Case 21Central Retinal Vein Occlusion
Clinical Presentation
A 65-year-old woman recently suffered a sudden, marked, and painless loss of vision in one eye. She has only 'hand motion' visual acuity. The opposite eye appears normal, and she complains of no systemic symptoms. The fundus of the involved eye is illustrated.
Learner Questions
- Describe the ophthalmoscopic findings and explain the pathophysiology.
- What is the diagnosis?
- Are there predisposing systemic conditions? What are they?
- What is the recommended treatment? Is the prognosis favorable?
Answer Framework
Findings + pathophysiology Predisposing conditions
'BLOOD AND THUNDER' fundus: flame hemorrhages in ALL FOUR QUADRANTS (along NFL Hypertension (most common - ~70%), DM, hyperlipidemia, GLAUCOMA (IOP compresses radially from disc), dilated tortuous ('corkscrew') veins in all quadrants, disc edema, cotton- CRV at lamina cribrosa - specific risk factor), hypercoagulable states (Factor V Leiden, wool spots (NFL infarcts), macular edema (primary cause of VL). Pathophysiology: antiphospholipid syndrome, hyperhomocysteinemia, protein C/S deficiency - especially in thrombosis at lamina cribrosa -> venous outflow obstruction -> backpressure into all younger patients), OCP, anomalous disc, myeloproliferative disorders. Workup: BP, lipids, tributaries -> capillary rupture (hemorrhages) + ischemia (CWS) + VEGF release (CME + NV glucose, CBC, hypercoagulable panel (<50 years). risk).
Diagnosis Treatment + prognosis
CRVO. Subtypes: Non-ischemic (75% - milder VL, few CWS, absent RAPD, intact FFA Macular edema: intravitreal anti-VEGF (aflibercept/ranibizumab - CRUISE trial) + capillary perfusion, NV risk ~10%, relatively favorable prognosis). Ischemic (25% - severe intravitreal dexamethasone implant (Ozurdex). Neovascularization (ischemic CRVO): VL [HM or worse], >5 CWS, RAPD present, >=10 disc areas of capillary non-perfusion on FFA, monthly monitoring for rubeosis iridis x 6 months, PRP (panretinal photocoagulation) for NV glaucoma risk ~45% within 3-6 months - '90-day glaucoma'). This patient likely has NV of iris/angle/disc/retina, anti-VEGF as adjunct. Prognosis: Non-ischemic = relatively ISCHEMIC CRVO. favorable. Ischemic = poor (most retain HM/CF vision; NVG risk 45%).
Teaching Pearl
CRVO 'blood and thunder': hemorrhages in ALL 4 quadrants + dilated tortuous veins + disc edema. Critical distinction: ischemic (HM vision, RAPD, extensive capillary non- perfusion on FFA) vs. non-ischemic. Ischemic CRVO -> ~45% risk of neovascular glaucoma ('90-day glaucoma') - mandatory monthly gonioscopy/iris exam for 6 months. CRVO vs. CRAO: CRVO = thrombotic/HTN (dilated veins, hemorrhages) vs. CRAO = embolic (cherry-red spot, pale retina).
Original answer transcript
Findings + pathophysiology Predisposing conditions
'BLOOD AND THUNDER' fundus: flame hemorrhages in ALL FOUR QUADRANTS (along NFL Hypertension (most common - ~70%), DM, hyperlipidemia, GLAUCOMA (IOP compresses
radially from disc), dilated tortuous ('corkscrew') veins in all quadrants, disc edema, cotton- CRV at lamina cribrosa - specific risk factor), hypercoagulable states (Factor V Leiden,
wool spots (NFL infarcts), macular edema (primary cause of VL). Pathophysiology: antiphospholipid syndrome, hyperhomocysteinemia, protein C/S deficiency - especially in
thrombosis at lamina cribrosa -> venous outflow obstruction -> backpressure into all younger patients), OCP, anomalous disc, myeloproliferative disorders. Workup: BP, lipids,
tributaries -> capillary rupture (hemorrhages) + ischemia (CWS) + VEGF release (CME + NV glucose, CBC, hypercoagulable panel (<50 years).
risk).
Diagnosis Treatment + prognosis
CRVO. Subtypes: Non-ischemic (75% - milder VL, few CWS, absent RAPD, intact FFA Macular edema: intravitreal anti-VEGF (aflibercept/ranibizumab - CRUISE trial) +
capillary perfusion, NV risk ~10%, relatively favorable prognosis). Ischemic (25% - severe intravitreal dexamethasone implant (Ozurdex). Neovascularization (ischemic CRVO):
VL [HM or worse], >5 CWS, RAPD present, >=10 disc areas of capillary non-perfusion on FFA, monthly monitoring for rubeosis iridis x 6 months, PRP (panretinal photocoagulation) for
NV glaucoma risk ~45% within 3-6 months - '90-day glaucoma'). This patient likely has NV of iris/angle/disc/retina, anti-VEGF as adjunct. Prognosis: Non-ischemic = relatively
ISCHEMIC CRVO. favorable. Ischemic = poor (most retain HM/CF vision; NVG risk 45%).
TEACHING PEARL
CRVO 'blood and thunder': hemorrhages in ALL 4 quadrants + dilated tortuous veins + disc edema. Critical distinction: ischemic (HM vision, RAPD, extensive capillary non-
perfusion on FFA) vs. non-ischemic. Ischemic CRVO -> ~45% risk of neovascular glaucoma ('90-day glaucoma') - mandatory monthly gonioscopy/iris exam for 6 months.
CRVO vs. CRAO: CRVO = thrombotic/HTN (dilated veins, hemorrhages) vs. CRAO = embolic (cherry-red spot, pale retina).
