eMedicine Specialties > Emergency Medicine > Ophthalmology

Retinal Vein Occlusion: Treatment & Medication

Author: Mark Fonrose, MD, FACEP, Assistant Professor of Emergency Medicine, Kings County Hospital Center/State University of New York
Contributor Information and Disclosures

Updated: Aug 25, 2008

Treatment

Emergency Department Care

The cornerstone of emergency department (ED) treatment for retinal vein occlusion may rest with the awareness of the disease entity by the ED physician. When considered in the proper clinical scenario, expeditious consultation by an ophthalmologist in the ED, can enable definitive diagnosis and so that appropriate intervention and follow-up care is ensured.
 
Treatment remains controversial at the present time. The Canadian Journal of Ophthalmology 2008 noted "No intervention has emerged as the standard of care. Current management in most centers is close observation for complications and treatment as they arise."5 Another 2008 study notes that many different interventions have been advocated, but evidence is lacking as to their merit. Several randomized clinical trials are underway at the present time.6  

Current literature and practice for the treatment of CRVO remains controversial. Vitreous Retina Macula Consultants of New York, a large and well-established retina practice group in New York City, advocates laser photocoagulation for managing rubeosis irides.7 For the treatment of macular edema, they promote intraocular triamcinolone or bevacizumab (Avastin) in CRVO. Dalteparin was found superior to aspirin in improving visual acuity and preventing neovascularization in CRVO in a 2008 study.8 Radial optic neuropathy (RON) has shown good results in improving visual loss in severe CRVO in a limited 2008 study.5 Of note, a single case study in 2008 noted the use of hyperbaric oxygen, and subsequent visual improvement in a patient who refused other intervention.9

Current literature and practice for the treatment of BRVO is controversial as well. Vitreous Retina Macula Consultants of New York note that there is "no known medical treatment" for branch retinal vein occlusion.7  A small study in 2008 noted intravitreal triamcinolone and grid laser photocoagulation effective in the treatment of BRVO.10 In another 2008 study, triamcinolone acetonide retrobulbar injection was found effective for BRVO.11 Pars plana vitrectomy was effective when the macular edema was resistant to improvement with triamcinolone alone.

Consultations

Ophthalmologic consultation is mandatory. Management is outside the scope of emergency medicine.

Medication

In addition to corticosteroids, the drug bevacizumab (Avastin) is a monoclonal antibody Food and Drug Administration (FDA) approved in colon and breast cancer. Its use is experimental for macular edema in CRVO.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.


Triamcinolone (Amcort)

Useful in treatment of inflammatory and autoimmune reactions. By reversing increased capillary permeability and suppressing PMN activity, it may decrease inflammation.

Adult

Intraocular administration per ophthalmologist

Pediatric

Administer as in adults

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

More on Retinal Vein Occlusion

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

  1. Madhusudhana KC, Newsom RS. Central retinal vein occlusion: the therapeutic options. Can J Ophthalmol. Apr 2007;42(2):193-5. [Medline].

  2. Ho JD, Tsai CY, Liou SW, et al. Seasonal variations in the occurrence of retinal vein occlusion: a five-year nationwide population-based study from Taiwan. Am J Ophthalmol. Apr 2008;145(4):722-728. [Medline].

  3. D'Amico DJ, Lit ES, Viola F. Lamina puncture for central retinal vein occlusion: results of a pilot trial. Arch Ophthalmol. Jul 2006;124(7):972-7. [Medline].

  4. Jonas JB, Harder B. Ophthalmodynamometric differences between ischemic vs nonischemic retinal vein occlusion. Am J Ophthalmol. Jan 2007;143(1):112-6. [Medline].

  5. Weis E, Gan KD, Hinz BJ, et al. A retrospective cohort study of radial optic neurotomy for severe central retinal vein occlusions. Can J Ophthalmol. Feb 2008;43(1):73-8. [Medline].

  6. Raja MS, Goldsmith C. Interventions for CRVO. Ophthalmology. Jan 2008;115(1):219; author reply 219-20. [Medline].

  7. Vitreous-Retina-Macula Consultants of New York. Retinal Venous occlusive Disease: Branch Retinal Occlusion/Central Retinal Occlusion. Available at www.vrmny.com. Accessed April 2008.

