Branch Retinal Vein Occlusion

(BRVO)
 Classification

1 Major branch retinal vein occlusion (BRVO) at

the disc and away from the disc.

2 Macular BRVO involving only a macular branch

3 Peripheral BRVO not involving the macular

circulation
(A) Major at the disc; (B) major away from the disc; (C) minor
macular; (D–F) peripheral not involving the macula
 Diagnosis
Presentation depends on the extent of
macular circulation compromised by the
occlusion. Patients with macular involvement
often present with the sudden onset of
blurred vision and metamorphopsia, or a
relative visual field defect. Patients with
peripheral occlusions may be asymptomatic.
 Diagnosis ……..Cont
• Fundus
• Dilatation and tortuosity of the affected
venous segment.
• The site of occlusion is often identifiable as an
arteriovenous crossing point.

• Flame-shaped and dot/blot haemorrhages,

retinal oedema, sometimes cotton wool spots
affecting the sector of the retina drained by
the obstructed vein.
 Diagnosis………cont
FA shows:
1. variable delayed venous filling
2. blockage by blood
3. staining of the vessel wall
4. hypofluorescence due to capillary non-
perfusion and ‘pruning’ of vessels in the
ischaemic areas
Pictures of major superior branch vein
occlusion

• (A) Flame-shaped and blot

haemorrhage, a few cotton
wool spots and venous
tortuosity.

• (B) FA shows blockage by

blood and areas of capillary
non-perfusion.
Old major superior branch vein occlusion.
(A) Venous sheathing,
collaterals, exudates
and residual
haemorrhages.

(B) FA shows capillary

non-perfusion and
tortuous collaterals
extending across the
horizontal raphe
between the superior
and inferior arcades
 Prognosis
• At 6 months about 50% of eyes achieve vision
of 6/12 or better.

• Approximately 50% of untreated eyes with

BRVO retain 6/12 or better whilst 25% will
have vision of <6/60.
 The two main vision-threatening
complications
1. Chronic macular oedema
*is the most common cause of persistent
poor visual acuity after BRVO.
*Patients with visual acuity of 6/12 or worse
may benefit from laser photocoagulation,
provided the macula is not significantly
ischaemic
2. Neovascularization.
- Retinal neovascularization
occurs in about 60% of eyes with more
than 5 disc areas of non-perfusion and a
third with less than 4 disc areas – about
40% overall.
- NVE are considerably more common than

NVD.
- NVE usually develops at the border of the

triangular sector of ischaemic retina

drained by the occluded vein.
- New vessels
- usually appear within 6–12
months but may develop at any time.
- they can lead to recurrent vitreous
and pre-retinal haemorrhage, and
occasionally tractional retinal
detachment.
Long-standing major superior branch vein
occlusion
• (A) Few residual
haemorrhages and
cotton wool spots.

• (B) FA shows extensive

capillary non-perfusion
that carries a high risk
of neovascularization
 Further management

• Follow-up should be at about 3 months with

FA, if vision is compromised, provided retinal
haemorrhages have cleared sufficiently.
• Further management depends on visual acuity
and angiographic findings.
• With good macular perfusion and improving
visual acuity, no treatment is required.

• If macular oedema is associated with good

macular perfusion and visual acuity continues to
be 6/12 or worse after 3–6 months, laser
photocoagulation should be considered.
• Patients with visual acuity of less than 6/60 or
those with symptoms for over a year are
unlikely to benefit from laser.

• Prior to treatment, the FA should be studied

carefully to identify leaking areas.
• If macular non-perfusion is present and visual acuity
is poor, particularly if FA shows an incomplete foveal
avascular zone (FAZ), laser treatment is unlikely to
improve vision.

• Subsequent follow-up: 3–6 monthly intervals for

up to 2 years, dependent on clinical and FA
findings, because of the risk of
neovascularization.
 Treatment of macular oedema

1. Grid laser photocoagulation

- (50–100 µm, 0.1 second duration and
spaced one burn width apart) to produce
a gentle reaction in the area of leakage
as identified on FA.
-The burns should extend no closer to the
fovea than the edge of the FAZ and be no
more peripheral than the major vascular
arcades.
Grid laser Photocoagulation….cont
- Care should be taken to avoid treating over
intraretinal haemorrhage.

-It is also very important to identify

shunts/collaterals on FA, which do not leak
fluorescein, because they must not be
treated.
 Grid laser photcoagulation
• Follow-up should take place after three
months. If macular oedema persists, re-
treatment may be considered although the
results are frequently disappointing.
 Intravitreal triamcinolone (IVT)
• is as effective as laser in eyes with macular
oedema, but may cause cataract and elevation
of intraocular pressure. An average of 2
injections of 1 mg are given in the first year.
 Periocular steroid injection
• is less invasive, although probably less
effective, than the intravitreal route.
 Intravitreal anti-VEGF agents
• Bevacizumab (Avastin) 0.05 mL/1.25 mg) in a
regimen of 2–3 injections over 5–6 months
has shown promising effects on macular
oedema and vision, including in patients
resistant to laser.
 Arteriovenous sheathotomy
• Some positive results have been reported
both for sheathotomy and for vitrectomy
alone; a randomized controlled trial showed
similar benefit from IVT.
 Treatment of neovascularization

• Neovascularization is not normally treated

unless vitreous haemorrhage occurs because
early treatment does not appear to affect the
visual prognosis.
• If appropriate, scatter laser photocoagulation
(200–500 µm size, 0.05–0.1 s duration and
spaced one burn width apart) is performed
with sufficient energy to achieve a medium
reaction covering the entire involved sector as
defined by the colour photograph and FA. A
quadrant usually requires 400–500 burns.
• Follow-up should be after 4–6 weeks. If
neovascularization persists re-treatment can
be considered, and is usually effective in
inducing regression.