Retinal Review, Issue 58
Authored By, Burton Wisotsky, M.D.
A 48 year old man was referred for retinal hemorrhaging in his left eye. He noted the onset of blurred vision one week ago. Past medical and ocular history are unremarkable. On examination VA was OD: 20/20 and OS: 20/50. IOP’s and the SLE were normal. DFE is below:
The right eye is normal. There is no sign of retinal vasculopathy or hemorrhaging. In the left eye there is a CRVO with moderate venous engorgement and moderate intraretinal hemorrhages. The macula is mildly swollen, accounting for the reduced vision. Fluorescein angiography shows mild venous transit delay, scattered intraretinal hemorrhages and no sign of retinal ischemia. The patient was diagnosed with a perfused moderate CRVO.
There are two issues in this patient – first is why would a healthy 48 year old get a CRVO and second is what treatment should be instituted. Regarding the cause, all young patients with a vascular occlusion without a known history of hypertension should undergo a systemic evaluation looking for hypertension, diabetes, hyperlipidemia, autoimmune disease, systemic inflammation, and clotting abnormalities. Our patient was sent for extensive medical testing, all of which was negative. Some patients will develop a vascular occlusion without an underlying medical cause.
The next consideration is treatment. If this patient was in his 70’s there would be no discussion. Mainstay of treatment is antiVEGF therapy. He would have been started on a course of antiVEGF injections and likely would have had multiple injections over a one to two year period, usually with good results. Vision usually stabilizes and often improves. However, in some young patients, vein occlusions can resolve without treatment. We discussed the possibility of injections, but told the patient we would wait a few weeks and see if the occlusion improved on its own. To our delight (and the patient’s) the CRVO fully resolve by the second visit (see photos below). VA returned to 20/20 and most hemorrhages resolved. The patient has been followed with no recurrence. This underscores the need for initial observation in a young patient with vascular occlusion as it can and often does resolve on its own.