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Branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is a common retinal vascular disease of the elderly. It is caused by the occlusion of one of the branches of central retinal vein.^[1]

Epidemiology

BRVO is 3 times more common than CRVO.

Usual age of onset is 60–70 years.

An analysis of population from several countries estimates that approximately 16 million people worldwide may have retinal vein occlusion.^[2]

Risk factors

Studies have identified the following abnormalities as risk factors for the development of BRVO:

hypertension

cardiovascular disease

obesity

glaucoma

Diabetes mellitus was not a major independent risk factor.

Manifestations

Patients with BRVO usually complain of sudden onset of blurred vision or a central visual field defect. The eye examination findings of acute BRVO include superficial hemorrhages, retinal edema, and often cotton-wool spots in a sector of retina drained by the affected vein.The obstructed vein is dilated and tortuous.

The quadrant most commonly affected is the superotemporal (63%).

Retinal neovascularization occurs in 20% of cases within the first 6–12 months of occlusion and depends on the area of retinal nonperfusion. Neovascularization is more likely to occur if more than five disc diameters of nonperfusion are present and vitreous hemorrhage can ensue.^[3]

Diagnosis and testing

The diagnosis of BRVO is made clinically by finding retinal hemorrhages in the distribution of an obstructed retinal vein.

Fluorescein angiography is a helpful adjunct. Findings include delayed venous filling, hypofluorescence caused by hemorrhage and capillary nonperfusion, dilation and tortuosity of veins, leakage due to neovascularization and macular edema.

Optical coherence tomography is an adjunctive test in BRVO. Macular edema is commonly seen in BRVO in OCT exams. Serial OCT is used as a rapid and noninvasive way of monitoring the macular edema.

Treatment

Several options exist for the treatment of BRVO. These treatments aim for the two of the most significant complications of BRVO, namely macular edema and neovascularization.^[1]

Systemic treatment with oral Aspirin, subcutaneous Heparin, or intravenous thrombolysis have not been shown to be effective treatments for CRVO and for BRVO no reliable clinical trial has been published.

Laser treatment of the macular area to reduce macular edema is indicated in patients who have 20/40 or worse vision and did not spontaneously improve for at least 3 months (to permit the maximum spontaneous resolution) after the development of the vein occlusion. It is typically administered with the argon laser and is focused on edematous retina within the arcades drained by the obstructed vein and avoiding the foveal avascular zone. Leaking microvascular abnormalities may be treated directly, but prominent collateral vessels should be avoided.

The second indication of laser treatment is in case of neovascularization. Retinal photocoagulation is applied to the involved retina to cover the entire involved segment, extending from the arcade out to the periphery. Ischemia alone is not an indication for treatment provided that follow-up could be maintained.

Preservative-free, nondispersive Triamcinolone acetonide in 1 or 4 mg dosage may be injected into the vitreous to treat macular edema but has complications including elevated intraocular pressure and development of cataract. Triamcinolone injection is shown to have similar effect on visual acuity when compared with standard care (Laser therapy), However, the rates of elevated intraocular pressure and cataract formation is much higher with the triamcinolone injection, especially the higher dosage.^[4] Intravitreal injection of Dexamethasone implant (Ozurdex; 700,350 μg) is being studied, its effect may last for 180 days. The injection may be repeated however with less pronounced effect. Although the implant was designed to cause less complications, pressure rise and cataract formation is noted with this treatment too.^[5]

Anti-VEGF drugs such as Bevacizumab (Avastin; 1.25 -2.5 mg in 0.05ml) and Ranibizumab (lucentis) injections are being used and investigated. Intravitreal anti-VEGFs have a low incidence of adverse side effects compared with intravitreal corticosteroids, but are currently short acting requiring frequent injections. Anti-VEGF injection may be used for macular edema or neovascularization. The mechanism of action and duration of anti-VEGF effect on macular edema is currently unknown. The intraocular levels of VEGF are increased in eyes with macular edema secondary to BRVO and the elevated VEGF levels are correlated to the degree and severity of the areas of capillary nonperfusion and macular edema.^[6]

Surgery is employed occasionally for longstanding vitreous hemorrhage and other serious complications such as epiretinal membrane and retinal detachment.

