Basics
Description
Disease characterized by decreased visual acuity resulting from venous occlusion of any etiology á
Etiology
- Ischemic CRVO:
- 20-25% of cases
- Blocked venous return leads to backflow in capillaries, hemorrhage, and macular edema.
- Limited space at lamina cribrosa predisposes to thrombosis due to slow flow and vessel wall changes
- Theorize that arteriosclerotic changes in the adjacent artery may impinge upon the vein.
- Blood viscosity also thought to play a role
- Nonischemic CRVO:
- Milder, incomplete occlusion
Diagnosis
Signs and Symptoms
Classic description: á
- Acute, unilateral, painless vision loss
- "Blood and thunder"Ł appearance on fundoscopy
History
- Painless, unilateral vision loss
- If nonischemic, may be incomplete and intermittent vision loss
Physical Exam
- Decreased visual acuity:
- Usually worse than 20/200
- Afferent pupillary defect
- Dilated tortuous veins
- Retinal hemorrhages:
- If central, findings in all 4 quadrants
- Extensive hemorrhages give a dramatic look to fundus classically described as "blood and thunder appearance."Ł
- Disk edema
- Cotton wool spots
Essential Workup
- BP
- Visual acuity:
- Hand movements typically is all that is seen.
- Visual fields
- Fundoscopy
- Tonometry:
- Normal pressures are between 10 and 21 mm Hg.
Diagnosis Tests & Interpretation
Lab
- CBC
- PT/PTT
- ESR
- ANA
- Serum protein electrophoresis
Imaging
Fluorescein angiography: á
- Ophthalmologists use this to map areas of nonperfusion.
- Differentiates between ischemic and nonischemic
Diagnostic Procedures/Surgery
Gonioscopy: á
- Measure iris or angle neovascularization.
Differential Diagnosis
- Amaurosis fugax/transient ischemic attack
- Cavernous sinus thrombosis
- DM
- HTN/hypertensive retinopathy
- Hyperviscosity syndromes:
- Sickle cell, polycythemia, leukemia, multiple myeloma
- Hysterical blindness
- Ocular ischemia syndrome
- Papilledema
- Retinal artery occlusion
- Retinal detachment
- Severe anemia with thrombocytopenia
- Temporal arteritis
- Vitreal hemorrhage
Treatment
Pre-Hospital
No specific interventions need occur prior to arrival at the hospital in regard to the eye. á
Initial Stabilization/Therapy
- Initiate steps to lower intraocular pressure (IOP) if it is elevated.
- Treat underlying medical problems.
Ed Treatment/Procedures
- Recognition and prompt ophthalmologic referral is the cornerstone of ED treatment.
- Though not proven, the following may be tried in consultation with an ophthalmologist:
- Aspirin
- Anti-inflammatory agents
- Systemic steroids
- Systemic anticoagulation
- Fibrinolytics (controversial)
- Laser chorioretinal anastomosis
Medication
There is no proven treatment for CRVO, ophthalmologists may treat with the following: á
- Intravitreal triamcinolone
- Antivascular endothelial growth factor:
Considerations in Prescribing
Use of oral contraceptives can increase the risk of CRVO. á
Follow-Up
Disposition
Admission Criteria
Patients may be admitted for surgical intervention, depending upon the ophthalmologist. á
Discharge Criteria
Patients can be discharged from the ED as long as they have immediate follow-up with an ophthalmologist. á
Issues for Referral
- If no ophthalmologist is available, treatment should be initiated for concomitant conditions and patient transferred to nearest hospital with ophthalmologic consultation.
- Ophthalmologists often perform panretinal photocoagulation if neovascularization is found.
Follow-Up Recommendations
- Patients with ischemic CRVO need prolonged follow-up to catch neovascularization and glaucoma that typically develop.
- Patients with CRVO likely have other vascular diseases and need complete medical workups.
- Patients should also follow with an internist to manage comorbidities and risk factors.
Pearls and Pitfalls
- Increased IOP resulting from neovascularization and edema can cause vascular insufficiency and with delayed treatment vision loss can be permanent.
- When patients present with bilateral CRVOs or CRVO at a young age, workup must search for hyperviscosity syndromes.
Additional Reading
- Beran áDI, Murphy-Lavoie áH. Acute painless vision loss. J La State Med Soc. 2009;161(4):214-223.
- Di Capua áM, Coppola áA, Albisinni áR, et al. Cardiovascular risk factors and outcome in patients with retinal vein occlusion. J Thromb Thrombolysis. 2009.
- Khare áGD, Symons áRC, Do áDV, et al. Common ophthalmologic emergencies. Int J Clin Pract. 2008;62(11):1776-1784.
- Marx áJA, Hockberger áRS, Walls áRM, eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010.
- McAllister áIL. Central retinal vein occlusion: A review. Clin Experiment Ophthalmol. 2012;40(1):48-58.
- Turello áM, Pasca áS, Daminato áR, et al. Retinal vein occlusion: Evaluation of "classic"Ł and "emerging"Ł risk factors and treatment. J Thromb Thrombolysis. 2009.
- Yanoff áM, Duker áJ. Ophthalmology. 3rd ed. St. Louis, MO: Mosby; 2008.
See Also (Topic, Algorithm, Electronic Media Element)
- Central Retinal Artery Occlusion
- Visual Loss
Codes
ICD9
362.35 Central retinal vein occlusion á
ICD10
- H34.811 Central retinal vein occlusion, right eye
- H34.812 Central retinal vein occlusion, left eye
- H34.819 Central retinal vein occlusion, unspecified eye
- H34.813 Central retinal vein occlusion, bilateral
- H34.81 Central retinal vein occlusion
SNOMED
- 68478007 Central retinal vein occlusion
- 312997008 Central retinal vein occlusion - ischemic
- 312998003 Central retinal vein occlusion - non-ischemic (disorder)