1. Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh; sohel_sumon7070@yahoo.com
2. Combined military hospital, Camilla, Bangladesh; shamimara.yeasmin@gmail.com
3. Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh; drmostaknio@gmail.com
4. Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh; ahamedsoheb@gmail.com
5. Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh; shiblynio15@gmail.com

*             Correspondence: sohel_sumon7070@yahoo.com

Keywords: associated risk factors, demographic profile, retinal vein occlusion

1. INTRODUCTION

One prevalent retinal vascular illness that significantly impairs a patient’s quality of life is venous obstructive disease of the retina. RVO primarily affects the retina’s venous blood supply throughout (CRVO) or in a quadrant that is drained by one of the branches (BRVO); it less frequently affects the retina’s superior or inferior halves (HRVO) [1]. The pathogenesis, underlying systemic relationships, typical age of start, clinical history, and management of branch retinal vein obstruction (BRVO) and central retinal vein obstruction (CRVO) are different [2]. Most cases of CRVO are seen in older adults, typically those over 50. Central retinal vein occlusion can be predisposed to by a variety of systemic and local variables that aid in the formation of thrombus, including as hypertension, diabetes mellitus, hyperviscosity, hyperlipidemia, POAG, and hyperopia [3]. Three times as many branch retinal vein occlusions as central retinal vein occlusions occur. Either gender is equally affected, with a 60–70 year old average onset age [4]. At an arterio-venous crossover, where the vein and artery share an adventitial sheath, BRVO nearly always occurs. The majority of BRVOs happen superotemporally, most likely because that is where the greatest number of arteriovenous crossings are located. Systemic hypertension, diabetes, hyperlipidemia, glaucoma, smoking, and age-related atherosclerosis are the most frequent risk factors linked to BRVO.4 Higher levels of plasma homocysteine and antiphospholipid antibodies have been linked to a higher risk of venous occlusion [5-7]. In a cross-sectional observational study [9], the risk factors and demographics of a tertiary care hospital in South India were ascertained. Male patients made up 54% of the patient population, while the majority of the patients (55%) were over 60 years old. Additionally, the study discovered a substantial correlation between RVO and advancing age. One significant ocular risk factor was glaucoma. The most prevalent kind of RVO is BRVO. According to the results of their investigation, RVO is linked to numerous ocular and systemic conditions. By recognising and controlling these risk factors, the visual morbidity can be reduced and a second attack in either eye can be avoided. In a study [10], the prevalence and determinants of retinal vein occlusions (RVOs) in a large German cohort based on population were shown to be age- and sex-specific.  In all, 15010 people between the ages of 35 and 74 made up the study. RVO afflicted men 1.7 times more frequently than it did women. According to the results of their investigation, men were affected by RVO 1.7 times more frequently than women, with a 0.4% frequency in this German community. While BRVO was linked to atrial fibrillation and arterial hypertension, CRVO was connected with older age and a family history of stroke. At the Tilganga Institute of Ophthalmology of Nepal [11], a hospital-based case-control study was carried out to look into the patterns, risk factors, and demographics of RVO in this developing Asian nation.  During the study period, 218 individuals with RVO made their presentation. When compared to the control group, the rates of hypermetropia, primary open angle glaucoma, hypertension, combined diabetes and hypertension, and heart disease were significantly higher in RVO cases. According to their research, actions against these blinding diseases in poor nations that are comparable to Nepal can be informed by the demographics, trends, and risk factors of RVO in that country. Study demographics and risk factors for retinal vein occlusions in patients treated at the retina department of the Ispahani Islamia Eye Institute and Hospital in Dhaka were the focus of the investigation. The demographic traits and risk factors of RVO in the Western population are the subject of numerous studies. It’s possible that the findings of these research don’t accurately reflect the population of Bangladesh. The purpose of this study is to ascertain the demographic profile of RVO patients as well as the common ocular and systemic risk factors for RVO among patients from Bangladesh. We can lessen the severity of the condition and stop RVO from recurring in either eye by recognising and controlling the risk factors.

