The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Arteriovenous crossing sheathotomy for branch retinal vein occlusion.

It replaces the previous guidance on Arteriovenous crossing sheathotomy for branch retinal vein occlusion (NICE interventional procedures guidance 72, July 2004).  


Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disease after diabetic retinopathy. It results from a blockage of the part of the circulation that drains blood from the retina.

Symptoms of BRVO include peripheral visual loss, distortion of vision, or 'blind spots'. In some cases spontaneous improvement in vision can occur as the macular oedema (which follows acute occlusion of the vein) resolves.

BRVO typically occurs at arteriovenous crossings, where the artery and vein share a common adventitial sheath. Arteriovenous crossing sheathotomy is commonly used as an adjuvant to pars plana vitrectomy.

In arteriovenous sheathotomy, the overlying artery is separated from the vein with a microvitreoretinal blade. A pars plana vitrectomy is first performed (surgical removal of the vitreous). An incision is then made in the adventitial sheath adjacent to the arteriovenous crossing, and is extended along the membrane that holds the blood vessels in position to the point where they cross. At this point, the blade is used to separate adhesions holding the artery to the vein. The artery is then lifted away from the vein.

Cutting the sheath around the vessels and physically separating them where they cross should improve blood flow through the vein.

Coding and clinical classification codes for this guidance.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)