Advancements in the Management of Macular Edema following Retinal Vein Occlusion - Episode 1

An Overview of Retinal Vein Occlusion

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Experts define retinal vein occlusion and discuss risk factors, diagnostic testing, prognosis, and lifestyle modifications prevalent in the current paradigm.


Rishi P. Singh, MD: Hello and welcome to HCPLive® Peers & Perspectives. This presentation is entitled, “Advancements in the Management of Macular Edema Following Retinal Vein Occlusion.” My name is Dr Rishi Singh, staff surgeon at the Cleveland Clinic, Cleveland, Ohio, and professor of ophthalmology at the Lerner College of Medicine. And I’m joined today by my friend and colleague Dr Jayanth Sreedhar, an ophthalmologist at the University of Miami Hospital and Clinics in Miami, Florida.

Our discussion today will focus on the understanding and optimization of treatment plans of patients who have macular edema following retinal vein occlusion. We’ll talk about how we diagnose these patients, what imaging tests we get, what sort of laboratory values we’re most interested in potentially receiving, what are the risk factors for developing these conditions, and how we optimally treat patients in clinical practice for this condition. Jay, let’s start off by defining what it means to have a retinal vein occlusion.

Jayanth Sridhar, MD:In its purest form, a retinal vein occlusion is a blockage of one of the venules that we see coming off either the central retinal vein itself, or one of the venules coming off of it. This is different than other blockages of veins we see in the body. These are generally occlusions, they’re not necessarily clots in those veins, although there are scenarios where it can be, and that influences the risk factors we think of for retinal vein occlusion. Rishi, in my experience these are patients who, especially in the older patient population, they tend to be hypertensive, they may have diabetes, they may have other risk factors for atherosclerotic disease. It’s different than the venous thromboembolism and vein blockages we see in other parts of the body.

Rishi P. Singh, MD: Jay even before we get into the risk factors, which are going to be an important topic of discussion because obviously it differs based on what your work-up or what your comfortability is. Let’s talk about the classifications in more detail because there is the condition of a hemiretinal vein occlusion. Do you want to help define that better for our colleagues at home who are watching this today?

Jayanth Sridhar, MD: Yes. I would think that you can kind of separate the occlusions into 2 broad categories. There’s central, where the central vein gets blocked, or a branch, where it’s a smaller branch off of it, and a hemi is in between. One of those 2 large branches gets occluded, so either the inferior or superior part of the retina is affected. And it’s interesting, when we get later into how these differ in how they behave, hemis are interesting in how they behave because they’re a little bit like branch vein occlusions that tend to behave and respond more like central vein occlusions.

Rishi P. Singh, MD: Jay, when you see a patient with a vein occlusion in the clinic, or get referred I should say, to a patient, what’s your timeline for referral? For me, if the person gets an OCT [optical coherence tomography] prior, and it shows there’s either no macular edema or even a mild amount of macular edema, I’ll say within 2 to 4 weeks is reasonable to see this patient. What are your thoughts about when to see this patient from either an optometry, or a general ophthalmology referral to your practice?

Jayanth Sridhar, MD: I completely agree with that timeline. We don’t have data, as you know, that separates 1 week versus 2 weeks versus 3 weeks versus 4 weeks. But most of us agree that within a month is reasonable, and that’s important for colleagues to know because a lot of times these patients may not have the ability or access to come in right away. Once you get beyond a month, if it were my eye, I would be more uncomfortable waiting. I like that 2- to 4-week timeline too.

Rishi P. Singh, MD: That’s great. Say a patient walks in your door with a retinal vein occlusion, what sort of imaging tests do you find useful? What are you getting at baseline for that patient who walks in the door?

Jayanth Sridhar, MD: I’ve added imaging over time. My course, since I get what you get, an OCT, I want to make sure and evaluate whether there’s significant macular edema associated with that vein occlusion that may be correlated with a decline in visual acuity as part of your standard work-up. Over time, I’ve started getting standard fundus photography on all these patients, and that’s more from a counseling perspective and also for follow up. A lot of these patients are obviously alarmed, and they don’t quite understand, OCT can be a little abstract for some patients. But when they see a vein occlusion in the photo, it’s very visually striking. And when they can see the comparison to a normal fellow eye, it’s helpful, so I’ll get those 2. I’m curious Rishi, do you get angiography routinely on these patients?

