Treatment options for RVO
The major objective of treatment of RVO disorders is a desire to minimise the potential for further eyesight decline. Some patients will experience a significant improvement in eyesight as a result of embarking on some of our treatment pathways but stabilisation of vision remains the goal of any treatment.
We outline the treatment options that we at Bettersight can consider for the following scenarios:
- Treatment options for Macular Oedema
- Treatment options for New Blood Vessel Growth on the Retina
- Treatment options for New Vessel growth on the Iris (Rubeosis)
- Treatment options for Internal Bleeding (Vitreous Haemorrhage)
Treatment options for Macular Oedema
- Argon Laser Treatment
In mild cases of BRVO macular oedema we feel Argon laser photocoagulation of the macular area can in some case be a very effective method of managing macular oedema. When effective it can have a long lasting impact and still remains an active choice in our clinics.
- Anti-VEGF Therapy
As in wet AMD treatment anti vegf therapy has helped to revolutionise the treatment of macular oedema both in BRVO and especially so in CRVO where Laser has not proven to be as effective. At Bettersight we can provide anti vegf therapy either with Lucentis (Ranibizumab) or Avastin (Bevacizumab) depending on the patients circumstances.
We dont feel there is a great deal of difference in the response of the macular oedema with either of these two agents. Both drugs, when given into the eye as an injection, provide a powerful anti-swelling impact that can last for six to eight weeks. The number of injections required to bring the macular oedema under control will vary from case to case but in our experience on average around 4-6 injections will be required in the first year of treatment and 2-4 injections may be required in the second year. At Bettersight we have found that augmentation of the injection programme with argon laser treatment may be able to yield additional clinical effectiveness and help to reduce the overall number of injections required.
At present Lucentis (Ranibizumab) is the only anti-vegf treatment currently approved by NICE and by NHS authorities for use in treating RVO related macular oedema.
- Ozurdex™ Steroid Implant
Ozurdex™ is a tiny implantable device that is injected into the vitreous cavity of the eye where it slowly releases a potent steroid drug – Dexamthasone. This is also proven to help control macular oedema with injections normally scheduled every four to six months for a period of up-to two years or more. The major concern with steroid release devices such as this is the significant risk of developing a rise in the eye pressure that may require additional treatment.
A further additional side effect is the significantly higher chance of developing a cataract requiring cataract surgery. Ozurdex has received approval from NICE and NHS authorities for its use in the NHS for managing RVO macular oedema.
Treatment options for New Blood Vessel Growth in the Retina
- Argon Laser Pan Retinal Laser Photocoagulation
Its generally accepted that for the onset of retinal new blood vessel formation, argon laser treatment with delivery of laser treatment across a wide area of the retina remains a first line treatment. At Bettersight we have found this treatment to be quite effective. Some patients will require more than one treatment session. Side effects include a possibility of a mild narrowing of the field of vision.
In certain cases anti vegf therapy injections with either Lucentis or Avastin could be considered as a temporary means of reducing the risk of internal bleeding whilst the impact of a laser treatment programme takes full effect (up-to two months).
- Vitrectomy and Internal Laser
For particularly resistant cases of retinal new vessel formation, a vitrectomy operation together with extensive internal laser treatment can be considered. This is fairly unusual but has been employed successfully in very severe cases -especially when internal bleeding (vitreous haemorrhage) has made it impossible to apply sufficient laser onto the retina.
Treatment options for New Blood Vessel Growth on Iris (Rubeosis)
- Argon Laser Pan Retinal Laser Photocoagulation
For rubeosis the first line of treatment is pan retinal laser photocoagulation. This is a fairly intensive form of argon laser treatment and is often administered on two or even three consecutive occasions over a two to three week period. The aim of treatment is to cause a shrinkage of the new vessels in order to help minimise the risk of severe eye pressure elevation. Argon laser of this type is generally pretty effective if the condition is caught in time.
Sometimes if the rubeosis is seen to be very severe or there may be a delay in getting laser treatment onto the retina – an injection of Lucentis or Avastin anti vegf therapy can help to keep the condition stable whilst arrangements or eye conditions improve enough to allow laser treatment. Its important to note that anti vegf injections will only temporarily halt the progress of rubeosis – ultimately a more permanent treatment is required on the retina to help reduce the “drive” towards rubeosis.
Unfortunately in a small number of cases despite regular assessments the rubeosis may already have progressed to produce the very high eye pressures seen in rubeotic glaucoma. If this has occurred we would normally recommend additional eye pressure lowering treatment in the form a a range of eyedrops as well as oral medication. Such cases would also be liable to benefit from some injections of lucentis or avastin whilst other treatments build up their impact.
A small number of cases of rubeotic glaucoma resulting from iris new vessel formation will require additional surgical treatment (for example trabeculectomy / deep sclerectomy etc) for control of the eye pressure even after fully successful laser treatment has taken place.
- Cyclodiode laser
Unfortunately in some cases despite often heroic efforts the condition of rubeosis and rubeotic glaucoma is so severe that even surgical treatment for control of eye pressure is not sufficient. In such cases a treatment aimed at reducing the production of aqueous fluid in the eye can be considered. A cyclodiode laser device can be used to create this impact which can be very effective at controlling the high and indeed painful eye pressures that can result from rubeotic glaucoma.