Nonischemic Central Retinal Vein Occlusion Research Articles

Effects of repeated injection of intravitreal triamcinolone on macular oedema in central retinal vein occlusion

To investigate the effectiveness of repeated injections of intravitreal triamcinolone acetonide (IVTA) in the treatment of macular oedema caused by central retinal vein occlusion (CRVO). Seventeen pseudophakic or aphakic eyes of 17 patients (10 male, seven female) with macular oedema caused by CRVO received a repeat injection of 4 mg IVTA, 16 weeks after the first injection of the same dose. The examination included measurements of best-corrected visual acuity (BCVA) for distance and central foveal thickness (CFT) by optical coherence tomography (OCT), preoperatively and 1, 2, 3 and 4 months postoperatively. The values were compared by paired-t test. Side-effects were monitored. BCVA and CFT were not significantly different before initial and repeat injections. Transient improvements of BCVA and CFT were achieved after both injections. At the end of follow-up, BCVA and CFT were significantly different compared to pre-injection values in the same group (P = 0.032, 0.049 in the initial-injection group and P = 0.001, 0.008 in the repeat-injection group, respectively). However, compared to the initial injection, BCVA measurements were significantly worse at each time-point (P = 0.043, 0.011, 0.010 and 0.012, respectively) after the repeat injection, as were CFT at 1, 2 and 3 months post-injection (P = 0.040, 0.015 and 0.025, respectively). The achieved maximum mean intraocular pressures were 20.00 [standard deviation (SD) 2.06] mmHg and 18.56 (SD 3.65) mmHg after the first and repeat injections, respectively. These values were not significantly different (P = 0.467). No other significant adverse events were noted during the study. A repeat injection of 4 mg IVTA may not be as effective as an initial injection for the treatment of macular oedema caused by CRVO.

Early intravitreal bevacizumab for non‐ischaemic central retinal vein occlusion

To evaluate the effect of early intravitreal bevacizumab injections for the treatment of macular oedema caused by non-ischaemic central retinal vein occlusion (CRVO). The study included 25 patients (25 eyes) with macular oedema caused by non-ischaemic central retinal vein occlusion, who received three intravitreal injections of 1.5 mg bevacizumab with an interval of 6 weeks between the injections. Mean duration of central retinal vein occlusion prior to the first injection was 4.2 +/- 3.6 days. All patients were re-examined 1, 3 and 6 months after the first injection. The main outcome parameters were visual acuity and macular thickness, as measured by optical coherence tomography. Mean visual acuity improved significantly from 0.97 +/- 0.40 logMAR at baseline to 0.70 +/- 0.42 logMAR (P = 0.007) at 1 month, 0.69 +/- 0.46 (P = 0.006) 3 months and 0.69 +/- 0.52 (P = 0.015) 6 months after the first injection. Mean central retinal thickness decreased significantly from 530 +/- 152 microm at baseline to 347 +/- 127 microm (P < 0.001) at 1 month, 370 +/- 165 microm (P < 0.001) 3 months and 346 +/- 129 microm (P < 0.001) 6 months (P < 0.001) after the first injection. The increase in visual acuity correlated significantly (P < 0.01) with the decrease in macular thickness. Mean intraocular pressure was 14.2 +/- 3.2 mmHg at baseline and did not differ significantly from the measurement obtained at 1 month (P = 0.59), 3 months (P = 0.88) and 6 months after the first injection (P = 0.65). Intravitreal bevacizumab injections given shortly after onset of non-ischaemic central retinal vein occlusion may result in a significant increase in vision and a corresponding decrease in macular oedema.

