R&M Solutions

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1 Mohamed Hosny El-Bradey, MD., Assistant Professor of Ophthalmology, Tanta University. Wael El Haig, MD., Professor of Ophthalmology. Zagazeeg University. 1

2 Myopic CNV is considered the most common vision threatening complications occurring in 5-11% in patients with high myopia. Although, fluorescein angiography images visualize the distribution of FA molecules within vessels of fluid filled spaces testing the integrity of the inner and outer retinal barrier, OCT demonstrates the arrangement of different layers, spaces, features within and below the retina. Recently developed spectral-domain OCT (SD-OCT) devices offer improved image resolution of less than 5 µm and dramatically faster acquisition speeds ( to A scan/ second) and provide detailed views of the intraretinal microstructures as well 3-D images of the retina. 2

3 The aim of this study is to evaluate retinal morphologic changes, vitreoretinal interface, and CNV characteristics in myopic patients recently diagnosed with CNV using spectral domain high resolution OCT and to correlate these findings with best corrected visual acuity. From July 2008 to July 2011, 75 eyes of 75 patients recently diagnosed with myopic CNV (less than 12 weeks) were consecutively enrolled in this prospective case series. 3

4 (1) refractive errors of -6 D or more. (2) fundus changes typical of pathological myopia; chorio retinal degeneration, Fuch s spots, lacquer cracks and atrophic patches. (3) fluorescein angiography documentation of CNV. (4) recent patient symptoms (less than 3 months). (1) patients who underwent any previous management for myopic CNV (laser, surgical intervention, or intravitreal injection). (2) eyes with other macular abnormalities (idiopathic CNV, angioid streaks, other 2ry CNV). (3) media opacity that affects the quality of OCT imaging. (4) glaucomatous patients. 4

5 Ophthalmological examination: complete ophthalmological examinations were performed, including visual acuity, Refraction, IOP measurement, and slit-lamp biomicroscopy using 78 D lens. Documentation of CNV by color fundus photography and FA. All the patients underwent imaging using high resolution Spectral domain Cirrus HD-OCT (Cirrus; Carl Zeiss Meditec, Dublin, California) Two protocols have been used for all patients; 5 line raster, and macular cube

6 A 5 line raster scan centered on the fovea (4096 A-scans, scan length 6.0 mm), consisting of five closely spaced lines, was done and only foveal line was used for evaluation. Generates a cube of data through a 6mm square grid by acquiring a series of 128 horizontal scan lines each composed of 512 A-scans. In addition, a high definition crosshair scan is acquired first. Each high-definition scan is composed of 1024 A- scans. 6

7 Globe configuration: (Normal, concave, and convex configuration). Posterior hyaloid: (invesible, partial PVD, total PVD, vitreoschisis). ERM: (Absent, adherent ERM without traction, ERM with traction) CNV characteristics: - Location: (subfoveal or juxtafoveal). - Measurement: CNV max, GLD, CFT, Ret Max. Associated retinal changes: - Retinal edema and its pattern (dry, CME, subsensory, and mixed). - Associated retinal changes (shcisis, hole). - Adjacent chorioretinal atrophy. 7

8 The patient were classified into two groups, group 1 included 27 patients with VA 0.1 and group 2 which included 48 patients with VA 0.1. Both groups were compared to define the significant demographic and OCT characteristics associated with poor vision, VA 0.1. Comparison between proportions was evaluated with chisquare test or Fischer Exact test as appropriate. Student s t test was used to compare continuous variable. Multivariate logistic regression analysis was used to examine the relationship between decreased visual acuity (< 0.1) and other studied parameters. For each variable in the multivariate analysis, the ability to discriminate between patients with a poor vision and patients with better visual acuity was assessed by calculating the area under the receiver operating characteristics curves. This area may vary between 0.5 (no discriminative power) and 1.0 (perfect discrimination). The statistical package used was SPSS version 17 for windows (SPSS Inc, Chicago, IL, USA). A P value of <0.05 was considered significant. 8

9 Data Value M/F 35/40 Age 49.4 ± 13.2 (18-78) Refraction ± 3.9 (7-25) Duration of symptoms 6.75 ± 2.99 (1-12 W) Visual Acuity 0.16 ± 0.15 ( ) CNV max ± (74-681) CNV gld ± ( ) CFT ± 75.8 (52-450) Ret max ± 75.8 ( ) 9

10 55 eyes (73.3%( 10

11 20 Eyes (26.7%) 11

12 9 eyes (12%) 24 eyes (32%) 12

13 18 eyes (24%) 24 eyes (32%) 13

14 13 eyes (17.3%) 14

15 13 eyes (17.3%) 15

16 9 eyes (12%) 16

17 7 eyes (9.3%) 25 eyes (33.3%) 17

18 39 eyes (52%) 2 eyes (2.7%) 35 eyes (46.7%) 1 eye (1.3%) 18

19 Variables Age Refraction CNV max CNV GLD CFT Ret Max Membrane location Subfoveal Juxtafoveal Retinal edema Dry CME Subsensory Mixed Variables Globe configuration Normal Staphyloma Convexity Group 1 (VA 0.1) N= ± ± ± ± ± ±94 24 (88.9%) 3 (11.1%) 3 (11.1%) 8 (29.65) 3 (11.1%) 13 (48.1%) Group 2 (VA 0.1) N= ± ± ± ± ±57 287±56 31 (60.8%) 17 (39.2%) 6 (12.5%) 16 (33.3%) 15 (31.2%) 11 (22.9%) Group 1 (VA 0.1) N= (44.4%) 15 (55.55%) 0 Group 2 (VA 0.1) N=48 27 (56.2%) 20 (41.6%) 1 p value P value Partial PVD 5 (18.5%) 8 (16.7%) 0.83 ERM Absent Adherent With traction 17 (63%) 5 (18.5%) 5 (18.5%) 36 (75%) 8 (16.6%) 4 (8.4%) Retinoschisis 3 (11.1%) 4 (8.3%) Adjacent chorioretinal atrophy 12 (44.4%) 13 (27%) Lamellar hole 1 (3.7%) 1 (2.1%)

20 Variables OR (95% CI) p ROC AUC Age ( ) ( ) Refraction ( ) ( ) CNV gld ( ) (0, ) Ret max ( ) ( ) Spectral domain high resolution OCT gives us valuable information as regards the retinal morphological changes and vitreoretinal interface pathology associated with myopic choroidal neovascular membrane. Age, refraction, CNV gld, and Ret max, were the most independent factors that affected the VA in myopic CNV patients. 20

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