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30-year-old man was seen in the office on 9/16/2011. He was doing fine with his vision until he had an episode of vision loss in his left eye. He said he pretty much lost total vision there but then it got better. A few days later though it worsened and three days after that his vision got worse and did not improve. He saw an ophthalmologist out in San Diego. I have a note from his previous ophthlamologist documenting his history of a central retinal vein occlusion for which he was first examined on July 28th and his vision then was 4/200. He responded nicely to two Avastin treatments: One on July 20th and the other on August 16th. His vision has been good since, but he was warned that he probably would need further therapy. He does notice for the last four days paracentral scotomata where he has little blind spots in the vision in the left eye. He does have a family history of his father having strokes at a relatively young age of 56 and also may have had a central retinal vein occlusion. The patient has not had any clotting problems. He did have an injury where he was exiting a helicopter in Iraq and he was a little high off the ground. He fell with about 60 pounds of equipment and hurt his back and his hand. He did not have a loss of consciousness but did feel shaken up. His vision in the right eye is excellent. VISUAL ACUITY: Vision OD is 20/20, OS is 20/60. IOP: OD 15, OS 20. He does have about a 10-20 diopter exophoria of his left eye. SLIT LAMP EXAM: Normal with clear lenses. There is no rubeosis in the left eye. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is no posterior vitreous separation. The macula and periphery look healthy. OS: Vertical C/D ratio is 0.1. There is no posterior vitreous separation. The retinal veins are dilated in all four quadrants. There are multiple cotton-wool spots and hemorrhages and there is minimal macular edema. OCT SCAN: The OCT right eye shows an average central foveal thickness of 201 microns with a volume of 7.44 mm³. The left eye has an average central foveal thickness of 226 microns and a volume of 8.51 mm³. PHOTOGRAPHS: Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: The left eye shows good filling of the retinal arteries. He fills his arteries at 10 seconds. His recirculation time, however, is delayed and the veins are not completely full until 25 seconds, which gives him a 15-second recirculation time much higher than the 4 seconds which is normal. He has good perfusion throughout his macula. The foveal avascular zone is a reasonable size and sweeps of the periphery show no evidence of any capillary dropout. There is some obscuration of the retina where the retinal hemorrhages are and the cotton-wool spots. I checked his blood pressure, which was 120/80. IMPRESSION: 1. NONISCHEMIC CENTRAL RETINAL VEIN OCCLUSION WITH MACULAR EDEMA – LEFT EYE 2. RETINAL HEMORRHAGES – LEFT EYE 3. COTTON-WOOL SPOTS – LEFT EYE 4. EXOPHORIA, PROBABLY VISUAL ACUITY RELATED DISCUSSION: I explained to the patient he does have a central retinal vein occlusion in the left eye and there is about 60-70% chance of maintaining good vision with treatment with Avastin. Generally a monthly treatment for six months is reasonable and then after that treatment can be titrated, depending on the situation. The office visit included a 15-minute counseling session during which I reviewed the alternatives, risks, benefits and limitations of various treatment options. I injected the left eye with Avastin (1.25 mg/0.05 ml) today without any complications. I asked him to return for check in one month, sooner should he notice a problem. He has had a lot of blood tests but he has not had neuroimaging though. Given his history of an injury and also the fact that he now has a little bit of an intermittent strabismus problem, I think he should have neuroimaging, checking his brain and orbit for any possible lesions that might be associated with the vein occlusion. He was taking Tylenol daily and I asked him to switch that to aspirin which would actually thin his blood and he can continue the fish oil. I asked him to bring all of his labs when he comes next month. The fact that his father had a stroke at a young age and he has a central retinal vein occlusion, suggests that he probably does have a genetic predisposition and many of those can be tested for. Patients blood tests and MRI scan were normal.

