Therapeutics Effects of High Levels of Warfarin(Coumadin®) With Adjunctive Intraocular Triamcinolone(Kenalog®) in Patients Presenting With CRVO: A Pilot Study

Abstract

Purpose: : Central retinal vein occlusion (CRVO) is one of the leading causes of permanent retinal vascular blindness. In this study, the authors investigated the effects of high levels of warfarin (INR ≥ 3.0) in adjunctive therapy with intraocular triamcinolone over a period of 6-8 months in 4 patients presenting with CRVO.

Methods: : In a retrospective, noninterventional study, 4 patients recruited from period from 2003-2007 with CRVO were treated by administration of warfarin(coumadin®) and one time adjunctive intraocular triamcinolone (Kenalog®) over a period of 6-8 months from time of presentation. None of the eyes investigated had prior vascular pathology including diabetic retinopathy or prior laser/surgeries for retinal disease. Patients were observed with serial dilated clinical exam, dilated fundus photographs, fluorescein angiography (FA), Snellen visual acuity (VA), intraocular pressures (IOP) and OCT (optical coherence topography) during the study period. Coumadin levels were maintained in a range (INR 3-4) higher to standard normal levels of coumadin (INR 2-3). Any evidence of macular edema at the time of presentation was treated with a one time injection of 0.1 cc of 4 mg of Kenalog intravitreally from a pars plana approach.

Results: : Clinical improvement was observed in all patients as determined by Snellen VA. Two of the four patients had greater than 6 line visual improvement. 1 patient had visual improvement from 1/200 to 20/400, while one patient had visual improvement of only 2 lines. All the patients except for one were injected with Kenalog at the time of presentation. None of the patients examined developed neovascular glaucoma or early cataract formation by the end of the study period. There were no serious complications in any of the patients from the high levels of coumadin.

Conclusions: : Central retinal vein occlusion is a blinding disease. In this study the authors conclude that high levels of coumadin in adjunctive therapy with intraocular triamcinolone over a period of 6-8 months reduce the vascular insult caused by CRVO.Higher levels of coumadin may be allowing liver fibrinolysins to lyse thrombi found in CRVO.Higher levels of coumadin may be preventing extension of existing thrombi and de novo thrombosis. Visual improvement in all cases as well as visual preservation during the time of the study was noted.

Keywords: vascular occlusion/vascular occlusive disease • edema • retina