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Central Retinal Vein Occlusion
An 82-year-old woman presented with a 4-day history of "filmy vision" in the right eye. Her history included mitral valve prolapse with regurgitation, for which she took warfarin and digoxin, and mild hyperlipidemia, which was controlled with diet. The results of recent carotid artery studies were negative.
Case 1:
Impending Central Retinal Vein Occlusion
An 82-year-old woman presented with a 4-day history of "filmy vision" in the right eye. Her history included mitral valve prolapse with regurgitation, for which she took warfarin and digoxin, and mild hyperlipidemia, which was controlled with diet. The results of recent carotid artery studies were negative.
The patient's visual acuity was 20/30 in the right eye. A dilated funduscopic evaluation revealed mild retinal vein dilation and tortuosity. Numerous dot and blot hemorrhages were scattered throughout the fundus (A). A fluorescein angiogram revealed an impending nonischemic central retinal vein occlusion (CRVO).
The patient returned 20 days later, complaining that her vision had deteriorated further. Her visual acuity was only 20/60 in the right eye. A dilated funduscopic examination revealed optic disc congestion; increased retinal vein tortuosity and dilation; and a significantly increased number of dot, blot, and flame-shaped hemorrhages. The hemorrhages now involved the macula, which explained the patient's worsening visual acuity. A cotton-wool spot (infarction of the nerve fiber layer) was visible just temporal to the optic disc (B).
Predisposing factors for CRVO include systemic arterial hypertension, ECG abnormalities (such as those seen in patients with mitral valve prolapse and regurgitation), diabetes mellitus, peptic ulcer, and thyroid disease.1 In this case, the mitral valve prolapse and regurgitation were thought to be the underlying cause. This type of occlusion is believed to arise from either thrombus formation or emboli at the level of the lamina cribrosa.
The patient was referred back to her primary care physician for reevaluation of her systemic therapy, and she is being monitored monthly for evidence of ischemic changes in the iris or retina.
The treatment options for patients with CRVO are limited. Scatter panretinal photocoagulation is indicated for iris or retinal neovascularization. Chronic macular edema, such as seen in this patient, carries the risk of significant visual morbidity. Up to 60% of patients with this condition have a visual acuity of less than 20/125 after 3 years.2 Focal macular laser photocoagulation is not effective for this type of macular edema.2,3
References:
REFERENCES:
1.
Hayreh SS, Zimmerman B, McCarthy MJ, et al. Systemic diseases associated with various types of retinal vein occlusion.
Am J Ophthalmol.
2001;131:61-77.
2.
Central Vein Occlusion Study Group. Evaluation of grid pattern photocoagulation for macular edema in central vein occlusion. The central vein occlusion study group M report.
Ophthalmology.
1995;102:1425-1433.
3.
Gaudric A, Giorgi F, Sterkers M, et al. Photocoagulation with the argon laser in cystoid macular edema in retinal venous occlusions. Apropos of 68 cases [in French].
J Fr Ophtalmol.
1988;11:319-326.
