Table 4
Summarising treatment modalities for CRVO
| Reference | Type of vein occlusion | Study type | No of patients and follow up | Visual outcome (visual acuity – VA) | Complications and comments | ||
|---|---|---|---|---|---|---|---|
| Systemic steroids | |||||||
| Shaikh et al11 | Non-ischaemic CRVO | Case reports | 2 patients | Event in second eye. Patient seen 5/12 post-CRVO. 1/7 post IV methylpred: VA ↑ to 20/250 from CF 1/52 later VA ↑ 20/25 3/12 later VA ↓ to 20/400 3 years later VA 20/200 Periocular steroid improved VA to 20/30 initially (in past) Initial VA 20/20 RE and 20/80 LE 60 mg pred: VA 20/40 LE at 10 days 8/12 later VA 20/80 again Repeat steroid by mouth: VA ↑ to 20/60 2/12 later: more CMO + ↓ VA now refractory to steroid | Nil Transient response 1 year hx of CRVO | ||
| Intravitreal steroids | |||||||
| Greenberg et al13 | Haemorrhagic CRVO in 2nd affected eye with macular oedema | Case report | 1 patient | Initial VA 20/400 LE, CF Re (LE has acute visual loss). VA 20/80 in LE 6/52 post-injection and 20/30 after 3/12. But ↓ VA 6/12 post procedure however macular oedema ↓ 2nd triamcinolone injection VA 20/50 1/12 later. Macular oedema resolved after each injection (shown by OCT) Note: no effect of triamcinolone on fellow eye with longstanding CRVO | Nil ↑ IOP (25% eyes) Cataract Retinal detachment, endophthalmitis. FFA showed no ischaemia initially. Rarely Rx may be necessary for visual improvement before longstanding macular oedema causes irreversible photoreceptor damage | ||
| Ip et al15 | Non-ischaemic CRVO | Case report | 1 patient, 16 months follow up | 10 months hx of ↓ VA. Initial VA 20/40 in RE VA fell to 20/200 when injection given 1 month later VA ↑to 20/25 with resolution of macular oedema | Nil 4 mg triamcinolone acetonide | ||
| Ip et al15 | Ischaemic CRVO | Case report | 1 patient, 8 months follow up | 8 months hx of CRVO 3/52 post-injection, VA ↑ from 20/200 to 20/100 with ↓ macular oedema 3/12 post injection VA ↓ to 20/400 | Nil Temporary benefit in ischaemic CRVO VA improvement less marked | ||
| Jonas et al16 | Bilateral CRVO with longstanding macular oedema | Case report | 1 patient, 4 months RE follow up 6 weeks LE follow up | RE: VA ↑ from 0.05 to 0.25 LE: VA ↑ from 0.125 to 0.25 Reduced leakage at macula on FFA | Nil RE, CRVO 2 years ago; LE, CRVO 1.5 years ago 25 mg triamcinolone into each eye 10/52 apart | ||
| Intravenous thrombolysis | |||||||
| Kohner et al29 | CRVO less than 7 days | 20 patients, 1 year follow up | VA not significantly different between Rx + control groups | Neovascular glaucoma (1 treated patient) (4 control patients). Vitreous haemorrhage (within 3/7 in 3 treated eyes; within 1 month in 4 control eyes, pre-vitrectomy era) | |||
| Elman et al30 | CRVO (perfused) | Pilot study (for future randomised controlled trial) | 96 patients, 6 months follow up | 42% (n = 89) gained 3 + lines of vision. 37% remained stable. 21% lost 3+ lines. In eyes with 20/100 or worse pre-Rx vision (n = 32). 59% gained 3+ lines (average gain 6.4 lines). 31% stable. 4% lost 3+ lines | 3 patients developed intraocular bleeding. GI bleeding (1 patient). Fatal CVA (1 patient). Oozing from previous venepuncture sites or slight bruises (all patients). Inferior subretinal PE haemorrhage (1 patient). Vitreous.haemorrhage with retinal detachment (1 patient). Haemorrhagic sub-RPE detachment (1 patient).<6/12 duration of CRVO t-PA + aspirin t-PA + aspirin + heparin t-PA + aspirin + heparin + warfarin | ||
| Intravitreal t-PA | |||||||
| Lahey et al31 | CRVO | Prospective with no control group | 26 patients CRVO = 23 patients Hemiretinal vein occlusion = 3 patients, 6 months follow up | CRVO: VA improved in 7/23 patients (30.4%) at 6 weeks and 8/23 (34.8%) at 6 months | ↑ in macular oedema vitreous haemorrhage1 ↑ in size of macular haemorrhage2 | ||
