Occlusive vascular disorders of the retina

Occlusive vascular disorders of the retina


5 Learning outcomes 6 By the end of this lecture the students would be able to 1. Classify occlusive vascular disorders (OVD) of the retina and identify risk factor for these disorders. 2. Correlate the clinical features of OVD of the retinal with the underlying pathophysiological changes. 3. Identify CRVO, BRVO, HRVO in given clinical cases or on fundus photgraphs.

4. List complications of CRVO and describe prognosis of a given case on the basis of clinical data. 5. Outline treatment of BRVO and CRVO. Retinal vein occlusion 7 Central retinal vein occlusion (CRVO) Branch retinal vein occlusion (BRVO)

Hemiretinal vein occlusion (HRVO) Retinal arterial occlusion Central retinal artery occlusion (CRAO) Branch retinal artery occlusion (BRAO) Hemiretinal artery occlusion (HRAO) 8 BRVO

CRVO HRV O Epidemiology 9

Retinal vein occlusion is the second most common cause of visual loss due to retinal vascular disease BRVO is the most common type It is a significant cause of severe visual loss in people over the age of 40 yrs Pathophysiology 10 Can you think of some anatomical

factors that could predispose retinal veins to occlusion? 11 With occlusion of the central retinal vein (CRVO) increased venous & capillary pressure Stagnation of blood in the retinal venous system & increased resistance to venous blood flow ischemic damage to the retina increased production of vascular endothelial growth

factor (VEGF) Capillary neovascularization of the posterior and anterior leakage segment Neovascula r Glaucoma , NVD, Complicati ons of

Macular oedema Ischemic Maculopat hy Risk factors 12 Hypervi socsity

Hype rlipid. Clotting . Dis Oral Contrace p Blood Ocular

RVD Smo king Vessel Age wall Infl. DM, Sarcoi HTN, d.

AS Beche t IOP RV INFL M 13 CRVO Clinical presentation

Clinical entities Non ischemic CRVO (about 75% of cases) Ischemic CRVO (worse prognosis) How would you diagnose retinal ischemia?

14 CRVO Clinical presentation From painless visual loss to panful blind eye Decreased vision, metamorphopsia Visual loss

sudden or gradual, over a period of days to weeks. ranges from mild to severe. Patients can present with transient obscurations of vision

initially, later progressing to constant visual loss. Asymptomatic Photophobia Redness of eyes Painful blind eye Clinical examination 15 Patients should undergo a complete eye examination, including visual acuity

pupillary reactions slit lamp examination of the anterior and posterior segments undilated examination of the iris.Why? gonioscopy Dilated fundus examination Signs 16

Visual acuity: (Best-corrected vision acuity) It is one of the important indicators of the final visual prognosis. Pupillary reactions: normal/ relative afferent pupillary reflex. If

the iris has abnormal blood vessels, the pupil may not react. Conjunctiva: Advanced stages may show congestion on conjunctival and ciliary vessels. Cornea: Signs 17

Iris normal/ neovascularization The anterior chamber angle it may show neovascularization with open angles and later show total peripheral anterior synechia and closed angles. Signs 18

Fundus examination: Retinal hemorrhages Dilated tortuous veins Optic disc edema Cotton-wool spots

Macular oedema Late signs: Neovascularization optic (NVD, NVE), disc cupping, optociliary shunt vessels at the disc (a prognostic sign), pigmentary changes in the macula 19

20 21 22 23 24 25 26

Rubeosis 100 day glaucoma 27 Non-Ischemic & Ischemic RVO NICRVO

VA Mild to moderate loss Haemorrhages, CWS, mild macular oedems ComplicationCMO ICRVO

Severe visual loss May be painful (NVG) As of NICRVO with RAPD CWS Complications- NVD,

Rubeosis, NVG, CMO, Ischemic maculopathy Investigations 28 Risk factors screening (Lab tests)

FFA Optical Coherence Tomography (OCT) especially for the assessment of macular oedema Electro-retinogram (ERG)- amplitude of the b-wave is decreased relative to the a-wave 29 Haemorrhges blocking retinal fluorescence Areas of retinal ischemia

CRVO Prognosis 30 The prognosis depends upon the reestablishment of patency of the venous system by recanalization, dissolution of clot, or formation of optociliary shunt vessels.

Signs resolve in 6-12 months TREATMENT 31 Depends on the type & stage of CRVO Principles of treatment are

Treat the underlying cause Monitor Treatment modalities Intravitreal corticosteroid and antiVEGF agents Dexamethasone intravitreal implant Laser photocoagulation Follow -up 32

Regular follow up babysit" for these eyes during that period when they are at maximum risk of developing neovascular glaucoma, i.e. first 7-8 months Prognosis- For nonischemic CRVO 33

complete recovery with good visual recovery occurs only in about 10% of cases. 50% of patients will have 6/60 or worse vision. About 1/3rd of patients convert to ischemic CRVO within 3 years; 15% within the first 4 months.

Important to remember Prognosis- For ischemic CRVO 34 more than 90% of patients will have

6/60 or worse vision. About 60% of patients develop ocular neovascularization About 7-10% of patients can develop CRVO or other type of vein occlusions within either the same eye or the contralateral eye within 2 years. Important to remember 35 36

37 Topics for Test 38 1. 2. 3. 4. 5. Diseases of lids

Diseases of cornea Refractive errors Uveitits VR disorder

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