NEWS & EVENTS
Retinal Review, Issue 03
CASE OF THE MONTH
A 73 year old woman noted vision loss OS two weeks prior to presentation. Vision loss was sudden and painless. Past ocular history is significant for mild cataracts. Medical history is significant for hypertension and hypercholesterolemia. Entering acuities were OD: 20/25 and OS: 20/100. Applanation tensions were normal. The anterior segments were intact. Dilated examination was significant for moderate cataracts OU. The vitreous cavities were clear. The right fundus was significant for mild hypertensive retinopathy. In the left eye there was a superotemporal branch vein occlusion with hemorrhage and exudation involving the macula.
Up until a few years ago, the only treatment available for branch vein occlusion (BVO) was laser photocoagulation. Based on the branch vein occlusion study, if vision is reduced to 20/40 or worse due to macular edema (not hemorrhage or ischemia), grid laser can be applied several months after the initial blockage which can in some cases improve vision moderately. If ischemia is present and the patient develops retinal or optic nerve neovascularization, sector panretinal laser can be applied to reduce the risk of vitreous hemorrhage.
Although laser is beneficial and is still frequently used, there are other treatment options for BVO. Avastin, an antiVEG-F agent, has been approved for use in BVO. Avastin is injected intravitreally on a monthly basis to reduce exudation and hemorrhage. Vision often improves as the hemorrhage and exudation lessen. The potential drawback of antiVEG-F agents is that the response can be transient and often mulitiple treatments are necessary. To add to the long term success, laser is often applied after hemorrhage and exudation lessen in order to more permanently stabilize vision. Another option which has recently been approved is injection of a long acting intravitreal steroid implant. We will often give several Avastin injections a month apart followed by an intravitreal dexamethasone implant (Ozurdex), which can give off intravitreal steroid for 4 to 6 months. Results can be dramatic and in some cases permanent. Potential side effects such as cataract development and glaucoma seem to be rare with this implant.
We discussed all the treatment options with our patient and elected to proceed with two Avastin injections a month apart. Vision after two injections improved to 20/40. Hemorrhage was still present but improving. By the third month however, macular edema recurred and vision slipped to 20/70. OCT improvement regressed and cystic changes recurred.
We elected to insert an Ozurdex implant. Within a few weeks vision improved to 20/30 and has remained at that level for multiple follow up examinations. The retina structurally improved and OCT returned essentially to normal. There has been no sign of recurrent edema. Please note the white cylindrical Ozurdex implant in the inferior vitreous cavity in the color fundus photograph. Patients usually see the implant in their superior field for a day or two and then it becomes invisible. The implant gradually dissolves over several months. If the edema recurs, another implant can be considered.
One month after Ozurdex injection
Two months after Ozurdex injection
This case highlights the new treatment options available for BVO. By keeping up with new developments we can offer your patients the best possible care. Please contact us with any thoughts about this case and do not hesitate to call on us for any urgent or non-urgent retinal problems.