CASE 1: CRVO

The patient in Figure 1 presented to me with widespread hemorrhaging and a swollen optic nerve. All these features are consistent with CRVO. The patient also had collateral vessels on the surface of the nerve. The patient's visual acuity was 20/250 on the Early Treatment for Diabetic Retinopathy (ETDRS) scale. Fluorescein angiography (FA) showed dilated tortuous veins and a capillary leakage (Figure 2).

Our management options were: A) observation; B) antivascular endothelial growth factor (VEGF) therapy with either bevacizumab (Avastin, Genentech) or ranibizumab (Lucentis, Genentech); or C) steroids, using the intravitreal dexamethasone implant (Ozurdex, Allergan Inc) or triamcinolone acetonide. We think that observation would have no expected visual acuity improvement in this patient, based on past studies such as the Central Retinal Vein Occlusion Study. Anti-VEGF therapy has a high proportion of long-term response, with a marked improvement in visual acuity in treated patients, and it has a very low risk of side effects. Corticosteroids have a relatively poor longterm visual acuity response, and triamcinolone acetonide in particular has a high proportion of side effects, including the potential for glaucoma and cataracts.

For this patient, we chose anti-VEGF therapy with ranibizumab.

By 2 months, at follow-up after monthly injections, the patient's clinical appearance improved (Figure 3). The veins were much less dilated and tortuous, and there was less vascular leakage present on FA (Figure 4). There was remarkable resorption of the intraretinal hemorrhages were remarkable in this patient. In addition, the optic nerve swelling had abated, although the collaterals were still present on the surface of the nerve. The patient's visual acuity improved to 20/80 ETDRS.

At 4 months follow-up, the patient's optic nerve continued to show improvement; however, the collateral vessels remained (Figure 5). There was a continuation of remarkable intraretinal hemorrhage resorption. The patient's visual acuity was 20/50, and has remained stable for 3 years.

CASE 2: CRVO

Another patient with CRVO presented with dilated tortuous veins and intraretinal hemorrhages, and his optic nerve was swollen and erythematous. Visual acuity was 20/200. Note that the central macula in Figure 6A shows cystoid changes in the fovea; this cystoid change, particularly in the center part of the fovea, is more evident in the red-free photograph (Figure 6B).

The FA showed blockage by the intraretinal hemorrhage but demonstrates pronounced amounts of venous dilation and tortuosity (Figure 7A). A later phase FA shows a significant amount of leakage into the retina (Figure 7B).

Management options are: A) observation; B) anti- VEGF therapy; and C) either the intravitreal dexamethasone implant or intravitreal triamcinolone acetonide. Again, based on the experience from the CVOS, we did not expect to see visual acuity improvement with observation for a patient with this level of visual acuity loss. Anti-VEGF therapy, on the other hand, has been shown to have a high proportion of long-term response with a low risk of side effects. For this patient, we chose anti-VEGF therapy using ranibizumab because we thought this treatment had the highest potential for visual acuity improvement and the lowest risk for side effects.

At 2 months, the patient had less venous dilation and tortuosity and the intraretinal hemorrhages are also starting to resorb. The patient did not have any collateral vessels (Figure 8). The FA showed a near cessation of leakage into the retina, and hemorrhages are no longer blocking the background fluorescein (Figure 9). The patient's visual acuity at 2 months had improved to 20/40.

Thirty-eight months after initial presentation, the patient's retina looked almost normal, with no collaterals in the no longer swollen disc. The patient's visual acuity was 20/20. We found it interesting that the blood vessels leading into the disc all appear to be normal. There is no macular edema and no intraretinal hemorrhages (Figure 10). The fellow eye (Figure 11) appeared similar to the treated eye, which on optical coherence tomography (Figure 12), has a normal foveal contour with no increase in thickness.

Richard F. Spaide, MD, is in private practice at Vitreous Macula Retina Consultants of New York in Manhattan and specializes in diseases of the retina and vitreous. He is a member of the Retina Today Editorial Board. Dr. Spaide can be reached at +1 212 861 9797.