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Dr. Andrew Rynne

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What causes retinal vein occlusion?

Answered by
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Dr. Dadapeer K

Ophthalmologist

Practicing since :2003

Answered : 5709 Questions

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Posted on Sat, 30 Aug 2014 in Brain and Spine
Question: I got a branch retinal vein occlusion 2 years ago. The cause still remain unknown although I went through a wide array of tests. Also Brain MRI (with contrast) after the occlusion was ok (no signs of lesions or other problems). A three months ago, I got a weird pressure sensation in the back of my head and the next morning I woke up with a strong unsteadiness feeling (like I was heavily drunk) while I got up and started walking. This got slowly better until a week ago, I was hit by another bout of unsteadiness, along with nausea and shortness of breath. I've also had occasional episodes of waking up from a sleep with a feeling like I'm about to choke, along with shaking feeling (perhaps a panic attack?). I'm most concerned of the possibility that I might have some blood flow related problem with my brain stem (did I had a TIA perhaps?) or maybe this is something else. I've also had intermittent ear fullness sensations often in the past 6 months along with vision related issues. What action should I take?Few more things. First of all, after the the retinal vein occlusion a few years ago, I had intermittent headaches that originated from the back of my head every time I bent over to tie my shoes, sneezed or strained myself. I don't get the headaches anymore, but those maneuvers now cause me to get dizzy for a while.

Because of my vision complaints, my eyes have been checked for numerous times and they seem to be perfectly fine (excluding the occlusion of course, which has left me with some blind spots in my right eyes vision). One of my major visual problems is palinopsia, meaning I still see the visual stimulus a few seconds after the object has been removed from my view. For example, if I look at a black coffee cup and then turn gaze on a white wall, I see the black coffee bug on the wall for a few seconds before it vanishes. As far as I know from what I've read, palinopsia is often caused with problems in the back side of the brains (lesions sometimes, sometimes something else), see: http://www.sciencedirect.com/science/article/pii/S0000

In addition to brain stem problems, I've been also reading interesting medical articles about chiari malformation and intracranial pressure, which I feel might have something to do with my case. However, I haven't been diagnosed nor tested for either one.
doctor
Answered by Dr. Dadapeer K 22 hours later
Brief Answer:
Need to rule out afterimages and aura of migraine.

Detailed Answer:
Hello
Welcome to Health care magic.

I reviewed your history.
The cause for branch retinal vein occlusion is emboli or thrombus occluding the vein.
However not all in cases underlying cause or source of thrombus or emboli can be found out.
But we investigate to rule out potential causes which may cause recurrence or cause emboli or thrombus formation which may involve the other arteries or veins like cerebral or cardiac vessels and to prevent stroke or ischemic hear diseases.
That is the reason for prescription of Primaspan.

Coming to the symptoms of unsteadiness... and other stymptoms indicate dizziness probably because of transient ischemic attack or because of migraine. Since you also have vasomotor rhinitis vascular causes needs to be ruled out for your headache.

Coming to your second question regarding palinopsia. Palinopsia is persistence of images even after removal of stimulus. The research done by you regarding palinopsia is right and it is commonly seen in brain stem lesions. It can also be seen with drug abuse. head injuries, epilepsy...

But since you have undergone MRI, also these lesions are unlikely I feel. We need to rule out visual aura associated with migriane and after images.

Hence I advice you not to worry about it. First try to rule out migraine as a cause for it by consulting your physician. If the symptoms persist rule out carotid artery diseases and other vascular causes by MRI. A normal MRI will rule out causes resulting in raise of intracranial pressure, XXXXXXX chiari formation...

Hope I have answered your question and the information is helpful to you.

Thank you
with regards
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Dadapeer K 2 hours later
Thank you for the answer!

Yes, because of the occlusion, they did a whole bunch of testing at the university hospital in my city (this was nearly 2 years ago). These studies included blood clotting tests (normal), thyroid function (near hyperthyroidism, but not over the official limit), brain MRI with contrast (normal), carotid ultrasound, electro- & echocardiogram (normal), lumbar puncture twice (first one showed inflammation, second was normal - during the first test, I was having genital herpes symptoms, so I think that might have caused the first results). I was diagnosed with herpes simplex (type 2 I believe) in 2009. Of course, they also did many eye related exams which gave the diagnosis of branch retinal vein occlusion.

I had follow up visits for 6 months after the occlusion and no problems in that regard.

I've had "ocular migraine" once, that was in 2012, about a month after my occlusion. I saw the usual migraine aura in my left eye's vision (the occlusion happened in my right eye), but got no headache. Palinopsia developed soon after this incident. I haven't had similar migraine attacks since. The palinopsia is persistent, meaning I see like this 24/7. In the morning, it's much more pronounced for the first 5 minutes after waking. It doesn't really bother me that much in bright day light. Dim lighting seems to make it always much more prominent.

