Vascular anatomy. Retinal Vascular Disorders. Bring it to the basics! Vascular anatomy. Choroid. Clinical Challenges (Dx a/o Tx) 3/15/2016

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1 Vascular anatomy Retinal Vascular Disorders Mohammad Rafieetary, OD, FAAO Bring it to the basics! Vascular anatomy In the Era of Nanotechnology getting hung-up by minutiae and missing the boat is easy. 20/20 vision smokes two packs/day Consult to see eye injection will help! Don t forget the choroid! Clinical Challenges (Dx a/o Tx) Choroid Rushing to Dx Medical Errors Misdiagnosis Mismanagement Limitation of Testing Confusing sign and symptoms Limitation of Therapy Unresponsive to conventional Therapy Significance of Retinal Vascular Disease in Presence of Comorbid Conditions often the Underlying Etiology! Challenges in clinical examination Complexity of the structure 1

2 Patient with loss of vision Fairly normal retina End result carotid artery disease Significance and Relationship Between Systemic Disease Retinal Vessels And Retinal Vascular/Background Findings Public misconception that all eye problems can be fixed by a better pair of glasses (+)Understanding of the significance by the PCPs (+)Attention by the eye-care providers What is our role as ODs? Intricacy of retinal vasculature Source of the image 1 The most common causes of death in the United States All causes 1,989,841 All causes 2,403,351 Diseases of heart 761,085 (August 2011) CDC Data indicates that the deaths from CLRD has surpassed CVA as 3rd leading cause of the death in the US. CLRD= asthma, chronic bronchitis, emphysema, others Diseases of heart 710,760 2 Malignant neoplasms [Cancer of All Types] 416,509 Malignant neoplasms [Cancer of All Types] 553,091 3 Cerebrovascul ar diseases 170,225 Cerebrovascul ar diseases 167, Am Lung Assoc. 2009, 21% US Adults smoke 6 Unintentional injuries Chronic obstructive pulmonary diseases Pneumonia and influenza 105,718 56,050 54,619 Chronic lower respiratory diseases (CLRD) Unintentional injuries Diabetes mellitus 122,009 97,900 69,301 7 Diabetes mellitus 34,851 Influenza and pneumonia 65,313 Mechanism of Retinal Vascular Disorders Conditions that physically alter blood vessels (Retina a/o choroid) Locally or Generalized Conditions that alter blood chemistry Conditions that do both Is this a normal macula? 2

3 Did the patient know they have a problem? Long-term outcome? Patient was asymptomatic! Is lack of symptom justify no TX? Challenges Co-morbidities DX? How often do we see this? (or ignore it) 3

4 We can easily miss or ignore these! How many people that worry about this have any understanding of Retinal vascular disease? (lack of PSAs) But all fear blindness! Should we have a conversation with our patient beyond the eye finding? Reasons to miss subtle signs! Symptoms May Show Overnight! but these signs didn t develop overnight! Association of Retinal Findings and Systemic Disease (Morbidity, Mortality) Wong et al: Prospective cohort study of retinal vessel diameters and risk of hypertension. (Beaver Dam eye study) Conclusions: Narrowed retinal arterioles are associated with long term risk of hypertension Bruno et al: Vascular Outcome in Men With Asymptomatic Retinal Cholesterol Emboli (Annals of Internal Medicine Feb 1995, V22:4) (VA Setting) Conclusion: Asymptomatic retinal cholesterol emboli is an important risk factor for CVA independent of commonly recognized vascular risk factors Klein et al: Retinal Emboli and Stroke (Beaver Dam Study) Higher incidence of CVA in patients with retinal cholesterol emboli 4

5 Hemorrhage Characteristics Hypertensive RetinopathyandRisk ofstroke Yi-Ting Ong,et al.hypertension. 2013;62: Retinal imaging may someday help assess if you re more likely to develop a stroke the nation s No. 4 killer and a leading cause of disability. 54 Y/O WM Healthy, vague visual disturbance. Referred as Retinal Hemorrhages, CRVO! Retinal Hemorrhage Roth s Spots White or pale centers are composed of coagulated fibrin, usually caused by immune complex mediated vasculitis. May be seen in leukemia, diabetes, subacutebacterial endocarditis, pernicious anemia, ischemic events, and HIV retinopathy. Patient dxedwith acute myelogenousleukemia (AML) and died within a year. CRVO? Typical Retinal Hemorrhage? 63 Y/O AfAMF Diabetic Last seen 2010 recently referred back by PCP overdue fundus exam 5

6 Referred for Diabetic Retinal Eval Case of unexpected findings and patient's disappointment! 55 Y/O BF DM x20yrs Referred as emergency macular on RD recent onset vision loss (NPDR OS) Patient arrives end of the day!!! OD:HM OS:20/50 Wants her vision fixed today need to get back to work! -Future of this area -Mechanism of sight loss -What can be done about it? -Status of Fellow Eye -Coexisting Disease Macula On vs. OFF 6