This issue of Acta

The cover illustrations are contributed by Gysbert van Setten and show the bimanual insertion of a capsular tension ring as reported in this issue of Acta. Anders Behndig discusses the pros and cons of operating both eyes for cataract at the same time and discusses the article by Lundström et al. in this issue. Resch and associates in Vienna review the evidence for endothelial dysfunction in glaucoma and its relevance in the ischemic nature of glaucoma. Kawasaki and Purvin in Switzerland and USA present a comprehensive review of giant cell arteritis including epidemiology, pathophysiology and treatment. Lundström et al. in Sweden point out that it is less expensive to operate both eyes of a cataract patient in the same setting. The pros and cons of this approach are discussed further in the editorial by Behndig. Karalezli et al. in Turkey find changes in conjunctival impression cytology and the tear film in patients with Mediterranean fever. Kimura et al. en Japan did not find adenovirus before the onset of symptoms in adenoviral conjunctivitis. Wollensak and Iomdina in Germany and Russia found that photodynamic collagen cross-linking increases the rigidity of the rabbit cornea. Berker et al. in Turkey examined the genetic pattern of Peters' anomaly. Bordaberry et al. in Brazil found peribulbar injection of trimacinolone to reduce inflammation in Graves' ophthalmopathy and optic neuropathy. Hradilek et al. in the Check Republic describe transient changes in orbital hemodynamics in optic neuritis in multiple sclerosis. Konstas et al. in Greece and United States found that a fixed combination of travoprost and timolol reduces intraocular pressure over a 24-hour period. Rensch et al. in Germany found that intravitreal bevacizumab improves vision and reduces macular edema in non-ischemic central retinal vein occlusion. Sharma et al. in United States suggest that preconditioning may protect retinal pigment epithelial cells from oxidative stress in an in vitro experiment. Schmid-Kubista in Vienna found that patients with age-related macular degeneration produce less melatonin than control patients without macular degeneration. Saricaoglu et al. in Turkey describe decompression retinopathy following glaucoma filtering surgery. Abouzeid et al. in Switzerland and Germany used optical coherence tomography to show that subretinal fluid may persist for months after scleral buckling surgery inferior detachments. Song et al. in Korea used intravitreal bevacizumab to treat choroidal neovascularization with a choroidal osteoma. Ikewaki et al. in Japan describe a fungal abscess following triamcinolone injection. I hope that the readers of Acta find sources of enjoyment and education in this issue of Acta. I wish you all a Happy New Year.

Intravitreal bevacizumab treatment of macular edema in central retinal vein occlusion: one-year results

To report on the anatomic and visual acuity response after intravitreal bevacizumab injection in patients with macular edema due to non-ischemic central retinal vein occlusion (CRVO). In a retrospective study, 21 consecutive patients (21 eyes) with non-ischemic CRVO underwent, on average, 3.7 intravitreal bevacizumab injections (1.25 mg). Ophthalmic examination included best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and follow-up visits. Fluorescein angiography was performed at baseline and at follow-up visits if needed. Primary outcomes were change of BCVA and CRT. The follow-up period for all of the included patients was 12 months. The mean BCVA was unchanged at the 12-month examination (baseline: 20/160; 12 months: 20/160) (P = 0.771). The mean CRT decreased from 780 microm (standard deviation [SD] +/- 324 microm) at the baseline to a mean of 462 microm (SD +/- 248 microm) at 12 months (P < 0.05). Intravitreal bevacizumab resulted in a significant decrease in CRT without significant improvement of visual acuity in patients with non-ischemic CRVO after a follow-up of 12 months.

Ischaemic change after intravitreal bevacizumab (Avastin®) injection for macular oedema secondary to non‐ischaemic central retinal vein occlusion

