DESCRIPTION

Disease characterized by decreased visual acuity resulting from venous occlusion of any etiology

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

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

Classic description:

• Acute, unilateral, painless vision loss
• "Blood and thunder" 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."
• 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:

• Ophthalmologists use this to map areas of nonperfusion.
• Differentiates between ischemic and nonischemic

Diagnostic Procedures/Surgery

Gonioscopy:

• 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

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

No specific interventions need occur prior to arrival at the hospital in regard to the eye.

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:

• Intravitreal triamcinolone
• Antivascular endothelial growth factor:
  • Bevacizumab

Considerations in Prescribing

Use of oral contraceptives can increase the risk of CRVO.

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Patients may be admitted for surgical intervention, depending upon the ophthalmologist.

Discharge Criteria

Patients can be discharged from the ED as long as they have immediate follow-up with an ophthalmologist.

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.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 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.

ICD9

362.35 Central retinal vein occlusion

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

[Outline]

• ICD9
• ICD10

• Beran DI, Murphy-Lavoie H. Acute painless vision loss. J La State Med Soc. 2009;161(4):214–223.
• Di Capua M, Coppola A, Albisinni R, et al. Cardiovascular risk factors and outcome in patients with retinal vein occlusion. J Thromb Thrombolysis. 2009.
• Khare GD, Symons RC, Do DV, et al. Common ophthalmologic emergencies. Int J Clin Pract. 2008;62(11):1776–1784.
• Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010.
• McAllister IL. Central retinal vein occlusion: A review. Clin Experiment Ophthalmol. 2012;40(1):48–58.
• Turello M, Pasca S, Daminato R, et al. Retinal vein occlusion: Evaluation of "classic" and "emerging" risk factors and treatment. J Thromb Thrombolysis. 2009.
• Yanoff M, Duker J. Ophthalmology. 3rd ed. St. Louis, MO: Mosby; 2008.

See Also (Topic, Algorithm, Electronic Media Element)

• Central Retinal Artery Occlusion
• Visual Loss

Lisa Jacobson

Yasuharu Okuda