Author:
Lisa A.Jacobson
YasuharuOkuda
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
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 10-21 mm Hg
Diagnostic 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 - diabetic papillitis
- HTN/hypertensive retinopathy
- Hyperviscosity syndromes:
- Sickle cell, polycythemia, leukemia, multiple myeloma
- Hysterical blindness
- Ocular ischemia syndrome
- Papilledema
- Papillophlebitis
- Retinal artery occlusion
- Retinal detachment
- Severe anemia with thrombocytopenia
- Temporal arteritis
- Vitreal hemorrhage
Prehospital
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:
- 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:
Considerations in Prescribing
Use of oral contraceptives can increase the risk of CRVO
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
- CoscasG, LoewensteinA, AugustinA, et al. Management of retinal vein occlusion - consensus document . Ophthalmologica. 2011;226:4-28.
- KiireCA, ChongNV. Managing retinal vein occlusion . BMJ. 2012;344:e499.
- McAllisterIL. Central retinal vein occlusion: A review . Clin Experiment Ophthalmol. 2012;40(1):48-58.
- WallsRM, HockbergerRS, Gausche-HillM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed.St. Louis, MO: Mosby; 2017.
See Also (Topic, Algorithm, Electronic Media Element)
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
H34.813 Central retinal vein occlusion, bilateral
H34.81 Central retinal vein occlusion
SNOMED
68478007 Central retinal vein occlusion
312997008 Central retinal vein occlusion - ischemic
312998003 Central retinal vein occlusion - non-ischemic (disorder)