7.4 Summary of Key Points

Table 7.6 Changes in visual acuity during follow-up of hemicentral retinal vein occlusions

Type HCRVO/N Worse (%) Same (%) Better (%)

Data from Hayreh and Hayreh52

N denotes the number in the sample

average for more than 1 year (Table 7.6).52 Using a change of at least two Snellen lines of visual acuity as the threshold for change in visual acuity, it was found that perfusion status had little effect on change in visual acuity. Therefore, because ischemic HCRVOs initially have worse visual acuity, they also end up with worse visual acuity than nonischemic HCRVOs.

Sparse evidence has been published concerning the migration of eyes from visual acuity subgroups at the initial visit to the Þnal visit. In a study of 40 eyes with nonischemic HCRVO and macular edema followed until macular edema resolved, 6% (2/32) of eyes with 20/60 or better visual acuity worsened.58 Fifty percent (4/8) of eyes with 20/70 or worse visual acuity at baseline improved.56 In a study of 10 eyes with ischemic HCRVO followed for 9Ð15 months, 25% (1/4) of eyes with 20/60 or better visual acuity worsened.52 Sixty percent (3/5) of eyes with 20/70 or worse visual acuity at baseline improved after 9Ð15 months follow-up.58

Little information concerning HCRVO has been published from population-based studies,

probably because HCRVO is the least common type of RVO. In an exception, one-third of patients with HCRVO in the Blue Mountains Eye Study had visual acuity less than or equal to 20/200.96 Presumably, most of these patients would be in the stable, later stages of the condition.

The small number of patients with HCRVOs handicaps the study of associations of visual outcomes with factors of interest. However, two studies by the same group reported that development of disc collaterals was not associated with Þnal visual acuity outcome.52,58

7.4 Summary of Key Points

¥Symptomatic RVO causes painless blurred visual acuity and a relative scotoma.

¥Peripheral BRVOs and mild CRVOs, mild macular BRVOs, and mild HCRVOs can be asymptomatic.

¥The average initial visual acuity is better in BRVO than CRVO.

¥The acute fundus picture of BRVO features a wedge-shaped region of the retina with dilated veins and intraretinal hemorrhages. The wedge points toward an arteriovenous crossing where the thrombus is found. Other clinical signs are variable and evolve over time.

¥The acute fundus picture of CRVO features dilated veins and intraretinal hemorrhages in

all quadrants of the retina. Other clinical signs are variable and evolve over time.

¥Proportions of RVO that are ischemic vary according to the deÞnition of ischemia, which varies widely, and time after the RVO. Conversion of nonischemic to ischemic RVO occurs for all types of RVO at rates that, again, depend on the deÞnition of ischemia.

¥Using a deÞnition of ischemia based on ßuorescein angiography, up to 34% of nonischemic CRVOs convert to ischemic CRVOs over 3 years of follow-up. Predicting which nonischemic CRVOs will convert is risky. Therefore, all CRVOs require extended, regular follow-up.

¥Visual acuity in BRVO, on average, improves spontaneously.

¥Visual acuity in CRVO, on average, declines spontaneously.

¥Initial and follow-up visual acuities for all forms of RVO tend to be better for nonischemic than ischemic subtypes.

¥Approximately 42% of untreated BRVOs end with visual acuity of 20/40 or better, and 31% end with visual acuity of 20/200 or worse.

¥Approximately 28% of untreated CRVOs end with visual acuity of 20/30 or better, and 50% end with visual acuity of 20/200 or worse.

¥Untreated macular edema in BRVO eventually resolves in 80% of cases.

¥Untreated macular edema in CRVO persists for more than a year and lasts longer in ischemic than nonischemic cases.

¥In nonischemic CRVO with macular edema, approximately 30% show spontaneous resolution.

¥Optic disc collaterals develop in 30Ð77% of patients with CRVO at a median time of 4Ð15 months. They protect against anterior segment neovascularization, but not against macular edema or loss of visual acuity.

¥In ischemic CRVO, an estimated 23% of eyes will develop NVG over 15 months.

¥The clinical picture of RVO evolves over time with poor predictability, so all patients with RVO need regular follow-up until a stable Þnal state is reached.

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Ancillary testing is important in the diagnosis and management of retinal vein occlusion (RVO). Fluorescein angiography (FA) and electroretinography (ERG) can help determine the ischemic status of central retinal vein occlusion, which inßuences the frequency of follow-up. Optical coherence tomography (OCT) provides a sensitive and objective test over time for the diagnosis of macular edema and is necessary for the treatment of this complication of RVO. Familiarity with ancillary tests and their limitations is therefore necessary for optimal management. All ancillary tests cost money to obtain and interpret. Because Þnancial resources for health care are scarce, ophthalmologists need to judge whether a test adds sufÞcient value to the care of a patient to make obtaining it worthwhile. There is an inherent conßict of interest in fee-for-service systems of health care (e.g., in the United States). The ophthalmologist proÞts by ordering more ancillary tests. Therefore, the topic is not only important to discuss but also sensitive.11

A table of abbreviations that will be used in this chapter follows (Table 8.1). The abbreviations will be spelled out at their Þrst occurrence.

The value of a diagnostic test is determined by its sensitivity, speciÞcity, reproducibility, and cost. The Þrst two characteristics are deÞned by referring to a 2 × 2 table that displays the true health status of the patient compared to

the status as deÞned by the test (Fig. 8.1) (p. 89).46 The implication is that there is a gold standard against which the test can be compared, but in many cases, there is no such standard. Instead, the gold standard may be the consensus of a panel of graders using some other method of assessment. Despite the inelegance of real life, the assumption of a gold standard for diagnosis is useful in understanding the underlying concept. The deÞnitions of these terms follow.

¥Sensitivity Ð a/(a + c) the proportion of truly diseased patients deemed so by the test. Sensitivity is most important in screening for disease because a clinician does not want to say mistakenly that a diseased patient is healthy. Therefore, high sensitivity in a test is desirable.39

¥Specificity Ð d/(b + d) the proportion of truly nondiseased patients deemed so by the test. SpeciÞcity is most important in making a decision about beginning treatment because a clinician does not want to risk side effects caused by treatment based on an erroneously positive test. Therefore, high speciÞcity in a test is desirable.39

Reproducibility is an important characteristic of a test because it gives the clinician an idea of how trustworthy the test result is.9 For example, the grading of ischemia based on interpretation of FA in RVO is poorly reproducible and