Ophthalmology
A 76 year old woman presents to the Emergency Department with a 2 hour history of a change to the vision in the right 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
- 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 |
