Spark ImageWise 6 – Retina

Branch Retinal Vein Occlusion- Clinical and Imaging Correlation

Dr. Sarang Lambat, Dr. Vinay Nangia 
Suraj Eye Institute, 559 New colony, Nagpur, India

Case Description
A female, 45 years of age, came with blurring of vision in left eye since 3 months. She was a known diabetic and hypertensive under treatment since 2 years. Her best corrected visual acuity was 6/6 in right eye (OD) and 6/24 in the left eye (OS). Anterior segment examination was normal in both eyes (OU). Intraocular pressure recorded by Goldmann applanation tonometer was 18 mmHg in OD and 15 mmHg in OS. Fundus examination revealed a normal macula in OD with a vertical cup disc ratio (VCDR) of 0.4 and an old inferonasal retinal vein occlusion. Left eye fundus showed presence of Infero-temporal vein occlusion with macular edema and neovascularisation of the disc.

Figure 1a: Left eye fundus photograph shows presence of thickening at macula with retinal hemorrhages surrounded by hard exudates along the infero-temporal quadrant. There is presence of tortuous and sclerosed vessels. The disc shows presence of multiple small vessels which are extending beyond its margins suggestive of neovascularisation of the disc. Collateral vessels are also seen below the disc.
Figure 1b: Fluorescein angiogram (FFA) photo shows presence of significant disc leakage (red arrow) and capillary non perfusion areas (yellow arrows) along the inferotemporal arcade along with leakage along the edges suggestive of macular edema.
Figure 2: A vertical line scan of SDOCT of the left eye passing through the fovea showing presence of cystoid spaces at the fovea in the outer nuclear (yellow arrow head), outer plexiform, inner nuclear layer (green arrow head) and ganglion cell layer (red arrow head). Hyper reflective dots (green arrows) are also seen within the retinal layers. The posterior hyaloid is still attached.

Figure 3a: Fundus photograph of the right eye shows a normal macula and optic disc. There is presence of tortuous vessels in the infero nasal quadrant (green arrows) along with RNFL thinning (red arrows) suggestive of an old branch retinal vein occlusion.
Figure 3b: FFA of the right eye shows a normal dye transit.

On the basis of these findings she was given one dose of intravitreal anti VEGF in the left eye followed by sectoral retinal as well as macular laser. She improved significantly in terms of reduction in macular edema and resolution of neovascularization. Her BCVA improved to 6/12 in the left eye. 

Figure 4: Fundus photograph of the left eye one month post injection anti VEGF shows significant reduction in macular edema along with the retinal hemorrhages. The hard exudates have also reduced in number. The new vessels at the disc have disappeared. Sclerosed vessels are now seen more prominently.
Figure 5: A vertical line scan of SDOCT of the left eye passing through the fovea a month after anti VEGF injection showing appearance of foveal pit along with resolution of macular edema. The outer nuclear layer shows thinning in the involved segment (yellow arrows) . There is loss of external limiting membrane, ellipsoid zone below the fovea (green arrows). Hyper reflective foci are still seen within the retinal layers. The posterior hyaloid shows separation from the ILM (red arrows).

Discussion

This patient had a major vein occlusion which drains a larger retinal area. FFA showed presence of significant amount of retinal ischaemia which is a predictor of subsequent neovascularisation. Anti VEGFs have a significant role in controlling retinal neovascularization due to various causes. Additional laser photocoagulation to ischaemic areas prevents recurrent neovascularization and subsequent problems because of vitreous traction and retinal breaks.
As per the Marvel report no 3, baseline central macular OCT thickness of <500 μm, hyper-reflective dots, and GCL cystoid spaces are associated with poorer gains in visual acuity. In our case patient just improved 2 lines of vision which could be attribute to presence of all the 3 features mentioned in this report along with increased duration of presentation. 

Readwise

  1. Narayanan R, Stewart MW, Chhablani J, Panchal B, Pappuru RR, Das T, Jalali S, Ali MH. Baseline morphological characteristics as predictors of final visual acuity in patients with branch retinal vein occlusions: MARVEL report no. 3. Indian J Ophthalmol. 2018 Sep;66(9):1291-1294. doi: 10.4103/ijo.IJO_342_18. PMID: 30127143; PMCID: PMC6113821.
  2. Venkatesh R, Pereira A, Sangai S, Thomas S, Yadav NK. Prognostic Value of Hyperreflective Material on Visual Acuity in Treatment-Naïve BRVO. Ophthalmic Surg Lasers Imaging Retina. 2020 Jun 1;51(6):320-327. doi: 10.3928/23258160-20200603-02. PMID: 32579690.

Correspondence 

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

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