FA Conference. Lara Rosenwasser Newman, M.D. 10/2/14 University of Louisville Department of Ophthalmology and Visual Sciences

Size: px

Start display at page:

Download "FA Conference. Lara Rosenwasser Newman, M.D. 10/2/14 University of Louisville Department of Ophthalmology and Visual Sciences"

Beryl Brooks
6 years ago
Views:

1 FA Conference Lara Rosenwasser Newman, M.D. 10/2/14 University of Louisville Department of Ophthalmology and Visual Sciences

2 Patient Presentation CC: (sent by optometrist) Blurry/foggy vision HPI: 62 yo WM was sent from optometrist for retinal findings. In retrospect, he remembers getting blurred vision overnight approximately 5-6 months prior.

3 History POHx: hx of Bell s palsy right side in early 1980s PMHx: Hypertension, Hyperlipidemia FAMHx: neg for glaucoma, retinal detachment, or blindness ROS: blurred vision OS MEDS: lisinopril/hctz, sildenafil, Norco ALLERGIES: NKDA

4 Exam 20/20 (plano x 109) 21, 21 VA TP P 20/30 ( x 018) 21, 20 Pt already dilated EOM: full OU/ortho in primary gaze CVF: unable to identify inferonasal OS, otherwise full (15 days after initial presentation; not documented initially)

5 Exam OD OS LIDS/LASHES CONJ CORNEA IRIS PTOSIS OD>OS WNL WNL WNL WNL WNL, no NVI WNL, no NVI LENS 1+NS 1+NS

6 Exam OD OS NERVE C/D 0.1 C/D 0.1 MACULA WNL dot & blot heme & exudates along superotemporal arcade VESSELS WNL cuffing along superotemporal vein, arteriolar attenuation PERIPHERY focal RPE hypertrophy dot/blot heme & exudates outside sup arcade, focal RPE hypertrophy chorioretinal scar inferonasal

7 IR Photos OD OS

8 OCT OD OS

9 Fluorescein Angiogram Arterial phase 0:28:23 Proper filling of retinal arterioles

10 Fluorescein Angiogram Early venous phase 00:31:30 Delayed venous perfusion of superotemporal arcade

11 Fluorescein Angiogram Venous phase Recirculation phase 0:38:10 Beginning venous filling of superotemporal arcade No significant macular ischemia (?ST FAZ) 0:40:98 Completed venous filling of superotemporal arcade with localized non-perfusion and collateralization

12 Fluorescein Angiogram Late phase 01:35:48 Widespread superotemporal non-perfusion with collateralization No macular ischemia

13 Summary 62 yo WM presents sent from optometrist for fundus appearance of BRVO 5-6 months after sudden blurred vision overnight OS. BCVA 20/30 initially, 20/25 15 days later. Represents a chronic superotemporal BRVO with retinal ischemia and vascular collaterlization OS.

14 Branch Retinal Vein Occlusion Turbulence in vein caused by atherosclerosis in crossing artery Thrombus formation at arteriovenous crossing point Varying severity of intraretinal hemorrhage, retinal edema, dilated and tortuous veins, +/- CW spots Most often superotemporal

15 Branch Retinal Vein Occlusion Photo Examples

16 Risk Factors Described by The Eye Disease Case-Control Study Group, 1993 Hypertension Cardiovascular disease Open angle glaucoma High body mass index NOT diabetes mellitus

17 2014 Almost 500,000 enrollees, 2283 with BRVOs Increased hazard of developing BRVO in pts with: HTN alone HTN and metabolic syndrome components DM, HLD DM with END-ORGAN DAMAGE Hx of CVA

18 Branch Retinal Vein Occlusion Grid & Scatter Laser Pars plana vitrectomy Intravitreal Steroids Intravitreal anti-vegf Treatment Options

19 Branch Vein Occlusion Study (BVOS) Started data 1977, published in 1984, 1986 Argon grid laser photocoagulation improved visual outcome significantly in eyes with BRVO with decreased VA to 20/40 20/200 due to macular edema not macular ischemia Scatter argon laser photocoagulation decreased risk of neovascularization from 22% to 12% in eyes with recent BRVO involving at least 5 DD of retinal non-perfusion Scatter laser also decreased risk of vitreous hemorrhage from 60% to 30% in recent BRVO eyes with neovascularization

20 Branch Vein Occlusion Study (BVOS) Vision Outcomes Eyes treated with macular laser more likely to be 20/40 or better at 3 years follow-up Mean VA improved 1.3 ETDRS lines (vs. 0.2 lines) Mean treated VA: 20/30 20/50 Mean untreated VA: 20/70

21 Branch Retinal Vein Occlusion Treatment justification for this patient: No macular ischemia with VA 20/25 Macular edema, mostly temporally with VA 20/25 No neovascularization Therefore observed at this point Any other treatment options recommended?

