RETINA. OCT in the Optometric Prac4ce OCT. New stuff 11/7/17 AMD. Disclosure Statement

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1 Disclosure Statement OCT in the Optometric Prac4ce Steven Ferrucci, OD, FAAO Chief, Optometry Sepulveda VA Professor, SCCO/MBKU Speakers bureau/advisory Board Alcon B&L Centervue Genentech MacuLogix Optovue Science Based Health OCT AMD DME ERM/VMT CSR Macula edema from BRVO/CRVO Plaquenil screening Macular Holes Glaucoma New stuff More scans Up to 70K Widefield 12x9 mm vs. standard 6x6 mm OCT angiography Anterior segment Angles Pachymetry Epithelial mapping RETINA AMD 1

2 Dry AMD Widefield 83 yo male Followed >13 years for dry AMD VA 20/25 OU since 2013 AREDS 2 BID: reports good compliance Notes vision has go]en blurrier Metamorphosia OU x 2 mos Assessment/plan DRY AMD OS>OD Stage 3 OU Mul4ple confluent drusen OU No fluid on OCT Con4nue AREDS 2 BID HAG RTC 3 mos for repeat OCT Wet AMD 81 year old male h/o POAG for years T ½ and Latanaprost h/o dry AMD OU for years Last VA: 20/40 OD, 20/30 OS Rarely does HAG Type 2 DM for years No re4nopathy or CSME Wet AMD OCT-Widefield In for 3 mos follow-up Reports lost glasses VA Today: 20/40 OD 20/70 OS Did not no4ce a change un4l checked in clinic Again, rarely does Amsler 2

3 11/7/17 OCT-A OS Re4na Clinic Wet AMD OS Avas4n series x 3 OS. Repeat OCT/OCT-A afer 3rd injec4on AMD Change in VA or metamorphopsia should always be taken seriously OCT to rule out fluid FA/ OCT-A if needed Evidence of heme or fluid should be referred ASAP for treatment Earlier treatment/smaller lesion size correlates with be]er final visual acuity DIABETES/DME CHANGE IN VA OR METAMORPHPSIA IN DRY AMD PT IS CONVERSION TO WET UNTIL RULED OUT!!! 3

4 DM case 1 Widefield 47 y o AA male Type 2 DM x 10 years Glipizide, mejormin Last A1c 9.9 LEE: 5 years ago at Lenscrafers VA 20/20 OU CSME suspected OD temporal to macula Assessment/plan Mild NPDR OU Mild non-central DME OD, no DME OS Pt ed re BS control Pt states adjus4ng meds with PCP as we speak RTC 3-4 mos repeat OCT OD Refer to re4na if increasing edema or decreasing VA 63 year old male Type 2 DM x 10 years Insulin x 3 years Last A1c 9.7 (h) DM case 2 VA 20/30- OD, 20/25+ OS CSME OD noted on clinical exam Widefield Re4na Clinic Center involved DME OD Discuss with re4na clinic An4-Vegf x 3 Repeat OCT afer 3 rd injec4on Pt ed re BS/BP control 4

5 DM case 3 50 year old male Type 2 DM x 20 years Last A1c 8.7 Insulin and liraglu4de (Victoza) Reduced VA OD x 9 mos h/o injec4ons OD last year Told earlier this year no more injec4ons needed. Unclear why VA decreased OD Schedule FA DM case 3 Moderate NPDR OU No center involved DME OD Macular ischemia OD>>OS on OCTA No need to do FA No treatment available Op4mize acuity Op4mize BP/BS control RTC 3 mos. Repeat OCT/ OCTA DM/DME Refer if center involved DME/CSME evident on OCT in 1-2 weeks If not center involved, follow closely in 3-6 mos OCT if unexplained vision loss in pt with diabetes Look for ischemia Pt ed re role of BS/BP control Treatment: FML vs. serial an4-vegf ERM ERM 68 year old male h/o oc htn on generic latanprost qhs OUx 3 years Pre tx IOPs 30 Post treatment mid teens VF full OU In for IOP check. Doing well, good compliance, but notes mild decrease VA OD with metamorphosia when reading small print 5

6 En Face ERM #2 83 year old male Catarct sx ou x2015 Notes OS blurrier than OD HTN BCVA 20/20 OD, 20/25 Os ERM Case #3 70 yo Hispanic male Notes decreased VA OD since previous exam Last year 20/20 OU Mild HTN, early cataracts BCVA 20/30 OD 20/20 OS Assessment ERM OD Plan ERM #3 Will monitor due to good VA RTC 6 mos ERM AGE INCIDENCE < % % % % BLUE MOUNTAIN EYE STUDY, AUSTRALIA 6

7 ERM Consider surgery if: VA 20/40ish or worse Symptomatic Visual need of patient Make sure you have an experienced surgeon!! VMT VMT case 82 year old male In for yearly exam Notes no change in vision h/o mild to moderate cataracts, VA 20/30 OU VA today 20/40 OD- one line decrease 20/30 OS-stable VMT CASE VMT OS with 20/40 acuity Discussion re op4ons Surgery Monitor Pt elects to monitor, as not bothered by vision and would like to avoid surgery RTC 3 mos with repeat OCT. Pt agrees with plan 7

