Download Marquez, M - American Academy of Optometry

Potential Resolution of Vitreomacular Interaction Associated with Geographic Atrophy
Abstract: Vitreomacular Interaction (VMI) has been linked with pathogenesis and progression of
geographic atrophy (GA). Studies have shown that Ocriplasmin can resolve the vitreoretinal interface
and possibly reduce progression of geographic atrophy.
I. Case History
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Patient Demographics: 66 year old Caucasian male
Chief Complaint: Patient presented to the eye clinic with no complaints. His last eye exam was
in 2011. He denies any noticeable changes in vision.
Ocular History: Ocular history is remarkable for dry AMD OU
Medical History:
o Left middle cerebral artery stroke with resultant severe expressive aphasia
o Receptive aphasia
o Hypertension
o Dysplipidemia
o Obesity
Ocular Medications:
o Preservision supplements 1 tablet BID
Systemic Medications:
o Atorvastatin 80mg
o Metoprolol Tartrate 100mg
o HCTZ/Lisinopril 20mg
o Fish Oil 100mg
Other Salient Information: Patient currently smokes 1 cigarette per day. He has no pertinent
ocular family history.
II. Pertinent Findings
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Clinical
o Vision
 Entering Visual Acuity: 20/60 OD, 3/300 OS with Feinbloom
 Previous Visual Acuity: 20/60 OU
 Best Corrected Visual Acuity: 20/40 OD, no improvement OS
o Entrance Testing
 Extraocular Muscles and Confrontation Fields Normal OD&OS
 Pupils: 1+ APD OS
o Ocular Health
 Slit Lamp Exam
 Unremarkable
 Dilated Fundus Exam
 Diffuse epiretinal membrane OD (not noted in 2011)
 1/4 disc diameter of foveal geographic atrophy (not noted in 2011)
 Macular OCT revealed normal foveal contour with loss of inner retinal
layers
Physical
o Normal
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Laboratory and Radiologic Studies
o None
III. Differential Diagnosis
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Full Thickness Macular Hole
o With the reduction of VAs since the 2011 eye exam and clinical findings on the dilated
fundus exam, the appearance of the lesion resembled a macular hole, which would have
also prompted the use of a macular OCT scan.
Wet Macular Degeneration
o The patient had a history of dry macular degeneration. Due to his noncompliance with
both reporting for follow up exams and usage of AREDS Preservision vitamin, coupled
with his reduction of vision, it was concerning that the patient had developed a
choroidal neovascular membrane.
IV. Diagnosis and Discussion
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Diagnosis: Advanced dry age related macular degeneration with geographic atrophy involving
the center of the macula with an overlying VMI.
Discussion:
o Geographic atrophy (GA) is classified as an end stage form of dry macular degeneration.
o GA is defined as loss of cells in the RPE, outer retinal layers, and choriocapillaris
o Macular drusen always presents before GA
o Category 3 dry advanced AMD
 Definition: Choroidal neovascular membrane development or GA at the fovea
 GA develops within 5-6 years along with confluent soft drusen
 Vision loss is usually not significant until it involves the fovea
o Average progression rate of the area of the lesion varies & depends on:
 size of the atrophy
 number of lesions
o Average Enlargement of GA area per year = 1.2mm2 to 2.8mm2
 Lesions larger in size could grow as much as 6mm.
o The patient in this report likely experienced progression during the 4 years that he was
lost to follow up based on the natural history of the condition.
o OCT is a great diagnostic tool in monitoring patients for increased progression of GA
associated with VMI
 Progression rates in GA patients with VMI = 2.99mm2 +/- 0.66mm2
 Progression rates in GA patients without VMI = 1.45+/-0.67mm2.
 Progression is measured by spectral domain OCT that demonstrates areas of GA
which are distinguished by the greatly reduced signal causing distinct
hypofluorescent areas.
o The patient in this case study possibly had multiple factors contributing to his vision loss
from GA.
 The patient’s OCT shows VMI that is directly above the lesion which raises
suspicion of a multifactorial cause of progression.
o Hypotheses on the effect of VMI on dry AMD:
 Induced mechanical stress between the vitreous and the lesion, similar to that
of studies regarding VMI associated with wet AMD.
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Vitreomacular attachment could confine inflammatory mediators to the
macular region promoting AMD progression or even causing hypoxia to the
macula and causing the release of vascular endothelial growth factor (leading to
wet AMD).
V. Treatment, Management
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Treatment
o Asymptomatic vitreomacular adhesion:
 a pars plana vitrectomy (usually not performed if good vision and/or
asymptomatic)
 pharmacologic vitreolysis
o Ocriplasmin (Jetrea); FDA approved 10/2012
 Intravitreal drug used in the treatment of vitreomacular traction and/or
adhesion.
 Induces separation of the vitreous and retina by day 28
 Also used in patients with macular holes.
 Mechanism of Action: lyses laminin and fibronectin within the vitreous to cause
release from the retina interface.
o Resolution of VMI:
 More effective in younger patients (<65)
 Patients older than 65 already had a spontaneous PVD and were less likely to
respond to Ocriplasmin.
 However, 26.5% of patients had resolution of their VMT.
 28% of patients achieved 2 lines or more of BCVA improvement 6 months after
treatment.
Management
o After discussing treatment options with the patient, he decided that he would no
undergo any treatment. The patient deferred all treatment options and opted to be
monitored.
o The attending retinal ophthalmologist decided to monitor the patient in 4 months.
Bibliography
o Hannan Abdillahi. Vitreoretinal Interface Changes in Geographic Atrophy. American
Academy of Ophthalmology 2014; 121:9: 1734-1739
o Julia Haller. Efficacy of Intravitreal Ocriplasmin for Treatment of Vitreomacular
Adhesion. American Academy of Ophthalmology; 122:1: 117-122
o Frank G. Holz. Geographic Atrophy Clinical Features and Potential Therapeutic
Approaches. Translational Science Review 2014; 121:5:1079-1091
o Priya Sharma. Efficacy of Intravitreal Ocriplasmin on Vitreomacular Traction and FullThickness Macular Holes. American Journal of Ophthalmology 2015; 159:5: 861-867
o Zohar Yehoshua. Progression of Geographic Atrophy in Age-Related Macular
Degeneration Imaged with Spectral Domain Optical Coherence Tomography. American
Academy of Ophthalmology 2011; 118:4:679-686
VI. Conclusion
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The patient discussed in this report had already developed GA within his fovea. Although his
vision was already reduced, there are patients who may have geographic atrophy in areas
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outside of the macula that could benefit from Ocriplasmin treatment to possibly slow the
progression of GA development within the center of the macula caused by a VMI.
Although no treatment options have been identified for curing geographic atrophy, the goal of
Ocriplasmin treatment is to preserve remaining vision and prolong any possible severe loss of
vision.