The opthalmoscopi findings of acute branch retinal vein occlusion (BRVO) include superficial

hemorrhages, retianal edema, and often cotton-wool spots (nerve fiber layer infarcts) in a sector of
retina drained by the affected vein. Branch retinal vein occlusions most commonly occur at visual
impairment. When the occiusion does not occur at an arteriovenous crossing, the possibility of an
underlying inflammatory condition should be considered. The mean age for patients at the time of
occurrence is in their sixties.

The obstructed vein is dilated tortuous, and with the time the corresponding artery may become
narrowed and shathed. The quadrant most commonly affected is the superotemporal (63%), nasal
occlusions are rarely detected clinically. A variant based on congenital variantion in central vein anatomy
may involve either the superior half of the retina (hemispheric or hemicentral retinal vein occlusion.

The eye disease case-control study identified the following abnormalities as risk factors for the
development of BRAVO.

- history of systemic arterial hypertension

- cardiovascular disease
- increased body mass index at 20 years of age
- history of glaucoma.

Diabetes mellitus was not a major independent risk factor.

Histologic studies suggest that common adventitia binds the artery and the vein together at
arteriovenous crossing and the thickening of the arterial wall compresses the vein, resulting in the
turbulence of flow, endothelial cell demage, and thrombotic occlusion. The thrombus may extend
histologically to the capillary. Secondary arterial narrowing often develops in the area occlusion.

Visual prognosis in BRVO is most closely related to the extent of capillary damage and retinal ischemic.
Fluorescein angiography is used to assess the extent and location of retinal capillary nonperfusion. The
integrity of parafoveal capillaries is an important prognostic factor for visual recovery. Vision may be
reduced in acute cases from macula edema, retinal hemorrhage, or perifoveal retina capillary occlusion.
The hemorrhage resolve over time, and capillary compensation and collateral formaton may permit
restitution of flow with resolution of the edema and improvement in visual function. In other eye,
however, progressive capillary closure may occur.

Extensive retinal ischemia (greater than 5 disc diameters) results in neovascularization from the retina
or optic nerve in approximately 40% of eyes, and 60% of such eyes with develop preretinal bleeding if
laser photocoagulation is not performed. Overall, approximately 50-60% of patients with all types of
BRAVO will maintain visual acuity of 20/40 or better after 1 years.

(Argon laser scatter photocoagulation for preventive of neovascularization and vitreous hemorrhage in
branch vein occlusion, a randomized clinical trial. Branch vein occlusion study group)

Finding eyes with permanent visual loss from bravo include the following

- macula ischemic
- cystoid macular edema
- macular edema with hard lipid exudates
- pigmentary macular disturbance
 - subretinal fibrosis
- epiretinal membrane formation

less commonly, vision is lost from vitreous hemorrhage or tractional and/or rhegmatogenous retinal
detachment, which typically develops following a break in the retinal adjacent to, or underlying, an area
of retinal neovascularization.

Photocoagulation

Photocoagulation therapy BRVO is considered for the 2 major complications, chronic macular edema in
eyes with intact perifoveal retinal capillary perfusion and (2) posterior segment neovascularization. For
eye with macula edema, it is suggested that therapy be delayed for at last 3 month to permit the
maximum spontaneous resolution of the edema and intraretinal blood. Despite the persistence of
macular edema, some eyes will not be candidates for treatment because of permanent structural
alterations caused by central retinal capillary shutdown. Neovascularization of the iris is seen in
approximately 1% of eyes with BRVO. Scatter panretinal laser photocoagulation can be considered in
such instance to prevent the development of neovascular glaucoma.

Photocoagulation for macular edema accompanying BRVO is usually given to eyes with vision falling
20/4-20/200 range if the perifoveal retinal capillary capillaries are intact. It is typically administered with
argon laser and is focused on edematous retina within the arcades drained by the obstructed vein. Areas
of capillary leakage as identified by recent fluorescein angiography are treated with a light grid pattern
using 100-um and 200-um spots. Leaking microvascular abnormalities may be treated directly, but
prominent collateral vessels should be avoids.

Central retinal vein occlusion

Long associated with a characteristic fundus appearance of dilated and tortuous retinal veins, a swollen
optic disc, intraretinal hemorrhage, and retinal edema, CRVO is now classified by 2 ends of spectrum of
disease:

- nonischemic, a milder from sometimes referred to as partial, perfused, or venous stasis

retinopathy.
- Ischemic a from characterized by at least 10 disc area, as demonstrated by fluorescein
angiography, of retinal capillary nonperfusion on a posterior pole view, also known as
nonperfused, complete, or hemorrhagic.
-