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Branch Retinal Vein Occlusion

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Last updated: July 6th, 2022

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Summary of Evidence

Treatment of Macular Edema

Intravitreal anti-VEGF injections

Intravitreal ranibizumab provides rapid, effective treatment for macular oedema following BRVO (BRAVO, 2010). {Campochiaro PA, Heier JS, Feiner L, Gray S, Saroj N, Rundle AC, Murahashi WY, Rubio RG; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010 Jun;117(6):1102-1112.e1.}

 

Laser Photocoagulation (Macular laser)

Laser photocoagulation is recommended for macular oedema secondary to BRVO (BVOS, 1984). {Argon laser photocoagulation for macular edema in branch vein occlusion. The Branch Vein Occlusion Study Group. Am J Ophthalmol. 1984 Sep 15;98(3):271-82.}

 

Intravitreal triamcinolone

There was no difference in visual outcomes between laser and intravitreal triamcinolone, but with higher rates of adverse events in the latter (SCORE, 2009). {Scott IU, Ip MS, VanVeldhuisen PC, Oden NL, Blodi BA, Fisher M, Chan CK, Gonzalez VH, Singerman LJ, Tolentino M; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009 Sep;127(9):1115-28.}

Treatment of Neovascularization

Laser panretinal photocoagulation

Peripheral scatter treatment should be applied after the development of neovascularization rather than before the development of neovascularization (BVOS, 1986). {4. Argon laser scatter photocoagulation for prevention of neovascularization and vitreous hemorrhage in branch vein occlusion. A randomized clinical trial. Branch Vein Occlusion Study Group. Arch Ophthalmol. 1986 Jan;104(1):34-41.}

Evidence

1 Background

Review

2018 Khayat et.al.

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2018
Review

Review of ischemic retinal vein occlusion: definition, diagnosis, epidemiology, risk factors and pathogenesis, the structural and functional effects of this disease in the eye and its complications, natural history, and outcomes after treatment. {5. Khayat M, Williams M, Lois N. Ischemic retinal vein occlusion: characterizing the more severe spectrum of retinal vein occlusion. Surv Ophthalmol. 2018 Nov-Dec;63(6):816-850.}

Khayat et.al.
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Review

2014 Chatziralli et.al.

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2014
Review

Review of treatment modalities of branch retinal vein occlusion.{Chatziralli IP, Jaulim A, Peponis VG, Mitropoulos PG, Moschos MM. Branch retinal vein occlusion: treatment modalities: an update of the literature. Semin Ophthalmol. 2014 Mar;29(2):85-107.}

Chatziralli et.al.
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Review

2013 Jaulim et.al.

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2013
Review

Review of branch retinal vein occlusion: epidemiology, pathogenesis, risk factors, clinical features, diagnosis, and complications.{Jaulim A, Ahmed B, Khanam T, Chatziralli IP. Branch retinal vein occlusion: epidemiology, pathogenesis, risk factors, clinical features, diagnosis, and complications. An update of the literature. Retina. 2013 May;33(5):901-10.}

Jaulim et.al.
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1.1 Epidemiology

Meta-analysis

2019 Song et.al.

Article link

2019
Meta-analysis

The prevalence of any RVO, branch RVO (BRVO) and central RVO (CRVO) all increased with advanced age, but didn’t differ significantly between sexes. In 2015, the global prevalence of any RVO, BRVO and CRVO in people aged 30-89 years was 0.77%, 0.64% and 0.13%. For any RVO, the pooled five-year cumulative incidence was 0.86% and the pooled ten-year cumulative incidence was 1.63%. Hypertension was the strongest risk factor for any RVO, with a meta- odds ratio (OR) of 2.82.{Song P, Xu Y, Zha M, Zhang Y, Rudan I. Global epidemiology of retinal vein occlusion: a systematic review and meta-analysis of prevalence, incidence, and risk factors. J Glob Health. 2019 Jun;9(1):010427.}

Song et.al.
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Review

2010 Rogers et.al.

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2010
Review

The age- and sex-standardized prevalence was 5.20 per 1000. Prevalence varied by race/ethnicity and increased with age, but did not differ by gender.{Rogers S, McIntosh RL, Cheung N, Lim L, Wang JJ, Mitchell P, Kowalski JW, Nguyen H, Wong TY; International Eye Disease Consortium. The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia. Ophthalmology. 2010 Feb;117(2):313-9.e1.}

  • Pooled analysis of the prevalence of retinal vein occlusion from studies in the United States, Europe, Asia, and Australia using individual population-based data.

Rogers et.al.
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2 Treatment of Macular Edema

Review

2020 Ang et.al.

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2020
Review

Review of the real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion. Visual and anatomical gains achieved in the real-world for anti-VEGF therapy were not as impressive as seminal RCTs, possibly due to reduced injection frequency in the real world and differences in baseline characteristics.{Ang JL, Ah-Moye S, Kim LN, Nguyen V, Hunt A, Barthelmes D, Gillies MC, Mehta H. A systematic review of real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion. Eye (Lond). 2020 Oct;34(10):1770-1796.}

Ang et.al.
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2.1 Laser Photocoagulation

2.1.1 Argon laser photocoagulation (conventional laser)

2.1.1.1 Laser vs control

Clinical Trial

1984 BVOS Group

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1984
Clinical Trial

Laser photocoagulation is recommended for macular oedema secondary to BRVO.{Argon laser photocoagulation for macular edema in branch vein occlusion. The Branch Vein Occlusion Study Group. Am J Ophthalmol. 1984 Sep 15;98(3):271-82.}

  • Randomized controlled trial of Argon laser photocoagulation vs control in BRVO with Macular oedema (139 patients)
  • Findings (6-months):
    • There were significantly more patients in the laser group with visual acuity gain (of at least two lines of visual acuity from baseline maintained for two consecutive visits) compared to control.

BVOS Group
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2.1.1.2 Laser vs Corticosteroid

Clinical Trial

2009 Scott et.al. (SCORE)

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2009
Clinical Trial

Grid photocoagulation remains the standard of care for macular oedema secondary to BRVO; There was no difference in visual outcomes between laser and intravitreal triamcinolone, but with higher rates of adverse events in the latter.{Scott IU, Ip MS, VanVeldhuisen PC, Oden NL, Blodi BA, Fisher M, Chan CK, Gonzalez VH, Singerman LJ, Tolentino M; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009 Sep;127(9):1115-28.}

  • Randomized controlled trial of Grid laser photocoagulation vs intravitreal triamcinolone in BRVO with Macular oedema (411 patients)
  • Findings (1-year):
Outcomes Laser IVTA 1mg IVTA 4mg
VA gain ≥ 15 letters from baseline 29% 26% 27%

Scott et.al. (SCORE)
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2.1.2 Subthreshold micropulse laser therapy

Review

2020 Eng & Leng

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2020
Review

Subthreshold laser therapy (SLT) is safer and as effective as conventional laser photocoagulation for the treatment of macular edema associated with BRVO. SLT may be used in combination with anti-VEGF intravitreal injections to enhance improvement in visual acuity and macular edema resolution.{Eng VA, Leng T. Subthreshold laser therapy for macular oedema from branch retinal vein occlusion: focused review. Br J Ophthalmol. 2020 Sep;104(9):1184-1189.}

  • Analysis of fourteen studies involving 315-405 eyes diagnosed with BRVO.

Eng & Leng
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2.2 Anti-VEGF

2.2.1 Ranibizumab

Observational study

2020 Pearce et.al. (LUMINOUS)

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2020
Observational study

One year results from the LUMINOUS real-world study showed a clinically meaningful VA improvement with ranibizumab in treatment-naïve patients with BRVO; numerically higher VA gains were achieved in patients who received more injections and those with poor baseline VA. No new safety signals were observed.{Pearce I, Clemens A, Brent MH, Lu L, Gallego-Pinazo R, Minnella AM, Creuzot-Garcher C, Spital G, Sakamoto T, Dunger-Baldauf C, McAllister IL; all the LUMINOUS™ study investigators. Real-world outcomes with ranibizumab in branch retinal vein occlusion: The prospective, global, LUMINOUS study. PLoS One. 2020 Jun 18;15(6):e0234739.}

Pearce et.al. (LUMINOUS)
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Clinical Trial

2020 Wei et.al. (BLOSSOM)

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2020
Clinical Trial

In Asian patients with BRVO, individualized PRN ranibizumab treatment was statistically superior to sham at month 6 and led to early visual gains that were maintained up to 12 months. Results from the sham group indicate the importance of early treatment in achieving optimal visual outcomes in BRVO.{Wei W, Weisberger A, Zhu L, Cheng Y, Liu C; BLOSSOM Study Group. Efficacy and Safety of Ranibizumab in Asian Patients with Branch Retinal Vein Occlusion: Results from the Randomized BLOSSOM Study. Ophthalmol Retina. 2020 Jan;4(1):57-66.}

Wei et.al. (BLOSSOM)
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Clinical Trial

2012 Heier et.al. (HORIZON)

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2012
Clinical Trial

In the extension trial of BRAVO, vision in BRVO patients remained stable with 3 monthly reviews and intravitreal ranibizumab injection PRN.{Heier JS, Campochiaro PA, Yau L, Li Z, Saroj N, Rubio RG, Lai P. Ranibizumab for macular edema due to retinal vein occlusions: long-term follow-up in the HORIZON trial. Ophthalmology. 2012 Apr;119(4):802-9.}

