Download document 8028393

25/02/2014
Disclosure

Retina in Your Chair: Treat
if or Out of There??
I have been on advisory boards/a consultant
to/received honoraria from/ or been on speakers
bureau list of the following:

Allergan, Alcon, Arctic Dx, Bausch
& Lomb, Carl Zeis Meditec, Essilor, Optos, Optovue,
Reichert,
VSP, ZeaVision
Jeffry D. Gerson, O.D., F.A.A.O.
Shawnee, KS
[email protected]

What does
this mean to
you?
34yo female
Need Rx for CL’s (1-800) wouldn’t fill
20/20 vision OU
 VF, EOM, Pupils normal
 Med Hx: Normal except overweight
 Meds: None, but going to weight loss
“clinic”
 Oc Hx: Normal
 Ant seg: normal
 Post seg: as seen
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Follow-up
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1 month later
Has lost a few pounds
on program
Still 20/20, refraction
unchanged
Post seg improved
On meds for HTN
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What next?
BP: 150/94
Prescriber?
FBG in office: 134
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25/02/2014
Disaster Strikes
1 yr f/u
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Normal retinal exam with exception of
tortuous vessels, no hemes or exudates
Systemic health has been good
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Recently stopped taking BP Med
Never really lost any weight
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BP checked in office
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Random Blood sugar in office
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140/92
142
What do you suggest now?
Disaster…..
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Pt called PCP yesterday w sx and unable
to speak w Dr or nurse, told may want to
go to urgent care or ER
Instead, came to me next day: still w sx of
dizzy, nausea, malaise and faint
Complaining of blurred vision OD>OS, FBS
OD
OcHx: CE OS 6yrs ago
Meds: Lantus (6units TID), Statin, HTN
med
SMBG: never
Exam Findings
Entering VA: 20/400 OD 20/200 OS
Refract: -4.00
20/80
+3.75-4.25x125 20/30Anterior Segment: see photo below
Posterior segment: OD: unable to see
OS: mild NPDR, no CSME
RBG: 554mg/dL A1c: >13
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The Talk…
I WANT HER OUT OF MY CHAIR
But Where to??
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Discussed grave nature of
situation..cataract surgery can wait!
Had husband drive her to the hospital**
She returned 2 wks later for Cataract eval
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Had been in hospital for 1 wk, Dx w CHF
Was home for 3 days, than back for 3 days
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Released 2 days before appt w me
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The EMERGENCY ROOM!!!
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CT/MRI and ultrasounds, full cardio w/u
Now has new PCP….new lease on life!
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25/02/2014
What would you do with this…
1 yr f/u
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Has had CE on and YAG in other eye
20/25 OU BCVA
New PCP, on Metformin and Byetta
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A1c between 6 and 6.5
No NPDR present
A completely different person
In this case, no “wrong” answer….
Your worst patients…
65yo male
 Occupation: retired, but used to be field
medic in military
 “My optometrist referred me because of
my right eye, I am not sure what is wrong”
 “Good general health, my blood pressure
runs low”
 My exam…
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Hypertension??
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Vision: 20/400 OD
Anterior Segment: normal
Blood Pressure: 196/120
What next….
Sent to PCP directly from
office
Started on HTN meds
Returned for laser 2 wks
later
Hypertension
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50-60 million Americans have systemic HTN (by
today’s standards)
Usually asymptomatic, but can lead to MI, PVD,
CVA, renal disease, retinopathy
Significant CVD risk at 140/90, and risk doubles
with every increase of 20/10mmHg
Risk factors include smoking, dyslipidemia, DM,
age, family history, race, sedentary, obese,
sodium…
Hypertension
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Category*
Systolic
Diastolic
Normal
<120
<80
Pre-HTN
120-139
80-89
Stage 1
140-159
90-99
Stage 2
>160
>100
HTN
Malignant
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>120
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Refer to PCP in timely
manner
Goal of BP reduction to
as low as tolerated
Most patients will require
2 medications
Lifestyle modification
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30 minutes of physical
activity >4 days/wk can
lower SBP by up to
9mmHg
Weight loss of 10kg can
lower SBP by 5-20mmHg
*The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH
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25/02/2014
Branch Retinal Vein Occlusion
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ME and 20/25-…What would you have done
in 2008 and now in 2014?
