Diagnosis in AMD. Managing your AMD Patients

Transcription

1 Managing your AMD Patients Robert W. Dunphy, O.D., F.A.A.O. Diagnosis in AMD Have suspicion Identify relative risk Conduct surveillance Biometry Utilize technology to facilitate detection of change / stability over time Therapeutic Principles Once damage (GA, CNV) ID and intervene if possible Prior to damage reduce contributors Partner with informed patients Observation is KEY component of Rx Anti VEGF is temporizing measure Post Injury Background OCT is a directed study OCT must be referenced Proper decision develop from proper interpretation of properly ordered and performed studies We are in the midst of a paradigm change OCT Interpretation Identify ILM/Vitreous interface Identify RPE Basal elements, choroid Review inner retinal organization post=>anterior Review RNFL Perform regional comparisons for consistency Inner/Outer Segment Junction Line 5 1

2 Outer Retina SDOCT Outer Retina Dry ARMD 2 1 IS / OS ELM OS/RPE Interdigitation IS RPE + OS Attenuation OS Attenuation 4 RPE BRUCHS 3 RPE Window effect DRUSE/DRUSENOID PED Interpreting SD-OCT Reference fundus image Identify orientation, location of scan Retinal topography symmetry of stratification Inner retinal contour Intraretinalarrangement Outer retinal stratification OCT Interpetation in AMD Identify ILM Identify RPE Line Identify outer retinal complex 11 OCT Outer Retinal Complex Bands Outer Retina SD-OCT ELM IS/ OS IS/ ES RPE / OS s RPE 1 ELM IS/ OS 2 IS/ ES 3+4 RPE OS/RPE Interdigitationabsent IS / OS IS / ES 5 BRUCHS (not visible) 5 BRUCHS 13 2

3 AMD OCT Sub RPE deposits (below 4, above 5) Altered RPE contour (4) Regional loss of outer retinal elements (3, 2) RPE dropout/hypertrophy and signal variability Often thin choroid Reading in AMD Identify arrangement and symmetry anterior to RPE Identify arrangement and symmetry posterior to RPE Look for modification of normal features Be open to unrelated findings Reading for diagnosis Outer Retina SDOCT Alterations of normal structure Additional structural features Group various signs Relate to differential 2 1 ELM IS / OS 4 RPE OS/RPE Interdigitation IS BRUCHS 3 ELM IS/OS ELL OS/RPE RPE Base Bruch s Key Features Line 1 Line 2 Line 3 Line 4 Bruch s RPE Base Band (4) Continuity Flat contour Absence of Bruch s 4 3

4 OS/RPE interface line (3) Regional asymmetry or irregularity Regular separation from RPE Associate with signal variation IS/OS line (2) ELLIPSOID Strong signal band between ELM and RPE May be evident w/o OS/RPE line (3) 3 4 IS/OS line (2) ELLIPSOID Strong signal band between ELM and RPE May be evident w/o OS/RPE line (3) PR Cell Bodies (ONL) Symmetry Signal regularity Watch for irregular jagged signal Regular anatomic arrangement ELM Autofluorescence Endogenous fluorescent compounds - RPE / Retina Non-invasive imaging technique Information re: RPE/outer retina complex Lipofuscin Generation Abnormal production/clearance Increased shedding outer segments Disrupted RPE phagocytosis Inability to recycle metabolites 4

5 Melanolipofuscin Additional fluorophore Resides in RPE Fluoresces to longer wavelength Excitation and Filter as for ICGA Less interaction with overlying retina NL FAF Pattern Fig. 2. Color fundus photograph (A) and fundus autofluorescence imaging (B) of the right eye in a normal subject with the confocal scanning laser ophthalmoscope (Heidelberg Retina Angiograph, HRA 2, Heidelberg Engineering, Dossenheim, Germany). Topographical distribution of FAF intensity shows typical background signal with shadows on optic disc (absence of autofluorescent material) and retinal vessels (absorption). Further, intensity is markedly decreased over the fovea due to the absorption of the blue light by yellow macular pigment. FAF role in Differential Diagnosis Expanded information re: RPE/Retina status Elucidation of regional metabolic status Elucidation of RPE status Qualities of subretinal fluid Best s Disease FAF Clinical Macular Drusen Macular Hole Image Courtesy of William Freeman (Shiley Eye Center, UCSD), Ethan Priel (Israel) Ophthalmic Photographers Society, Giovanni Staurenghi (Sacco Hospital Milan, Italy). SWAF Individual frame AAOpto Multifocal 2009 Choroiditis ONH Drusen Stargardt s disease 12 5

6 Real Time Mean Photographic FAF Specialized excitor / barrier filters Adjustable flash intensity 32 Fundus Camera Early Spaide system Excitation Max 580 Range Barrier Max 695 Fundus Camera AF Diabetic Reitnopathy Later Spaide Excitation Max Emit Modified x 1 Modified x 2 6

7 x 3 Different System Different info Chronic ICSC Retinal Pigment Epithelium change Different imaging modalities reveal different types of information 7

8 IR c SLO cslo FAF Outer retinal damage changes fluorescence 8

9 ICSC Retinal Thinning Chronic detachment Outer retinal elements damaged Reduced thickness Increased BPFAF in thinned regions AMD vs ICSC Outer retinal damage RPE damage Altered Fluorescence Signal changes mark change over time Autofluorescence in AMD Junctional Zone Patterns Does fluroescence information help with AMD Dx and Prognosis Does Fl information educate patients What is optimal role for Fl information Dry AMD - Progression Slow- no FAF abnormal Banded more rapid Granular - Rapid Granular Trickling - very Rapid Images are adopted from Holz et al. American Journal of Ophthalmology.) AMD evolution 72 yo man followed for GA OD Followed for moderate risk dry AMD OS Clinical change over time When is intervention indicated 9

10 Blue Peak FAF

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12 months later

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14 Interval Follow - up 81 1 AMD Management We need to refer those patients who require immediate intervention Intervention when: SRF Symptoms AMD Management There is therapeutic Repair via AntiVEGf treatment in ophthalmology Primary Care offers risk amelioration and Maintenance Oil changes and preventive maintenance are not Sexy Great numbers of patients benefit from PreRx prevention / delay Change in Approach Evidence for risk reduction via support Primary Care providers offer status report and risk profile Technology facilitates Assessment and clinical education Informed patients make better decisions Detect and Manage risk with informed partner, Maximize detection abilities and reduce risk, not enhanced Detect and Refer Thank You! 14