Retinal Occlusion Delays Cataract Surgery

BRVO occurs when blood flows into retina but not out, causing swelling. Eye injections keep it in check.

As a teen, Violet Rice volunteered at a hospital in her hometown of Hagerstown, Maryland. That and the fact that her mother and several friends’ mothers were nurses led her to pursue that field.

Injections of EYLEA have Violet seeing 20/20 in her left eye.

During a nearly 30-year career, Violet served in several nursing capacities, including instructor, administrator and at the bedside.

“I liked working on the staff,” Violet shares. “I worked in a variety of specialty areas, including the operating room, emergency room, medical-surgical unit and rehabilitation unit. I can’t say that I had a favorite area because I liked them all.”

The majority of Violet’s career was in Maryland, with one notable exception.

“I was recruited to be director of nursing for a rehabilitation center in the Kingdom of Saudi Arabia. It was a two-year contract,” she reveals.

“I wouldn’t do it again. They have restrictions as far as women are concerned, and things have gotten quite unsafe over there. I would never go back.”

Violet, 81, retired in 1991 and relocated to Florida in 2015. Following her move, she began having trouble with blurry vision, halos around lights and difficulty seeing at night. Her eye doctor diagnosed her with cataracts and recommended surgery to remove them.

Cataracts are a clouding of the lens that develops from a breakdown of fibers or a clumping of proteins. They are removed surgically through an outpatient procedure typically performed on one eye at a time, with a week or two in between. During each surgery, the affected lens is removed and replaced with a synthetic lens.

Violet’s cataract surgery was delayed, however, by a complication in one eye.

“When I went for my presurgical examination, the doctor discovered inflammation in the retina of my left eye,” Violet elaborates. “He said that would have to be assessed before I could undergo cataract surgery.”

Violet was diagnosed with a retinal vein occlusion and referred to Thomas A. Barnard, MD, at Florida Retina Institute in Titusville.

Dr. Barnard, a board-certified, fellowship-trained retina specialist, performed a test on Violet’s left eye called optical coherence tomography, or OCT, which produces cross-sectional images of the retina.

“Ms. Rice came to us in May 2016 complaining of blurry vision,” Dr. Barnard recalls. “The OCT revealed swelling in the retina of her left eye. That finding confirmed the diagnosis of a branch retinal vein occlusion, or BRVO.”

Stiff Arteries

A BRVO occurs when a vein in the retina gets pinched off by an artery. Arteries carry oxygen-enriched blood to organs and tissues while the veins carry oxygen-depleted blood back to the heart. In the retina, arteries and veins run side-by-side and crisscross.

“The arteries are stiffer than the veins, so where there’s a crossing point, a vein will sometimes become kinked,” the doctor explains. “That kink prevents the blood that’s flowing into the retina from flowing back out. As a result, blood gets backed up and causes swelling, which leads to blurry vision.”

A BRVO can happen to anyone, Dr. Barnard points out, but there are factors that put an individual at higher risk.

“If a person has high blood pressure, diabetes or high cholesterol, they have a higher chance of developing a BRVO,” he observes. “It’s also more common as people get older because their arteries become stiffer over time. They stiffen even more if the person has high blood pressure or high cholesterol.”

Treatment typically involves injections into the eye of a medication that reduces retinal swelling, thus improving vision. The three FDA-approved medications used at Florida Retina Institute are bevacizumab (brand name AVASTIN®), ranibizumab (LUCENTIS®) and aflibercept (EYLEA®). Sometimes, a steroid medication is used.

During the injection, the eye is numbed with topical anesthetic drops so patients typically feel little to no pain.

“The frequency of the injections depends on how quickly the swelling returns,” Dr. Barnard asserts. “For some people, we perform a few injections and the swelling stays away. In others, the swelling keeps coming back so we have to continue adding the medicine. Some people need it monthly. Others need injections every three or four months.”

A BRVO cannot be cured, nor does it resolve on its own or with treatment.

“We cannot get the kink out of the retinal vein,” Dr. Barnard explains. “But after a while, the body grows a new drainage channel, so eventually, the blood starts to flow more normally. The injections don’t fix the blocked vein, they just ease the swelling and, as a result, improve the blurry vision.”

Violet has been receiving EYLEA injections since 2016, and had her cataract procedures at the end of that year. She uses reading glasses but no longer needs glasses for distance.

In some people, a BRVO will settle down and cause less swelling, Dr. Barnard says. However, it’s common for the occlusion to remain symptomatic long term and require ongoing treatment.

“Ms. Rice hasn’t been able to go longer than six weeks between injections before the swelling returns and her vision is affected,” the doctor notes. “With the schedule that we’re following, however, we’ve been able to get the vision in her left eye to 20/20.”

“My Vision Has Improved”

Dr. Barnard regularly monitors Violet’s BRVO using OCT imagery. If swelling is observed, he moves forward with the EYLEA injection into her left eye.

“My vision has improved, and it’s maintaining,” Violet enthuses. “I do have one spot in my left eye that’s sort of a grey spot. But other than that, I’m functioning pretty well.”

Violet has high praise for the retina specialist as well as his staff.

“Dr. Barnard is great,” she raves. “He’s very gentle and considerate. He’s also proficient, competent and knowledgeable. He explains things and takes time to answer any questions. I don’t feel rushed when I’m with him. Trusting the doctor treating my eyes is the top thing on my importance list.

“The staff is very professional and respectful to everyone. They’re friendly and willing to answer questions. Even though they’re busy, they maintain a welcoming and congenial relationship with patients. They carry out their duties in an effective and efficient manner. I highly recommend Florida Retina Institute.”

© FHCN staff article. Photo by Jordan Pysz. mkb
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    • Florida Retina Institute

      Founded by James A. Staman, MD in 1979, Florida Retina Institute has 19 locations throughout Central Florida, North Florida, and Southeast Georgia. They have proudly delivered Excellence in Vitreo-Retinal Diseases and Surgery for 40 years. T... Read More

    • Thomas A. Barnard, MD

      Thomas A. Barnard, MD, is certified by the American Board of Ophthalmology. He earned a Bachelor of Science degree from Stetson University in DeLand and a Doctor of Medicine degree from the University of South Florida in Tampa. After g... Read More