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Michel Paques, Alexandra Pierru, Jean-François Girmens; Clinical patterns of perfused central retinal vein occlusion: the initial presence of perivenular whitening shifts the balance between disc and macular edema. Invest. Ophthalmol. Vis. Sci. 2014;55(13):1079.
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The highly heterogeneous presentations of central retinal vein occlusion (CRVO) has yet defied clinical modelling; this impairs the determination of an individual prognosis. We previously identified a peculiar presentation of acute CRVO defined by the presence of perivenular whitening (PVW), a feature most likely due to panretinal hypoperfusion (Paques and Gaudric, 2003). We then identified the inner nuclear layer as the anatomical site of PVW, which later on undergoes atrophy (Sarda et al, 2010). Subsequently, we found a high rate of disc edema in these patients which prompted us to further investigate the prognostic value of the initial presence of PVW on the anatomical outcome of CRVO.
The charts of 130 cases of recent-onset perfused CRVO with at least 3 months of follow-up seen in two centers were reviewed. The anatomical outcomes of those with (n=45) or without (n=85) evidence of PVW at inital examination were compared.
In groups with and without PVW, mean age (48.9y vs 53.2y) were similar while there were more women in the group with PVW (58% versus 31%, p<0.05). Patients with PVW had a higher incidence of glaucoma (22% versus 11%) but a lower incidence of arterial hypertension (32% versus 66%). During follow-up, spotty or diffuse atrophy of the inner nuclear layer was exclusively observed in the PVW group. The incidence and topography of macular thickening differed between groups: eye with initial PVW developing macular thickening had more often fluorescein leakage from the disc (80%) than from the macula (15%); Accordingly, macular thickening predominated nasal to the fovea. By contrast, eyes without PVW were more prone to show leakage in the macula (77%) versus the disc (69%). Rates of rubeosis iridis were comparable.
Our findings suggest that, during perfused CRVO, the initial presence of PVW predicts to some extent the anatomical course. CRVO showing evidence of PVW are indeed more prone to develop atrophy of the inner nuclear layer and disc edema. The presence of PVW is also correlated with a peculiar profile of risk factors, raising the hypothesis that ocular perfusion pressure, which is lower in eyes with PVW, modulates the clinical presentation. Distinguishing disc from macular edema may be of interest for defining personnalized intravitreal injection regimen.
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