Retinal Ischemia

Retinal ischemia is an important possible aftereffect of a central

retinal vein occlusion (CRVO). Ischemia is a term used to describe
a tissue whose blood supply has been reduced to an insufficient
level. Lack of oxygen in the retinal tissue may lead to retinal cell
death or cell dysfunction, and thereby, result in reduced vision.
Lets take a minute to look at this condition as it occurs in the
retina.
The retina, of course, is the light sensing tissue that covers the back
inside wall of the eye. To properly function, the retina must have
oxygen, nutrients and a way to dispose of its cellular wastes. These
needs are usually met by two circulation pathways serving the
retina.
Circulation Pathway #1: CRA/CRV
The first pathway, which was
discussed on the home page of
this site, serves the retina from
the inside of the eye. This
pathway involves the central
retinal artery (CRA) bringing
oxygen rich blood along the
center of the optic nerve and
through the back wall of the
eye where the vessel then
branches out to bring oxygen
rich blood to almost all areas of the retina. Likewise, the central
retinal vein (CRV) is part of a similar network of vessels that
facilitates the outflow of blood from the retina.

Circulation Pathway #2: The Choroid

retina is shown in orange.

Underneath
the
retina,
however, is a second pathway
of circulation that supplies
blood to the retina. This
systems primary component is
called the choroid. The choroid
is a network of blood vessels
situated in the wall of the eye
underneath
the
entire
retina. Here, the choroid is
shown in yellow and then the

The
choroid
is
supplied
oxygenated blood through a
number of arteries, shown here in
red, which enter the back wall of
the eye at a distance from the
optic nerve. These arteries are
called posterior ciliary arteries. In
real life, there would be several
more of these arteries extending
into the back wall of the eye.
As these arteries enter the wall of
the eye they branch into the
choroid, the vast network of
vessels underlying the retina.

After the blood has circulated through the capillaries of the choroid,
the oxygen depleted blood flows into small veins that coalesce into
larger veins.
These larger veins exit the eye and are called vortex veins.

So these two circulation pathways supply blood to the retina. The

CRA and CRV supply blood to the retina from the inside of the
eye....
....while the choroid supplies blood to the retina from underneath
the retina.
Inside the Retina
Inside the retina these two pathways work together to nourish the
retinal nerve cells. The retinal vessels bring oxygenated blood down
to the top two layers or retinal nerve cells, while the choroid
nourishes the lowest layer of nerve cells.

During a CRVO, as the CRV becomes obstructed, the backup of

oxygen depleted blood in the retinal veins prevents oxygen rich
blood from freely flowing through the surface layers of the retina
and the retina is at least partially starved for oxygen.
In the second circulation pathway, because the circulation of the
choroid depends on the vortex veins and not the CRV, the blood
supply of the choroid is not interrupted by a CRVO. The choroid
continues to supply oxygen to the retina. Unfortunately, this
circulation is not always enough to prevent areas of oxygen
starvation.
Short interruptions of blood flow from the retinal vessels may have
no lasting consequences. The nerve cells are able to survive. But
longer interruptions of blood supply may set in motion a
progression of cell death. This cell death becomes evident in blind
spots or diminished vision.
Terminology: Ischemic
A tissue that suffers from ischemia is said to be "ischemic." In this
context the term ischemic describes the condition of a tissue. But
the term ischemic is also used to indicate a particular type of
CRVO. CRVO is traditionally classified as ischemic or
nonischemic CRVO. Ischemic in this context refers to a disease
classification.
So with the word ischemic, context is important. Is the word
ischemic being used to describe the condition of a tissue or as a
disease classification? The difference may be important. For
example just because an eye has an area of ischemic tissue does not
necessarily mean that the person has been diagnosed with a case of
ischemic CRVO.

Terminology: Perfusion
A term closely related to ischemia that you may hear is
perfusion. Perfusion has to do more precisely with the flow of a
fluid or the pouring of a fluid. Where blood flows through the
vessels of a tissue, that tissue is said to be perfused. Where there
is a lack of blood flow, the tissue is said to be nonperfused.
Testing for Retinal Ischemia
A test called a fluorescein angiogram is used to look for areas of
nonperfusion in the retina. The total extent of nonperfusion noted
on a fluorescein angiogram is one primary criterion used by many
doctors to classify cases of CRVO as either ischemic (the more
severe form of CRVO) or nonischemic (the less severe form of
CRVO).
Treatments
Many strategies have been employed in attempts to alleviate retinal
ischemia due to CRVO. Unfortunately, these interventions have not
yet been so clearly successful as to be widely adopted by the medical
community. They remain experimental. Indeed, a number of the
experimental procedures have turned out to do more harm than
good. These experimental treatments may have serious
complications and are, to varying degrees, controversial with regard
to safety and/or efficacy:

chorioretinal anastomosis

hemodilution

hyperbaric oxygen

intravitreal injection of tissue plasminogen activator

(t-PA)

low-dose tissue plasminogen activator (t-PA)

optic nerve sheath decompression

radial optic neurotomy

retinal vein injection of tissue plasminogen activator

(t-PA)
CRVO is divided into two types: non-ischemic and ischemic. Nonischemic is the less serious type of central retinal vein occlusion and is
the more common type in the United States. Initially, there may be
little impact on your vision. Ischemic CRVO is more serious, and can
either occur on its own or evolve from non-ischemic. Ischemic CRVO
will usually be accompanied by a serious change in your vision.
The cause of CRVO is the subject of debate. However, the central
retinal vein and arteries share a common vessel or sheath as they exit
the optic nerve. Any compression or damage to this sheath can cause
an occlusion in the vein. Also, a thrombus or clot may form in the
central retinal vein causing the blockage. Such a blockage results in a
backup of blood in the retina, which can lead to the production of the
hormone that stimulates neovascularization. This hormone is called
vascular endothelial growth factor or VEGF, for short. In addition to
stimulating neovascularization, VEGF can also increase leakage in the
capillaries which can lead to macular edema.
In its initial stages, there may be little or no impact on your vision.
However, it is also possible for vision loss to be rapid. As the disease
progresses, your vision will continue to deteriorate without treatment
and you may notice an increasing level of discomfort and redness, if
intraocular pressure rises due to neovascularization.