Efficacy and Safety of Adjunctive Therapies in Retinal Vein Occlusion: A Systematic Review and Clinical Synthesis of Laser, Corticosteroids, and Surgery

Objectives The substantial treatment burden of anti-vascular endothelial growth factor (anti-VEGF) monotherapy for retinal vein occlusion (RVO) has driven the investigation of adjunctive laser, corticosteroids, and surgery. This systematic review evaluates the efficacy and safety of these combination therapies compared to anti-VEGF monotherapy. Methods A comprehensive search of databases (2010–2025) identified 46 studies (RCTs and non-randomized studies). Faced with extreme clinical heterogeneity and frequent absence of reported variance data, a quantitative meta-analysis was precluded. A rigorous qualitative synthesis with vote-counting was therefore performed. Primary outcomes were Best-Corrected Visual Acuity (BCVA) and Central Retinal Thickness (CRT); injection burden was a key secondary outcome. Results Anti-VEGF monotherapy was reaffirmed as the visual acuity standard. Adjunctive laser photocoagulation demonstrated no consistent visual benefit, with vote counting revealing more studies favoring monotherapy (4) than combination (2) and high-quality RCTs indicating a signal of potential visual inferiority with laser addition. Steroid adjuncts consistently reduced CRT and injection frequency but failed to provide superior long-term visual acuity compared to monotherapy, highlighting a discordance between anatomical and functional outcomes. In contrast, surgical Laser-Induced Chorioretinal Anastomosis (L-CRA) showed promising visual superiority and significant treatment burden reduction in pilot studies. Conclusion Current evidence does not support the routine use of adjunctive laser for macular edema, restricting its role to neovascularization management. Corticosteroids should be strategically deployed as a "burden management" tool rather than for vision enhancement. Surgical L-CRA emerges as the most promising adjunct, warranting prioritization in definitive multicenter trials as a hemodynamic intervention targeting the underlying venous obstruction.