Is there any role for observation before initiating treatment for BRVO, perhaps to avoid the need for pharmacotherapy?

Presenting vision is important

Michael A. Singer

If a patient presents with vision worse than 20/40, I discuss injection therapy immediately, but I still do not perform injections on the spot. I prefer to bring patients back after they have had time to think about the procedure, for the family to get over the “sticker shock” and for them to read the literature about the disease.

Patients usually return within 2 weeks for a follow-up. I may repeat some testing, especially when the patient reports a change in visual acuity or perception, because I have seen OCT change as much as 100 µm in a week. It is important to get the most accurate baseline data. A number of patients show improvement without treatment.

For a patient with 20/40 or better vision, I am more likely to watch for a few weeks. I monitor three different parameters: OCT, Snellen visual acuity and visual perception. If any of these parameters change, then I recommend injection. The patient appreciates that there has been deterioration and is more willing to undergo a repeated injection regimen.

If the patient has significant visual requirements in daily life, I may treat earlier because we know that in the major clinical trials, especially in the BRAVO and CRUISE data, there can be significant visual improvement in a week. In addition, these patients are younger than typical AMD patients and are more likely to be employed in occupations that require binocular vision.

The BRAVO, CRUISE and Ozurdex trials have taught us that patients treated in the second 6 months never really caught up in terms of vision. I am not going to wait months to see what happens. Chronic edema causes photoreceptor loss, and our goal is to keep as many photoreceptors as possible. The quicker the edema is resolved, the better for the patient. We have an incredible amount of experience with a lot of these therapies. We know they are safe, and injecting into the eye is now standard for many retinal diseases.

Michael A. Singer, MD, is a retina specialist at Medical Center Ophthalmology Associates of San Antonio, Texas.

Patient’s lifestyle is important

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.