When to Refer to RETINA. Joseph M. Coney, MD February 17, 2017 Memphis, TN

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1 When to Refer to RETINA Joseph M. Coney, MD February 17, 2017 Memphis, TN

2 Financial Disclosure Commercial Interest What was received For what role Aerpio Grant Support Contracted Research Alcon Laboratories Grant Support Contracted Research Alimera Consulting Fee Consultant/Advisor Allergan Consulting Fee Consultant/Advisor Allergan Grant Support Contracted Research Apellis Grant Support Contracted Research Genentech Grant Support Contracted Research Genentech Consulting Fee Consultant/Advisor Hoffman La Roche Grant Support Contracted Research Lowy Medical Research Institute Grant Support Contracted Research Notal Vision Consulting Fee Consultant/Advisor Ohr Grant Support Contracted Research Ophthotech Grant Support Contracted Research Regeneron Equity Ownership Interest Regeneron Consulting Fee Consultant/Advisor Tyrogenex Grant Support Contracted Research

3 Overview Alphabet Soup Endophthalmitis/IOI CRAO PVD RD NVI/NVA CNVM VH CRVO/BRVO NPDR/PDR ERM MH VMT

4 Endophthalmitis

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7 Hypopyon

8 Hypopyon

9 Bacterial Endophthalmitis Types Acute post-operative Chronic post-operative Bleb-associated Endogenous Intravitreal injection-related Post-traumatic

10 Bacterial Endophthalmitis Course/Prognosis Depends on type of endophthalmitis duration of time to presentation & Rx virulence of organism Bleb-associated, post-traumatic, endogenous endophthalmitis have poorest prognosis

11 Bacterial Endophthalmitis Presenting Symptoms Decreased vision Pain Red eye Swollen lid Hypopyon Most common organisms Acute Post-op Staphylococcus epidermidis (70%) Other gram positives (24.2%) Staph aureus (10%) Streptococcus (9%) Enterococcus (2.2%)

12 Bacterial Endophthalmitis Treatment Prompt intervention critical to restore vision/salvage globe Vitreous tap & intravitreal antibiotic injections can be done in office with no delays In very severe or resistant cases, pars plana vitrectomy in operating room

13 Central Retinal Artery Occlusion

14 CRAO Incidence About 1:10,000 general patient visits Most patients over 60 years Most patients final VA < 20/400 Etiology Usually embolic Cholesterol emboli suggest carotid atheromatous origin (20% of cases) Temporal arteritis: 1-2% of cases If TA suspected, urgent Rx indicated

15 CRAO Therapy Permanent ischemic injury > 90 minutes Occasional improvement after many hours Efficacy of therapy questionable A/C paracentesis Ocular massage Inhalation RX (Carbogen: 95/5% O 2 /CO 2 OR HYPERBARIC OXYGEN CHAMBER) Oral acetazolamide & ASA 20% develop rubeosis 1-12 weeks post occlusion Scatter laser Rx

16 CRAO with Cilioretinal Artery Sparing

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19 Acute Posterior Vitreous Separation Prevalence of PVD related to Axial length of eye Age Pts < 50 yrs of age (10%) Pts 70 yrs: 63% have PVD Incidence of retinal tears Low in asymptomatic patients 10-15% of patients with acute symptoms 50-70% risk in pts with vitreous hemorrhage

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21 Acute PVD Management Symptomatic pts should be seen within hours if possible Pts with VH need close follow-up Retinal breaks generally should be treated with laser or cryopexy After initial evaluation, some pts should be seen again within 3-4 weeks as breaks may evolve over time Esp. myopes, aphakes, pseudophakes, lattice

22 Rhegmatogenous Retinal Detachment

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25 Rhegmatogenous Retinal Detachment Predisposing factors Vitreous liquefaction Acute PVD Abnormally firm vitreoretinal adhesion Lattice degeneration Cystic retinal tufts Myopia

26 RRD Treatment options Pneumatic retinopexy (PR) In-office procedure Cryopexy followed by intraocular gas tamponade Appropriate for superior breaks Overall anatomic success: 70% Key advantages No delay in treatment Low morbidity Low cost

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28 RRD Scleral buckling Circumferential buckles produce permanent indentation that relieves vitreoretinal traction Relative indications Localized RDs with small breaks Multiple breaks in multiple quadrants Presence of PVR Overall success rate: 90%

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31 RRD Pars plana vitrectomy Utilization has increased dramatically Giant retinal tears Pseudophakes Posterior breaks Co-existent macular hole or VH PVR Morbidity less than SB, especially 25-gauge Anatomic success rate 90%

32 RRD

33 RRD Barricade laser Appropriate for peripheral RRDs no symptomatic visual field loss chronic or subacute RRDs Offers least risk & morbidity High success rate in selected cases

34 Tractional Retinal Detachment

35 Tractional Retinal Detachment

36 TRD Common etiologies Proliferative diabetic retinopathies Proliferative vitreoretinopathy Sickle cell retinopathy ROP Penetrating trauma Retinal vascular disease Treatment Peripheral TRDs can be observed TRDs involving or threatening macula require PPV

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38 Retinal Detachment Timing of surgical intervention Dependent on several factors: Type of RD Status of macula General medical condition of patient Cases amenable to barricade laser or PR should be done on initial visit in the office