| Glacet- Bernard et al32 | 15 patients, 5–21 months (mean 8 months) follow up | VA ↑ to 20/30 + in 5 eyes (36%) including 2 with complete recovery. VA worse than 20/200 in 3 eyes (28%). Initial VA ⩽ 20/40. At end: 5 (36%) eyes had VA ⩾ 20/30; 5 (36%) had VA 20/200 to 20/30, and 4 (28%) had <20/200 | Nil | ||||
| Recent onset CRVO (1–21 days duration mean 8 days). 75- 100 μg t-PA + low dose heparin | |||||||
| Elman et al34 | CRVO (perfused on FFA) | Prospective non-comparative case series | 9 patients, >6 months follow up | 4/9 eyes (44%) had 3 + lines improvement at 6 months (average improvement 7 lines). 2 eyes had 6 or more lines loss of vision at 6 months. 3 eyes needed PRP | PRP, 3 eyes for neovascularisation 100 μg t-PA 1 baby aspirin t-PA within 2 weeks of symptoms | ||
| Ghazi et al35 | CRVO | Prospective non-controlled study | 12 patients | 55% of patients with initial VA < 20/200 had a final visual acuity of 20/50 or better | Symptom duration was <3 days | ||
| t-PA into retinal vein | |||||||
| Weiss and Bynoe37 | CRVO | Prospective non-comparative interventional case series | 28 patients, 11.8 months follow up (range 3–24 months) | VA 20/400 or worse. 22 of 28 patients (79%) experienced at least 1 line of visual improvement Initial VA ⩽20/400 15 eyes (54%) – 3 + line ↑ in VA in 3/12 14 eyes (40%) had 3 + line ↑ VA by end of follow up 10 eyes (36%) ↑ at least 5 lines 5 eyes ↑ by at least 8 lines 1 eye recovered from 20/400 preop to 20/20 post-op | |||
| Ophthalmic artery fibrinolysis | |||||||
| Paques et al39 | CRVO + CRAO | Retrospective | 26 patients CRVO + CRAO : 9 patients CRVO + cilioretinal AO: 3 patients CRVO only: 14 patients, 10 months follow up range 2–24 months | Initial VA <20/60 or CRVO in fellow eye or ↓ VA after initial improvement and if other eye lost. 6 patients had ↑ in VA within 48 hours – 4 for these were CRAO + CRVO (in latter, VA was ⩾20/50) | Unable to catheterise vein in 1 patient. ↓ of vision after initial improvement. Intravitreal haemorrhage (2 patients). Mean duration of symptoms 26 days (range 12 hours to 7 months) Urokinase into ophthalmic artery | ||
| Vallee et al46 | Severe non-ischaemic CRVO | Prospective no control group | 13 patients, 1 year follow up | 5/13 patients had ↑ VA + retinal perfusion in 24–48 hours VA returned to normal in 24–48 hours in 3 patients, within 1 week in 1 patient + 1/12 in 1 patient. 1 patient relapsed 1/12 later (repeat CRVO when heparin stopped) At end of follow up 1 had normal vision, 7 had no improvement | Stopping aspirin led to ↓ VA to 20/200 due to macular oedema. Visual loss <30 days + urokinase VA, 20/200 IV heparin 48 hours 1000 Mw heparin 1 month, oral aspirin 3 months | ||
| Vallee et al41 | CRAO + CRVO | Prospective | 11 patients, 6 years follow up | 7 of 11 patients had slight ↑ in mean VA (p = 0.006)) and then remained stable throughout follow up (p>0.1) not significant | 1 patient, intravitreal haemorrhage, needing vitrectomy and PRP leading to NPL vision. Visual loss 12–72 hours (mean 32.5 hours), except 1 patient treated after 10 days for compassionate reasons. Urokinase | ||
| Radial optic neurotomy | |||||||
