Visual
Loss and Retinal Vein Occlusion: Have We Lost Sight of the Problem?
Peter
James Glasman, Louis G Clearkin
Peter
James Glasman, St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool,
United Kingdom
Louis
G Clearkin, Depatment of Opthalmology, Wirral
University Teaching Hospital, Wirral, United Kingdom
Correspondence to: Peter James Glasman, St. Paul’s Eye
Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
Email: peter.glasman@doctors.net.uk
Telephone: +44-151-7062000
Received: January 27,
2015
Revised: February 10, 2015
Accepted: February 14, 2015
Published online: June 1, 2015
ABSTRACT
CRVO is a common
cause of sight loss. Treatment modalities such as intravitreal anti-VEGF,
intravitreal steroids and laser do not address the cause of the pathology, but
rather its effects as this letter highlights.
© 2015 ACT. All
rights reserved.
Key words: Retinal vein occlusion; Intravitreal steroid; Anti-vegf;
Thrombolysis
Glasman PJ, Clearkin LG. Visual Loss and
Retinal Vein Occlusion: Have We Lost Sight of the Problem? International
Journal of Ophthalmic Research 2015; 1(1): 34-35 Available from: URL:
http://www.ghrnet.org/index.php/ijor/article/view/1039
LETTERS TO THE EDITOR
Thrombosis of the central retinal vein causes central retinal vein
occlusion (CRVO)[1]. Current standard treatment modalities,
including intravitreal steroid implant, intravitreal anti-vascular endothelial
growth factor and laser, are directed at the consequences of the CRVO, rather
than the cause itself. Whilst these are useful for treating the effects of
vascular leakage and capillary non-perfusion, clearly it would be preferable to
reverse the root cause of the pathology if possible.
Kohner showed
in 1976[2] that systemic streptokinase was beneficial in CRVO, with
approximately a 3 Snellen line benefit in favour of the treated group. However,
this was balanced against a 15% vitreous haemorrhage rate - at the time an
untreatable and often blinding complication as it pre-dated modern vitrectomy
techniques. The study was also limited by small sample size and wide inclusion
criteria, with patients included despite presenting many days after the onset
of symptoms. Several authors since have considered “primary” intervention by
other methods, including tissue plasminogen activator[3], haemodilution[3],
and low molecular weight heparin[4,5]. Whilst these have shown
promise, they are limited by a lack of standardisation, and in particular a
wide variation in time to treatment, often up to 30 days.
It is tempting to
make an analogy with the recent change in the management of acute stroke.
Whereas management had previously been mainly supportive, the focus is now on
timely (within 4 hours) thrombolysis, often at regional centres. Whilst funding
such a service may be an issue, the current NICE-approved therapies in CRVO,
Lucentis and Ozurdex, are costly at £26,200 and £22,831 per QALY respectively.
The real-world cost is unknown as both licenses are open-ended, therapy is
usually prolonged, and it may be associated with serious complications. We
therefore suggest that Kohner’s idea is worth revisiting.
Abbrevations
NICE: National
Institute for Health and Clinical Excellence, United Kingdom;
QALY: Quality
Adjusted Life Year
CONFLICT OF INTERESTS
The author has no conflicts of interest to declare.
REFERENCES
1 Browning,
David J., and SpringerLink (Online service). Retinal Vein Occlusions:
Evidence-based Management. New York, NY: Springer, 2012
2. Kohner
EM, Pettit JE, Hamilton AM, Bulpitt CJ, Dollery CT. Streptokinase in retinal
vein occlusion: a controlled clinical trial. BMJ 1976 1, 550-553.
3. Hattenbach
LO, Friedrich AC et al. Retinal vein occlusion and low-dose anti-fibrinolytic
therapy: a prospective, randomised controlled multicenter trial of tPA versus hemodilution. Retina 2009; 29 932-940.
4. Faravash
MS et al. Dalteparin in the managment of recent onset central retinal vein
occlusion: a comparison with salicylic acid. Can J Ophthal 2008; 43: 79-83.
5. Ageno W et al. Parnaparin versus
aspirin in the treatment of central retinal vein occlusion. A
randomised, double blind control study. Thromb Res 2010;
125(2), 137-41.
Peer reviewer: Alparslan SAHIN,
Associate Professor, Department of Ophthalmology, Dicle University School of
Medicine, 21280, Sur, Diyarbakir, TURKEY.
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