SPARK IMAGEWISE 36

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.

Case description 
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. 

Figure 1: Fundus photograph of the right eye shows a moderate sized disc with 50 percent cupping and a healthy neuro-retinal rim
Figure 2: Fundus photograph of the left eye shows presence of retinal hemorrhages along the infero-temporal arcade (green arrow) along with cyst at fovea fovea suggestive of macular edema (yellow arrow). Disc is of moderate size with 40 percent cupping and a healthy neuro-retinal rim
Figure 3: The optical coherence tomography line scan of right eye passing through the fovea shows a normal foveal contour and normal retinal layers.
Figure 4: The optical coherence tomography vertical line scan of left eye passing through fovea  shows presence of hypo reflective areas in outer nuclear and outer plexiform layers (yellow arrows) suggestive cystoid macular edema. There is presence of hypo reflective area at the fovea creating a space between neurosensory retina and the RPE suggestive of sub-retinal fluid (blue arrow). There is evidence of widening of the retinal nerve fibre layer (red arrow) suggestive of edema of RNFL.

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.

Figure 5: Shows the follow up scans after monthly intravitreal injections. Swelling had resolved almost completely (a) but there was presence of retinal hemorrhages (red arrows). Macular edema has reappeared (b) due to delay in reporting. Resolution of edema after a month of the 3 rd injection of anti VEGF.

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. 

Figure 6: Status of macula in February 2020. She had recurrence of macular edema with appearance of subtle vitreomacular traction (yellow arrow). 

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. 

Figure 7: SDOCT follow up scans in October 2020 shows presence of cyst at fovea (red arrow) with minimal schitic changes, an epiretinal membrane (green arrow) and vitreo macular traction (yellow arrow). 

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

Figure 8: SDOCT line scan showing a better appearance of macula with minimal degenerative cysts near fovea (yellow arrow) and loss of ellipsoid zone at fovea (green arrow). Resolving hard exudates can also be seen along the outer plexiform layers (blue arrow) 

Discussion 

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.

Readwise

  1. Jaulim A, Ahmed B, Khanam T, Chatziralli IP. Branch retinal vein occlusion: epidemiology, pathogenesis, risk factors, clinical features, diagnosis, and complications. An update of the literature. Retina. 2013 May;33(5):901-10. doi: 10.1097/IAE.0b013e3182870c15. PMID: 23609064.
  2. McIntosh RL, Mohamed Q, Saw SM, Wong TY. Interventions for branch retinal vein occlusion: an evidence-based systematic review. Ophthalmology. 2007 May;114(5):835-54. doi: 10.1016/j.ophtha.2007.01.010. Epub 2007 Mar 30. PMID: 17397923.
  3. Bae JH, Al-Khersan H, Yannuzzi NA, Hasanreisoglu M, Androudi S, Albini TA, Nguyen QD. Surgical Therapy for Macular Edema: What We Have Learned through the Decades. Ocul Immunol Inflamm. 2019;27(8):1242-1250. doi: 10.1080/09273948.2019.1672194. Epub 2019 Oct 24. PMID: 31647684.

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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