Are all retinal vein occlusion patients suitable for the treat and extend treatment protocol?

Introduction:

The RCOphth published guidance on retinal vein occlusion (RVO) treatment includes standard treatment for macular oedema (MO) with approved anti-vascular endothelial growth factor agents (anti-VEGFs) or dexamethasone implant and application of retinal laser reserved for development of retinal neovascularisation from recognised severe retinal ischaemia only.

However, in recent years, the anti-VEGF treat and extend (T&E) regimen has been rapidly and widely adopted for patients with many macular/retinal diseases as a way to deal with high service demands.

Our local RVO treatment protocol focuses on eliminating retinal ischaemia, starting with anti-VEGFs loading phase, applied Fluorescein angiogram (FFA) thereafter to guide retinal laser need for every RVO patient. Dexamethasone implant is offered as second-line treatment, reserved for chronic MO without ischaemia (or treated ischaemia).

Although RVO shares the complication of MO with age-related macular degeneration, the former has the potential risks of blindness from vitreous haemorrhage/rubeotic glaucoma (NVG) from rapid retinal neovascularisation.

Therefore, we hypothesise that the T&E regimen based on mainly OCT results (managed by allied professionals) may not be suitable for all RVO patients, as it risks missing detection of severe retinal ischaemia-related complications, and potential unnecessary “over-injections”