39 Retinal Detachment RRD Timing of surgical repair Macula ON & immediately threatened, surgery at earliest opportunity within 24 hrs. If Rx must be delayed, pt can be positioned to prevent progression of RD (highly effective) Macula OFF <1 week, surgery should be done <1 week Macula OFF >1 week, surgery can be done electively in 1-2 weeks In some cases of PVR, can be advantageous to defer surgery several weeks to allow membranes to mature and facilitate peeling

40 Retinal Detachment For chronic RRD Signs include Non-bullous Atrophic retina Subretinal bands, PVR Demarcation lines Asymptomatic Surgery can be scheduled electively Observation also an option

41 Retinal Detachment Tractional RD Can usually be done electively Within 7-10 days if macula recently involved Preoperative laser often helpful in cases of PDR Anti-VEGF injections also helpful but can increase risk of progression if surgery delayed

42 Rubeosis

43 Rubeosis Predisposing Conditions Systemic vascular disease Carotid occlusive disease Giant cell arteritis Ocular vascular disease Diabetic retinopathy CRAO CRVO & BRVO Sickle cell disease Other ocular diseases Uveitis, chronic RD, tumors, trauma

44 Rubeosis Prompt treatment indicated, especially in cases of NVA Treatment delay can result in synechial angle closure and NVG Treatment Panretinal photocoagulation Anti-VEGF injections Rx of underlying condition

45 Rubeosis CRVO with NVI/NVA Before Avastin CRVO 1 week post IVA

46 Add surgical video of Ahmed Valve and PPV for NVG

47 Choroidal Neovascularization

48 CNV POHS Juxtafoveal CNV In MPS era, juxtafoveal CNV required immediate referral and Rx before CNV progressed into fovea In anti-vegf era, early Rx important but not an acute emergency Pts should be seen at earliest opportunity within 1 week

49 CNV AMD Subfoveal CNV

50 CNV Timing of Rx for subfoveal CNV Generally non-emergent More urgent if rapid progression of vision loss new heme monocular or better-seeing eye functional vision in affected eye Early intervention will stabilize CNV & maintain useful vision in > 90% of cases

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52 8/2015 CF 12/ /400 4/ /40

53 Vitreous Hemorrhage

54 Vitreous Hemorrhage Most common etiologies PDR Acute PVD Trauma Retinal vascular disease CRVO & BRVO CRAO Ocular ischemic syndrome

55 Vitreous Hemorrhage Urgency of evaluation depends on suspected etiology & patient history Recurrent VH in PDR not urgent New VH in diabetic More urgent can potentially apply PRP before localized VH disperses If fellow eye has no or only mild NPDR, suspect PVD & retinal tear more urgent evaluation indicated

56 Vitreous Hemorrhage

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58 Retinal Vein Occlusions

59 Retinal Vein Occlusions Ischemic CRVO or BRVO If no NVI/NVA not urgent If NVI/NVA present (or increased IOP), pt should be seen ASAP PRP if view adequate Anti-VEGF injections also useful Non-ischemic CRVO or BRVO Not urgent Pts with CME may benefit from early Rx

60 Retinal Vein Occlusions Bilateral CRVO Rare Suggests underlying systemic disease Malignant hypertension Blood dyscrasia Leukemia Waldenstrom macroglobulinemia Urgent systemic evaluation indicated

61 Bilateral CRVO

62 Bilateral CRVO - Case 58-year-old black female Gradual loss of vision for several weeks VA = 20/400 OD & 20/200 OS Bilateral CRVO with severe CME Found to have multiple myeloma Systemic Rx resolution of CRVOs

63 Diabetic Retinopathy NPDR PDR VH DME TRD Rubeosis

64 Epiretinal Membrane - ERM 20/400 Pre-op Va to 20/60 Post-Op Va

65 Prognostic Factors in Post-op VA Improvement Retinal vascular leakage, CME, and RPE disruption of any etiology all have been associated with poorer prognosis

66 Prognostic Factors in Post-op VA Improvement Eyes with poorer pre-op VA tend to have a greater VA improvement compared with eyes with better pre-op visual levels but also have poorer final VA

67 Prognostic Factors in Post-op VA Improvement Removal of traction upon the retina and perifoveal microvasculature allows for gradual resolution of macular edema Chronic traction results in permanent retinal vascular incompetence, such that persistent vascular leakage and macular edema remain post-op and limit visual gains

68 Add in ERM video from Dubrovnik

69 VMT 20/60 MH Ph 20/100-1 Post-op Ph 20/40 NSC

70 Macular Hole

71 9Nov /25 Macular Hole 1Apr /30 6Jan /25 22Mar /50 20Sep /50 21Jun /60 22Nov /200 23Jan /80

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73 Conclusions Most common retinal disorders can be evaluated electively Endophthalmitis needs emergent Rx Retinal detachments: Urgency highly variable and must be tailored to individual patient Retinal vascular disease & DR: Usually not urgent unless high-risk PDR or rubeosis present

74 = Satellite offices = Surgery Centers: CELSC = Cleveland Eye & Laser SC CSC = Canfield SC LSC = Lippy SC Green Rd Chardon Elyria CELSC Bedford Brecksville CSC Medina Canton LSC New Castle PA Mansfield