VITREOMACULAR UPDATE FOR THE PRIMARY CARE OD

Transcription

1 VITREOMACULAR UPDATE FOR THE PRIMARY CARE OD VITREOMACULAR UPDATE FOR THE PRIMARY CARE OD 1 2 DISCLOSURE STATEMENT I have received lecture honoraria from TearScience. I have no direct financial or proprietary interest in any companies, products or services mentioned in this presentation. VITREOMACULAR UPDATE FOR THE PRIMARY CARE OD Please silence all mobile devices At the conclusion of this course, please properly dispose of your trash as you leave this room 3 To: Text: christopherw667 To participate in audience polling: In the song Yellow Ledbetter what is the first word(s) mumbled by Eddie Vedder? 1. On the ceiling 2. Unsealed 3. One bizarre hymn 4. And the wizard 6 1

2 Inner Nuclear Ganglion Cell Vitreous Inner Plexiform Posterior Hyaloid RNFL Outer Nuclear ELM Outer Plexiform Choroid PIL RPE 7 8 EPIRETINAL MEMBRANE & VITREOMACULAR TRACTION 9 Epiretinal Membrane & Vitreomacular Traction 10 Case 1: 41 year old white female Case 1: 41 year old white female CC: distorted vision after putting a contact in her eye that made her right eye red and irritated I see a blurry circle surrounded by a clear circle FHx: glaucoma OcHx: strabismus OD MHx: depression (Paxil) BVA: OD: x /30 2 OS: x /20 CT: 18 pd CRET Anterior Segment: Unremarkable OU Posterior Segment: Faint circular foveal distortion OD Unremarkable OS

3 Case 1: 41 year old white female Case 1: 41 year old white female Case 1: 41 year old white female 6 weeks later Summary of Care VMT Date Service(s) Price(s) Based on 2017 Medicare NV 7/31/ , 92250, (ABN) $168.50, $68.53, $ /7/ , 92134, (cash), CL eval (cash) $127.79, $42.50, $ 50, $50 15 Total Care: $ Case 2: 16 year old white female Case 2: 16 year old white female CC: mild blurred vision and difficulty with depth perception FHx & MHx: unremarkable OcHx: Blunt trauma OD BVA: OD: x /20 OS: DS 20/20 EOM and CT: full and ortho Anterior Segment: Unremarkable OU Amsler: negative OU Posterior Segment: Vitreoretinal adhesion superiorly with traction and membrane OD Unremarkable OS

4 Case 2: 16 year old white female Case 2: 16 year old white female ERM/VMT RISK FACTORS PVD Prior intraocular surgery Trauma Intraocular inflammation Macular holes TRADITIONAL TREATMENT Monitor If VA is 20/50 or worse consider PPV w/ peel 75% will have improved VA MACULAR HOLES Case 3: 69 year old white male Macular Holes CC: vision has been blurry for about 6 weeks in my left eye FHx: grandmother was blind from some unknown eye disease OcHx: unremarkable MHx: Elevated cholesterol (Lipitor) BVA: OD: x /25 OS: x /100 Anterior Segment: Mild NS OU Amsler: Normal OD, pt can not see center dot OS

5 Case 3: 69 year old white male Posterior Segment: Unremarkable OD Faint circular foveal distortion with fluid cuff and PVD OS Case 3: 69 year old white male Case 3: 69 year old white male 250 microns Macular Hole Fundusoscopy Stages Stage 1 loss of foveal depression with a yellow spot or ring Stage 2 Full thickness hole overlying pseudo operculum Stage 3 Full thickness hole with overlying operculum NO PVD Stage 4 Full thickness hole with overlying operculum W/ PVD VMA/VMT OCT Classification VMA VMT

6 Macular Hole OCT Stages Stage 1 Stage 2 Stage 3 Stage 4 Traditional Treatment for Macular Holes Stage 1 No treatment Spontaneous closure occurs in 50% Stage 2 PPV w/ peeling Intraocular bubble Face down positioning for 1 2 weeks Success is good if MH is less than 1 year in duration Literature Update 28 days after injection non surgical resolution occurred in: VMT: 26.5% Jetrea 10.1% placebo Macular hole 40.6% for all holes Jetrea 58% for holes < 251 microns wide 25% for holes between microns wide 10.6% placebo Literature Update Rate and timing of spontaneous resolution in VMP group: Should the role of watchful waiting be re evaluated as an alternative to Ocriplasmin therapy? Dimopoulos et al, Br J Ophthalmol Mar; 99(3);350 3 Spontaneous VMT Closure Rate: 20 out of 46 patients 43% Time to Spontaneous VMT Closure: Within 1 year Risk of waiting: Macular hole formation in 3 patients, loss of 1 ETDRS letter/ year if VMT is not treated Clinical Take home FOR SMALL HOLES (<250) Absolute Risk Reduction 48% Number Needed to Treat 2 FOR LARGE HOLES ( ) Absolute Risk Reduction 28% Number Needed to Treat

7 Literature Update Based on Jetrea study how many people with macular holes would fall into these classifications: Any stage Macular Hole with VMT 19 eyes (14.1%) Macular Hole < 400 microns w/ VMT 9 eyes (6.7%) Of all the macular holes (125), 9 would be candidates for Jetrea injection and at a 40% closure rate, 2.7% would benefit from Jetrea Cost Effectiveness of Jetrea Literature Update Can macular hole surgery be effective without facedown positioning? Closure rate: 100% Mean Pre op VA: 20/95 Mean Post op VA: 20/ HYDROXYCHLOROQUINE TOXICITY Hydroxychloroquine Toxicity

8 Case 1: CC: vision does not seem as sharp as it has in the past FHx: unremarkable OcHx: Unremarkable MHx: SLE (plaquenil 400 mg PO QD x ~6 years), Wt: 130 BVA: OD: x /20 2 OS: x /20 Anterior Segment: Unremarkable OU Posterior Segment: Unremarkable OU RIGHT MACULA LEFT MACULA RIGHT 10 2 LEFT RIGHT MACULA LEFT MACULA

9 RIGHT MACULA LEFT MACULA AAO screening Recommendations Baseline (within first year of starting Plaquenil) and annually after 5 years DFE 10 2 Automated VF Any of the following: SD OCT mferg FAF Thank You! EyeCode Education Contact Information: EyeCodeQuestions@gmail.com website: Blog: