What are the recommended management strategies for a patient with CRVO who presents with significant visual impairment?

For a patient presenting with central retinal vein occlusion (CRVO) and significant visual impairment, the primary management strategies focus on addressing macular oedema, which is a common cause of vision loss in CRVO, and providing comprehensive supportive care ¹,²,³,⁴,⁵. Significant visual impairment can be defined as visual acuity of 6/9 or worse, or 78 ETDRS letters or less ⁴.

• Pharmacological Treatment for Macular Oedema: The main treatments for macular oedema associated with retinal vein occlusion (RVO), including CRVO, are anti-vascular endothelial growth factor (anti-VEGF) therapies and intravitreal steroid implants (Munk et al., 2024). Anti-VEGF drugs, such as ranibizumab, bevacizumab (off-label use), aflibercept, brolucizumab, and faricimab, are first-line therapies for treating and stabilising conditions involving vascular permeability and neovascularisation ²,³,⁴. These are typically administered via intravitreal injection, often starting with a loading phase (e.g., monthly for 3 months), with subsequent injections depending on the patient's response ²,³,⁴. If the response to anti-VEGF treatment is suboptimal after the loading phase, or at 12 months, or if the patient does not wish to continue regular anti-VEGF injections, switching to an intravitreal steroid implant may be considered ⁴. Macular laser treatment can also be considered as an adjuvant therapy if the response to anti-VEGF treatment is suboptimal ⁴.
• Supportive Care and Rehabilitation: Patients with significant visual impairment should be offered access to low vision services ¹,²,³. These services help individuals adapt to their visual difficulties and can provide advice on optical or electronic magnifying lenses, bright lights, and electronic reading aids to optimise existing visual function ²,³. A group-based rehabilitation programme may also promote independent living ²,³. For those with central vision loss, eccentric viewing training can be beneficial ²,³.
• Psychological Support: Visual impairment can lead to psychological problems, such as depression, and support and treatment should be offered where possible ²,³. Patients with visual impairment are at an increased risk of depression ²,³.
• Information and Signposting: Provide practical information and advice, including how to apply eye drops if relevant, the need for regular monitoring, and how to contact eye clinic liaison officers (ECLOs) ⁵. Signpost patients to relevant support organisations, such as The Macular Society (www.macularsociety.org) and the Royal National Institute of Blind People (www.rnib.org.uk), which offer comprehensive information and support ²,³,⁵. Citizens Advice (www.citizensadvice.org.uk) can provide advice on available benefits ²,³. Information regarding the Certificate of Vision Impairment (CVI) and Driver and Vehicle Licensing Agency (DVLA) regulations should also be provided ⁵.
• Management of Comorbidities and Lifestyle Factors: Encourage patients to stop smoking, as this can reduce the risk of progression in existing eye conditions ²,³. Advise a healthy, balanced diet rich in fruits, green leafy vegetables, and omega-3 fatty acids, and modification of cardiovascular risk factors, including lowering cholesterol and saturated fat intake and controlling hypertension ²,³. Optimise care for any other significant comorbidities ²,³.