Download Choroidal Neovascular Membrane Mimicking a Branch Retinal Vein

Choroidal Neovascular Membrane Mimicking
a Branch Retinal Vein Occlusion
Resident’s Day Case Report
Lindsey M. Jendrasko, OD
Optometry Resident, VA Togus
[email protected]
Abstract
Idiopathic CNVM can mimic other retinal diseases including BRVO. OCT can miss
early cases, while FA is a more reliable test for definitive diagnosis.
I. Case History
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61 year old Caucasian male
Chief Complaint
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Black spot in center of vision, right eye only, for past two months.
Noted wavy lines when looking at roofs. Condition constant and
relatively stable since onset.
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Ocular History
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Medical History
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No history of eye exam.
Coronary Artery Disease
Hyperlipidemia
Congestive Heart Failure
Esophageal Reflux
Paroxysmal Ventricular Tachycardia
Smoker
Medications
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Carvedilol
Clotrimazole
Lisinopril
Omeprazole
Rosuvastatin
Vitamin C
Aspirin 325 mg
Ezetimibe/Simvastatin
Omega 3 Acid
Vitamin E
II. Pertinent Findings
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Initial Exam
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VA sc
OD: 20/30-1 PH 20/20-2
OS: 20/25-1 PH 20/20
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Amsler Grid OD: Superior Distortion
OS: Normal
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Dilated Fundus Exam
 OD: cluster of blot hemorrhages and swelling following
distribution of retinal venule
 OS: Normal ocular health
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Macular OCT
 OD: Central Thickness 282, intraretinal thickening inferior
temporal to macula
 OS: Central Thickness 234, normal foveal contour
OD
OD
OS
OD
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Differential Diagnosis
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Impression
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Following consult with ophthalmology, patient asked to:
1. Return in one month.
2. Begin home Amsler Grid.
3. In case of deterioration, Anti-VEGF was planned.
Two Week Follow-Up- An Early Return
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OD
Branch Retinal Vein Occlusion
Plan
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Branch Retinal Vein Occlusion (BRVO)
 Risk factor of coronary artery disease
 Intraretinal hemorrhages and macular edema consistent with
typical presentation
Juxtafoveal Retinal Telangietctasia (JFRT)
 Age and sex of patient consistent with unilateral, idiopathic
presentation that JFRT can exhibit
 Often presents with exudates which are not present in this
patient.
Diabetic Retinopathy (DR)
 Blot hemorrhages and macular edema consistent with DR
 Medical record showed regular care and labs were not
indicative of diabetes
Choroidal Neovascular Membrane (CNVM)
 Age of patient appropriate for suspicion of CNVM due to
macular degeneration
 No drusen or pigmentary changes in either eye.
Patient returned two weeks early with worsening vision and
increased Amsler Grid distortion in the right eye.
Best corrected visual acuity worsened in the right eye to 20/40Dilated Fundus Exam
 OD: Cluster of hemorrhages, 1DD of edema inferior to macula.
Also noted: a grey-green appearance in the edematous area.
Macular OCT
 OD: Central thickness 372 microns, change analysis of +90
microns, thickening with disruption and elevation at level of
RPE/choroid
 OS: Central thickness 230 microns, stable & normal
OS
OD
 Fluorescein Angiography (FA)
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OD: Early, well-defined hyperfluorescence consistent with a
classic choroidal neovascular membrane
OS: Normal
OD
III.
Differential Diagnosis: Causes of CNVM
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Age-Related Macular Degeneration
 Age and smoking status of patient suggestive
 No drusen or RPE disruption in diseased or fellow eye.
Myopic Degeneration
 Patient is not myopic.
Angioid Streaks
 None present.
Trauma
 No history of trauma.
Inflammation (such as Presumed Ocular Histoplasmosis Syndrome)
 No signs of ocular inflammation
 No risk factors in medical history for inflammatory disease.
IV. Diagnosis and Discussion
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V.
Final Diagnosis: Idiopathic Choroidal Neovascular Membrane
 No associated signs suggesting underlying disease process.
OCT failed to show the lesion early on, but later did at follow-up. The diagnosis
was then confirmed with a fluorescein angiogram.
 Variability exists in the literature regarding the detection of subtle OCT
changes in chorioretinal disease9.
 Some report morphologic changes on OCT precede subjective and
functional changes8, while others cite discrepancies between FA and OCT
in the detection of macular disease.
It has been suggested that a retinal vein occlusion could preclude the
development of a CNVM 1, but this does not seem likely in this case.
 The lack of collateral vessel formation does not point to a causal
relationship.
 If this was the case, it would likely occur more frequently in ischemia
from diabetic retinopathy and retinal vein occlusion, which are the two
leading causes of retinal vascular disease in the United States1,2.
Treatment & Management
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Following the FA, a treatment series of three intravitreal Lucentis injections was
initiated.
 The patient will return in 1 month for the second injection.
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Anti-VEGF therapy has been successfully used in the treatment of neovascular
AMD, proliferative diabetic retinopathy, retinal vein occlusion, diabetic macular
edema and retinopathy of prematurity2,7.
 Large clinical trials investigating anti-VEGF for idiopathic CNVM have not
been performed, but several smaller studies suggest it is beneficial, safe
and well tolerated for CNVM secondary to non-AMD causes3,4,5,6.
VI.
Conclusion
CNVM, especially idiopathic, can mimic a BRVO. Even in the absence of
associated signs and risk factors, CNVM must remain a top differential
diagnosis in cases of macular edema with intraretinal hemorrhaging.
o OCT provides limited information in the early detection of choroidal changes,
and fluorescein angiography remains an important diagnostic indicator in
chorioretinal disease of unclear etiology.
o Home Amsler Grids can detect subtle changes and facilitate earlier diagnosis
and treatment.
o Lastly, anti-VEGF has become the standard treatment for chorioretinal
diseases involving the macula.
o
VII. Bibliography
1. Fea, Antonio et al. Subfoveal choroidal neovascularization in a patient with
hemicentral vein occlusion. Int Ophthalmol 2010; 2=30: 207-210.
2. Channa, R, et al. “Treatment of macular edema due to retinal vein occlusions.”
Clinical Ophthalmology 2011:5 705-713
3. Ciulla, Thomas A. et al. Anit-Vascular endothelial growth factor therapy for
neovascular ocular diseases other than age-related macular degeneration. Curr
Opin Opthalmol 20: 166-174.
4. Mandal, Subrata, et al. Intravitreal Bevacizumab for Subfoveal Idiopathic Choroidal
Neovascularization. Arch Ophthalmol. 2007; 125 (11): 1487-1492
5. Chang, Louis K, et al. Bevacizumab Treatment for Subfoveal Choroidal
Neovascularization From Causes Other Than Age-Related Macular Degeneration.
Arch Ophthalmol. 2008; 126(7):941-945
6. Carneiro, Angela, et al. Ranibizumab Treatment for Choroidal Neovascularization
from Causes Other than Age-Related Macular Degeneration and Pathological
Myopia. Ophthalmologica 2011; 225: 81-88
7. Campochiaro, PA, et al. “Ranibizumab for Macular Edema following Branch Retinal
Vein Occlusion.” Ophthalmology 2010; 117 (6): 1102-1112
8. Hoerster, R, et al. “Subjective and functional deterioration in recurrences of
neovascular AMD are often preceded by morphologic changes in optic coherence
tomography.” Br J Ophthalmol (2011) doi:10.1136/bjo.2010.201129
9. Kozak, I, et al. Discrepancy between fluorescein angiography and optical coherence
tomography in detection of macular disease.” Retina. 2008 April; 28(4):538-544