Steven Ferrucci, OD. FAAO; Jeffry Gerson, OD, FAAO; Robert Prouty, OD, FAAO; Leo semes OD, FAAO

Transcription

1 PARDON THE OBJECTION: RETINA Steven Ferrucci, OD. FAAO; Jeffry Gerson, OD, FAAO; Robert Prouty, OD, FAAO; Leo semes OD, FAAO 1. Introductions/Disclosures (Ferrucci) 2. The genetics of AMD (Gerson) a. Background b. Utility c. Availability i. Macular risk ii. Nicox no more iii. Autogenomics iv. Others d. Role of Zinc and controversy i. Awh et al ii. Emily Chew et al iii. Awh et al, part two iv. Take home e. Future of genetics i. Treatments ii. Predictions 3. Is Geographic Atrophy next? (Ferrucci) a. Introduction b. Current studies i. Lampiluzimab 1. Mahalo study 2. Chroma., Spectri ii. Oracea 1. Low dose doxycycline 2. TOGA study iii. Zimura iv. Illuvien 1. Steroid implant 2. MAP GA study v. Brimonodine 1. Neuroprotective insert 2. BEACON Study vi. CNTF vii. Macuclear 1. Works on choroidal blood flow viii. Eximustat

2 1. Visual Cycle Modulator ix. Metformin x. Stem cells 4. VMT/VMA (Semes) a. Case Example b. Incidence i. VAST study ii. Risk factors c. Classifications System i. VMT vs VMA ii. Size i. When to refer 1. VA 2. Anatomy ii. Jetrea? iii. Vitrectomy 5. When do I refer my ERM cases? (Prouty) a. Intensity of the light reflection of the membrane i. Intensity of reflection is not proportional to the severity of the disease b. Degree of macular folding and ectopia i. With significant contracture and distortion (flattening) of the foveal contour, the necessity for membrane peel increases c. Diminished VA & metamorphopsia i. Metamorphopsia is far less reported than decreased VA yet both are important 1. Metamorphopsia is VERY disturbing if reported so if the peel does not improve VA but diminishes the distortion, the patient is usually satisfied with the outcome 2. Diminished VA: a. Consider the fellow eye b. Significantly reduced VA c. The longer the pathology persists, the higher the probability of sustaining irreversible vision loss d. The ultimate goal of surgery is to restore/maintain reading vision (>20/50) i. In one survey, the probability for the patient NOT to have at least 20/40 vision four years after surgery: 1. ~ 5% when the preoperative VA was 20/40 2. ~ 10% when the preoperative VA was 20/50 3. ~ 30% when the preoperative VA was 20/ Retinal Detachments What should my pts and I expect (Gerson) a. Case report b. Types of detachment

3 c. Pre op i. Urgency vs. emergency ii. Pt education iii. Caveats d. Surgical correction i. Buckles ii. Cryo iii. Gas e. Post op care i. Follow up ii. Complications iii. pitfalls f. Take home 7. Laser Floater Vitreolysis: Has its time arrived? (Prouty) a. Development of YAG lasers i. 1 st laser = Ruby laser (Ted Maiman 1960) at Hughes Research Labs ii. 1 st YAG was built by Guesic, Marcos & Van Uteit (1964) at Bell Labs 1. Continuous wave (CW) 2. Pulsed lasers (Q switched & mode locked) developed in 1970 s iii. By 1985, there were at least 30 companies marketing Q switched YAG lasers for ophthalmic use b. Application in the vitreous i. By early 1980 s, Dr. Fankhauser in Switzerland was using a Q switched YAG to work in the vitreous using special optics he developed ii. Dr. Scott Geller iii. Dr. John Karickhoff c. The changing vitreous i. Vitreous liquefaction and fiber formation was identified in the aging vitreous in 1970 s ii. Development of Posterior Vitreous Detachment (PVD) &/or floaters 1. Uchino Arch Oph Webb Int J Oph 2013 i. Observation ii. Vitrectomy iii. Enzymatic Vitreolysis Jetrea TM (Ocriplasmin) iv. Laser Vitreolysis 1. CPT Coding: 2. Reimbursement: 8. Hypertension and the retina (Semes) a. Classification system b. Clinical Signs i. AV changes

4 ii. NFL hemes iii. CWS iv. Optic nerve head edema/macula edema c. Referral patterns d. Management e. Systemic concerns 9. Diabetes and Diabetic retinopathy: What s new? (Gerson) a. New criteria for diagnosis b. New meds c. When to refer for treatment i. PDR? ii. Severe NPDR? iii. CSME? i. Laser ii. Injections 1. Which is best? 2. Protocol T iii. Steroids/ steroidal implants e. Nutritional supplements 10. Nevus vs melanoma? Now what? (Semes) a. Case report b. Clinical features i. Nevus vs melanoma ii. TFSOMs iii. Ultrasound c. Tools i. Photos ii. Ultrasound iii. FAF iv. OCT v. Others 11. Retinal Electrodiagnostic applications (VEP/ERG): Useful in more than just glaucoma (PROUTY) a. ERG: Electroretinogram i. A direct and objective test of retina function 1. Measures function of rods & cones and inner retinal layers ii. Flashes of light are presented under dark and light adapted conditions to separate the rod (night vision) and cone (color vision) systems of the retina

5 b. PERG: Pattern ERG i. The changing of the stimulus to a flickering checker board pattern on a TV monitor screen while measuring an ERG ii. It enables diagnosis and a quantitative assessment of early macular disease as well as the differentiation between localized macular disease and more widespread retinal disease c. Multifocal Electroretinogram (mferg) i. A new technology that is capable of assessing focal electrophysiologic responses in the central retina including the macula ii. Useful in identifying early hydroxychloroquine (plaquenil) retinopathy or toxicity and is used in a variety of retinal dystrophies, macular dystrophies and other macular disorders d. Visual Evoked Potential (VEP) i. VEPs can provide important diagnostic information regarding the functional integrity of the visual system from the optic nerve to the occipital cortex in the brain 1. Multi contrast stimuli: a. uses a checkerboard pattern at both low contrast and high contrast to test the integrity of both the magnocellular (peripheral vision) and parvocellular (central vision) pathways e. Case example of application 12. Concluding remarks (Ferrucci)