Arteriovenous sheathotomy has been reported in small, uncontrolled series of patients with BRVO. BRVO typically occurs at arteriovenous crossings, where the artery and vein share a common adventitial sheath. In arteriovenous sheathotomy an incision is made in the adventitial sheath adjacent to the arteriovenous crossing and is extended along the membrane that holds the blood vessels in position to the point where they cross, the overlying artery is then separated from the vein.

Course and outcome

In general, BRVO has a good prognosis: after 1 year 50–60% of eyes have been reported to have a final VA of 20/40 or better even without any treatment. With time the dramatic picture of an acute BRVO becomes more subtle, hemorrhages fade so that the retina can look almost normal. Collateral vessels develop to help drain the affected area.

References

^ ^a ^b Basic and clinical science course (2011–2012). Retina and vitreous. American Academy of Ophthalmology. pp. 150–154. ISBN 978-1615251193.
^ Rogers, S et al. (Feb 2010). "The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia.". Ophthalmology 117 (2): 313–9.e1. doi:10.1016/j.ophtha.2009.07.017. PMC 2945292. PMID 20022117.
^ Myron Yanoff, Jay S. Duker (2009). Ophthalmology (3rd ed.). Mosby Elsevier. ISBN 9780323043328.
^ Scott, IU et al. (Sep 2009). "A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6.". Archives of ophthalmology 127 (9): 1115–28. doi:10.1001/archophthalmol.2009.233. PMC 2806600. PMID 19752420.
^ Haller, JA et al. (Dec 2011). "Dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results.". Ophthalmology 118 (12): 2453–60. doi:10.1016/j.ophtha.2011.05.014. PMID 21764136.
^ Karia, N (Jul 30, 2010). "Retinal vein occlusion: pathophysiology and treatment options.". Clinical ophthalmology (Auckland, N.Z.) 4: 809–16. doi:10.2147/opth.s7631. PMC 2915868. PMID 20689798.

UpToDate Contents

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1. 網膜静脈閉塞：疫学、臨床症状、および診断 retinal vein occlusion epidemiology clinical manifestations and diagnosis
2. 網膜静脈閉塞：治療 retinal vein occlusion treatment
3. 視覚変化が認められた小児患者に対するアプローチ approach to the pediatric patient with vision change
4. 全身性疾患および感染に関連した網膜血管炎 retinal vasculitis associated with systemic disorders and infections
5. 原発性眼障害関連の網膜血管炎 retinal vasculitis associated with primary ocular disorders

English Journal

Changes in aqueous cytokines after intravitreal triamcinolone versus bevacizumab for macular oedema in branch retinal vein occlusion.

