First Author: F.Peck UK
Co Author(s): D. Roberts P. Johnstone
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To describe the clinical features of an unusual cause of bilateral Central Retinal Vein Occlusion and to discuss the ophthalmological and medical management of retinal vein occlusions in general.
Ophthalmology Department, Ninewells Teaching Hospital, Dundee, UK
A single case study of a previously fit 66 year old male patient who was referred via their community optometrist with a short history of bilaterally reduced vision. Baseline fundus photographs were taken and an OCT scan was conducted. The patient was subsequently referred for an in depth haematological assessment and systemic management. Serial OCT scans and fundus photographs were taken to chart his progress with correlation to his haematological markers. In addition, radiological investigations and bone marrow aspirates were conducted.
The visual acuity at presentation was reported to be CF bilaterally with pin-hole improvement to 6/18 on the right. Laboratory tests revealed that the cause of the occlusions was his hyperviscous state with a plasma viscosity of 13.65 and a haemoglobin of 67. From a haematological point of view he underwent plasmapheresis and fludarabine therapy once investigations had confirmed his diagnosis. From an ophthalmological point of view he was initially observed to see if he would improve with systemic medical therapy alone and was offered 3 rounds of bilateral Anti-VEGF intravitreal injections when he failed to do so. His visual acuity has subsequently improved to R: 6/6 and L 6/9 and he continues to demonstrate stability in clinic follow up appointments.
Central retinal vein occlusions are thought to occur when a thrombus occludes the outflow of retinal blood at the lamina cribrosa. It may be associated with disc oedema, vessel tortuosity, haemorrhage, cotton wool spots and macula oedema. These occlusions are classified as ischaemic or non ischaemic. In general, the incidence of retinal vein occlusions increases with advancing age and are most commonly seen in patients with risk factors for atherosclerosis. However, other factors causing hyperviscosity or abnormalities of the vessel lumen may also contribute. Optometrists and ophthalmologists are often the first point of contact with patients who have had retinal vein occlusions. The examination and management of these patients often requires a collaborative approach between different specialties, particularly in bilateral cases. There may be underlying medical implications in this diagnosis which need to be addressed. These patients need to be followed up from an ophthalmological point of view to monitor risk of rubeosis and to assess progress.