Editor, A 65-year-old male patient with a 12-year history of diabetes presented with decreased visual acuity in his right eye of 3 months duration. Best-corrected visual acuity (BCVA) was 0.4 in the right eye (RE) and 1.0 in the left eye (LE). A slit-lamp examination showed grade two bilateral nucleosclerosis with no further abnormalities of the anterior segment. Fundus examination and fluorescein angiography showed flame-shaped retinal haemorrhages in four quadrants and optocillary shunt vessels. These ocular findings were consistent with non-ischaemic central retinal vein occlusion (CRVO). Optical coherence tomography (OCT) showed submacular fluid and macular elevation with a central macular thickness of 533 μm in the RE (Fig. 1). An intravitreal off-label bevacizumab injection was recommended. The patient was informed about the treatment beforehand and provided written informed consent. The injection was performed in a sterile setting and prophylactic topical antibiotics and carbonic anhydrase inhibitor were given for 1 week pre- and post-injection. The intravitreal dosage of bevacizumab was 1.25 mg (0.05 ml). Repeat examinations of visual acuity, intraocular pressure and fundus examinations were scheduled at 1 day, 1 week and 1 month after injection. Three weeks after injection, the patient reported a deterioration of visual acuity in the RE. His visual acuity in the RE was 0.02 and a fundus examination showed disc oedema with extensive flame-shaped retinal haemorrhages in the four retinal quadrants (Fig. 2). A fluorescein angiogram of the RE demonstrated severe non-perfusion including the fovea with blocked hypofluorescence. OCT imaging showed a central macular thickness of 560 μm (Fig. 2). Six months after the injection, his visual acuity in the RE was 0.02 and panretinal photocoagulation was performed. Fundus photography (A), fluorescein angiography (B) and optical coherence tomography (OCT) (C) images at initial presentation. (A) Fundus photograph showing multiple intraretinal haemorrhages and dilated retinal veins with optociliary shunt vessels. (B) Fluorescein angiograph in the late phase showing blocked hypofluorescence with patelloid pattern of dye leakage in the fovea in the right eye. (C) A vertical OCT image of the right eye showing cystoid macular oedema with a central macular thickness of 533 μm. Fundus photography (A), fluorescein angiography (B) and optical coherence tomography (OCT) (C) images 3 weeks after intravitreal bevacizumab administration. (A) Fundus photograph showing extensive flame-shaped retinal haemorrhages and disc swelling. (B) Fluorescein angiograph in the late phase showing severe non-perfusion and dye leakage at the optic disc. (C) Vertical OCT image showing subretinal fluid with a central macular thickness of 560 μm. Bevacizumab represents a new treatment option for early intervention against the formation of macular oedema in various disease conditions. Several short-term results have been published on intravitreal bevacizumab for macular oedema secondary to retinal vein occlusion with CRVO (Iturralde et al. 2006; Spandau et al. 2006; Pai et al. 2007). These reports suggest that intravitreal bevacizumab may reduce macular oedema and increase visual acuity in CRVO. But because a physiological level of vascular endothelial growth factor (VEGF) may be necessary for retinal homeostasis, precautions may have to be taken to avoid the possible negative effects of a complete blockade of VEGF, particularly in primarily ischaemic diseases. However, no report has been issued regarding complications associated with intravitreal bevacizumab except for endophthalmitis. Here, we present a case of non-ischaemic CRVO conversion to ischaemic CRVO after injecting bevacizumab intravitreally. The formation of a new blood flow balance is presumably supported by the formation of collateral vessels with a new drainage route. Spandau et al. (2006) suggested the possibility of complete blockage of VEGF by intravitreal bevacizumab. Although 11–34% of non-ischaemic CRVO cases convert to ischaemic CRVO over a natural course of 3–5 years, we suggest that intravitreal bevacizumab injection affected the outcome in this case (TCVOS 1997). This is because ischaemic CRVO occurred 3 weeks after the injection, when bevacizumab has its peak effect and relatively good initial visual acuity and perfusion status. There were no other patient factors that might cause the ischaemic conversion of CRVO except diabetes. The causes and mechanisms of treatment failure associated with bevacizumab administration must be elucidated further in vitro and by clinical studies. Furthermore, the possibility that bevacizumab has a negative long-term effect on collateral vessel formation because of its anti-VEGF action requires investigation.

RADIAL OPTIC NEUROTOMY FOR CENTRAL RETINAL VEIN OCCLUSION

To evaluate the complications after radial optic neurotomy (RON) for central retinal vein occlusion (CRVO). Seventy-three consecutive patients (73 eyes) with CRVO who were treated with RON participated in a retrospective, uncontrolled, interventional, multicenter case series at 7 institutions from 6 countries. In the ischemic CRVO group (n = 53), 32% of eyes had an improvement in best-corrected visual acuity (BCVA) (mean, 5.5 lines), 35.8% had worse BCVA (mean, 6.4 lines), and 32% had BCVA that remained the same after RON. In the nonischemic CRVO group (n = 20), 50% of eyes had an improvement in BCVA (mean, 6.5 lines), 15% had worse BCVA (mean, 4.3 lines), and 35% had BCVA that remained the same after RON. Complications occurred in 71.2% of cases, including cataract in 17 eyes (23.2%), vitreous hemorrhage in 16 eyes (20.5%), persistent macular edema in 15 eyes (20.5%), neovascular glaucoma in 7 eyes (9.5%), anterior segment neovascularization in 5 eyes (6.8%), retinal detachment in 3 eyes (4.1%), and phthisis bulbi, choroidovitreal neovascularization, central retinal artery perforation, and optic nerve atrophy in 1 eye (1.3%) each. RON may improve visual acuity in some eyes with CRVO, but complications are common. In our series, surgery by itself did not seem to improve the outcome of CRVO when compared with its natural history.

