Combined retinal vascular occlusion: Demography, clinical features, visual outcome, systemic co-morbidities, and literature review

Abstract

Purpose: To document the clinical features, systemic association, and treatment outcome of patients with a combined retinal vein and artery occlusion (CRVAO) and review of literature.

Methods: A retrospective chart review of patients diagnosed with CRVAO at a tertiary eye care center. Patient's demographic details and associated ocular and systemic factors were recorded. Treatment included laser photocoagulation, anti-vascular endothelial growth factor (VEGF) intravitreal injection or transscleral cyclophotocoagulation (TSCPC), alone or in combination. At last, follow- up treatment response was measured in visual acuity status, regression of neovascularization, and control of intraocular pressure (IOP). All cases reported in the current decade were analyzed and compared with this study.

Results: Seventeen eyes with CRVAO accounted for 0.3% of total vascular occlusion (total 5151 patients were seen in this period). The mean age was 48.12 ± 17.5 years (range: 12-87 years) and there were 9 females. Nine eyes had CRVO + CRAO; 6 eyes had BRVO + BRAO, and one patient each had CRVO + BRAO and CRAO + BRVO. Fluorescein angiography (FA) showed delayed 'arm to retina' time (>20 seconds) in all 10 eyes and delayed arteriovenous transit time in 9 out of 10 eyes. Optical coherence tomography (OCT) showed hypereflective inner retinal layers (16 eyes) and neurosensory detachment (7 eyes). The most common systemic associations were hypertension and dyslipidemia (n = 7 people; 41.18%) each. Four patients (23.5%) had a plaque in carotid arteries with normal 2D echocardiography. Ten (59%) eyes were treated with intravitreal bevacizumab + laser; four (23.5%) eyes were treated with laser only, and three (17.6%) eyes were treated with laser + anti-VEGF + TSCPC. At last follow up, vision improved in 9 (52.9%) eyes; stable in 3 (17.7%) eyes, and reduced to perception of light in 5 (29.4%) eyes.

Conclusion: Combined CRVAO is a rare emergency leading to acute vision loss. Early diagnosis and treatment for ocular complications and systemic evaluation for cardiovascular risk factors are needed.

Keywords: Cardiovascular factors; combined retinal artery and vein occlusion; intravitreal bevacizumab; laser photocoagulation.

Figure 1

Case 2. (a) Left eye with combined central retinal vein and artery occlusion with a cherry red spot at the macula. (b) FA in late phase showed hypofluorescence areas with no evidence of dye in retinal vessels except small perfused area supplied by the cilioretinal artery. (c) Fundus at the last follow-up showed optic atrophy with sclerosed retinal vessels with gross macular ischemia. (d) OCT at presentation showed hyperreflective inner retinal layers with neurosensory detachment. (e) OCT at the last follow-up showed complete atrophy of inner retinal layers with thin epiretinal membrane

Figure 2

Case 6. (a) Left eye with superotemporal quadrant combined branch retinal artery and vein occlusion. (b) FA in the late phase showed blocked fluorescence with blockage of dye in peripheral retinal arteries. (c) OCT showed hyperreflective inner retinal layers with neurosensory detachment involving the fovea. (d) Fundus at last follow-up showed resolution of hemorrhage with complete perfusion of retinal vessels. (e) FA in the late phase showed reperfusion of dye in all retinal vessels with few areas of stippled isofluorescence. (f) OCT at last follow-up showed normal foveal contour with the resolution of edema