RVO Management

Retinal vein occlusion (RVO) management for patients involves treating any complications due to the vein occlusion in addition to systemic disease etiology, such as hypertension, hyperlipidemia and diabetes (known risk factors for RVO).^1-3 A meta-analysis and systematic review suggests patients with any RVO have an increased risk of cardiovascular events and all-cause mortality.^4,5 Therefore, as part of retinal vein occlusion management, the eye physician should refer patients with a RVO to their primary care provider (PCP) for appropriate management of their systemic condition(s). The eye physician should also communicate all eye examination results.^4,6

Central retinal vein occlusion (CRVO)

The ischemic subtype of CRVO accounts for about 20% of cases and is associated with worse initial presenting visual acuity (VA) and poor visual prognosis even after edema resolution.^7,8 The irreversible loss of VA in macula edema is usually attributed to permanent loss of photoceptor cells.⁹ In 2019, the AAO recommended intravitreal anti-VEGF vision loss therapy as first-line treatment for macular edema secondary to RVO, reserving corticosteroids as second-line treatment due to secondary glaucoma and cataract formation. Panretinal laser photocoagulation has also been recommended in the setting of neovascular complications secondary to RVO.⁴

A common first-line vision loss treatment protocol for CRVO patients would include a loading dose of monthly injections over 3 months of an vascular endothelial growth factor (VEGF) inhibitor, such as ranibizumab or aflibercept (or off-label bevacizumab).⁸ Monthly treatment should continue until visual and anatomical outcomes are stable over 3 consecutive monthly assessments.¹⁰ For individuals who develop iris neovascularization or retinal neovascularization following development of CRVO, the best treatment is dense peripheral panretinal photocoagulation (PRP).^4,11

Branch retinal vein occlusion (BRVO)

Branch retinal vein occlusion management (BRVO) depends on visual acuity, macular edema and ischemic changes.^1,12 Patients with a non-ischemic BRVO and VA of 20/40 or better should be monitored in 3-month intervals.¹⁰ Monthly anti-VEGF injections should be initiated if VA is worse than 20/40 or if there is macular edema.¹⁰