2. MATERIALS AND METHODS

The investigation, which was a prospective observational cross-sectional study, was carried out from December 1, 2021, to May 31, 2022, in the vitreo-retina department of the Ispahani Eye Institute & Hospital in Farmgate, Dhaka. The study population consisted of patients with retinal vein blockage from the vitreo-retina clinic at Ispahani Islamia Eye Institute and Hospital. The study was carried out with institutional approval for data collection. Every patient party received a thorough explanation of their illnesses and available treatments in an understandable, stable local language. Prior to intervention, the patients, attendees, and parents provided written informed consent. The study didn’t touch on moral or social issues or interfere with patient management. All of the data and documents were kept private. The study included 200 consecutive patients with blockage of the retinal vein. In the study, purposeful sampling was applied. The study included all individuals with retinal vein blockage who had clear media available for assessment. The study excluded patients with additional ocular conditions that pose diagnostic challenges. Study variables included risk factors and demographic characteristics. Interviews for the purpose of selecting the sample, obtaining consent, gathering data, and getting ready for tabulation were all completed. Materials included a slit-lamp biomicroscope, a volk 90D lens, an applanation tonometer, a B-scan, paper, and a pen. Every patient received a thorough ophthalmic examination, which included an assessment of their anterior segment using slitlamp-biomicroscopy, a post-dilated examination of their fundus using indirect ophthalmoscopy, and visual acuity testing. Complete blood counts, ESRs, random blood sugar levels, HbA1c, ECGs, serum lipid profiles, serum creatinines, and additional tests (as needed) such as serum homocysteine levels were all examined. The Statistical Package for Social Sciences, version 23.0 for Windows, was used to conduct the statistical analyses (SPSS Inc., Chicago, Illinois, USA). It was determined what the mean values for continuous variables were. Frequencies and percentages were used to illustrate the quantitative observations. Cross tabulation of categorical variables indicated the use of the Chi Square test. For statistical significance, a probability (p) value of less than 0.05 (p<0.05) was applicable.

3. RESULTS AND DISCUSSION

As seen in Figure 1, the majority of the patients—147, or 73.5%—were diagnosed with BRVO, followed by 44, or 22.0%, with CRVO, and 9 patients, or 4.5%, with HRVO. Table 1 revealed that the age group most commonly afflicted by RVO (33.5%) was 61–70 years old. The majority of the patients with HRVO and BRVO were in the age range of 61–70 years (66.7%) and 36.1%, respectively. Patients with CRVO were primarily in the age range of 41–50 (34.1%). Table 2 revealed that 81 patients (40.5%) were female and 119 patients (59.5%) were male. Of the patients that were male, 25 had CRVO (56.8%), 6 had HRVO (66.7%), and 88 had BRVO (59.9%). Three patients (33.3%) had HRVO, 19 (43.2%) had CRVO, and 40.1% of the female patients had BRVO. According to Table 3, the bulk of the patients, 78 (39.0%), were housewives. Of these, 18 (40.9%) had CRVO, 3 (33.3%) had HRVO, and 57 (33.8%) had BRVO. Some other outcomes are shown. Table 4 revealed that 117 patients, or 58.5% of the total, were from rural areas. Of them, 26 patients (59.1%) had CRVO, 6 patients (66.7%) had HRVO, and 85 patients (57.8%) had BRVO. Table 5 demonstrated that the majority of the patients in the CRVO and BRVO groups were from middle-class families, with 63.6% of CRVO patients and 55.1% of BRVO patients being from this stratum. The majority of HRVO patients (55.6%) belonged to lower socioeconomic classes. According to Table 6, hypertension was the cause of over 50% of RVO cases (p<0.001), and it was considerably more common in BRVO patients (64.6%) compared to CRVO (20.5%) and HRVO patients (44.4%). Compared to CRVO (22.7%) and HRVO (33.3%) patients, BRVO patients had a considerably higher prevalence of diabetes mellitus (DM) at 43.5%. In comparison to CRVO (31.8%) and BRVO (13.6%) patients, dyslipidemia was substantially more common in HRVO patients (88.9%). Patients with HRVO (77.8%) smoked significantly more than those with CRVO (38.6%) and BRVO (27.2%). Compared to CRVO (15.9%) and BRVO (6.8%) patients, the percentage of HRVO patients with glaucoma were significantly greater (33.3%). IHD, short axial length, and hyperomocysteinemia, however, did not substantially correlate with RVO.