  8. Farahvash MS, Moghaddam MM, Moghimi S, et al. Dalteparin in the management of recent onset central retinal vein occlusion: a comparison with acetylsalicylic acid. Can J Ophthalmol. Feb 2008;43(1):79-83. [Medline].

  9. Wright JK, Franklin B, Zant E. Clinical case report: treatment of a central retinal vein occlusion with hyperbaric oxygen. Undersea Hyperb Med. Sep-Oct 2007;34(5):315-9. [Medline].

  10. Ozdek S, Deren YT, Gurelik G, et al. Posterior subtenon triamcinolone, intravitreal triamcinolone and grid laser photocoagulation for the treatment of macular edema in branch retinal vein occlusion. Ophthalmic Res. 2008;40(1):26-31. [Medline].

  11. Kawaji T, Takano A, Inomata Y, et al. Trans-Tenon's retrobulbar triamcinolone acetonide injection for macular oedema related to branch retinal vein occlusion. Br J Ophthalmol. Jan 2008;92(1):81-3. [Medline].

  12. Batioglu F, Astam N, Ozmert E. Rapid improvement of retinal and iris neovascularization after a single intravitreal bevacizumab injection in a patient with central retinal vein occlusion and neovascular glaucoma. Int Ophthalmol. Feb 2008;28(1):59-61. [Medline].

  13. Binder S, Aggermann T, Brunner S. Long-term effects of radial optic neurotomy for central retinal vein occlusion consecutive interventional case series. Graefes Arch Clin Exp Ophthalmol. Oct 2007;245(10):1447-52. [Medline].

  14. Ferrara DC, Koizumi H, Spaide RF. Early bevacizumab treatment of central retinal vein occlusion. Am J Ophthalmol. Dec 2007;144(6):864-71. [Medline].

  15. Gandhi JS. Natural history of non-ischemic central retinal vein occlusion versus iatrogenic intervention. J Postgrad Med. Oct-Dec 2007;53(4):270; author reply 270-1. [Medline].

  16. Gumus K, Kadayifcilar S, Eldem B, et al. Assessment of the role of thrombin activatable fibrinolysis inhibitor in retinal vein occlusion. Retina. Jun 2007;27(5):578-83. [Medline].

  17. Hasselbach HC, Ruefer F, Feltgen N, et al. Treatment of central retinal vein occlusion by radial optic neurotomy in 107 cases. Graefes Arch Clin Exp Ophthalmol. Aug 2007;245(8):1145-56. [Medline].

  18. Keith S, Humphries R. Current Diagnosis & Treatment of Emergency Medicine. 6th ed. McGraw-Hill Co; 2008.

  19. Koizumi H, Ferrara DC, Brue C, et al. Central retinal vein occlusion case-control study. Am J Ophthalmol. Dec 2007;144(6):858-863. [Medline].

  20. Kreutzer TC, Alge CS, Wolf AH, et al. Intravitreal bevacizumab for the treatment of macular oedema secondary to branch retinal vein occlusion. Br J Ophthalmol. Mar 2008;92(3):351-5. [Medline].

  21. Leoncini G, Bruzzese D, Signorello MG, et al. Platelet activation by collagen is increased in retinal vein occlusion. Thromb Haemost. Feb 2007;97(2):218-27. [Medline].

  22. Mohamed Q, McIntosh RL, Saw SM, et al. Interventions for central retinal vein occlusion: an evidence-based systematic review. Ophthalmology. Mar 2007;114(3):507-19, 524. [Medline].

  23. Morley M, Heier J. Ophthalmology. Part 8; Section 5. 2nd ed. Mosby; 2004.

  24. Recchia FM, Chen E, Li C, et al. Use of cox-2 inhibitors in patients with retinal venous occlusive disease. Retina. Jan 2008;28(1):134-7. [Medline].

  25. Sodi A, Giambene B, Marcucci R, et al. Atherosclerotic and thrombophilic risk factors in patients with recurrent central retinal vein occlusion. Eur J Ophthalmol. Mar-Apr 2008;18(2):233-8. [Medline].

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Further Reading

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Keywords

retinal vein occlusion, RVO, ischemic retinal vein occlusion, cause of blindness, retina disorder, nonischemic retinal vein occlusion, retinal apoplexy, venous stasis retinopathy, hemorrhagic retinopathy, macular edema, macular ischemia, neovascular glaucoma

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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.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

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.

CME Editor

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.

 
 
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