Current status of adventitious sheathotomy for BRVO

José Garcia-Arumi, V. Martinez, A.Boixadera (Barcelona)

Purpose: The common adventitial sheath that surrounds the retinal venule and arteriole at the crossing site plays a crucial role in branch retinal vein occlusion (BRVO).
The purpose of this study was to report the surgical recanalization of the occluded vein using a bimanual technique and recombinant tissue plasminogen activator (t-PA).We will also report our experience with intravitreal triamcinolone acetonide as treatment of macular edema in BRVO, employed alone or associated with surgery.
Methods: A prospective nonrandomized study was conducted in 60 patients with BRVO and decreased visual acuity (VA) resulting from macular edema. In 40 of these patients (Group 1), we performed arteriovenous sheathotomy, using a bimanual technique with vascular forceps and scissors, followed by fluid-air exchange and injection of 25 mg of recombinant t-PA over the area of the
occluded vein; in 10 patients, the arteriovenous sheathotomy was followed by intravitreal injection of 8 mg of triamcinolone acetonide (Group 2), and in the last 10 patients (Group 3), 0.1ml containing 4mg of triamcinolone acetonide were injected intravitreally through the temporal pars plana.
Results: Intraoperative sectioning of the common arteriovenous sheath was achieved in all 50 patients.
Thrombus release was observed in 14 cases (28%). Optical coherence tomography showed a decrease of macular thickness in group 1 from 461 to 253?, in group 2 from 534 to 332?, and in group 3 from 570 to 370?. The mean VA increased from 20/150 to 20/50 in group 1 (6 months), from 20/150 to 20/40 in group 2 (6 months), and from 20/200 to 20/60 at 3 months, decreasing to 20/80 at 6 months in group 3.
Conclusions: Surgical venous decompression using bimanual surgery and injection of recombinant t-PA may effectively manage macular edema secondary to BRVO, thus improving anatomic and visual outcomes. The combination of surgery with intravitreal injection of triamcinolone acetonide may increase the effectiveness of the technique.
A randomized, controlled trial, and a larger number of patients are needed to prove the efficacy and safety of this procedure.


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