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“Young Female with Painless Blurry Vision”

Explore the case of a young female with painless blurry vision in her right eye, diagnosed as central retinal vein occlusion. Learn about the differential diagnosis, risk factors, imaging techniques, and treatment options including anti-VEGF therapy and surgical approaches.

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“Young Female with Painless Blurry Vision”

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  1. “Young Female with Painless Blurry Vision” Mohammad Ali Sadiq, MD – PGY2 March 01, 2019

  2. Patient Presentation CC “Blurry vision in right eye” HPI 25 year old white female presented with • Sudden, painless, blurry vision OD for the past one week.

  3. History Past Ocular Hx: None Past Medical Hx: • Sinus tachycardia Fam Hx: Mom had a history of a retinal illness when she was 55 years old. Meds: None

  4. History Allergies: Penicillin Social Hx: No smoking/alcohol ROS: Negative except as in the HPI

  5. External Exam

  6. Anterior Segment Exam

  7. Posterior Segment Exam

  8. Fundus Photographs

  9. OCT

  10. Assessment and Plan A 25 year old white female with who presented with sudden onset, painless decreased vision OD. Differential Diagnosis: • Impending CRVO • Papillophlebitis • Hyperviscosity retinopathy (waldenstrom, multiple myeloma or blood dyscrasias) • Ocular Ischemic syndrome Plan: • Ordered extensive coagulopathy/infectious work up. • Re-assess in 2 weeks.

  11. Labs • CBC • ANA • Protein-C • Factor V Leiden • Homocysteine • Antithrombin Activity • Anticardiolipin • RPR, Lyme • Quantiferon • Lipid panel

  12. Update • No further visual changes • VA 20/25 and 20/20 • Work up was negative • Mild macular edema in OD on OCT Plan: • Continue to observe • Follow up in 3 weeks

  13. OCT

  14. Central Retinal Vein Occlusion • Second most common vascular cause of visual loss after DR • Most commonly associated with advancing age and hypertension. • Vision loss is sudden and painless • Ranging along a spectrum from non-ischemic (mild) to ischemic (severe).

  15. Non-Ischemic CRVO • Also known as partial, perfused or venous stasis retinopathy. • Vision >20/200 • Mild or no RAPD • Minimal areas of non-perfusion on FA • Anterior segment neovascularization is rare

  16. Ischemic CRVO • Also known as complete, non-perfused or hemorrhagic retinopathy • Defined as having ≥10 DD of retinal capillary non-perfusion. • Usually associated with poor vision. • Associated with anterior segment neovascularization • Presence of RAPD • More extensive venous dilation/tortuosity and hemorrhages

  17. Anterior Segment Neovascularization • High rate in ischemic CRVO (up to 60%) • Occurs on average 3-5 months after onset of symptoms. • Poor VA is the risk factor most predictive of iris NV in these patients. • Other risk factors include area of non-perfusion and presence of intraretinal blood (CVOS study).

  18. Risk Factors • Most important risk factor is age (>90% are older than 50). • Hypertension • Open-angle glaucoma • Diabetes mellitus • Hyperlipidemia • Hypercoagulability

  19. Hypercoagulability • Hyperhomocystinemia • Protein S deficiency • Protein C deficiency • Factor V leiden mutation • SLE • Sarcoidosis

  20. Management

  21. Management • Multimodal imaging • Initial evaluation with monthly visits x 6 months • In the CVOS study 16% of initially non ischemic CRVOs converted to ischemic by 4 months. By 36 months, the percentage increased to 34%

  22. IMAGING

  23. Collateralization

  24. CRVO and Cilioretinal Artery Occlusion

  25. CRVO and Carotid Cavernous Fistula

  26. Fluorescein Angiography

  27. OCT-Angiography

  28. Management Laser: • Grid laser not recommended for CRVO with macular edema. • Prophylactic PRP did not result in significant reduction in incidence of iris NV. • PRP when iris neovascularization is observed.

  29. Pharmacological Management • Anti VEGF agents have been well-studied for CRVO. • CRUISE – Ranibizumab • COPERNICUS – Aflibercept • SCORE – Intravitreal Triamcinolone • SCORE 2 – Bevacizumab and Aflibercept • Systemic anticoagulation not recommended

  30. Other Surgical Approaches • Peripheral laser anastomosis between retinal vein and choroidal circulation • Radial relaxing incision of optic nerve scleral ring • Retinal vein cannulation with infusion of TPA.

  31. Conclusions • CRVO is a common vascular cause of visual loss. • Mostly seen in patients above the age of 50. • Important to rule out precipitating causes of CRVO in the younger population. • Need to differentiate between ischemic and non-ischemic CRVO. • Anti VEGF therapy plays a critical role • PRP if there is anterior segment neovascularization.

  32. “If you can’t find a cause for something…. blame it on a VIRUS !” – Charles Barr, MD

  33. Acknowledgements • Charles Barr, MD • Efrat Fleissig, MD

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