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Questions Answered: 300

Final Score 76%

229
71

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Ophthalmology

Question 155 of 300

An 86 year old man presents to the Emergency Department complaining of a sudden loss of vision in his left eye. Your fundoscopy findings are shown. What is the diagnosis?

Answer:

Presentation of retinal vein occlusion:
  • Sudden, painless, unilateral loss of vision
    • BRVO present with vision loss in one quadrant
    • CRVO presents with visual loss in the whole visual field
    • HRVO presents with visual loss in either the superior or inferior hemisphere
  • Relative afferent pupillary defect
Fundoscopy findings of retinal vein occlusion:
  • Venous tortuosity and dilatation
  • Intraretinal haemorrhages
  • Cotton wool spots
  • Optic disc oedema
  • 'Stormy Sunset' appearance
  • In CRVO - all four quadrants of retinal tissue are affected
  • In BRVO - features only present in one retinal quadrant
  • In HRVO - features only present in superior or inferior retinal hemisphere

Retinal Vein Occlusion

Ophthalmology

Last Updated: 8th September 2021

Retinal vein occlusion (RVO) is an obstruction of the retinal venous system by thrombus formation and may involve the central (CRVO), hemi-central (HRVO) or branch (BRVO) retinal vein.

Pathophysiology

Increased venous pressure can cause venous tortuosity, intraretinal haemorrhage, and oedema in the affected region of the retina. Furthermore, as a result of ischaemia, local elevation of growth factors such as vascular endothelial growth factor (VEGF) may cause macular oedema and neovascularisation.

Risk factors

  • Age > 65 years
  • Hypertension
  • Diabetes mellitus
  • Hyperlipidaemia
  • Smoking
  • Glaucoma
  • Hypercoagulability
  • Vasculitis

Presentation

  • Sudden, painless, unilateral loss of vision
    • BRVO present with vision loss in one quadrant
    • CRVO presents with visual loss in the whole visual field
    • HRVO presents with visual loss in either the superior or inferior hemisphere
  • Relative afferent pupillary defect

Fundoscopy findings

  • Venous tortuosity and dilatation
  • Intraretinal haemorrhages
  • Cotton wool spots
  • Optic disc oedema
  • 'Stormy Sunset' appearance
  • In CRVO - all four quadrants of retinal tissue are affected
  • In BRVO - features only present in one retinal quadrant
  • In HRVO - features only present in superior or inferior retinal hemisphere

Management

Patients should be referred within 24 hours to an on-call ophthalmologist. Management depends on the area and degree of occlusion.

Complications

  • Macular oedema
  • Retinal ischaemia with neovascularisation
    • Vitreous haemorrhage
    • Neovascular glaucoma
    • Tractional retinal detachment

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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