Central Retinal Vein Occlusion Associated With Cilioretinal Artery Occlusion

To describe the clinical characteristics and pathogenesis of central retinal vein occlusion (CRVO) associated with cilioretinal artery occlusion (CLRAO). The study included 38 patients (38 eyes) who had CRVO associated with CLRAO and were seen in our clinic from 1974 to 1999. At their first visit to our clinic, all patients provided a detailed ophthalmic and medical history and underwent comprehensive ophthalmic evaluation, color fundus photography, and fluorescein fundus angiography. At each follow-up visit, the same ophthalmic evaluations were performed, except for fluorescein fundus angiography. Of 38 eyes, 30 had nonischemic CRVO, 5 had ischemic CRVO, and 3 had nonischemic hemi-CRVO. Patients with nonischemic CRVO were significantly younger (mean age +/- SD: 45.3 +/- 16.0 years) than those with ischemic CRVO (72.3 +/- 9.2 years; P = 0.001) and those with nonischemic hemi-CRVO (64.7 +/- 7.5 years; P = 0.018). At least one third of the patients gave a definite history of episode(s) of transient visual blurring before the onset of constant blurred vision. Initially, the ophthalmoscopic and fluorescein angiographic findings were similar to those seen in CRVO and hemi-CRVO, except that all these eyes had retinal infarct in the distribution of the cilioretinal artery; its size and site varied widely. Fluorescein angiography typically showed only transient hemodynamic block and not the typical CLRAO. During follow-up, visual acuity improved markedly in nonischemic CRVO (P < 0.001) and nonischemic hemi-CRVO but deteriorated in ischemic CRVO. Retinopathy resolved spontaneously in 22 eyes with nonischemic CRVO (mean duration +/- SD: 42.0 +/- 101.0 months), in 2 eyes with ischemic CRVO (15.4 +/- 4.5 months), and in 1 eye with nonischemic hemi-CRVO. Retinociliary collaterals developed in 30% of eyes with nonischemic CRVO, in 40% of eyes with ischemic CRVO, and in 66% of eyes with nonischemic hemi-CRVO. CRVO associated with CLRAO constitutes a distinct clinical entity. The pathogenesis of CLRAO in CRVO is due to transient hemodynamic blockage of the cilioretinal artery caused by a sudden sharp rise in intraluminal pressure in the retinal capillary bed (due to CRVO) above the level of that in the cilioretinal artery.

INDUCTION OF RETINOCHOROIDAL VENOUS ANASTOMOSIS IN CENTRAL RETINAL VEIN OCCLUSION WITH MACULAR EDEMA VIA A FULL-THICKNESS RETINOCHOROIDAL INCISION

To report the induction of retinochoroidal venous anastomosis (RCVA) in the treatment of nonischemic central retinal vein occlusion (CRVO) with macular edema via a full-thickness retinochoroidal incision. In nine eyes with nonischemic CRVO and intractable macular edema, one or two full-thickness incisions transacting a major retinal branch vein to the level of inner sclera were made in conjunction with vitrectomy. Fluorescein angiography was conducted to evaluate the formation of functional RCVA. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were compared before and after the surgery. The mean follow-up period +/- SD was 12.0 +/- 5.1 months. All nine eyes developed functional RCVA after the surgery. The mean BCVA +/- SD improved from 0.75 +/- 0.30 logMAR (logarithm of the minimal angle of resolution) to 0.55 +/- 0.26 logMAR (P = 0.018), and the mean CMT +/- SD was reduced from 686 +/- 265 microm to 251 +/- 150 microm (P = 0.011). Additional surgery was performed on one eye due to persistent vitreous hemorrhage. Full-thickness retinochoroidal incision appears to raise the rate of successful RCVA formation and may improve the outcome of CRVO with macular edema.

Clinical Course of Young Adults With Central Retinal Vein Occlusion

Purpose: To describe the clinical course of young patients with central retinal vein occlusion (CRVO). Methods: We reviewed the records of patients 50 years or younger who presented with CRVO and who were followed up for at least 6 months. Results: The average age of the patients was 37.7 years, and the mean follow-up time was 26.3 months. Participants included 27 patients with CRVO younger than 50 years among the total 393 patients with CRVO, and the sex distribution was nearly equal; 13 patients were male and 14 patients were female. Associated systemic diseases were hypertension (8 patients), diabetes (3 patients), stroke (3 patients), and myocardial infarction (1 patient). Of the 17 patients who had no systemic disease, 8 patients had hypercholesterolemia or another hematologic abnormalities. Of the 18 eyes with non-ischemic CRVO, 10 eyes (55.6%) showed improved final visual acuities (2 or more lines). Of the 9 eyes with ischemic CRVO, only 1 eye (11.1%) showed improved visual acuity. Conclusions: Hematological examination and treatment with systemic evaluation were recommended to younger patients with CRVO. The classification of retinal ischemia of young patients as well as that of older patients could be useful for the follow-up of patients and the assessment of its progression in the future.

Central retinal vein occlusion in a young adult during risperidone therapy.

