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Branch Retinal Vein Occlusion (BRVO)

Branch Retinal Vein Occlusion (BRVO) occurs when branches of the retinal vein become blocked, causing blood and fluid to spill out of the vein into the retina. This can lead to macular swelling and vision loss as nerve cells die without blood circulation.

Types​

Branch Retinal Vein Occlusion (BRVO): Blockage in smaller branch veins - more common, better prognosis

Central Retinal Vein Occlusion (CRVO): Blockage in the main central retinal vein - more severe

Ischemic vs Non-Ischemic:

  • Ischemic BRVO: Significant lack of blood flow to the retina, higher risk of complications
  • Non-Ischemic BRVO: Partial blood flow maintained, better prognosis

Causes​

  • Often unknown cause
  • Can occur when disease makes the walls of arteries thicker and harder (arteriosclerosis), putting pressure on a vein
  • Compression at arteriovenous crossing points

Risk Factors​

  • Age: 50 years and older
  • High blood pressure (hypertension)
  • Diabetes
  • Glaucoma
  • Arteriosclerosis (hardening of arteries)
  • Blood clotting disorders (in patients under 40)
  • Smoking
  • Obesity
  • High cholesterol

Symptoms​

Vision Changes:

  • Vision loss or blurry vision in part of field of view
  • May be sudden or gradual
  • Possible sudden complete vision loss

Floaters:

  • Dark spots, lines, or squiggles in vision
  • Caused by blood clumps in the vitreous

Painless: BRVO typically causes no eye pain

Diagnosis​

Eye Examination:

  • Dilated eye exam
  • Visual acuity testing
  • Visual field testing

Imaging Tests:

  • Optical Coherence Tomography (OCT): Scans for retinal swelling and macular edema
  • Fluorescein Angiography: Dye injection to visualize blocked vessels and areas of poor blood flow
  • Fundus Photography: Documents retinal hemorrhages and abnormalities

Additional Tests:

  • Blood sugar testing (diabetes screening)
  • Cholesterol testing
  • Blood pressure measurement
  • Blood clotting disorder testing (for patients under 40)

Treatment​

Primary Goal​

Reduce macular swelling (macular edema) to preserve or restore vision

Treatment Options​

1. Anti-VEGF Injections

  • Most common first-line treatment
  • Medications: Eylea, Lucentis, Avastin, Accentrix (biosimilar)
  • Reduce swelling by blocking vascular endothelial growth factor
  • Require regular repeat treatments (monthly or as needed)
  • Success rate: High for reducing macular edema

2. Focal Laser Treatment (Photocoagulation)

  • Creates tiny burns to areas around the macula
  • Stops fluid leakage from damaged blood vessels
  • May be used in combination with injections
  • Generally performed after waiting 3-6 months for spontaneous improvement

3. Steroid Injections/Implants

  • Used for cases not responding to anti-VEGF therapy
  • Options: Ozurdex (dexamethasone implant), triamcinolone injection
  • Help about one-third of patients
  • Risk: May raise intraocular pressure and blood sugar levels

4. Observation

  • Some cases improve spontaneously without treatment
  • Regular monitoring required

Special Considerations​

For Diabetic Patients:

  • Steroid treatments may spike blood sugar levels
  • Close monitoring of glucose required

For Patients on Blood Thinners:

  • Anti-VEGF injections generally safe with antiplatelet therapy
  • Consult cardiologist before pausing blood thinners
  • Monitor for increased eye redness/bleeding

For Immunosuppressed Patients:

  • Higher risk of endophthalmitis (eye infection)
  • Prophylactic antibiotic eye drops may be prescribed
  • Strict sterile technique during injections

Complications​

Macular Edema:

  • Most common complication
  • Main cause of vision loss in BRVO

Neovascularization:

  • Growth of abnormal new blood vessels
  • Can lead to vitreous hemorrhage or neovascular glaucoma
  • Requires laser treatment (panretinal photocoagulation)

Vitreous Hemorrhage:

  • Bleeding into the gel-like substance filling the eye

Neovascular Glaucoma:

  • Severe form of glaucoma from abnormal vessel growth

Permanent Vision Loss:

  • If macular damage is severe or prolonged

Prognosis​

Vision Outcomes:

  • Most patients see some vision improvement with treatment
  • Some show no improvement but treatment may prevent future loss
  • Best outcomes when treatment starts early

Treatment Duration:

  • Ongoing treatment typically needed
  • Swelling often returns when medication wears off
  • May require injections for months to years

Spontaneous Improvement:

  • Some cases improve without treatment over 6-12 months
  • Better prognosis for non-ischemic BRVO

Prevention​

Lifestyle Modifications:

  • Low-fat diet
  • Regular exercise
  • Maintain ideal weight
  • Don't smoke
  • Control blood pressure
  • Manage diabetes
  • Regular eye examinations (especially for diabetics)

Key Questions to Ask Your Doctor​

About Diagnosis:

  1. "Does the OCT show any macular edema in my eye?"
  2. "Is the blockage ischemic (lacking blood flow) or non-ischemic?"
  3. "What is the current stage of the disease?"

About Treatment:

  1. "Are you recommending Anti-VEGF injections (Eylea, Lucentis, Accentrix) or laser therapy?"
  2. "How many injections will I need over the next few months?"
  3. "What is the success rate for my specific type of BRVO?"
  4. "Can we use a more affordable biosimilar like Avastin or Accentrix instead of Eylea?"

For Patients with Other Conditions:

  1. "I am on blood thinners for my heart stent. Do we need to pause them before the injection?"
  2. "I take immunosuppressants for kidney transplant. Am I at higher risk for eye infection?"
  3. "If steroid treatment is recommended, will it raise my eye pressure or blood sugar?"
  4. "Is laser therapy an option, or are injections the only way to save my vision?"