Long term follow up in a case of branch retinal vein occlusion
Dr. Sarang Lambat, Dr. Shashank Somani, Dr. Prabhat Nangia, Dr. Vinay Nangia
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.
A female, 76 years of age, came to us in 2017 with complaints of blurring in left eye since a month. She was a known case of systemic hypertension and bronchial asthma since 5 years. Her best corrected visual acuity was 6/9 in right eye and 6/18 in left eye. Anterior segment examination was normal in both the eyes. Intraocular pressure recorded by Goldmann applanation tonometer was 18 mmHg in both eyes.
On the basis of this patient was diagnosed to have left eye inferotemporal branch retinal vein occlusion with macular edema. She was explained about requirement of regular and multiple intravitreal injections. She underwent first anti VEGF injection in the left eye in February 2017.
With not so regular follow up she received a total of 12 anti VEGFs injections in combination with 4 injections of triamcinolone acetonide and 4 dexamethasone implant insertion over a period of 3 years. Last intervention was cataract with anti VEGF with dexamethasone implant which was done in October 2019.
She was explained about requirement of vitrectomy in the future if the traction worsens. She received one more injection of anti VEGF with dexamethasone implant. She didn’t follow up with us for another 8 months due to COVID pandemic. She reported to us in October 2020.
Since an ERM had formed and there was a persistent macular edema with traction we decided to subject the patient to pars plana vitrectomy with anti VEGF injection with dexamethasone implant. She underwent the same in November 2020
This is a typical case of BRVO who received multiple intravitreal injections of anti VEGF and steroids in combination over a period of few years for recurrent macular edema. This case demonstrates that such patients require a long term follow up and repeated interventions to address the macular edema and prevent vision loss. The patient received long acting dexamethasone implants as well. Such strategies help reduce the follow up and interventions and mounts a better control on the macular edema. It is important to note that a delay in treatment after each recurrence leads to some degree of permanent loss of visual function which does not recover. Another important aspect related to these patients is to arrange an escort for them for each follow up visit. This is known to cause treatment drop outs and delay in treatment which could have a significant impact on vision.
This patient developed subtle vitreo macular traction 3 years after treatment (Fig. 6) which increased in subsequent visit along with development of epiretinal membrane (Fig. 7) Decision of vitrectomy along with additional pharmacotherapy was taken because of these interface issues apart from the macular edema due to BRVO. Post vitrectomy patient did well and there was significant reduction of macular edema along with return of the foveal pit (Fig. 8) It is important to note that the final visual acuity is subnormal due to the chronic nature of the disease and she is not going to recover it back by any means. Hence this has to be adequately emphasised while explaining the prognosis in such cases.
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Dr. Sarang Lambat
Suraj Eye Institute
Email – firstname.lastname@example.org