Figure 01: Distribution of RVO types (n=200)

Table 01: Age distribution of RVO patients (n-200)

Table 02: Sex distribution of RVO patients (n-200)

 Table 03: Occupational status of RVO patients (n-200)

 Table 04: Residence distribution of RVO patients (n-200)

Table 05: Socioeconomic status of RVO patients (n-200)

Table 06: Risk factors of RVO patients (n-200)

   *S= significant; ns = not significant, P value reached from Chi square test

This prospective observational cross sectional study carried out with an aim to find out the demographic profile and risk factors of patients with retinal vein occlusion. Patients with other ocular diseases that create dilemma in diagnosis were excluded from the study. The results of this study were reviewed and contrasted with those of related earlier publications. Nine patients (4.5%) were diagnosed with HRVO, 44 (22.0%) with CRVO, and the bulk of 147 patients (73.5%) with BRVO. 354 patients (63.6%) and 203 patients (36.4%) with CRVO and BRVO, respectively, were diagnosed in a study [12]. According to a study [13], branch retinal vein occlusion (BRVO) 7 (26%), was less common than central retinal vein occlusion (CRVO) 20 (74%) in terms of prevalence. According to findings from another study [14], the population’s prevalence of RVO, CRVO, BRVO, and HRVO was 0.1%, 0.8%, 0.32%, and 0.40 percent, respectively. In these two trials, the prevalence of BRVO and CRVO was 0.6% vs. 0.5% and 0.2% vs. 0.1%, respectively [15]. The age group most frequently affected by RVO, according to the current study, was 61–70 years old (33.5%). The majority of the patients with HRVO and BRVO were in the age range of 61–70 years (66.7%) and 36.1%, respectively. Patients with CRVO were primarily in the age range of 41–50 (34.1%). 50 to 69 years old was the age group most frequently affected by RVO (60.87%), according to a study [16]. According to a study [17], 36.7% of BRVO and CRVO patients were in the age range of 61–70 years. Elderly people were more likely to have RVO, and the percentage of BRVO cases increased with age in comparison to CRVO cases. According to a different earlier study [18], the mean ages of the two groups were comparable (59.8 years [range: 16-89] for CRVO and 58.2 years [range: 31-97] for BRVO). Furthermore, there were no variations in the age distributions.  Male patients made up 119 (59.5%) of the total in this study, while female patients made up 81 (40.5%). Of the patients that were male, 25 had CRVO (56.8%), 6 had HRVO (66.7%), and 88 had BRVO (59.9%). Three patients (33.3%) had HRVO, 19 (43.2%) had CRVO, and 40.1% of the female patients had BRVO. 44.4% of patients in the CRVO group were female and 55.5% of patients were male. 42.8% of BRVO patients were female and 57.1% of patients were male. Of those, 6456 (49.8%) were women and 6498 (50.2%) were men, according to Ponto et al. 9. A single female participant, belonging to the youngest age group, showed a weighted prevalence of 0.07% for HRVO. RVO afflicted men 1.7 times more frequently than it did women (men’s prevalence of RVO: 0.52% against women’s 0.29%). Thapa and colleagues [10] revealed that out of 127 male patients, 84 patients with BRVO, 3 with BRVO/CRVO, and 40 with CRVO. Overall, women made up 22 (37.3%) of the 59 persons with RVO, 18 (38.3%) of the 47 with BRVO, and four (33.3%) of the 12 with CRVO. A small female preponderance of RVO was seen in a population-based study conducted in Singapore [19], however the difference was not statistically significant. Similar proportions of males and women were found in the CRVO group, according to another study by Lee et al.4; while, the BRVO community had a larger proportion of female patients. Our research therefore aligns with the writings of the aforementioned authors.