Sohn HJ1, Han DH, Lee DY, Nam DH.Author information 1Department of Ophthalmology, Hongik Hospital, Seoul, KoreaDepartment of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea.AbstractPurpose: To investigate the changes in the aqueous levels of various cytokines after intravitreal triamcinolone or bevacizumab for branch retinal vein occlusion (BRVO). Methods: Twenty-four eyes with macular oedema associated with BRVO and six eyes of six patients undergoing cataract surgery participated in this study. Each patient with BRVO randomly received an intravitreal injection of either 4 mg triamcinolone or 1.25 mg bevacizumab. Aqueous samples were obtained before and 4 weeks after the intravitreal injection in the BRVO group and before surgery in the control group. Aqueous concentrations of 16 cytokines were measured via multiplex bead assay. Results: Prior to the administration of the drugs, aqueous levels of interleukin (IL)-6, IL-8, IL-17 and vascular endothelial growth factor (VEGF) were significantly higher in the BRVO group than in the control group (p = 0.044, p = 0.013, p < 0.001, and p = 0.008, respectively). Between the control group and the BRVO group, no significant differences were noted between pre- and postinjection best-corrected visual acuity (p = 0.60, p = 0.54) and central foveal thickness (p = 0.47, p = 0.82). In the triamcinolone group, levels of IL-6, IL-17, IP-10, platelet-derived growth factor (PDGF)-AA and VEGF were reduced significantly (p = 0.012, p < 0.001, p < 0.001, p = 0.015, and p < 0.001, respectively). But in bevacizumab group, only VEGF was significantly reduced (p < 0.001). Between the IVTA group and the IVBe group, no significant differences in the changes in VEGF levels were noted (p = 0.06). Conclusion: Triamcinolone injection reduces plural inflammatory cytokines in BRVO, while bevacizumab has no influence on other cytokines as selective anti-VEGF therapy. No differences in the therapeutic effect were noted between an inhibition of plural inflammatory cytokines and an inhibition of VEGF only.
Acta ophthalmologica.Acta Ophthalmol.2014 May;92(3):e217-24. doi: 10.1111/aos.12219. Epub 2013 Jul 26.
Purpose: To investigate the changes in the aqueous levels of various cytokines after intravitreal triamcinolone or bevacizumab for branch retinal vein occlusion (BRVO). Methods: Twenty-four eyes with macular oedema associated with BRVO and six eyes of six patients undergoing cataract surgery p
PMID 23889803

Electroretinograms and level of aqueous vascular endothelial growth factor in eyes with hemicentral retinal vein occlusion or branch retinal vein occlusion.

Yasuda S1, Kachi S, Ueno S, Ushida H, Piao CH, Kondo M, Terasaki H.Author information 1Department of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan.AbstractPURPOSE: Hemicentral retinal vein occlusion (hCRVO) is a disease related to CRVO but not to branch retinal vein occlusion (BRVO). We reported a significant correlation between aqueous vascular endothelial growth factor (VEGF) levels and the implicit time of 30-Hz flicker electroretinogram (ERG) in CRVO eyes. The purpose of this study was to compare aqueous VEGF levels and ERG components between hCRVO and BRVO eyes.
Japanese journal of ophthalmology.Jpn J Ophthalmol.2014 May;58(3):232-236. Epub 2014 Mar 26.
PURPOSE: Hemicentral retinal vein occlusion (hCRVO) is a disease related to CRVO but not to branch retinal vein occlusion (BRVO). We reported a significant correlation between aqueous vascular endothelial growth factor (VEGF) levels and the implicit time of 30-Hz flicker electroretinogram (ERG) in C
PMID 24668132

A United Kingdom-based economic evaluation of ranibizumab for patients with retinal vein occlusion (RVO).