Various articles in the literature point out the higher risk of venous thrombosis in patients taking antipsychotic drugs. However, to our knowledge, an association with central retinal vein occlusion (CRVO) has not been reported before. We describe the clinical and angiographic findings of a patient with CRVO that may have been related to his antipsychotic medication. A 19-year-old patient had been taking risperidone and fluoxetine for the last 7 months. He presented with atypical nonischemic CRVO with atypical deep intraretinal hemorrhages, a swollen optic disk, dilatation and engorgement of retinal veins, and optic disk capillaries. Despite a detailed workup, no systemic or ocular risk factors for a thromboembolic event were found. He had hyperprolactinemia resulting from his medication. The use of risperidone may be a risk factor for CRVO.

INTRAVITREAL BEVACIZUMAB INJECTIONS FOR TREATMENT OF CENTRAL RETINAL VEIN OCCLUSION

To evaluate the effect of intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) injections on visual acuity and foveal retinal thickness in patients with central retinal vein occlusion (CRVO). In this prospective, noncomparative, consecutive, interventional case series, 46 patients received repeated intravitreal injections (1.25 mg) of bevacizumab. Main outcome measures were visual acuity (Snellen and ETDRS charts) and optical coherence tomography measurements in a 6-month follow-up period. Mean visual acuity improved from 20/250 at baseline to 20/80 at the 6-month follow-up (P < 0.001). ETDRS chart findings revealed a mean letter gain +/-SD from baseline to 6 months of 13.9 +/- 14.4 letters. Mean central retinal thickness +/-SD decreased from 535 +/- 148 microm at baseline to 323 +/- 116 microm at the 6-month follow-up. Ischemic CRVO was associated with significantly lower visual acuity than nonischemic CRVO (P < 0.001). However, visual acuity gain was similar in both groups. Independent of duration of symptoms, CRVO was associated with a similar gain in visual acuity. Intravitreal injection of bevacizumab appears to be a new treatment option for patients with macular edema secondary to CRVO.

Central Retinal Vein Occlusion as a Possible Presenting Manifestation of Sneddon Syndrome

We report a case of central retinal vein occlusion (CRVO) and livedo reticularis in a patient in whom Sneddon syndrome was subsequently diagnosed. A 61-year-old man presented with a sudden and painless decline in visual acuity of his right eye. Visual acuities evaluated with Early Treatment Diabetic Retinopathy Study (ETDRS) measurements were 0.62 ETDRS lines (20/60 Snellen equivalent) for the right eye and 0.9 ETDRS lines (20/30 Snellen equivalent) for the left eye, there was no relative afferent pupillary defect, and intraocular pressures were 18 mm Hg in both eyes. Examination of the right fundus revealed retinal edema, optic disc swelling, tortuous and dilated retinal veins, and extensive superficial hemorrhages in all four quadrants. A diagnosis of acute CRVO was made. Pre-fluorescein angiographic red-free fundus photography (Fig. 1) showed venous stasis but good retinal capillary perfusion, disc edema, tortuosity, and dilation of all branches of the central retinal vein and a few scattered peripheral fundus hemorrhages, consistent with nonischemic CRVO. The periphery of the eye showed no extensive areas of capillary nonperfusion or neovascularization.FIG. 1: Red-free fundus photography of the right eye at presentation shows tortuosity and dilation of all branches of the central retinal vein, mild disc edema, a few scattered peripheral fundus hemorrhages, and good retinal capillary perfusion. These are features consistent with nonischemic central retinal vein occlusion.The patient had no personal or family history of eye disease, systemic hypertension, diabetes mellitus, thrombophilia, or malignancy. Systemic examination revealed a generalized livid discoloration of the skin in a net-like pattern all over the body except on the face (Fig. 2). The patient had noted the skin discoloration 13 days earlier.FIG. 2: Left hip shows livedo reticularis, a reddish netlike discoloration of the skin.Results of ultrasound studies of the heart and extracranial vessels as well as laboratory serology analyses were negative, including antinuclear antibodies (ANAs), antineutrophilic cytoplasmic antibodies (ANCAs), complement C3 and C4, antiphospholipid antibodies, and lupus anticoagulant, prothrombin time, antithrombin III, fibrinogen, protein C, protein S, and activated protein C resistance. Brain MRI showed an old cerebral infarction in the left basal ganglia. Aortic arch, neck, and brain MRA revealed no evidence of atherosclerosis or vasculitis. A skin and skeletal muscle biopsy revealed endothelial thickening in the small vessels of the subcutis without signs of vasculitis, consistent with Sneddon syndrome. The patient was treated with 400 mg intravenous pentoxifylline daily and 7,500 IU dalteparin sodium subcutaneously for 7 days, followed by 100 mg aspirin per day. On re-examination 3 months later, visual acuity had increased to 0.71 ETDRS lines (20/50 Snellen equivalent) for the right eye and remained at 0.9 ETDRS lines (20/30 Snellen equivalent) for the left eye. The right fundus revealed persisting optic disc swelling and retinal hemorrhages but a reduction in retinal edema. Repeated fluorescein angiography showed no signs of ischemia of the right eye. Sneddon syndrome, first described in 1965, is characterized by generalized livedo reticularis and stroke (1,2). The etiology of this syndrome is unknown, although there are correlations with the antiphospholipid syndrome, systemic secondary vasculitis, and coagulopathies. It may start as an inflammatory and possibly immunologically mediated disorder and lead to a proliferation of smooth cells of small blood vessels and obstruction of the vessel lumen. Although central retinal artery occlusion (3-5) and peripheral retinal capillary occlusions and neovascularization (6) have been reported previously in Sneddon syndrome, CRVO has not. It is unclear whether the CRVO in our patient was directly related to Sneddon syndrome. Tina Aggermann, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Department of Ophthalmology Rudolf Foundation Clinic Vienna, Austria [email protected] Paulina Haas, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Vienna Austria Susanne Binder, MD Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery Department of Ophthalmology Rudolf Foundation Clinic Vienna, Austria