The majority of the 78(39.0%) patients in this study were housewives; of these, 18(40.9%) had CRVO, 3(33.3%) had HRVO, and 57(38.8%) had BRVO. A majority of 117 patients, or 58.5%, were from rural areas. Of them, 26 patients (59.1%) had CRVO, 6 patients (66.7%) had HRVO, and 85 patients (57.8%) had BRVO. According to the current study, the majority of the patients in the CRVO and BRVO groups were from middle-class families; 63.6% of CRVO patients and 55.1% of BRVO patients belonged to this stratum. The majority of HRVO patients (55.6%) belonged to lower socioeconomic classes. According to a study [11], the majority of patients in the CRVO and BRVO groups came from middle-class families; specifically, 91.3% of BRVO patients and 83.33% of CRVO patients belonged to this socioeconomic category. In terms of RVO risk factors, this study found that BRVO patients’ (64.6%) hypertension was substantially greater than that of CRVO (20.5%) and HRVO patients (44.4%). Compared to CRVO (22.7%) and HRVO (33.3%) patients, BRVO patients had a considerably higher prevalence of diabetes mellitus (DM) at 43.5%. In comparison to CRVO (31.8%) and BRVO (13.6%) patients, dyslipidemia was substantially more common in HRVO patients (88.9%). Patients with HRVO (77.8%) smoked significantly more than those with CRVO (38.6%) and BRVO (27.2%). Compared to CRVO (15.9%) and BRVO (6.8%) patients, the percentage of HRVO patients with glaucoma was significantly greater (33.3%). IHD, short axial length, and hyperomocysteinemia, however, did not show a significant correlation with RVO. According to a study by Lee et al.(4), both groups had usually high rates of both diabetes mellitus and hypertension. On the other hand, the BRVO group had a greater prevalence of hypertension at baseline (48.2%) than the CRVO group (34.7%, P = 0.002). CRVO patients (20.2%) had a greater baseline prevalence of DM than BRVO patients (9.9%, P = 0.001).  While DM may be linked to the development of CRVO, hypertension may be a more significant contributing factor to the development of BRVO. Diabetes mellitus and hypertension were present in several of our cases; while this was a substantial risk factor for BRVO, it was not for CRVO. Consistent with the findings of Ratz et al.17, diabetes was not a significant risk factor for any type of RVO in the absence of hypertension. Deb and Paul11 found that 24 out of 46 cases, or 52.17% of RVO cases, had hypertension. 55% of BRVO patients and 47% of CRVO patients, respectively, had hypertension. Therefore, in our investigation, individuals with BRVO had a higher incidence of hypertension than patients with CRVO. Quinlan et al. (18) discovered that whilst just 8% of instances in the younger age group, those under 50, had diabetes, 18% of central vein occlusion cases in older patients were linked to the disease. The Deb and Paul11 investigation found that 13 RVO patients, or 28.2%, had diabetes. There were 29% in the CRVO group and 27% in the BRVO group. According to Dodson et al.’s study, the prevalence of hyperlipidemia (28.8%) and hypercholesterolemia (23.7%) was found to be significantly higher in the group with branch retinal vein occlusion than in the group with central vein occlusions (32.2%) and hyperlipidemia (22.5%) than in the control group. Regarding arterial hypertension in participants with CRVO and BRVO, Ponto et al.’s study from 2009 found that, in terms of participants with CRVO vs. BRVO, 1 (8.3%) vs. 5 (10.6%), 2 (16.7%) vs. 14 (29.8%), and 6 (50%) vs. 18 (38.3%) had uncontrolled/insufficiently treated hypertension, well-controlled arterial hypertension, and none at all. Out of the 12 890 participants without RVO, 287 (2.2%) cases of glaucoma were found, whereas three (5.1%) of the 59 individuals with RVO (two BRVO and one CRVO) had glaucoma (P =.139). Thapa et al.10 also reported that BRVO patients had significantly higher rates of hypertension (60%) compared to control patients (16%), and that BRVO patients had significantly higher rates of combined hypertension and diabetes (10.3%) compared to controls (2%). Similarly, CRVO patients’ rates of hypertension (51.7%) were significantly greater than those of controls (16%). Additionally, BRVO patients had a considerably greater rate of cardiac disorders (3.8%) compared to the control group (0.3%). Of the RVO patients, 11.9% had glaucoma, with half of those instances being primary open angle glaucoma (POAG). As a result, our research supports those of the aforementioned authors. This study did not involve a big sample or a multicentered investigation. As a result, multicentered studies with significant sample sizes may be conducted in the future. Participants that were unwilling were excluded from this study.

4. CONCLUSIONS

In conclusion, RVO is a significant cause of visual impairment, with BRVO being more common. The commonest age group affected in RVO was 61-70 years and male are more predisposed to the disease than female. The results of this study show that hyperten­sion and DM were strongly associated with BRVO and dyslipidemia, smoking and glaucoma were more strongly associated with CRVO in patients with RVO. The findings obtained at the initial visit and the ocular imaging data obtained at baseline give us additional information related to visual acuity. The results of this study can be applied to future studies on RVO.

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