Traitement des occlusions veineuses rétiniennes

Certains d’entre nous restent souvent peu interventionistes devant une occlusion veineuse rétinienne (en dehors de la photocoagulation en cas d’ischémie rétinienne ou des injections intravitréennes de corticoides en cas d’oedème maculaire…).
Un article vient de paraitre dans Ophthalmology pour illustrer cette attitude, méta-analyse des études parues dans la littérature sur le domaine : non seulement, les études interventionnelles « sérieuses » (=contrôlées) ne sont pas nombreuses, mais surtout ne permettent pas actuellement de proposer grand chose d’autre (autrement dit, avec un fort niveau de preuve) pour les formes centrales. En voilà l’abstract :

TOPIC: To assess the evidence for the effectiveness of interventions to improve visual acuity (VA) and prevent or treat neovascularization secondary to central retinal vein occlusion (CRVO).
CLINICAL RELEVANCE: Central retinal vein occlusion is a common cause of visual morbidity and blindness. Many different interventions have been advocated, but the evidence justifying their use remains unclear.
METHODS/LITERATURE REVIEWED: English and non-English language articles were retrieved using a keyword search of Medline (1966 onwards), Embase, the Cochrane Collaboration, the National Institutes of Health Clinical Trials database, and the Association for Research in Vision and Ophthalmology (2003-2005). This was supplemented by manually searching references of review articles. Two investigators independently identified all randomized clinical trials (RCTs) on interventions in CRVO with more than 3 months’ follow-up.
RESULTS: Of 4133 citations retrieved, 17 RCTs comparing intervention with a control group were identified. There were 4 RCTs on laser photocoagulation. Grid macular laser photocoagulation did not improve VA in CRVO with macular edema. Prophylactic panretinal photocoagulation did not prevent angle and iris neovascularization in ischemic CRVO, but resulted in regression of angle and iris neovascularization and reduced progression to neovascular glaucoma. There were 4 RCTs that reported improvement in VA with inpatient hemodilution, 2 RCTs with no significant improvement, and 1 RCT showing deterioration in VA after outpatient hemodilution. Randomized clinical trials evaluating ticlodipine, troxerutin, and streptokinase showed a limited or no benefit.
CONCLUSIONS: This review found limited level I evidence for any intervention to improve VA in patients with CRVO. Panretinal photocoagulation resulted in regression of neovascularization. Hemodilution may improve vision in some patients, but the data conflict. More robust randomized controlled trials evaluating current treatments for CRVO are needed. The results of ongoing RCTs on intravitreal triamcinolone, anti-vascular endothelial growth factor agents, and chorioretinal anastomosis are awaited with interest.

Référence : Mohamed Q, McIntosh RL, Saw SM, Wong TY. Interventions for central retinal vein occlusion: an evidence-based systematic review. Ophthalmology. 2007 Mar;114(3):507-19, 524.