A 65-year-old man presents to your clinic with complaints of decreased
vision in the left eye for the past one week. His visual acuity OS is
20/100. There is no afferent pupillary defect. His anterior segment
exam is completely normal. His dilated fundus exam is shown above along
with a corresponding OCT. According to the CRUISE study, which of the
following is the recommended initial treatment?
Retina and Vitreous
Retinal Vascular Diseases
No
U
C
This patient presents with the typical "blood and thunder" fundus appearance of a central retinal vein occlusion (CRVO). This is demonstrated by the diffuse intraretinal hemorrhages, swollen optic nerve, and acutely-decreased vision.
The CRUISE study1, published in 2010, investigated the
effect of intravitreal ranibizumab (0.3 and 0.5 mg doses) versus sham
injection on CRVO-associated macular edema involving the fovea. The
treatment protocol consisted of monthly intravitreal ranibizumab injections for 6 months
followed by a 6-month "observation period" during which all
participants could receive additional injections according to a
pre-specified reinjection protocol.
This pivotal study showed that both ranibizumab dosages were highly effective in improving the vision of patients with CRVO-associated macular edema.
Specifically, at the initial 6-month endpoint, the mean change from
baseline visual acuity (the primary endpoint) was a gain of 12.7 and
14.9 letters in the ranibizumab groups compared to only 0.8 letters in
the sham injection group. The drug groups also showed significant
positive results for other visual parameters (e.g. gain of at least 15
letters) as well as quality-of-life scores.
The same issue of Ophthalmology in which the CRUISE study was published also contained articles for the initial BRAVO2 and Ozudex3
results. Briefly, the BRAVO trial was an analogous trial to CRUISE
which enrolled patients with BRVO-associated macular edema. It showed
similar results to the CRUISE trial. The Ozudex trial (Answer "B")
showed the efficacy of a single dexamethasone intravitreal implant on
macular edema associated with either BRVOs or CRVOs.
1Ranibizumab for Macular Edema following Central Retinal
Vein Occlusion. Six-Month Primary End Point Results of a Phase III
Study. Ophthalmology. 2010;117:1124-1133.
2Ranibizumab for macular edema following branch retinal
vein occlusion: six-month primary end point results of a phase III study
Ophthalmology. 2010;117:1102-1112.
3Randomized, sham-controlled trial of dexamethasone
intravitreal implant in patients with macular edema due to retinal vein
occlusion. Ophthalmology. 2010;117:1134-1146.
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