Wide-Field Scanning Laser Ophthalmoscope Imaging and Angiography of Central Retinal Vein Occlusion
A 64-year-old man with a longstanding history of arterial hypertension underwent a diagnostic workup for a decrease of vision in his right eye. At the time of presentation, his blood pressure was treated with ramipril 2.5 mg twice per day but still was moderately increased (150/95 mm Hg, measured according to Riva Rocci [RR]). No other medication was taken. Visual acuity of the right eye had decreased from 20/20 to 10/100 overnight, whereas the left eye was unaffected. Clinical examination including ophthalmoscopy suggested a retinal vein occlusion on the right eye.
An Optomap wide-field scanning laser ophthalmoscope (SLO) fundus scan and wide-field angiography were performed for documentation and to investigate retinal perfusion. Optomap wide-field SLO and angiography allow retinal images of up to 200° to be obtained without pupil dilation in 1 scan. Optomap covers a much wider area of the peripheral retina than any other digital instrument for retinal imaging and has proven to be a valuable tool for screening purposes.1,2 The Optomap Panoramic200MA (Optos PLC, Dunfermline, United Kingdom) imaging system provides high-resolution images (3900×3072 pixels/scan; 17 to 21 pixels/degree), and when the specific viewing software that enables the user to zoom in on any detail of the scan is used, even small peripheral and central lesions of the retina can be assessed.1,2
The wide-field SLO scan of the right eye showed a fully developed central retinal vein occlusion (CRVO) with a swollen optic disc, widespread retinal hemorrhages in all 4 quadrants, and marked dilated and tortuous retinal vessels (Figure 1). The diagnosis was confirmed by wide-field angiography in which a delayed retinal vascular filling, a marked increased retinal arteriovenous transit time (early phase), papillary exudation, and widespread venous leakage could be seen (late phase; Figure 2). The wide-field SLO scan and angiography of the left eye did not show significant abnormalities (Figures 3 and 4⇓).
In general, the visual prognosis of CRVO is poor, especially in cases in which more than 10 disc areas of retinal capillary nonperfusion can be detected in angiography and when visual acuity is poor at presentation (<20/200).3 Retinal vein occlusion can be considered an ischemic event that affects the central nervous system, or at least a structure derived from the central nervous system. It is the second most common retinal vascular disease after diabetic retinopathy and a frequent cause of visual loss. The prevalence of CRVO is reported to be in the range of 0.6% to 1.6%, with an incidence rate of 2.14/1000 people in those 40 years of age and older.4,5 CRVO is commonly associated with conditions such as hypertension, diabetes mellitus, glaucoma, and a wide variety of hematologic disorders. Therefore, management always should include treatment of associated general disease.3
Patients with CRVO report difficulty with many aspects of daily life and have a decreased vision-related quality of life.6 A major complication of CRVO is macular edema that results in loss of central vision. Two thirds of eyes with ischemic CRVO may develop iris neovascularization or angle neovascularization and subsequent neovascular glaucoma.3 In most cases, after panretinal laser photocoagulation, regression of neovascularization occurs, and the risk for neovascular glaucoma can be reduced to 1%.5 Therefore, if anterior-segment neovascularization is detected, panretinal laser photocoagulation should be performed promptly.5 Focal laser photocoagulation and/or intravitreal antivascular endothelial growth factor treatment may be helpful to improve vision.5 Current data indicate that early intravitreal antivascular endothelial growth factor treatment can lead to significant and sustainable improvement in visual acuity and a reduced risk of neovascular complications.7
The authors thank Stefanie Guthmann for excellent technical assistance.