Central retinal vein occlusion: workup and follow-up
- Emergency
A blocked central retinal vein floods the retina with blood. Treating macular oedema and catching new vessels saves vision; blood pressure is the usual cause.
See it in 3D: Retina · Optic disc · Macula
What it is
Central retinal vein occlusion is a thrombosis of the main vein of the retina, usually where it passes through the lamina cribrosa. It causes painless blurred vision, often noticed on waking. The fundus shows haemorrhages in all four quadrants, swollen tortuous veins and a swollen disc. It is not treated by unblocking the vein: vision depends on treating macular oedema and preventing neovascular glaucoma, and the patient's systemic risk factors must be found.
How to recognise it
- Painless blurred vision in one eye, often on waking.
- Haemorrhages in all quadrants, dilated veins, cotton-wool spots and disc swelling.
- Poor vision and an afferent pupillary defect suggest the ischaemic type, with a high risk of new vessels.
- Pain and redness weeks later: neovascular glaucoma.
- Age under 50 or no risk factors: look for a clotting or blood disorder.
What to do at once
- Measure acuity, check for an afferent pupillary defect and measure eye pressure.
- Measure blood pressure; the occlusion may be its first sign.
- Order glucose or HbA1c, lipids, blood count, ESR and kidney function.
- In young patients add tests for thrombophilia, antiphospholipid antibodies, homocysteine and hyperviscosity.
- Refer to ophthalmology within days (the same day if vision is very poor or the eye is painful).
Mistakes that cost sight
- Hypertension, diabetes, glaucoma and age are the main risk factors; glaucoma in the other eye must also be looked for.
- Neovascular glaucoma typically appears within the first months ('ninety-day glaucoma'), so early visits are monthly in ischaemic cases.
- Macular oedema is treated with intravitreal anti-VEGF injections or corticosteroid implants; laser to the peripheral retina treats new vessels.
Next step / Initial management
- Ophthalmology within days for imaging (OCT, angiography) and treatment of macular oedema.
- Treat the systemic risk factors: blood pressure, glucose, lipids, smoking; lower the eye pressure if it is raised.
- Follow-up monthly for the first months in the ischaemic type to detect iris or angle new vessels.
- Warn the patient to return at once if the eye becomes painful or red.
Test yourself
Think of the answer, then tap the question to see it.
What does the fundus show in central retinal vein occlusion?
Haemorrhages in all four quadrants, dilated tortuous veins, cotton-wool spots and a swollen disc.
What is the most feared complication of ischaemic CRVO?
Neovascular glaucoma from new vessels on the iris and angle, usually within the first months.
Which extra tests are done in a patient under 50 with CRVO?
Tests for thrombophilia, antiphospholipid antibodies, homocysteine and hyperviscosity.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
In Pharmacology3
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Central Retinal Vein Occlusion (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.