Download V. Wong - American Academy of Optometry

Veronica Wong
Primary Eye Care Resident
Southern College of Optometry
Topic – Posterior Segment
Abstract Title - Intravitreal Bevacizumab for the Treatment of Peripapillary Choroidal Neovascular Membrane
Associated with Idiopathic Intracranial Hypertension
Abstract Text - Peripapillary choroidal neovascularization is a rare secondary complication of idiopathic
intracranial hypertension that can cause profound vision loss due to extension into the macula. This case
details a patient who was treated with intravitreal bevacizumab.
I. Case History
 Patient demographics
28-year-old, African American female
 Chief complaint
Patient was referred by local OD for retinal evaluation. Patient complained of cloudy, distorted vision
OD. She stated that it has been constant for the past 10 months and had gradually increased in size
and severity. It was described as a large, black, hazy circular area in her central vision. It was initially
associated with intermittent white flashes and streaks that have decreased.
 Ocular, medical history
-Ocular: No ocular history
-Procedures: No prior ocular surgeries/procedures
-Infectious: No history of infectious diseases
-Illnesses: Migraine
-Surgeries: No prior surgical procedures
-Head/Ocular Trauma: No history of head/ocular trauma
-Social: Denies drinking, never smoker, occupation – receptionist
-Family History: No family history of clinical finding
 Medications
-Diamox Sequels 500 mg 1 cap po bid
-NKDA
 Other salient information
Patient stated that she was recently admitted to the hospital for severe headaches, at which time a
MRI and subsequent lumbar puncture were performed. She reported that MRI findings were
unremarkable and her opening pressure was 55 cm H2O (normal range is 10-20 cm H2O). She was
prescribed Diamox Sequels 500 mg 1 tab bid po and instructed to follow up with neurology. She
admitted to apprehension and non-compliance with neurology follow-up. She eventually sought care
through her local OD who then referred her for a retinal evaluation.
II. Pertinent findings
 Clinical
-Patient was alert and oriented
-Best Corrected distance visual acuity: 20/150 OD, 20/20 OS
-Auto refraction: -2.25 DS OD, -0.50-0.25x163 OS
-IOP: 14 OD, 12 OS @ 1217 with Tonopen
-Confrontation VF: normal OD, OS
-Pupils: 6.5 mm, ERRL, (-) APD OD, OS
-Muscle balance: ortho
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-Ocular motility: normal
-Anterior segment: unremarkable
-Posterior segment: papilledema OU, retina attached OU
-Macula: OD – questionable choroidal neovascular membrane at temporal disc margin with
fluid extending to macula; OS – normal
Physical
-Height 60 in., weight 160 lbs., blood pressure 114/72, BMI 31.42, pulse 85 at initial neurology exam
-Height 60 in., weight 159 lbs., blood pressure 116/72, BMI 31.05, pulse 78 at neurology follow-up
Laboratory studies
-Comprehensive Metabolic Panel: all values within normal range
Radiology studies
-MRV: Negative; no venous sinus occlusions or stenosis
Others
-OCT: OD – disc elevation, juxtapapillary CNV with serous retinal fluid; OS – disc elevation
-IVFA: OD – juxtapapillary CNV, patch of subretinal hemorrhage; OS – mild staining of optic disc
-Fundus photos: OD – disc edema, CNV temporal disc margin, small subretinal hemorrhage along
inferior temporal arcade, multiple drusenoid lesions nasal to disc; OS – disc edema
III. Differential diagnosis
 Primary/leading
Peripapillary CNV secondary to papilledema from idiopathic intracranial hypertension
 Others
N/A
IV. Diagnosis and discussion
 Elaborate on the condition
Idiopathic intracranial hypertension is characterized by headaches and papilledema. Patients are more
commonly females of child-bearing age that have a history of significant weight gain. Permanent vision
loss typically occurs from damage to the optic nerve due to the papilledema. Medical and surgical
management of papilledema can reduce symptoms and prevent loss of vision.
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Expound on unique features
Choroidal neovascularization is an uncommon secondary complication from idiopathic intracranial
hypertension with an estimated prevalence of 0.53%.1 Peripapillary CNV composes only 10% of all types
of neovascularization and can result in 20/500 or worse vision after 3 years if left untreated.2 It is more
commonly found in older patients with age-related maculopathy (45.2%) and can also be idiopathic
(39.1%).3
V. Treatment, management
 Treatment and response to treatment
-Initial exam
-Plan: Ordered same-day intravitreal Avastin injection. Scheduled appointment with
neurologist. Scheduled 1 month follow-up with OCT.
-1 month after initial exam
-CC: Patient reported improved vision OD from last exam. She states that she is taking
Diamox qd instead of bid.
-Corrected distance visual acuity: 20/20 OD, 20/20 OS
-OCT: OD – increased peripapillary swelling, regression of juxtapapillary CNV; OS – increased
peripapillary swelling
-Plan: Discussed extreme importance of appointment with neurologist. Advised patient to
resume Diamox 500 mg twice daily. Scheduled 1 month follow-up with OCT.
-2 months after initial exam (last exam to present)
-CC: Patient reported decreasing vision and pain behind OD for the past 3 days. She stated
that she is scheduled for a MRV in 2 weeks.
-Corrected distance visual acuity: 20/25- OD, 20/20 OS
-Posterior segment: OD – mild papilledema, no retinal hemorrhage, chorioretinal scar
temporal to disc, retina attached
-OCT: OD – edema slightly improved, CNV regressed; OS – edema slightly improved
-Plan: Observe; follow up with neurologist as planned. Scheduled 2 month follow-up with
OCT.
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Refer to research where appropriate
1. Wendel, Lucas, Andrew G. Lee, H. Culver Boldt, Randy H. Kardon, and Michael Wall. “Subretinal
Neovascular Membrane in Idiopathic Intracranial Hypertension.” American Journal of
Ophthalmology 141.3 (2006): 572-74.
2. Jutley, G., G. Jutley, V. Tah, D. Lindfield, and G. Menon. “Treating Peripapillary Choroidal
Neovascular Membranes: A Review of the Evidence.” Eye 25.6 (2011): 675-81.
3. Hamoudi, Hassan, and Torben Lykke Sorensen. “Effect of Intravitreal Ranibizumab in the
Treatment of Peripapillary Choroidal Neovascularisation.” Journal of Ophthalmology 2011
(2011): 1-4.
Bibliography, literature review encouraged
1. Browning, D., and C. Fraser. “Ocular Conditions Associated with Peripapillary Subretinal
Neovascularization, Their Relative Frequencies, and Associated Outcomes.” Ophthalmology
112.6 (2005): 1054-061.
2. Jamerson, Scott C., Guruswami Arunagiri, Brian D. Ellis, and Monique J. Leys. “Intravitreal
Bevacizumab for the Treatment of Choroidal Neovascularization Secondary to Pseudotumor
Cerebri.” International Ophthalmology 29.3 (2008): 183-85.
3. Kaeser, Pierre-Francois, and Francois-Xavier Borruat. “Peripapillary Neovascular Membrane: A
Rare Cause of Acute Vision Loss in Pediatric Idiopathic Intracranial Hypertension.” Journal of
American Association for Pediatric Ophthalmology and Strabismus 15.1 (2011): 83-86.
VI. Conclusion
 Clinical pearls, take away points if indicated
Peripapillary choroidal neovascularization is a rare secondary cause of vision loss in patients with
idiopathic intracranial hypertension. Management of these patients is similar to other retinal
neovascularization with anti-vascular endothelial growth factor agents injected intravitreally in
addition to lowering their cerebral spinal fluid pressure.