Comprehensive ophthalmologists should be familiar with treatment options for retinal vein occlusion

Issue: October 10, 2010

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

Retinal vein occlusion, including branch retinal vein occlusion and central retinal vein occlusion, is the third most common retinal pathology that presents to the comprehensive ophthalmologist, trailing only age-related macular degeneration and diabetic retinopathy.

The therapeutic approach to these patients has evolved during my career from observation for complications such as cystoid macular edema (CME) and the rarer rubeosis iridis with secondary glaucoma to a more aggressive treatment plan. The treatment options include local photocoagulation for branch retinal vein occlusion and either intravitreal steroid or VEGF inhibitor for central retinal vein occlusion. The goal is to either prevent or treat the loss of vision from CME and perhaps reduce the chance for ischemic maculopathy.

The comprehensive ophthalmologist who either treats or participates in the management of these patients needs to be aware of the treatment options, their expected outcomes and their potential side effects.

With photocoagulation or no treatment, one can anticipate a slow resolution of CME over months. There are really no meaningful side effects to monitor, except for the possibility of neovascularization, which might require further therapy. If CME does not resolve with photocoagulation, further therapy with intravitreal steroid or an anti-VEGF may help.

For intravitreal steroids, the well-known complications are steroid-induced pressure elevation and secondary cataract. In most cases, the elevated pressure can be controlled with topical drops to prevent glaucoma damage, but some cases with vulnerable nerves may require glaucoma surgery. Pressure checks, optic nerve imaging, visual fields, gonioscopy and funduscopy, as in any glaucoma patient, are appropriate. Secondary cataract can be treated with phacoemulsification and IOL implantation, but recurrence of macular edema in the early postoperative period is a significant risk, and I treat these patients more aggressively with topical steroids and NSAIDs both preoperatively and for at least 2 months postoperative.

Some cataract surgeons will utilize subconjunctival or intravitreal steroids or intravitreal VEGF inhibitors at the time of surgery in these patients as well. The primary issue with the VEGF inhibitors is their limited duration of action, with loss of effect and recurrence of CME. In these cases, the injection can be repeated or a longer acting steroid can be used as an alternative. VEGF inhibitors seem to provide a more rapid effect, and intravitreal steroids, especially those with extended release, a longer therapeutic benefit. Of course, they can be used in combination, and further study is needed on this, as well as the possibility of using one or both in combination with laser photocoagulation.

Like every other pathology we face, it seems the more we learn, the more new questions arise that require well-designed studies to answer. With the current approval of a potent topical steroid, difluprednate, it is possible that topical steroids can be of benefit, and some of the newer NSAIDs also penetrate into the posterior segment as well. Further evaluation of the role of topical agents in preventing and reducing CME is needed, as these agents used long term might reduce the chance of relapse or recurrence.

Of course, any intravitreal injection carries the risk of sterile or infectious endophthalmitis, and this should be watched for. With organisms of low virulence, such as Staphylococcus epidermidis, the onset can be mild, with only vitreous cells to raise our suspicion. Once established, vitreous cells are significant and associated with the hallmark signs of lid edema and pain. Careful preoperative prepping of the eye and lids with povidone iodine, the use of prophylactic antibiotics such as a fourth-generation fluoroquinolone and the use of a lid speculum have reduced the risk of infectious endophthalmitis significantly.

In closing, I must congratulate our retina colleagues for their use of well-designed prospective randomized clinical trials to provide level 1 evidence as to how best to treat our patients with sight-threatening retinal disease. They and their funding partners, including the National Eye Institute and, yes, the manufacturers of the therapeutic agents we utilize to treat, have made a major contribution to the benefit of millions of patients worldwide.