  • Extension study of BRAVO, a randomized controlled trial of intravitreal ranibizumab vs sham in BRVO with Macular oedema (304 patients)
  • Findings (1-year):
    • Vision in BRVO patients remained stable, while CRVO had a decline in vision. This could be due to reduced follow up and fewer ranibizumb injections in the second year of treatment.
BRVO CRVO
Mean no. of injections 2-2.4 2.9-3.8
Change in BCVA score (letter) -2.3 to +0.9 -5.2 to -4.1

Heier et.al. (HORIZON)
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Clinical Trial

2011 Brown et.al. (BRAVO)

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2011
Clinical Trial

Intravitreal ranibizumab PRN from months 6 to 11 maintained benefits achieved by 6 monthly ranibizumab injections in patients with macular oedema following BRVO.{Brown DM, Campochiaro PA, Bhisitkul RB, Ho AC, Gray S, Saroj N, Adamis AP, Rubio RG, Murahashi WY. Sustained benefits from ranibizumab for macular edema following branch retinal vein occlusion: 12-month outcomes of a phase III study. Ophthalmology. 2011 Aug;118(8):1594-602.}

  • Randomized controlled trial of intravitreal ranibizumab vs sham in BRVO with Macular oedema (397 patients)
  • Findings (1-year):
Outcomes Time point RAN 0.3mg RAN 0.5mg Sham (RAN after 6mo)
Mean BCVA change (letter) 6 months +16.6 +18.3 +7.3
12 months +16.4 +18.3 +12.1
Gained ≥15 letters in BCVA 6 months 55.2% 61.1% 28.8%
12 months 56.0% 60.3% 43.9%
BCVA ≥20/40 6 months 67.9% 64.9% 41.7%
Reduction in CFT 6 months 337um 345um 158um

Brown et.al. (BRAVO)
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Clinical Trial

2010 Campochiaro et.al. (BRAVO)

Article link | Archive link | Metrics cited by count

2010
Clinical Trial

Intravitreal ranibizumab provides rapid, effective treatment for macular oedema following BRVO at 6 months.{Campochiaro PA, Heier JS, Feiner L, Gray S, Saroj N, Rundle AC, Murahashi WY, Rubio RG; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010 Jun;117(6):1102-1112.e1.}

  • Randomized controlled trial of intravitreal ranibizumab vs sham in BRVO with Macular oedema (397 patients)
  • Findings (1-year):
Outcomes Time point RAN 0.3mg RAN 0.5mg Sham (RAN after 6mo)
Mean BCVA change (letter) 6 months +16.6 +18.3 +7.3
12 months +16.4 +18.3 +12.1
Gained ≥15 letters in BCVA 6 months 55.2% 61.1% 28.8%
12 months 56.0% 60.3% 43.9%
BCVA ≥20/40 6 months 67.9% 64.9% 41.7%
Reduction in CFT 6 months 337um 345um 58um

Campochiaro et.al. (BRAVO)
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2.3 Intravitreal Triamcinolone

2.3.1 Corticosteroid vs Laser

Clinical Trial

2009 Scott et.al. (SCORE)

Article link | Archive link cited by count

2009
Clinical Trial

Grid photocoagulation remains the standard of care for macular oedema secondary to BRVO; There was no difference in visual outcomes between laser and intravitreal triamcinolone, but with higher rates of adverse events in the latter.{Scott IU, Ip MS, VanVeldhuisen PC, Oden NL, Blodi BA, Fisher M, Chan CK, Gonzalez VH, Singerman LJ, Tolentino M; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009 Sep;127(9):1115-28.}

  • Randomized controlled trial of Grid laser photocoagulation vs intravitreal triamcinolone in BRVO with Macular oedema (411 patients)
  • Findings (1-year):
Outcomes Laser IVTA 1mg IVTA 4mg
VA gain ≥ 15 letters from baseline 29% 26% 27%

Scott et.al. (SCORE)
Journal full text Archive

cited by count

3. Treatment of Neovascularization

3.1 Laser photocoagulation (Sectoral PRP)

Clinical Trial

1986 BVOS Group

Article link | Archive link cited by count

1986
Clinical Trial

Peripheral scatter treatment should be applied after the development of neovascularization rather than before the development of neovascularization.{Argon laser scatter photocoagulation for prevention of neovascularization and vitreous hemorrhage in branch vein occlusion. A randomized clinical trial. Branch Vein Occlusion Study Group. Arch Ophthalmol. 1986 Jan;104(1):34-41.}

  • Randomized controlled trial of PRP vs control in BRVO (401 patients)
  • Findings (4-years):
    • The development of neovascularization and vitreous haemorrhage was significantly less in treated eyes.
    • Data accumulated from this study suggested that peripheral scatter treatment should be applied after the development of neovascularization rather than before the development of neovascularization.

BVOS Group
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References

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