Major BRVO
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1st order temporal
branch at ON or 1st
order away from ON
but involving macula
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Minor BRVO
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Peripheral BRVO
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Only macular branch
No macular
involvement
So pt presents
with VO & ME
THESE are TODAY’S FDA approved
options
Anti-VEGF
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First and foremost: Any ME from VO is
no longer an “optometric” management:
There is proven benefit to Tx
that are implemented earlier
than before
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Which treatment is best?
 Not exactly
up to us…But sort of
….you choose!
Steroid implants
Ozurdex for BRVO and CRVO
Bravo/cruise
For BRVO/CRVO
VEGF-trap
Galilelo/copernicus
For CRVO
Laser for BRVO/ME
BVOS
Retinal specialists preferred tx option & when they decide to tx may remain
controversial in regards to what is standard of care. Yet, many employ AVT
more frequently & start treating earlier than before
What about ASA / Anti-platelet use?
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Historically thought to be beneficial especially
in light of likely systemic Dz
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When Sohan Singh Hayreh speaks..people
listen
ASA does not improve (actually worsens)
outcomes in CRVO and HRVO pts
Ok to cont if needed, but don’t start because
of
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So, what is the new standard
for BRVO and/or CRVO
Bottom line: Options available and no
clear RIGHT answer. The wrong answer
now seems to be: DO NOTHING
So, when do they need to be out of your
chair??
S.S. Hayreh: CRVO/HRVO and anticoagulants. Ophth. 8/11.
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25/02/2014
Central “Spot”
Central Serous Choroidopathy
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Characterized by breakdown of the outer retinal barrier,
with leakage of fluid through a defect in the RPE into the
subretinal space, resulting in a neurosensory
detachment
Often times associated with high stress +/
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50yo female referred in with a “spot” in the center of her
vision
Present for 1-2 wks
Referring OD noticed abnormality
VA 20/20 OU
Denies High stress or type “A” personality
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ED (Emotional Distress) may be related1
FA or OCT must be done to rule out CNVM
Other systemic associations
Use of corticosteroids* (Well documented in literature),
pregnancy, increased adrenaline level, hemodialysis, collagen
vascular disease, and hypertension
Treatment?
Letter of diagnosis to PCP to make aware
1. Conrad et al. Alexithymia and emotional distress in ICSC. Psychosomatics. 2007 Nov-Dec;48(6):489-95
ICSC
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What would “FA” look like?
Proposed Treatments?
 You fill in the blank
 Anti-VEGF
Is it too easy to be
successful with new
treatments??
Can this be treated
“Optometrically”?
Classic “smoke stack”
These are not FA’s:
They are en-face
OCT scans
PDT for RPE leaks in CSC. Ober, M et al. Ophthalmology. Dec. 2005.
ISCS…getting all the facts…
Was this the initial
presentation…and how would we
know???
Hyperautofluorescence: Metabolically overactive: Dying
Hypoautofluorescence: Metabolically inactive: Dead
*
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25/02/2014
New Guidelines per AAO
(the other one)
Plaquenil Screening: A HOT TOPIC!!
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Historical screening tests:
Baseline macula photos
 Color vision testing
 Amsler grid
 10-2 Visual fields
 Yearly exams
 Very rare to find plaquenil toxicity
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We now know that if we use these
techniques, we will be too late!!
Risk increases sharply to 1% at 5-7yrs or
cumulative dose of 1000g (usual dose
400mg/d HCQ or 250mg/d CQ)
 New screening guidelines include baseline
exam and then annually at 5yrs
 Objective tests: mfERG or FAF or SDOCT
 Subjective test: 10-2
 Fundus exam still important, but findings
are generally late stage
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Recommendations screening for CQ and HCQ Retinop.Marmor et al. Ophthalmology 2/11
So what about this pt on Plaquenil?
Color Optomap: Note macular
change
Fundus Image OD
What do you think?
What next??
Case 5: Optomap® FAF OD
PAF images reveal a peri-foveal ring of hypo AF in each eye.
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25/02/2014
So, Plaquenil in your
chair….???
62yo Female 20/20 OU
When do you want these patients in your
chair?
 When do you want them out?
 How if at all do you communicate?
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20/20 OU
Anterior seg normal
 IOP, VF, pupils WNL
 What else do you
want to know?