7 Unmet Expectations Spectrum of DR (#Ways to failure) 31 Y/O BF Referred by OD for diabetic retinal exam DM X 20 yrsa1c 8 daily average Blurred vision on going OD 20/30 OS 20/100 (wears spectacles) 7/24/2013 IVA OU 7

8 -Progression of RD -Regression of SRH and NV -Post-op VA loss as expected and discussed with patient 8/14/2013 IVA OU SchSX OS RBA including high% of post-op VA loss -Not all cases obvious a/o symptomatic but will not remain that way -Not all cases have obvious underlying etiology -Variation in presentation OD 20/ OS PH 20/400 Sep 11, 2013 IVA OD Sch SX (Discussed RBA including further vision loss ) Not all cases due to an underlying systemic dieases 8

9 Not all cases present with similar severity but this had an early stage in the past! When OS involved MRV showed blockage in left transverese and sigmoid sinuses Can t always find why? Further Anti-coagulation Therapy Canary in the coalmine Not all cases due to one group of underlying disease (Systemic Lupus) Sarcoidosis 59 Y/O M Excess Factor XII 9

10 Had missed follow-up care. Returns with New-Onset Symptoms (small floater OS) She is also on plaquenil Surprising Findings (Retinal Vascular Disease) 60 Y/O WM, Difficulty near vision lately, has stopped his BP meds Referred for Hemorrhage and Exudates OS VAs OD: 20/25, OS: 20/30 (1+ NS) Surprising Findings (Retinal Vascular Disease) 10

11 Surprising Findings (Retinal Vascular Disease) Challenges Following a long debate, patient agreed to revisit PCP, and to eye tx! 8/20/2013 Challenges 8/23/2013 Photo sent by referring doc Challenges IOP OD 25, OS 14 Now OD NLP, OS doing well post cataract sx 81 Y/O WM 4/200, 20/50 Challenges Photo sent by referring doc 11

12 VOD Unpredictable changes July 2010 March 2011 Case of rapid vascular alteration Case of rapid vascular alteration Case of rapid vascular alteration July 2010 IVA OS and No Show for follow-up Case of rapid vascular alteration March 2011 OD VA loss X 1month VOD predictable changes (noncompliant patient) 12

13 Predictable changes over time (complaint patient) PDR Progression Missed Jul 2012 appt shows Late sep HM OU (Now on kidney dialysis) PDR Progression PDR Progression (following first IVA) April 2011 PDR Progression PDR Progression (following second IVA) April 2012 by June 2012 Vas 20/40 OD/OS Ongoing Treatment and much improved. 13

14 PDR Progression (OD following PPV) Eventually 20/30 20/400 1 Day Post-op 20/200 PDR Progression (OD following PPV) I have no problems with my LE don t want treatment! 3 wks s/p VA 20/100 New View of Fundus Schfor PPV PDR Progression (OS following PPV) I have been blinded by treatment! (should not have had it, will tell everyone laser blinds you!!!) OS 1 Month 2 Months S/P PPV 14

15 Diabetes A group of metabolic diseases associated with high serum glucose level, either due to body s inability to produce sufficient insulin, or cells do not respond to the produced insulin Incidence/Epidemiology ( >25 million children and adults in US (8.3% of the population) Type 2: primarily lifestyle factors Type1: Multifactorial Diabetic Retinopathy Focal for ME 2.5 years is it really getting better? Diabetes Morbidity and Mortality In 2006 diabetes was the seventh leading cause of death listed on U.S. death certificates Complications Nephropathy, Neuropathy, Retinopathy Heart disease and stroke Hypertension In , 75% of adults with also had hypertension. Amputation More than 60% of nontraumatic lower-limb amputations More Pitfalls Diabetic Retinopathy Classification NPDR Mild: Microaneurysms only Moderate: More than mild less than Severe Severe: any of the following >20 IRH in 4 quads Definitive venous beading in 2 or more quads Prominent IRMA in 1 or more quad and no NV PDR: Definitive NV, PRH or VH 15

16 Systemic Hypertension Definition Achronic condition in which the arterial (blood) pressure is elevated Types Primary or Essential(90-95%) Secondary (5-10%) Caused by other conditions that affect the kidney, arteries, heart or the endocrine system. White coat, Isolated Systolic, Labile, Malignant Arteriolar narrowing Arterio-venous ratio Generalized and focal arteriolar narrowing Systemic Hypertension Complications Hypertension is the most important risk factor for morbidity and mortality in the industrialized world CVA, Hypertensive encephalopathy Cardiac: MI, CHF Nephropathy Retinopathy Arteriolar light reflex Arteriolosclerosis, with thinning of the blood column Copper wiring Silver wiring HTN and Posterior Segment Retinopathy Hypertensive, and exasperating diabetic and other vascular retinopathies Choroidopathy Macroaneurysm RVOs RAOs Others e.g., ION AV crossing changes Gunn sign Salus sign Precursors to BRVOs 16