Sudden loss of vision
Management dos and don’ts
CRVO is entirely different than retinal hemorrhage or vitreous hemorrhage. The correct diagnosis must be confirmed by an ophthalmologist, to ensure proper evaluation and management.
Reduce blood pressure
You return to your patient and share your conversation with the consultant. According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, the patient has Stage I hypertension. The goal for treatment is medical management to reduce pressure to below 120/80 mm Hg.3
The patient elects treatment with a beta-blocker rather than a thiazide diuretic; he wishes to avoid monitoring of electrolytes that would be necessary because he often becomes dehydrated on the job. He will have the nurse at his company monitor his blood pressure.
Reduce lipids
Also, according to the National Cholesterol Education Program, this patient meets criteria for treatment of hyperlipidemia.4 He is given dietary instruction, information about lipids, a prescription for a statin as he believes he has already been following a quite restrictive diet for over 4 months.
Use anticoagulant?
Finally, you consult a hematologist about the appropriate evaluation for a hypercoagulable state. Following is her report:
- The retinal vein is anatomically different from other veins, being tightly encased in a sheath with the retinal artery and optic nerve. Disorders of these structures can compress or inflame the vein, leading to thrombosis. Consequently, local factors may play a role in development of retinal vein thrombosis—a systemic disorder is not required for this process to occur. CVRO is seldom associated with an underlying hypercoagulable state.5,6
- The effectiveness of medical intervention is unproven. Acute anticoagulation is associated with retinal hemorrhage and is not recommended. Recurrent retinal venous occlusion in the contralateral eye occurs in approximately 12% of patients within 4 years. Because of the risks of anticoagulation and unproven benefits in CRVO, you both elect to avoid this treatment.
If the patient were to request anticoagulation, therapy should be withheld for 2 to 3 months, the time required for retinal perfusion to stabilize. Antiplatelet agents such as aspirin have no role in preventing recurrent venous thrombosis.
Confirmation of this controversy in treatment was obtained using a literature search. A review article in Eye discussed that while the role of thrombophilia is unclear, the need for a randomized study of anticoagulation in the patient with CRVO is needed.6
Final decisions
After considering your consultant’s suggestions, you realize that finding a prothrombotic state is unlikely and will be not change management. Moreover, medical intervention is unlikely to change the natural history of this condition, and it might lead inadvertently to insurance or employment discrimination. You review the previous complete blood count to make sure you have not missed erythrocytosis or thrombocytosis—both of which have well-defined treatments.
Follow-up monitoring was scheduled by the ophthalmologist and you continue to manage the patient’s hypertension and hyperlipidemia.
This patient had a relatively uncommon condition that necessitated consultation with 2 specialists. After weighing the evidence and likelihood of benefit of unproven therapies for CVRO, the patient elected to manage other clear risk factors for atherosclerotic vascular disease. Management of this patient melds issues of ethics and evidence, with core skills to foster a good doctor-patient relationship.
At the risk of sounding like a bad joke, I’d like to open my commentary with the question:
“Why did this patient go to the family physician?” This patient was seen in an urban setting with ample access to any medical specialist, and he had an insurance plan that allowed open access contact with most, if not all, of the physicians in the community. This patient also knew enough about his illness to know that the final answer or treatment for his presenting problem would likely not be found in the family physician’s office.
The value that the family physician brought to this patient can be described as follows:
Navigator/Coordinator: The family physician was able to help this patient through the maze of medical specialists to find the right physicians to evaluate and treat the presenting problem, and to arrange for ongoing evaluation and management after specialist consultations.
Interpreter/Translator: The family physician was able to take the information provided by the specialist physicians and translate that information into language the patient could understand. This process must occur if the patient is expected to comply with treatment, evaluation and lifestyle change recommendations.
Comprehensive caregiver: While supporting the patient in coping with his vision loss, the family physician used this unfortunate occurrence as motivation to address modifiable risk factors—hypertension, obesity, elevated blood glucose, and elevated lipids. Managing these conditions may not be glamorous, but addressing all facets of a patient’s well being is what we family physicians do best. Caring for patients, not just treating illnesses, is a core value of family medicine.
Imagine this patient’s thought process from his arrival with a loss of vision to his departure with a plan to deal with hypertension, obesity, elevated blood glucose, and elevated lipids, all in the context of his job and family and community life. The holistic management of this patient in the context of his life is the main value added by the family physician for this patient. This management also completely supports the patient’s wish to avoid “another stroke.”
One of my colleagues once asked me: “Wouldn’t you like to be the kind of physician whose patient comes in with a cold and leaves with an order for a mammogram?” Family physicians have the knowledge, skills, and perspective necessary to treat the patient, not just the illness. Let’s keep doing what we do best for our patients.
Paul Paulman, MD
