Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Retinal Vein Occlusion

Retinal vein occlusion (RVO) is the second most common retinal vascular disorder, affecting an estimated 28.06 million people aged 30-89 years worldwide in 2015 [S5]. Vision is lost mainly through macular oedema [S7] [S9], and intravitreal anti-VEGF is the recommended first-line treatment [S6] [S9]. RVO is also a marker of cardiovascular risk, including stroke [S10] [S6].

Key points - Hypertension is the strongest risk factor for RVO (odds ratio 2.82) [S5]; RVO patients have a higher risk of stroke (risk ratio 1.38) [S10]. - Anti-VEGF improves vision in macular oedema from both central (CRVO) and branch (BRVO) occlusion (high- to moderate-certainty evidence) [S1] [S7]. - Ranibizumab and bevacizumab gave comparable short-term results in direct comparisons [S12]. - Best outcomes come when intravitreal treatment starts early [S9]; laser is an option where reliable monitoring is not feasible [S6]. - Routine thrombophilia screening is not recommended [S4].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Extensive non-perfusion (ischaemic CRVO). In a small RAVE trial substudy, non-perfusion was profound at baseline and increased in all 12 eyes despite anti-VEGF, by about 8.1% of the perfused retina per year [S2]. The duration of non-perfusion is a crucial prognostic factor requiring timely intervention [S6].
• Uncontrolled vascular risk. RVO raised the risk of both ischaemic (risk ratio 1.37) and haemorrhagic (risk ratio 1.55) stroke [S10].
• Raised intraocular pressure on treatment. Intraocular pressure elevation was more frequent in the anti-VEGF network meta-analysis (odds ratio 1.924) and warrants monitoring [S11]; steroids increased cataract and raised pressure [S7].
• Delay in starting treatment worsens outcomes [S9].

Recognise it: who is at risk

• Global prevalence in people aged 30-89 years was 0.77% for any RVO, 0.64% for BRVO and 0.13% for CRVO; prevalence rises with age and does not differ by sex [S5].
• Hypertension is the strongest risk factor [S5]; cardiovascular disease is common in the elderly with retinal vascular disease [S6].
• Acute leakage produces the hallmark signs of retinal haemorrhage and oedema with marked retinal thickening [S6].
• Persistent macular oedema develops in 60% of eyes with BRVO; untreated, only 14% of eyes with chronic oedema keep 20/40 or better [S3].

Confirm it

• Trials measured central retinal thickness on OCT to assess macular oedema and its response [S7] [S1].
• Fluorescein angiography, and increasingly OCT angiography, evaluate retinal ischaemia and the risk of late complications [S6]. Wide-field angiography showed the extent of non-perfusion in ischaemic CRVO [S2].
• A basic systemic workup is advised to recognise systemic associations [S6]. Systematic thrombophilia screening cannot be recommended (all evidence low quality) [S4].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Check and treat blood pressure and other vascular risk factors; hypertension is the strongest risk factor and stroke risk is raised [S5] [S10].
• Do not order routine thrombophilia tests [S4].
• Refer promptly to an eye clinic: early intravitreal treatment gives the best outcomes [S9].

Tier B (general eye clinic)

1. Macular grid laser for BRVO. In one RCT, grid laser vs observation improved the chance of gaining 10 or more letters at 36 months (risk ratio 1.75, moderate-quality evidence) [S3]. Early or subthreshold laser was not supported [S3]. Laser may have an adjunctive role in BRVO but not in CRVO [S9].
2. Laser where monitoring is not feasible. EURETINA lists destructive laser as an option if reliable monitoring is not feasible (expert guideline) [S6].
3. Bevacizumab. Four RCTs (759 participants) found no significant difference from ranibizumab in visual acuity change at 6 months (mean difference 0.61 letters) [S12]. Doses are not stated in the abstract; follow local formularies.

Tier C (specialist centre)

1. Anti-VEGF for CRVO. Compared with sham, anti-VEGF made a gain of 15 or more letters at 6 months 2.71 times more likely and cut the risk of losing 15 or more letters by 80% (high-quality evidence) [S1].
2. Anti-VEGF for BRVO. Anti-VEGF outperformed sham, macular laser (mean 9.63 letters better at 6 months) and intravitreal steroid (mean 9.15 letters better at 12 months, high-certainty evidence) [S7]. The earlier grid laser review found insufficient evidence of anti-VEGF benefit over laser [S3]; the newer review is more favourable to anti-VEGF [S7].
3. Choice of drug. A 2025 network meta-analysis of 17 RCTs (4,272 eyes) found a pooled gain of 15.14 letters with anti-VEGF and ranked faricimab most effective, with aflibercept, ranibizumab and bevacizumab also beneficial [S11].
4. Steroids. Anti-VEGF is recommended over intravitreal corticosteroid because it is more effective and has fewer ocular adverse events [S9]. Steroids may be considered in patients with systemic cardiovascular risk [S6]; they increase cataract and pressure [S7].
5. Long-term care. RVO is chronic and monitoring should be individualised [S6]. Across 76 data sets, vision improved by 16.1 letters at 5 years with long-term intravitreal treatment [S8]. Surgery is advisable only for very few patients [S6].

Refer when

Pitfalls

• Treating RVO as an eye-only problem: stroke risk is raised [S10].
• Ordering thrombophilia screens routinely [S4].
• Starting treatment late [S9].
• Assuming anti-VEGF stops ischaemia: non-perfusion progressed during treatment in ischaemic CRVO [S2].
• Using macular laser for CRVO oedema [S9].

Evidence notes

• The two Cochrane reviews differ on anti-VEGF vs laser in BRVO: the 2015 review found insufficient evidence [S3]; the 2020 review found anti-VEGF better at 6 months [S7].
• The faricimab ranking comes from a network subgroup analysis, not head-to-head trials [S11]. Evidence on rare systemic events with bevacizumab vs ranibizumab is low to very low certainty [S12].
• The stroke association comes from observational cohorts [S10]; the long-term outcome review mixed randomised and non-randomised data [S8].
• Not covered by these sources: neovascular glaucoma management, PRP for ischaemic RVO, specific drug doses and intervals, and RVO in young patients.

Related articles

• Central Retinal Artery Occlusion: An Ocular Stroke
• Diabetic Macular Oedema
• Sudden painless vision loss: triage

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.