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Is there a role for observation before initiating treatment for BRVO, perhaps to avoid the need for pharmacotherapy?
N/A
No rationale for delaying treatment
 Paolo Lanzetta |
Recent results from trials on pharmacotherapy of retinal vein occlusion should persuade ophthalmologists of the necessity of an earlier treatment of macular edema associated with vein occlusion in the presence of visual acuity loss.
Before newer therapies with Lucentis or Ozurdex were available, there was no effective treatment for macular edema secondary to CRVO. For macular edema due to BRVO, laser photocoagulation was not used immediately but after an observation period of 3 to 6 months. The reason was that laser photocoagulation did not allow the remarkable outcomes that can be obtained with drugs, and sometimes spontaneous resolution resulted in visual acuity levels similar to laser. Also, laser photocoagulation could be applied only after the resolution of macular hemorrhages, which are a common complication of macular edema.
It is becoming more evident that, in the presence of macular edema with vision loss, the earlier we treat, the better results can be obtained. In a sub-analysis of the GENEVA study on Ozurdex, duration of macular edema was a major factor influencing visual acuity improvement after treatment. Each 1-month duration of macular edema had an effect on the odds ratio for achieving at least a three-line improvement in visual acuity 6 months after treatment. This decrease in odds was about 14%, 36%, 60% and 84% for 1, 3, 6 and 12 additional months, respectively. Similar effects might be expected with other pharmacotherapies. Treatment options are available, should be started as early as possible and can indeed modify the visual prognosis. Now there is no rationale for waiting and delaying the treatment.
Paolo Lanzetta, MD, is an OSN Europe Edition Editorial Board Member. Disclosure: Dr. Lanzetta is a consultant for Allergan and Novartis and is a patent holder with Iridex.
Patient’s lifestyle should be considered
 Pravin U. Dugel |
There is a role for observation as long as the macula is not involved because vision is rarely affected then. The more interesting question is, what about patients in whom the macula is involved, but the vision is very good? The recent major clinical trials only enrolled patients with vision worse than 20/40 and retinal vein occlusions involving the macula. So here is a niche of patients with good vision who do not fall into the study categories. So, the answer is that the treatment does have to be individualized.
Traditionally, at 20/40 or worse, we just observe, but that is an arbitrary and historical cutoff; in studies, you have to do that. In my experience, though, even when you have patients with good visual acuity after a vein occlusion that involves the macula, their vision to them is not very good. Even patients who recover to 20/20 after vein occlusion will tell you that their vision is never really as good.
For those patients with macular involvement with very good vision, I am more likely to treat now, but I still base that decision on the patient, and that is important to emphasize. If the patient is an 85-year-old retiree and the visual requirements are not that stringent, then I am happy to observe. On the other hand, if the patient is a young physician or a pilot or a policeman, then I am less likely to observe because even if the vision is good, the quality of vision is not very good. Remember that we measure visual acuity in a very artificial setting.
There is evidence that if you wait and allow anatomical damage to the photoreceptor cells, then the recovery of vision may not be as good. There are hints of that in the BRVO literature as well with the Ozurdex studies. Intuitively that makes sense. So, if the patient has a significant requirement in their vision, I do not wait. I feel the photoreceptor cell recovery will be better.
The question is, what do you treat with? The safest treatment for such a patient is probably three to four monthly injections of an anti-VEGF. That does not mean vision will be perfect, but in most cases, it helps appreciably.
Pravin U. Dugel, MD, is in practice at Retinal Consultants of Arizona, Phoenix, U.S.A. Disclosure: Dr. Dugel is a consultant for Abbott Medical Optics, Alcon, Allergan and Genentech.