Central Retinal Vein Occlusion

Aka: Central Retinal Vein Occlusion, CRVO

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II. Epidemiology

  1. Common cause of Vision Loss in older adults
  2. However, also common in young adults (one third of cases in age <45 years old)
    1. Contrast with Central Retinal Artery Occlusion in older adults

III. Pathophysiology

  1. Venous Occlusion results in Retinal edema, Hemorrhage and vascular leak
  2. Venous Thromboembolism may result from vessel damage or Hypercoagulable state

IV. Risk Factors

  1. Hypercoagulable State
  2. Age over 55 years
  3. Hypertension
  4. Hyperlipidemia
  5. Diabetes Mellitus
  6. Tobacco Abuse

V. Types

  1. Nonischemic Central Retinal Vein Occlusion (75% of cases)
    1. Progresses to ischemic types in 15% of patients within 4 months (34% within 3 years)
    2. Sudden painless, unilateral visual blurring (better than 20/200)
    3. Mild funduscopic findings
    4. No Relative Afferent Pupillary Defect
  2. Ischemic Central Retinal Vein Occlusion
    1. Sudden painless, severe unilateral visual loss (worse than 20/200)
    2. Relative Afferent Pupillary Defect
    3. Marked funduscopic changes

VI. Symptoms

  1. Monocular painless visual loss
  2. May initially present with transient episodes of mild Blurred Vision

VII. Signs

  1. Decreased Visual Acuity
    1. Non-ischemic CRVO: Vision better than 20/200
    2. Ischemic CRVO: Vision worse than 20/200
  2. Afferent Pupillary Defect may be present (esp. ischemic CRVO)
  3. Funduscopic Exam
    1. Retinal veins dilated and tortuous
    2. Blood streaked Retina or flame-shaped Hemorrhages (esp. in ischemic type)
      1. Diffuse Retinal Hemorrhages radiating from optic disc ("Blood and thunder Retina")
    3. Cotton wool patches may be present (esp. with Hypertension)

VIII. Differential Diagnosis

  1. See Acute Vision Loss
  2. Optic Neuritis
  3. Central Retinal Artery Occlusion

IX. Management

  1. Urgent Ophthalmology Consultation
    1. Antivascular endothelial growth factors
    2. Corticosteroids
    3. Photocoagulation (if neovascularization)
  2. No specific management to alter Hemorrhages
  3. Management is focused on reducing longerterm complications of Retinopathy including Glaucoma
    1. Non-urgent laser photocoagulation may be needed in some cases
  4. Management is also focused on reducing risk of disease progression
    1. Optimize management of Hypertension and Diabetes Mellitus
    2. Optimize hydration
    3. Decrease Intraocular Pressure (e.g. Acetazolamide)
  5. Patient Instructions
    1. Return immediately for Decreased Visual Acuity
  6. Follow-up after initial ophthalmology evaluations
    1. Follow-up ophthalmology in 3 months (monthly for at least 6 months if ischemic CRVO)

X. Prognosis

  1. For those who do not convert to ischemic CRVO, 50% will recover nearly normal Vision

XI. Complications

  1. Vision Loss
  2. Glaucoma

XII. References

  1. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  2. Sales, Patel and Patel (2019) Crit Dec Emerg Med 33(12): 3-13

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