Taylor M1, Serbetci E, Ferreira A, Gairy K, Lewis L, Blouin J, Mitchell P.Author information 1York Health Economics Consortium Ltd, University of York , York , UK.AbstractAbstract Objective: This study compares the cost-effectiveness of intravitreal ranibizumab vs observation and/or laser photocoagulation for treatment of macular edema secondary to retinal vein occlusion in a UK-based model. Methods: A Markov model was constructed using transition probabilities and frequency of adverse events derived using data from the BRAVO, CRUISE, and HORIZON trials. Outcomes associated with treatments and health states were combined to predict overall health costs and outcomes for cohorts treated with each option. Results: In branch retinal vein occlusion, ranibizumab produced a gain of 0.518 quality-adjusted life years at an incremental cost of £8141, compared with laser photocoagulation. The incremental cost-effectiveness ratio was £15,710 per quality-adjusted life year, and the incremental cost per month free from blindness was £658. In central retinal vein occlusion, ranibizumab produced a gain of 0.539 quality-adjusted life years at an incremental cost of £9216, compared with observation only. The incremental cost-effectiveness ratio was £17,103, and the incremental cost per month free from blindness was £423. Conclusions: These incremental cost-effectiveness ratios are below the £20,000-30,000 range typically accepted as a threshold for cost-effectiveness. This suggests that ranibizumab may be regarded as a cost-effective therapy for patients with macular edema secondary to retinal vein occlusion, relative to grid laser photocoagulation (for BRVO) and observation (for CRVO). Limitations include sparse data for utilities associated with the severity of visual impairment in the WSE in patients with RVO. A lack of direct comparative evidence between ranibizumab and the dexamethasone intravitreal implant for the treatment of BRVO and CRVO and the infeasibility of an indirect comparison due to significant heterogeneity in trial designs prevented the inclusion of this treatment as a comparator in the Markov model.
Journal of medical economics.J Med Econ.2014 Apr 22. [Epub ahead of print]
Abstract Objective: This study compares the cost-effectiveness of intravitreal ranibizumab vs observation and/or laser photocoagulation for treatment of macular edema secondary to retinal vein occlusion in a UK-based model. Methods: A Markov model was constructed using transition probabilities and f
PMID 24673384

Japanese Journal

BRVO,CRVOのマネージメント (特集網膜血管病の病態とマネージメント)

辻川明孝
眼科 53(9), 1091-1097, 2011-09
NAID 40018989892

Grid photocoagulation combined with intravitreal bevacizumab for recurrent macular edema associated with retinal vein occlusion.

Ogino Ken,Tsujikawa Akitaka,Murakami Tomoaki,Muraoka Yuki,Kurashige Yumiko,Yoshimura Nagahisa
Clinical ophthalmology (Auckland, N.Z.) 5, 1031-1036, 2011-07
… Methods: This retrospective study consisted of 19 eyes with branch retinal vein occlusion (BRVO) and nine eyes with central retinal vein occlusion (CRVO), which were treated with grid photocoagulation combined with IVB for recurrent macular edema after previous IVBs. … Compared with initial values, final foveal thickness was reduced significantly in both BRVO and CRVO groups (P < … 0.001), but improvement in VA was significant only for eyes with BRVO (P = 0.012). …
NAID 120003338838

Related Pictures

Branched Retinal Vein Occlusion (BRVO) Retinal Vascular Diseases Description Branch retinal vein occlusion BRVO relatively common cause of ret. vascular brvo cf photos, the classic appearance of a BRVO

★リンクテーブル★

リンク元	「網膜静脈閉塞症」「網膜静脈分枝閉塞症」「branch retinal vein occlusion」
関連記事	「BR」

「網膜静脈閉塞症」

　　[★]

英: retinal vein occlusion, obstruction of the retinal vein

分類

リスクファクター

参考1

年齢、高血圧、糖尿病、喫煙、肥満、凝固亢進状態(factor V Leiden, activated protein C resistance)、緑内障、網膜細血管異常(retinal arteriolar abnormality)

出典不明

動脈硬化

比較

SOP.134

	網膜静脈分枝閉塞症	網膜中心静脈閉塞症	網膜中心動脈閉塞症
	BRVO	CRVO	CRAO
概念	網膜動静脈交差部で静脈が閉鎖	網膜中心静脈の閉塞	網膜中心動脈の閉塞
疫学	CRVOより遙かに頻度が高い	50歳以上の中高年で高血圧症のある人に好発	(1)血栓塞栓子、(2)乳頭内での粥状硬化、あるいは動脈炎による血管攣縮による動脈の閉塞、(3)緑内障や外力による高眼圧
病型		静脈うっ滞網膜症　venous stasis retinopathy：静脈拡張、出血など静脈閉塞のみを主症状とする。出血性網膜症　hemorrhagic retinopathy：高度の血管床閉塞など動脈の循環障害を併発
症状	黄斑部を支配する静脈が閉塞すれば視力低下を痔核。	無痛性の片眼性の急激な視力低下	無痛性の高度視力障害
眼底	閉塞した静脈域で静脈の拡張し、透過性亢進による出血、浮腫、綿花白斑を生じる。数ヶ月の経過で出血は吸収され、静脈は白線化し、硬性白斑が残る。	視神経乳頭から放射状の火炎状出血、(重症例)暗赤色の出血斑。乳頭の充血、浮腫、網膜静脈の拡張蛇行、綿花様白斑、黄斑浮腫から嚢胞様黄斑浮腫	網膜は混濁、白濁。cherry-red spot
合併症	新生血管形成と硝子体出血。再発性硝子体出血と牽引性網膜剥離症(閉塞した静脈域の毛細血管の閉塞によりその領域周辺の網膜や視神経乳頭での血管新生をきたす)。	新生血管緑内障：予後不良。発症から3ヶ月が好発時期。前房隅角や虹彩に新生血管が生じ眼圧上昇をきたす。
治療	光凝固術：黄斑浮腫、新生血管に対して。硝子体手術：硝子体手術、牽引性網膜剥離	原疾患の治療新生血管緑内障予防：汎光凝固術	眼球圧迫マッサージ亜硝酸アミル (高眼圧の場合)前房穿刺
予後			1時間以内に血行が改善しないと網膜機能の回復は期待できない。

参考

1. [charged] Retinal vein occlusion: Epidemiology, clinical manifestations, and diagnosis - uptodate [1]

「網膜静脈分枝閉塞症」

　　[★]

英: branch retinal vein occlusion BRVO
関: 網膜静脈閉塞症、網膜静脈分枝閉塞

概念

網膜動静脈交差部で静脈が閉鎖

疫学

網膜静脈分枝閉塞症 CRVOより遙かに頻度が高い

症状

黄斑部を支配する静脈が閉塞すれば視力低下を痔核。

検査

眼底検査：閉塞した静脈域で静脈の拡張し、透過性亢進による出血、浮腫、綿花白斑を生じる。数ヶ月の経過で出血は吸収され、静脈は白線化し、硬性白斑が残る。

合併症

新生血管形成と硝子体出血。再発性硝子体出血と牽引性網膜剥離症(閉塞した静脈域の毛細血管の閉塞によりその領域周辺の網膜や視神経乳頭での血管新生をきたす)。

治療

光凝固術：黄斑浮腫、新生血管に対して。
硝子体手術：硝子体手術、牽引性網膜剥離

「branch retinal vein occlusion」

　　[★] 網膜静脈分枝閉塞症 BRVO

「BR」

　　[★]

[ao-1] Basic and clinical science course (2011–2012). Retina and vitreous. American Academy of Ophthalmology. pp. 150–154. ISBN 978-1615251193.

[Rogers-2] Rogers, S et al. (Feb 2010). "The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia.". Ophthalmology 117 (2): 313–9.e1. doi:10.1016/j.ophtha.2009.07.017. PMC 2945292. PMID 20022117.

[yanoff-3] Myron Yanoff, Jay S. Duker (2009). Ophthalmology (3rd ed.). Mosby Elsevier. ISBN 9780323043328.

[score-4] Scott, IU et al. (Sep 2009). "A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6.". Archives of ophthalmology 127 (9): 1115–28. doi:10.1001/archophthalmol.2009.233. PMC 2806600. PMID 19752420.

[haller-5] Haller, JA et al. (Dec 2011). "Dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results.". Ophthalmology 118 (12): 2453–60. doi:10.1016/j.ophtha.2011.05.014. PMID 21764136.

[karia-6] Karia, N (Jul 30, 2010). "Retinal vein occlusion: pathophysiology and treatment options.". Clinical ophthalmology (Auckland, N.Z.) 4: 809–16. doi:10.2147/opth.s7631. PMC 2915868. PMID 20689798.

匿名

検索

案内

案内

BRVO