Efficacy and safety of pegaptanib sodium for macular edema secondary to Central Retinal Vein Occlusion (CRVO)

Abstract Purpose: To assess the efficacy and safety of pegaptanib in the treatment of macular edema secondary to CRVO. Methods: This phase 2, multicenter, double‐masked, sham‐controlled study included subjects with nonischemic CRVO of &lt;6 months duration, baseline center point retinal thickness ≥250 μm, and best‐correct visual acuity (VA) of 65 to 20 ETDRS letters inclusive. Subjects were randomized (1:1:1) to intravitreous pegaptanib (0.3, 1 mg) or sham injections every 6 weeks for 24 weeks with follow‐up through 52 weeks. Additional therapy was allowed after week 30 for losses ≥15 letters. Endpoints included mean changes from baseline in VA and retinal thickness. Results: Baseline characteristics were well balanced across study arms (0.3, 1 mg, n=33; sham, n=32). Mean change in VA from baseline at week 30 was +7.1, +9.9, and ‐3.2 letters in the pegaptanib 0.3 mg, 1 mg, and sham groups, respectively (P&lt;.05 for 1 mg vs sham). At week 52, mean VA change was +7.5, +6.3, and ‐2.4 letters, respectively (P=ns). From baseline to week 52, fewer treated with 0.3 mg pegaptanib than sham lost ≥15 letters (9% vs 31%; P&lt;.05) and more gained ≥0 (P=.01), 5 (P=.02) and 10 or 15 letters (P=ns). From baseline to week 52, mean change in center point thickness in the 0.3 mg, 1 mg, and sham groups was ‐295 μm, ‐216 μm, and ‐183 μm, respectively. Conclusions: This is the first randomized trial to show any treatment benefit for macular edema due to CRVO compared with sham. The anatomical and functional benefits provided by pegaptanib are consistent with the clinical benefit already presented with diabetic macular edema, and the ocular neovascularization of diabetic retinopathy and age‐related macular degeneration.

Macular Hole and Intravitreal Injection of Triamcinolone Acetonide for Macular Edema Due to Central Retinal Vein Occlusion

To report a case of macular hole progression after intravitreal injection of triamcinolone acetonide (IVTA) for chronic macular edema secondary to nonischemic central retinal vein occlusion (CRVO). A 33-year-old woman with massive macular edema after CRVO underwent IVTA. Optical coherence tomography (OCT) and fluorescein angiography were performed before and after the procedure. At the 1-week IVTA injection control, the patient's best-corrected visual acuity improved from 20/400 to 20/200 and OCT detected a progression of macular hole stage. IVTA steroid injection may provide a significant improvement in macular edema, but injection-related complications may occur such as this uncommon macular reaction resulting in permanent visual loss.

Long-term effects of radial optic neurotomy for central retinal vein occlusion consecutive interventional case series

To investigate the long-term (minimum 24 months follow-up) clinical results of radial optic neurotomy (RON) following a pars plana vitrectomy (PPV) with internal limiting membrane peeling as treatment for central retinal vein occlusion (CRVO). Interventional case series of 14 consecutive patients (14 eyes) with CRVO who were treated with a PPV combined with RON within 1 year of diagnosis. Median baseline visual acuity (VA) was 1.05 logMAR (approximately 0.09 Snellen) in the affected eye. The follow-up period ranged from 24 to 48 months postoperatively, median 30 months. At the 24-month follow-up examination, median VA was 1.005 logMAR in the affected eye-a significant improvement (p = 0.013). Six patients (43%) gained 1 or more lines of VA (mean VA gain = 1.7 lines), while the VA of four patients (29%) improved by 3 or more lines. The eyes with nonischemic CRVO demonstrated a significantly higher improvement in VA (p = 0.0007) than the eyes with ischemic CRVO. With RON clinically relevant improvements on a long-term basis seem achievable. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO.

