Retinal vein occlusion
At a glance
Venous obstruction causes retinal haemorrhage and oedema. Distinguish branch from central occlusion and assess ischaemic risk.
CAVE
- Look for an afferent pupillary defect, iris/angle neovascularisation and raised IOP.
Clinical presentation
- Usually painless unilateral blur with sectoral or widespread retinal haemorrhages and venous dilatation.
Diagnosis & investigations
- Classify central, hemi-retinal or branch occlusion; document acuity, RAPD, IOP, iris/angle, haemorrhage distribution and disc/retinal neovascularisation. OCT quantifies oedema; angiography assesses non-perfusion when haemorrhage permits. Marked RAPD and poor vision support significant ischaemia but are not the sole criteria.
- Check blood pressure, glucose/diabetes and cardiovascular risk; coordinate appropriate blood count and other tests with primary care. Thrombophilia/autoimmune work-up is selective for atypical, young, bilateral or otherwise suggestive cases, not a routine panel for every isolated RVO.
Differential diagnosis
- Diabetic retinopathy, ocular ischaemic syndrome, hyperviscosity and retinal arterial disease.
Treatment
- Manage macular oedema and neovascular risk as separate problems. Start indicated treatment promptly; severe baseline visual loss does not automatically exclude a trial of therapy when potentially reversible oedema is present.
- Do not prescribe systemic anticoagulation or antiplatelet treatment solely to treat the ocular occlusion without another indication. Continue medicines required for established systemic indications in coordination with the treating physician.
| Finding | Action | Timing / detail |
|---|---|---|
| Macular oedema with visual impairment | Anti-VEGF or selected dexamethasone implant; consider lens status, glaucoma risk and visit burden | Use OCT and acuity to assess response; treatment does not remove neovascular risk |
| Ischaemic CRVO | Inspect iris and angle, including gonioscopy; maintain a separate surveillance schedule | RCOphth: monthly in the first 6 months for significant ischaemia, then about 3-monthly for a further year |
| New iris/angle neovascularisation | Urgent anti-VEGF as an adjunct and prompt panretinal photocoagulation; address IOP | Do not wait for painful neovascular glaucoma; anti-VEGF alone is not durable retinal ablation |
| BRVO with disc/retinal neovascularisation | Sector photocoagulation to the ischaemic retina | Do not apply routine prophylactic PRP to every vein occlusion without neovascularisation |
Follow-up
- At each visit assess acuity/OCT and anterior segment findings; a dry macula is not evidence that ischaemic surveillance can stop. Anti-VEGF may temporarily suppress neovascular signs. After stopping anti-VEGF in ischaemic CRVO, RCOphth advises close surveillance, typically every 1–2 months for the first year, adjusted to the clinical course.
Risk factors & context
- Assess hypertension, vascular risk and glaucoma.
- Investigate unusual or bilateral presentations selectively; routine thrombophilia screening is not indicated for every patient.
Complications
- Macular oedema, retinal ischaemia, vitreous haemorrhage and neovascular glaucoma.
- Anti-VEGF treatment does not remove the risk of neovascularisation.
When to refer
- Urgent review for pain, iris neovascularisation or pressure rise.
References 1
- Royal College of Ophthalmologists · Retinal vein occlusion guideline: executive summary ↗2022 · Macular oedema; ischaemic CRVO; iris/angle neovascularisation; follow-up after anti-VEGF cessation
UK guidance: referral pathways and funding criteria may differ elsewhere.