| Opremcak et al47 | Severe haemorrhagic CRVO | Retrospective | 11 patients Average 9 months (5–12 months range) | All had initial VA <20/400 All had improved fundus pics (photos + FFA) Equal or better Snellen VA in 9/11 patients (82%) VA improved in 8/11 patients (73%) – average 5 lines improvement (range 3–7 lines) 7/11 patients (73%) had final VA >20/200 5/11 patients (45%) had final VA >20/70 2/11 patients had 20/40 final VA 2 patients had worse VA both had iris rubeosis | Nil Potential Laceration of CRV or CRA optic nerve damage, globe perforation, retinal detachment Average duration of CRVO 4 months (range 1–7 months) Single surgeon Final VA did not correlate with duration of CRVO or presence of systemic changes Younger age of onset tended to give worse prognosis: patients with equal or worse VA had average age 54 and with improved VA 64 years | ||
| Garcia-Arumi et al51 | CRVO | Prospective case series no control group | 57% patients gained 1 or more line of vision, 43% patients improved in visual acuity by 2 or more lines | ||||
| Weizer et al50 | CRVO | Interventional case series | 5 patients 4.5 months follow up | 4 patients (80%) had improved VA, 2 patients (40%) improved to 20/80 postop. In 80% disc congestion improved and intraretinal haemorrhages resolved faster than expected | 40% incidence of neovascularisation requiring PRP | ||
| Isovolaemic haemodilution | |||||||
| Glacet-Bernard et al44 | Central or hemiretinal vein occlusion | Prospective | 142 patients 10 months follow up | 41% people treated within 2 weeks had a VA of 20/40 v 23% in the late treatment group. Final retinal ischaemia was greater in the late treatment group | Early treatment gave better results | ||
| Hansen et al45 | Ischaemic and non-ischaemic CRVO | Prospective randomised controlled trial | 19 patients (IHD + PRP) and 19 controls (PRP) 1 year follow up | Patients treated with IHD and PRP had a statistically significant improvement in VA compared to PRP alone | |||
| Hansen et al49 | Non-ischaemic CRVO | Randomised controlled trial | 14 patients and 14 controls 1 year follow up | 8 of 14 study patients had improved VA compared to none of the controls | Study stopped early because of treatment benefit | ||
| Optic nerve sheath decompression | |||||||
| Dev and Buckley58 | All with optic nerve oedema | 8 patients, 12.4 months follow up (3–27 months) | Mean preoperatively VA 20/160, mean postoperative VA 20/70. 6 patients improved in VA | ||||
| Laser chorioretinal venous anastamosis | |||||||
| McAllister et al62 | Non-ischaemic CRVO | Retrospective consecutive series | 91 patients, 12 months | Successful anastomosis in 49 eyes (54%) 84% eyes had average ↑ VA of 4.3 lines ±3.8 lines (range 2–20 lines) 16% had no improvement (6 eyes, 12%) or ↓ vision (2 eyes, 4%) No progression to ischaemia in eyes without anastomosis: 17 eyes (40.5%) had ↑ VA 8 (19%) had same VA 17 (40.5%) had ↓ VA Significant difference between groups. Progression to ischaemia in 15 eyes (38%) | 18 (20%) had neovascular complications—intravitreal, intraretinal, and subretinal neovascular membranes significantly associated with retinal ischaemia (p<0.001) Immediate: Subretinal haemorrhage Vitreous haemorrhage Late: Distal vein closure Fibrovascular proliferation, NVE, progressive capillary non-perfusion in 19 eyes (21%) | ||
| Fekrat et al64 | CRVO + BRVO | Retrospective review | 24 patients | CRVO anastomosis formed in 9/24 eyes (38%) (2/9 of these eyes had undergone grid laser Rx previously) within 2/12 VA ↑ 6 + lines in 2/24 eyes (8%), 1–3 lines in 5/24 (21%), no change in 2 eyes (8%) (chronic CMO + focal RPE hyperpigmentation) BRVO 3/6 eyes form anastmosis (50%) VA ↑ 1–3 lines in 2 eyes (33%), no change in 1 (16%) | Vitreous haemorrhage Preretinal fibrosis Localised choroidal neovascularisation 4 months plus before Rx | ||
| Surgical chorioretinal venous anastomosis | |||||||
| Peyman et al66 | Ischaemic CRVO | 5 patients, mean follow up 13.4 months | VA ↑ in 3 eyes, unchanged in 1 eye, ↓ in 1 eye | Minor fibrous proliferation Failure to form at site Complications of vitrectomy | |||