EARLY TREATMENT OF SEVERE CYSTOID MACULAR EDEMA IN CENTRAL RETINAL VEIN OCCLUSION WITH POSTERIOR SUB-TENON TRIAMCINOLONE ACETONIDE

To evaluate the clinical outcomes of posterior sub-Tenon (PST) injection of triamcinolone acetonide (TA) in the early treatment of severe cystoid macular edema (CME) in central retinal vein occlusion (CRVO). In a noncomparative, prospective study, 18 eyes of 18 patients with severe CME (central macular thickness, CMT >450 microm) secondary to recent-onset CRVO (the onset of symptoms < or =4 weeks) and a decrease in visual acuity (< or =80 letters of Early Treatment Diabetic Retinopathy Study [ETDRS] scores, 20/50) were included. PST injection of 40 mg of TA was given under topic anesthesia. All patients received three biweekly injections and were evaluated at baseline and at 1 day, 1, 2, 4, 6, and 8 weeks, and 3, 6, and 9 months after injection. The main outcome measures were ETDRS scores, CMT, intraocular pressure (IOP), cataract progression, and frequency of complications. The mean age of the 18 patients was 61.17 years (range, 24-81 years) and the mean duration of symptoms was 15.28 days (range, 9-28 days). Eight eyes were diagnosed with ischemic CRVO and 10 eyes with nonischemic CRVO. Mean baseline ETDRS visual acuity (VA) score was 36.89 +/- 18.22 in all affected eye. There was a significant improvement in VA at 1, 3, 6, and 9 months of follow-up. The mean VA at these time points were 46.61 +/- 20.21, 58.11 +/- 22.19, 59.39 +/- 22.98, and 58.67 +/- 23.27 (all P < 0.001), respectively. Both nonischemic and ischemic eyes benefited with a statistically significant VA improvement at each time point. A comparison of the gain in VA between two subgroups was not significant at 1 and 3 months (P > 0.05), but was statistically significant at 6 and 9 months (P = 0.009 and 0.008, respectively). VA gain of 10 or more letters was found in all nonischemic eyes (10/10) and 3 ischemic eyes (3/8) at the 9-month follow-up. Two ischemic eyes were found to have no gain of letters in VA at the 9-month follow-up. The mean baseline CMT for all eyes was 566 +/- 42 microm. There was a 29% reduction with a mean CMT of 404 +/- 49 microm (P < 0.001) at 1 month, 51% reduction with a mean CMT of 278 +/- 40 microm (P < 0.001) at 3 months, 61% reduction with a mean CMT of 222 +/- 56 microm (P < 0.001) at 6 months, and 63% reduction with a mean CMT of 210 +/- 30 microm (P < 0.001) at 9 months. Both nonischemic and ischemic eyes demonstrated a statistically significant reduction in CMT (all P < 0.001). A comparison of the reduction in CMT between these two subgroups was not significant at each visit (all P > 0.05). For both subgroups, there was no statistically significant difference in IOP change at baseline, 1 week, 1, 3, 6, and 9 months of follow-up. Only two patients required topic antiglaucoma drops for elevated IOP. Three patients developed a recurrence of CME accompanied with visual decrease. No cataract progression or other complications were observed. PST injection of TA is effective in reversing CME and improving visual acuity in recent-onset CRVO in the first 9 months. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO. Early treatment may be better for visual improvement before longstanding macular edema results in irreversible photoreceptor damage. Further study with longer follow-up period is necessary.

Intravitreal Triamcinolone Acetonide Injection in CRVO Associated With Wegener’s Granulomatosis

A 33-year-old man developed unilateral non-ischemic central retinal vein occlusion associated with systemic Wegener's granulomatosis. Four milligrams of triamcinolone acetonide was injected intravitreally twice 6 months apart in conjunction with ongoing systemic immunosuppressive therapy. No change was made in the systemic immunosuppressive regimen. Wegener's granulomatosis should be considered in the differential diagnosis of central retinal vein occlusion in the young age group and intravitreal triamcinolone acetonide is a good adjunct to systemic immunosuppressive therapy that eliminates the need for modifying the systemic treatment regimen.