My father has a history of ocular migraines as well, so I guess many of these symptoms could be explained by a migraine. It's odd though, that these symptoms are always there (they don't just appear and then vanish).

I'd say my most disturbing symptom at the moment is the actual dizziness / unsteadiness. For some reason, it seems to be worse in the early morning and in the evening. It has been better now for the past few days. A week ago, I feel nauseous right after waking up, along with the drunken feeling when I started moving around my apartment.

In addition to those symptoms mentioned earlier, other things that I get every now and then are

- pain / aching behind my eyes (once this happened in my left eye only for a period of week when I was looking up and right). I haven't had this symptom for a while, it seems to come and go
- Difficulty looking at patterns (as in, my vision gets really distorted if I try to look a pattern like this for example: http://st.depositphotos.com/0000/2066/i/950/depositphotos_0000-Illustration-of-grunge-checker-board-abstract-background..jpg)
- slight tremulousness feeling (especially in hands)
- left ear tinnitus
- aural fullness after exercise (especially if lifting weights) & trouble keeping my ears open on an airplane while descending
- NO real headaches at all, just an occasional pain in the back of my head when bending over, sneezing etc.
- Sometimes I get a temporary hearing loss (usually in my left ear) that lasts for 10 seconds or so. When the hearing returns normal, it comes back with a high pitched tinnitus sound, that also fades away within 10 seconds.
- In addition to the palinopsia, I also have all the usual symptoms that are coined under the term "visual snow" (it's still a very unknown condition, good paper on this -> http://www.ncbi.nlm.nih.gov/pubmed/0000). In this recent study, the researchers found out that with patients who have "visual snow", fMRI shows hypermetabolism in the brains in the area of lingual gyrus. They still don't know what causes this hypermetabolism, but palinopsia seems to be accompanied by the other symptoms in every case so I believe the cause is something similar to the palinopsia itself).

I'm quite sure I might have multiple different issues going on here. It's hard to come up with a one and only problem that would "solve" this case I think?

If the chiari and intracranial pressure would be ruled out (let's say that they are), I'd probably next want to rule out:

- Thyroid issues (I'm thinking hyperthyroidism and thyroid eye disease in particular)
- BVVP or labyrinthitis for the cause of my dizziness (of course it's all possible it's migraine related like you mentioned). I've also read somewhere that the herpes virus could actually cause vestibular neuronitis? Is this true?

I have no history of drug use, nor smoking. I also drink quite rarely and when I do, it's 2-3 beers or similar. I did have a sort of an accident at the gym back in 2011 that could have caused some sort brain / blood flow related problem. I was doing a heavy leg press exercise and could not lift the weights up with my feet, so I had to assist the lift with my hands. After I got the weights back in the rack, I noticed that part of my left eyes vision had a sort of big gray area in it. I could not see through that area. This lasted for 10-15 minutes and then my vision restored. I still wonder if I caused some sort of brain artery malformation issue at that time. I had MRI after the incident and got my eyes checked and all seemed ok. My recent occlusion happened in my right eye, not left as in this early "accident".

That's all I can come up with now about my medical past right now. I'm sure I still forgot something. Hope these clues help to narrow down something.

Also, if it helps, I still have all my scans and blood work results on my computer if you'd like to take a look at some of them.

Thanks for helping! I know this is definitely a "clear call" case. I've been through dozen of different doctors in the past few years and no real diagnosis / explanation for the various symptoms in addition to the occlusion itself has been given.

Cheers!
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Follow up: Dr. Dadapeer K 4 minutes later
I know this is definitely NOT a "clear call" case I meant to say! :)
doctor
Answered by Dr. Dadapeer K 20 minutes later
Brief Answer:
Yes multiple causes are likely.

Detailed Answer:
Hello
Thank you for the follow up question.

I reviewed your detailed description.

You are right in your assessment that most of your symptoms can be explained by ocular migraine.

Your prominent symptom of dizziness needs to be evaluated. The common causes for dizziness are ocular causes like migraine, ENT causes like inner ear disease, Meinier's disease, Labyrinthitis, Benign positional vertigo...
General causes like hypoglycemia, transient ischemia...

Since the complaints are multiple there can be more than one cause. But most of these can be explained by migraine. Hence do consult your physician for treatment and if treatment if the issues decrease then it will avoid further investigations.
If you are in doubt you can undergo radiological investigations like CT or MRI to rule out intracranial problems as a cause for your symptoms.
At the same time you need to continue the blood thinners to prevent recurrence of vascular events like branch retinal vein occlusion.

Hope the information is helpful.

Thank you
With regards
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Dadapeer K 29 minutes later
Thank you! I'll continue by monitoring if my dizziness passes in the next few weeks and if not, I'll get it checked out to find out what could be the issue there.

Cheers and have a great week!
doctor
Answered by Dr. Dadapeer K 45 minutes later
Brief Answer:
Thank you

Detailed Answer:
Hello
Thank you for writing to Health care magic.

Thank you
with regards
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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