8 VMT CASE 2 70 year old male in for rou4ne exam Notes mild change in distance vision, both eyes, since last exam 1 yr ago Thinks he needs new glasses 20/20 OD, 20/50 OS Pt surprised that VA OS was decreased. Did not no4ce un4l exam today VMT CASE 2 VMT OS with 20/50 acuity Discussion re op4ons Surgery Monitor Pt elects to monitor, as not bothered by vision and would like to avoid surgery RTC 3 mos with repeat OCT. Pt agrees with plan VMT: when to refer Natural progression of disease is rather variable Slow progression possible with near normal acuity Approx 10% will have spontaneous PVD and resolution within 30 days Therefore, close monitoring my be advised for some patients 8

9 VMT: when to refer In patients with poor vision, or symptomatic, a pars planar vitrectomy (PPV) may be considered Duration, severity should also be considered Jetrea (ocriplasmin) as option? Literature reports up to a 75% success rate and improvement of vision following PPV MACULAR HOLES LMH 78 year old male Had cataract surgery OS 5 years ago and unhappy with results Feels vision OS is worse now than before surgery No preop data available Unclear if ever explained to cataract surgeon or discussed with him reason for vision loss Unclear what tes4ng was/was not done LMH BCVA 20/20 OD, 20/30 OS Mild NSC OD PCIOL OS. Clear and well centered Post pole: Widefield LMH Lamellar Macula Hole OS Also called par4al thickness macular hole Pt ed. Monitor in 3 mos. Repeat OCT Consider re4na referral if worsens 9

10 CSR CSR 37 year old male Blurred vision OS x 5 days Black spot centrally OS Spot seems warped BCVA 20/80 OD 20/20 OS Med hx: albuterol PRN for asthma CSR Follow up CSR OD Ask about steroids Albuterol? Ask about stress? RTC for FA n/a Pt presents 1 mos later for FA Feels VA has improved OD significantly 20/20!! FA cancelled! Is this CSR? Pt notes acute onset of bent /crooked lines OD. No real change n vision Last exam 4 years ago at COSTCO CSR When to worry/refer If VA worse than 20/70 If pt demographics do not support If does not resolve in 6 mos If gets worse rather than be]er FA/ OCT does not support diagnosis Just doesn t feel right Pt is unable to accept vision/prognosis 10

11 CRVO VEIN OCCLUSIONS 75 year old male Presents for 3 mos glc check and 24-2 NTG x2010 Latanaprost qhs OU Has not used x 1 mos. IOP 19mm OU ( 14 ish when treated) Reports noted blurred vision OS about 2 weeks ago OD 20/20 OS 20/200 Type 2 DM and HTN A1C 7.4 BP 134/84 Raster Re4na Clinic CRVO OS with gross macular edema Avas4n series OS x4 Repeat OCT 1 mos afer last injec4on BRVO case 69 yo hispanic male Presents for yearly DM exam. No complaints HTN, DM, Obesity A1c 5.4 BP 154/81 BMI VA 20/20 OU BRVO case Increasing edema OD on OCT Approaching macula VA remains 20/20 Pt given op4on of following vs. injec4on, Pt elects to follow RTC 4 mos for repeat OCT 11

12 CRVO/BRVO Refer if macula edema within 1 week Laser vs. injec4on in BRVO Injec4on CRVO Steroids? Systemic workup recommended DM HTN Cholesterol panel Caro4d Doppler Look for NV/NVI/NVA/NVG esp. in CRVO, esp. if ischemic PLAQUENIL Plaquenil 31 yo AA female Sent from Rheumatology clinic pt on plaquenil. Please do re4nal screen including OCT + Lupus 200 mg HCQ BID x 7 years 20/20 OU 12

13 Case Normal re4na no evidence of plaquenil maculopathy Le]er back to rheumatology clinic Pt ed RTC 1 yr Plaquenil Be aware of new guidelines Rheumatology clinic/pcps aware HD-OCT, FAF recommended 1 st screening within 1 st year, then afer 5 years Risk factors >10 years Concurrent tamoxifen use Concurrent kidney disease Dose above 5 mg/kg of REAL body weight Incidence sill low, probably 1% Glaucoma GLAUCOMA 70 yo AA male Followed as GlC suspect x 4years Posi4ve family history Mom, maternal GM C/D: OD 0.45; OS 0.50 IOPs: OD; OS Ini4al 24-2 VF: no defects Ini4al 24-2 VF:August 2012 Todays exam No Complaints VA 20/20 OU IOP 22 mm OD, 23 OS 1+ NSC OU 13

14 24-2 Right Eye Assessment/Plan POAG OD>OS Start generic latanoprost QHS OU Goal 16 mm OU (30% reduc4on) Pt ed re side effects of g]s RTC 6 weeks for IOP check ANTERIOR SEG Normal angle anatomy Angle closure 14

15 Epithelial Mapping Conclusion NORMAL OCT has been a game changer in my prac4ce Help make be]er referrals Help keep pa4ents longer Helps take be]er care of your pa4ents Once you get one, not sure how you lived without!!! 15