Intraocular triamcinolone acetonide for macular edema due to CRVO. A multifocal-ERG and OCT study

To investigate the effectiveness of intravitreal triamcinolone acetonide in the treatment of cystoid macular edema due to central retinal vein occlusion (CRVO). A noncomparative, prospective, interventional case series. In this study 15 eyes of 15 patients (9 males and 6 females) with macular edema due to non-ischemic CRVO were treated with intravitreal injection of 4 mg triamcinolone acetonide and followed-up for 1 year. Examination included measurement of best-corrected visual acuity (BCVA) for distance, measurement of intraocular pressure (IOP), fluorescein angiography, foveal retinal thickness measurement by optical coherence tomography (OCT), and multifocal electroretinography recordings (MFERG) preoperatively 3, 6 and 12 months postoperatively. The visual acuity increased to a significant degree at 3 months, to a smaller degree at 6 months but at 12 months there was no significant improvement. The OCT macula thickness improved to a significant level all the follow-up period but with less significance at 12 months. The MFERG recordings from the fovea showed significant improvement at 3 and 6 months. The MFERG from the parafovea area showed significant improvement at 3 and 6 and to a smaller degree at 12 months. The intraocular pressure increased at 3 and 6 months but returned to pretreatment level at 12 months. Intravitreal injection of triamcinolone acetonide leads to a significant improvement of mean VA in patients with macular edema due to CRVO. However, this significant effect is not permanent and persists for a maximum of 3-6 months. Thereafter all the indexes tend to deteriorate.

Long-Term Visual Outcomes of Vitrectomy for Cystoid Macular Edema Due to Nonischemic Central Retinal Vein Occlusion

To report the long-term surgical outcome of vitrectomy for cystoid macular edema due to nonischemic central retinal vein occlusion (CRVO). A retrospective chart review of 25 consecutive eyes (25 patients) with cystoid macular edema due to nonischemic CRVO treated with vitrectomy was performed. All patients underwent a pars plana vitrectomy with the creation of a posterior vitreous detachment if still attached. Simultaneous phacoemulsification with intraocular lens implantation was also performed in phakic eyes. The main outcome measures were best-corrected visual acuity (BCVA) and changes in macular edema shown by contact-lens biomicroscopy. The mean follow-up time was 49 months (range, 16-108). The median BCVA before surgery was 0.31 and the median BCVA at last follow-up was 0.67. The BCVA at the last follow-up improved at least two Snellen lines in 17 (68%), remained unchanged in 4 (16%), and worsened in 4 (16%). The BCVA was 20/40 or better in 3 eyes (12%) preoperatively and in 18 eyes (72%) at the last follow-up. During the follow-up, four patients progressed to ischemic CRVO; one of them had neovascular glaucoma requiring surgical intervention. The data indicate that vitrectomy appears to be a possibly effective treatment in some eyes with cystoid macular edema associated with nonischemic CRVO.

Ophthalmodynamometric Differences Between Ischemic vs Nonischemic Retinal Vein Occlusion

To estimate the central retinal vein pressure in patients with ischemic vs nonischemic central retinal vein occlusion (CRVO). Prospective clinical observational comparative study. The study included 28 patients with CRVO, either of the ischemic type (n = 7) or the nonischemic type (n = 21). The control group consisted of 38 subjects without retinal disease. A new ophthalmodynamometer consisting of a Goldmann contact lens fitted with a pressure sensor into the holding grip of the contact lens, was used to indirectly estimate the central retinal artery and vein pressure. Central retinal vein pressure was significantly higher in the ischemic CRVO group than in the nonischemic CRVO group (91.5 +/- 30.1 arbitrary units vs 52.4 +/- 32.5 arbitrary units; P = .014), in which it was significantly (P < .001) higher than in the control group (4.8 +/- 8.1 arbitrary units). Central retinal vein pressure was higher than the diastolic central retinal artery pressure significantly (P = .039) more frequently in the ischemic CRVO group (7/7 or 100%) than in the nonischemic CRVO group (8/21 or 38%) or the control group (0/38; P < .001). Central retinal artery pressure was significantly (P = .017) lower in the ischemic CRVO group (46.0 +/- 10.6 arbitrary units) than in the nonischemic CRVO group (64.5 +/- 22.8 arbitrary units), in which it was significantly (P = .016) lower than in the control group (79.9 +/- 22.3 arbitrary units). Ophthalmodynamometric estimation of the retinal vein pressure may be helpful for the differentiation between the ischemic vs nonischemic type of CRVO. In the ischemic type, vein pulsations were usually observed at supradiastolic arterial values.