving the edema but also in corresponding improvement in vision.
    • Also, in patients with neovascular glaucoma, a similar dose has shown significantly decreased angle neovascularization and improved intraocular pressure control, both medically and surgically.
    • Even though the exact mechanism of action of intravitreal injections of bevacizumab is not known, bevacizumab probably reduces VEGF concentrations in the vitreous cavity. This leads to a reduction in capillary permeability and macular edema. The main drawback of these injections is post treatment recurrences of macular edema, requiring repeat injections.
    • In addition, significant complications reported due to the injection of bevacizumab include cataract, glaucoma, retinal detachment, vitreous hemorrhage, and endophthalmitis.
    • Significant complications were reported with high doses of bevacizumab given intravenously for the treatment of cancer. There have been no significant reports of these complications in the available small studies.

Surgical Care

Laser photocoagulation is the known treatment of choice in the treatment of various complications associated with retinal vascular diseases (eg, diabetic retinopathy, branch retinal vein occlusion). Panretinal photocoagulation (PRP) has been used in the treatment of neovascular complications of CRVO for a long time. However, no definite guidelines exist regarding exact indication and timing of PRP. A National Eye Institute (NEI) sponsored multicenter prospective study, the Central Vein Occlusion Study (CVOS), provided guidelines for the treatment and follow-up care of patients with CRVO.26,10,27,28,1

  • Neovascularization: CVOS evaluated the efficacy of prophylactic PRP in eyes with 10 or more disc areas of retinal capillary nonperfusion, confirmed by fluorescein angiography, in preventing development of 2 clock hours of iris neovascularization or any angle neovascularization or whether it is more appropriate to apply PRP only when iris neovascularization or any angle neovascularization occurs. CVOS concluded that prophylactic PRP did not prevent the development of iris neovascularization and recommended to wait for the development of early iris neovascularization and then apply PRP.
  • Argon green laser usually is used. Laser parameters should be about 500-µm size, 0.1-0.2 second duration, and power should be sufficient to give medium white burns. Laser spots are applied around the posterior pole, extending anterior to equator. They should be about 1 burn apart and total 1200-2500 spots.
  • If ocular media is hazy for laser to be applied, cryoablation of the peripheral fundus is performed. About 16-32 transscleral cryo spots are applied from ora serrata posteriorly.
  • Macular edema: CVOS evaluated the efficacy of macular grid photocoagulation in preserving or improving central visual acuity in eyes with macular edema due to central vein occlusion (CVO) and best-corrected visual acuity of 20/50 or poorer. Macular grid photocoagulation was effective in reducing angiographic evidence of macular edema, but it did not improve visual acuity in eyes with reduced vision due to macular edema from CVO. At present, the results of this study do not support a recommendation for macular grid photocoagulation for macular edema.
  • Chorioretinal venous anastomosis29,30,31,32,33
    • Chorioretinal venous anastomosis is performed by creating an anastomosis to bypass the site of venous occlusion in the optic disc. In this procedure, retinal veins are punctured, either using laser or by surgery, through the retinal pigment epithelium and the Bruch membrane into the choroid, thereby developing anastomotic channels into the choroid.
    • Chorioretinal venous anastomosis reduces macular edema and may improve vision in nonischemic CRVO. The success rate is low, and the complication rate can be quite high, including vitreous hemorrhages and choroidal neovascularization at the anastomosis site.
    • The exact indication and timing of the procedure has not been clearly studied.
  • Radial optic neurotomy34,35,36,37,38,39
    • Radial optic neurotomy (RON) is a new surgical technique in which a microvitreoretinal blade is used during pars plana vitrectomy to relax the scleral ring around the optic nerve. The central retinal artery and vein passes through the narrow openings of the cribriform plate in the optic disc.
    • Promoters of this technique suggest that CRVO may be due to the compression of the central retinal vein at this location creating a compartment syndrome. If this procedure is successful, it decompresses the closed compartment and leads to an improvement in venous outflow and a reduction of macular edema.  
    • In one recent study, RON resulted in clinically relevant improvements on a long-term basis. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO.
    • In another study, significant improvements were observed in the b-to-a ratio of the standard combined ERG after surgery in eyes with CRVO. 
    • The benefits from surgery have not been clearly documented. One study, looking into the biomechanical effect of RON, found negligible change in the space around the central retinal vein; RON is unlikely to be a procedure that could mechanically ameliorate the clinical sequelae of a central vein occlusion. The improvement of retinal function is most likely due to improved oxygenation of the retina caused by vitrectomy and not by RON. 
    • In addition to the regular complications of vitrectomy, RON can result in significant hemorrhage and neovascularization at the incision site.
    • No consensus currently exists among various researchers regarding the exact criteria for the use of RON.
  • Vitrectomy40
    • A vitrectomy is a technique in which the vitreous is surgically removed along with removal of the posterior hyaloid.
    • Some studies have shown that a vitrectomy may be beneficial for macular edema due to CRVO. One theory is that a vitrectomy may relieve traction on the macula and, thus, reduce macular edema. According to another hypothesis, removing the vitreous will also remove cytokines and VEGF associated with a venous occlusive event; thus, the stimulus for macular edema will be reduced.
    • At the present time, no convincing evidence indicates that a vitrectomy is the best approach.

Consultations

A general ophthalmologist should consult a retinal specialist for management of CRVO complications. Other consults include an internist for proper evaluation and management of any systemic medical problems. If patients develop neovascular glaucoma, a glaucoma specialist should be consulted.

Diet

Diet should be tailored to systemic medical problems.

Activity

No restrictions usually exist. If patients develop vitreous hemorrhage, they are advised to avoid strenuous activities, sleep with few pillows, and avoid bending and lifting heavy weights.

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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