Retinal Vein Occlusion Clinical Presentation

  • Author: Mark Fonrose, MD, FACEP; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jan 6, 2011
 

History

The evaluation of patients with unilateral visual loss should include a pertinent and thorough history of present and past medical history. Questions pertinent to the present medical history should include an inquiry into the rate of onset of visual loss, possible trauma, unilateral or bilateral in character, and if redness is present or not.

Central retinal vein occlusion (CRVO) is essentially a diagnostic finding of painless unilateral loss of vision. In some cases, this loss of vision is subtle in character, with intermittent episodes of blurred vision. In other cases, it may be sudden and dramatic. The nonischemic type is often the more subtle of the two, while the ischemic type is prone to the more acute clinical presentations.

  • Nonischemic CRVO - Subtle, intermittent visual loss; painless; mild-to-moderate visual loss
  • Ischemic CRVO - Acute visual loss; pain may be present; marked visual loss

BRVO is similar in presentation to CRVO. BRVO is often noted with an onset of blurred vision or visual field defect. Vision loss may be subtle. Patients with small occlusions of a branch retinal vein may often be asymptomatic. Larger obstructions can lead to significant visual loss. It is uniformly a unilateral disease. Nine percent of cases are bilateral.

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Physical

The performance of a pertinent physical examination and mandatory evaluation for visual acuity and visual field testing is prudent. An ophthalmoscopic examination is diagnostic. An article in the American Journal of Ophthalmology 2007, notes that the finding of an afferent pupillary defect, in ischemic CRVO, is of high diagnostic precision.[4]

Nonischemic central retinal vein occlusion

  • Mild vision loss, usually better than 20/120 measured
  • Rare afferent pupillary defect
  • Ophthalmoscopy findings consist of variable dot and flame hemorrhages in all 4 quadrants, optic nerve swelling, retinal vein engorgement and tortuosity, cotton wool spots are few

Ischemic central retinal vein occlusion

  • Marked visual loss, usually 20/200 to only hand motion
  • Afferent pupillary defect
  • Ophthalmoscopy findings of extensive retinal hemorrhages in all 4 quadrants, optic disc is edematous, retinal vein markedly edematous and engorged
  • Macular edema is often severe.
  • Bleeding may result in vitreous hemorrhage.
  • Retinal detachment may occur.

Branch retinal vein occlusion

  • Patients with BRVO have retinal hemorrhages confined to the distribution of the retinal vein.
  • The ophthalmoscopic examination may note triangular and flame-shaped hemorrhages.
  • Mild obstruction of a branch may only show scant hemorrhage. Complete obstruction may have extensive hemorrhage noted on examination, with cotton wool spots.
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Causes

Local disease processes include the following: trauma, glaucoma (history of glaucoma is 5 times more likely to have CRVO), and orbital structural lesions. Rarely, is local ocular disease seen in BRVO. When it is apparent in BRVO, one can consider toxoplasmosis, Behçet syndrome, ocular sarcoidosis, and macroaneurysms.

Systemic disease processes include the following: hypertension, atherosclerosis, diabetes, glaucoma, elderly, fasting, hypercholesterolemia, hyperhomocysteinemia, SLE, sarcoidosis, tuberculosis, syphilis, protein C resistance (factor V Leiden), protein C and S deficiency, antiphospholipid antibody disease, multiple myeloma, cryoglobulinemia, leukemia, lymphoma, Waldenstrom macroglobulinemia, polycythemia vera, and sickle cell disease.

In CRVO, a positive association has been found in ACE inhibitor use with atrial fibrillation. A counterintuitive finding was noted in a small study in 2007, where warfarin and aspirin use was linked with a surprising propensity to develop CRVO. A negative association can be found with the use of estrogen in postmenopausal women.

BRVO has a strong association with hypertension.

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Contributor Information and Disclosures
Author

Mark Fonrose, MD, FACEP  Assistant Professor of Emergency Medicine, Kings County Hospital Center/State University of New York

Mark Fonrose, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph A Salomone III, MD  Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

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