Rishi P. Singh, MD: Only if their visual acuity is down, because there have been some studies that show that if the patient’s visual acuity is 23/20 or beyond that, that’s a patient who has high risk for neovascularization, nonperfusion, those sorts of phenomenon. Only in those individuals I get a widefield fluorescence, but I don’t get it on standard practice for that matter. How about you?

Jayanth Sridhar, MD: Yes. I agree. The other thing that’s hard is, sometimes these patients, especially the patients with central retinal vein occlusion, they have so much hemorrhage that you get a lot of blockage on the FA [fluorescein angiography] and then it’s hard to assess the degree of nonperfusion. I agree with that. Those are the patients for whom I’m most worried about ischemia and later thinking, “Do I need to do something more permanent there like panretinal laser for neovascularization, and how am I going to follow that patient?” But often I find that I get the angiogram, and then if I find it’s not as helpful because of blockage, maybe repeating it down the line as those hemorrhages clear up. I’m curious Rishi, when you talk to these patients, a lot of times, the first question they asked me is, “Why did this happen?” That’s probably the most prominent question. How do you counsel them about why it happened, and what they can do on their own time, besides treatments we’ll talk about, to influence their disease?

Rishi P. Singh, MD: That’s a great question, Jay. What the patient can do a lot of times is based upon our risk factor assessment. That leads into some of this discussion about risk factors, and obviously the risk factors are well known, which are modifiable. Obesity, diabetes control, glaucoma, primary open-angle glaucoma control; those with advanced glaucoma can develop this over patients who have less advanced glaucoma. Those are one of the risk factors associated with this condition. Clearly controlling intraocular pressure can be one of those modifiable risk factors for patients. Those are the ones I initially think about. And we discuss them initially at the risk factor discussion point, but later it goes into the fact that we’re worried about their fellow eye more than their current eye, because obviously, the event has occurred now. It’s almost like the pregnancy has happened, so we have to manage the pregnancy more than we have to manage the situation with the vein occlusion at this point. Obviously, lifestyle modification, those sorts of things, can help with the fellow eye, but I’m not sure they can really help with the current eye. I don’t know if you have any references of studies that have been able to manage the systemic conditions that lead to less progression in these sorts of situations.

Jayanth Sridhar, MD: I don’t think there are any real great studies about fellow eye progression, but I agree. Besides that, when patients are worried about why it happened, they want to know what the prognosis is, and they’re often very alarmed. Especially the patients with central retinal vein occlusion, they have severe vision loss, they’re pretty distraught sometimes, and prognosis is sometimes really tough to discuss. We have some data we talk about from major trials about prognosis in patients with macular edema, but I’m curious how much detail do you go into in terms of prognosis? If a patient comes in and they’re, let’s say, 20/80, with a branch retinal vein occlusion and macular edema, what do you tell them in terms of long-term vision? Because in my patient population, these are a younger patient population than our patients with macular degeneration. Many of these patients are still working. They’re pretty alarmed and thinking, “OK, what does this mean for me 5, 10, 15 years from now?”

Rishi P. Singh, MD: The vast majority of patients, we can tell from some of the earliest studies, at least from the registration trials and other real-world analyses, that the vast majority will have stable vision. Ninety percent or so will have stable vision, and about 30% to 40% will have 2 to 3 lines of improvement of vision, depending on their baseline acuity, obviously, initially. That’s been borne out over multiple different studies and trials, so at least we have some idea as far as prognosis. Now for frequency, you’re absolutely correct as far as treatment goes. We have some patients from the CRUISE trial in fact who are with us from the initial registration phase of ranibizumab, who are still with us in our clinics, getting injections today. And we have other patients who’ve been in other studies who have, fortunately, had no further injections for their treatments over time.

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Transcript edited for clarity.