22 Branch Retinal Vein Occlusion Current Treatment Options Intravitreal steroids: SCORE study (2009) Intravitreal dexamethasone implant: OZURDEX GENEVA study Pars plana vitrectomy for non-resolving VH or for RD

23 Branch Retinal Vein Occlusion SCORE Study Standard Care Vs Corticosteroid for Retinal Vein Occlusion (2009) Intravitreal triamcinolone for treatment of macular edema in BRVO/CRVO BRVO arm: 1 mg vs 4 mg vs grid laser 26%, 27%, 29% respectively gained 3+ lines

24 Branch Retinal Vein Occlusion OZURDEX GENEVA Study (2010) Intravitreal dexamethasone implant for treatment of macular edema in BRVO/CRVO 0.7 mg vs 0.35 mg vs sham 26% vs 19% vs 17% respectively of 15+ letter gain

25 Branch Retinal Vein Occlusion BRAVO Study Branch Retinal Vein Occlusion Study (2010) Ranibizumab to eyes with macular edema 0.5 mg vs 0.3 mg vs sham 61.1%, 55.2%, and 28.8% respectively gained 15+ ETDRS letters at 6 months

26 Branch Retinal Vein Occlusion Prognosis Related to extent of capillary damage and retinal ischemia in macula Can try to assess with FA Integrity of parafoveal capillaries is the important prognostic factor for VA Macular edema, retinal hemorrhage, or perifoveal retinal capillary occlusion can reduce vision 50-60% of pts w/all types of BRVO maintain VA 20/40 or better after 1 year

27 2014 Retrospective chart review looked at what people are doing 885 BRVO pts treated with bevacizumab also looked at CRVO & DME pts Too few ranibizumab-treated pts for meaningful analysis 42% of BRVO pts received additional laser or IVTA therapy Patients treated with bevacizumab were monitored less frequently and received fewer injections than patients in major clinical trials of ranibizumab.

28 References 1. Argon laser scatter photocoagulation for prevention of neovascularization and vitreous hemorrhage in branch vein occlusion. A randomized clinical trial. Branch Vein Occlusion Study Group. Arch Ophthalmol. 1986(1); Campochiaro PA< Heier JS, Feiner L., et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six month primary end point results of a phase III study. Ophthalmology. 2010;117(6): Epub 2010 Apr Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010; 117(6): Epub 2010 Apr Hirashima T, Chihara T, Bun T, Utsumi T, Hirose M, Oh H. Intravitreal bevacizumab alone or combined with macular laser photocoagulation for recurrent or persistent macular edema secondary to branch retinal vein occlusion. J Ophthalmol. 2014;2014: doi: /2014/ Epub 2014 Jul 7. PubMed PMID: ; PubMed Central PMCID: PMC Kiss S, Liu Y, Brown J, Holekamp NM, Almony A, Campbell J, Kowalski JW. Clinical utilization of anti-vascular endothelial growthfactor agents and patient monitoring in retinal vein occlusion and diabetic macular edema. Clin Ophthalmol Aug 26;8: doi: /OPTH.S ecollection PubMed PMID: ; PubMed Central PMCID: PMC Kolar P. Risk factors for central and branch retinal vein occlusion: a meta-analysis of published clinical data. J Ophthalmol. 2014;2014: doi: /2014/ Epub 2014 Jun 9. Review. PubMed PMID: ; PubMed Central PMCID: PMC Newman-Casey PA, Stem M, Talwar N, Musch DC, Besirli CG, Stein JD. Risk factors associated with developing branch retinal vein occlusion among enrollees in a United States managed care plan. Ophthalmology Oct;121(10): doi: /j.ophtha Epub 2014 Jun 20. PubMed PMID: Retina and Vitreous, BSCS pp Risk factors for branch retinal vein occlusion. The Eye Disease Case-Control Study Group. Am J Ophthalmol. 1993;116(3): Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmology. 2009;127(9):

29 THANK YOU

Vascular Disease Ocular Manifestations of Systemic Hypertension

Vascular Disease Ocular Manifestations of Systemic Hypertension Maynard L. Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8 th Street, Suite 1650 Bellevue, WA 98004 USA 425-462-7664 Cerebrovascular