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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots537 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots2025 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots186 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots188 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots195 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots163 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots98 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots124 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots150 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots121 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots91 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots148 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots186 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots152 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots312 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots145 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots235 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots139 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots140 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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Non-Ischemic Central Retinal Vein Occlusion in Young Man (30 years) - Many Cotton Wool Spots1819 views30-year-old man with a history of a central retinal vein occlusion for which he was first examined on 2 months ago and his vision then was 4/200. He responded nicely to two Avastin treatments. OD is 20/20, OS is 20/6000000
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30-year-old man was seen in the office on 9/16/2011. He was doing fine with his vision until he had an episode of vision loss in his left eye. He said he pretty much lost total vision there but then it got better. A few days later though it worsened and three days after that his vision got worse and did not improve. He saw an ophthalmologist out in San Diego. I have a note from his previous ophthlamologist documenting his history of a central retinal vein occlusion for which he was first examined on July 28th and his vision then was 4/200. He responded nicely to two Avastin treatments: One on July 20th and the other on August 16th. His vision has been good since, but he was warned that he probably would need further therapy. He does notice for the last four days paracentral scotomata where he has little blind spots in the vision in the left eye. He does have a family history of his father having strokes at a relatively young age of 56 and also may have had a central retinal vein occlusion. The patient has not had any clotting problems. He did have an injury where he was exiting a helicopter in Iraq and he was a little high off the ground. He fell with about 60 pounds of equipment and hurt his back and his hand. He did not have a loss of consciousness but did feel shaken up. His vision in the right eye is excellent. VISUAL ACUITY: Vision OD is 20/20, OS is 20/60. IOP: OD 15, OS 20. He does have about a 10-20 diopter exophoria of his left eye. SLIT LAMP EXAM: Normal with clear lenses. There is no rubeosis in the left eye. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is no posterior vitreous separation. The macula and periphery look healthy. OS: Vertical C/D ratio is 0.1. There is no posterior vitreous separation. The retinal veins are dilated in all four quadrants. There are multiple cotton-wool spots and hemorrhages and there is minimal macular edema. OCT SCAN: The OCT right eye shows an average central foveal thickness of 201 microns with a volume of 7.44 mm³. The left eye has an average central foveal thickness of 226 microns and a volume of 8.51 mm³. PHOTOGRAPHS: Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: The left eye shows good filling of the retinal arteries. He fills his arteries at 10 seconds. His recirculation time, however, is delayed and the veins are not completely full until 25 seconds, which gives him a 15-second recirculation time much higher than the 4 seconds which is normal. He has good perfusion throughout his macula. The foveal avascular zone is a reasonable size and sweeps of the periphery show no evidence of any capillary dropout. There is some obscuration of the retina where the retinal hemorrhages are and the cotton-wool spots. I checked his blood pressure, which was 120/80. IMPRESSION: 1. NONISCHEMIC CENTRAL RETINAL VEIN OCCLUSION WITH MACULAR EDEMA – LEFT EYE 2. RETINAL HEMORRHAGES – LEFT EYE 3. COTTON-WOOL SPOTS – LEFT EYE 4. EXOPHORIA, PROBABLY VISUAL ACUITY RELATED DISCUSSION: I explained to the patient he does have a central retinal vein occlusion in the left eye and there is about 60-70% chance of maintaining good vision with treatment with Avastin. Generally a monthly treatment for six months is reasonable and then after that treatment can be titrated, depending on the situation. The office visit included a 15-minute counseling session during which I reviewed the alternatives, risks, benefits and limitations of various treatment options. I injected the left eye with Avastin (1.25 mg/0.05 ml) today without any complications. I asked him to return for check in one month, sooner should he notice a problem. He has had a lot of blood tests but he has not had neuroimaging though. Given his history of an injury and also the fact that he now has a little bit of an intermittent strabismus problem, I think he should have neuroimaging, checking his brain and orbit for any possible lesions that might be associated with the vein occlusion. He was taking Tylenol daily and I asked him to switch that to aspirin which would actually thin his blood and he can continue the fish oil. I asked him to bring all of his labs when he comes next month. The fact that his father had a stroke at a young age and he has a central retinal vein occlusion, suggests that he probably does have a genetic predisposition and many of those can be tested for. Patients blood tests and MRI scan were normal.