 ???What is this
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Debbie…a patient for over 10yrs
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With Patient
With Rheumatologist
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So, What is the true standard of care??
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Can we utilize fellow OD’s to perform
necessary scans?
Stargardt’s
Dystrophy
• Vision approximately 20/100
and stable for years
• Always wondering if vision will
get worse
• Some difficulties w job, but
nobody at workplace knows of
visual difficulties
• Drives w Bioptic and has for
years
What is the dx and can we tell if she is getting worse?
In your chair or out of there??
 38 yo male
Dangers of Addiction
 Healthy
• Does a patient with Stargardt’s need to be
referred out for treatment?
 No meds, but…
 Viagra PRN
 Frequent Alcohol
• What is the treatment?
 20/20 OD, 20/30 OS
• What about Low Vision rehab when needed?
 Ant Seg healthy
 Retina OS as seen
 Diagnosis?
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25/02/2014
Valsalva
Would you refer this patient
out??
 Not generally associated
with systemic disease,
but…
 More common in people with
DM, HTN, and sickle cell
 Typical ocular findings:
 Pre-retinal heme, sub-hyaloid
heme
 Caused by sudden raise in
intrathoracic pressure,
which leads to Increased
intraocular venous pressure
 Causes break in macular
capillary
“Drunken Pumpkin”
Valsalva Maculopathy
Uveitis…
 Common causes:
 Vomit, cough, sneeze,
constipation, exertion
 Often seen with alcoholism,
• 36yo w multiple
recurrences
bulemia and GI problems
 Tend to resolve on own
• 20/20 Vision
 No long lasting damage
• Retina unaffected
 What caused condition in this
patient?
• Systemic: ??
What if macula looked like this??
What if….
• The last patient is 78yo
• Ant seg clear
• PCIOL OU
• CE was 5 mos ago?
• Treat or refer?
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25/02/2014
What would you do about
‘postpost op’ CME??
Normal Macula with h/o Uveitis
4/08
• 39 yo AA female
• H/o uveitis
• H/o previous subtenons steroid for CME
• Just finishing PF Taper
and initially 20/20
• Then returned with
20/30
Same patient, later recurrence
5/8/08
5/15/08
5/27/08
Change over time analysis
Foveal lift
Threshold of
350microns
Timeline
Intraretinal
cysts
Does this
patient
need to
be
referred?
Ultimately retinal
thinning upon resolution
Clearly defined cyst
walls
Change in thickness
over time: ultimate
foveal thickness 219
Another view of change over time
Just 2 mos ago
• 42yo healthy Caucasian
2 mos ago
female
• Work-in appt for
“flashes in vision”
• 2 mo ago exam,
completely normal
exam
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25/02/2014
2 wk F/u:
All normal blood
work
What is it??
Ophthalmologist Dx: Capillary Periphlebitis, no
further testing necessary
Has now had
normal carotid,
cardio echo and
more blood work
Normal CBC, PT, PTT, ANA, SED, CRP, B12, A1c, Ferritin,VWF,
factor 5, high LDL and Cholesterol, BP 118/84
What about the periphery?
• When do you send patients out for second opinion to an
ophthalmologist?
Retinal picture has
changed some, but
not “better”
Yesterday in the office
• 34yo cauc female
• Got hit in eye last night w
volleyball
• No f/f noted
1. Peripheral retinal hemorrhage
2. Lattice degeneration
3. Lattice degeneration with holes
4. Asymptomatic retinal break
• Vision is good but blurred
spot above
• No pain
• Ant seg normal
5. Symptomatic retinal break
Now What???
Keep in your chair or out of there?
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25/02/2014
1 week later..complete resolution
of retinal signs and VF defect
Keep in chair, or out of there?
A quick preview for Grand
Rounds: WWYD
Retina in your chair
18 yo male
Serious soccer player
No sx upon
questioning
Healthy fellow eye
• It is often a fine line between what you will keep in your
chair and what will be “out of there”
• Each of us has to set that line for each condition that we
might see (before we see it)
• There may not be a “right” answer, but there are some
WRONG answers
• Utilize clinical exam, technology AND critical thinking to
make reasonable decisions
THANK YOU!
Jeffry D. Gerson, O.D., F.A.A.O.
[email protected]
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