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Home , Macular edema

Amy Zhang

Macular Complications: Treatment and Management Abstract Macular edema has various etiologies and can be complicated by concurrent diseases and medications. This case differentiates the various causes and discusses the challenges in diagnosing, treating and managing macular edema.

I. Case History • Chief complaint: Evaluation of macular edema secondary to Irvine Gass Syndrome vs. Diabetic Macular Edema • Ocular History: o IDDM with h/o PDR s/p PRP OD, h/o longstanding DME OD s/p multiple injections with no improvement o POAG OU, treated with QHS OU, treatment initiated in 2005 o Pseudophakia OU s/p YAG OD, s/p CE/IOL 10/15/2015 OD, 12/21/2015 OS II. Pertinent findings • Clinical Exam on 7/11/2017 with Specialist o VA sc: OD: 20/50 PH: NI; OS: 20/20; IOP: 17 OD, 17 OS o Pertinent findings: ▪ ONH C/D: 0.60/0.60, distinct margins OU ▪ Macula: macular edema OD; clear, flat OS ▪ Posterior Pole: dot/blot hemes, MAs, IRMA, venous beading OU ▪ Periphery: PRP scars OD, clear/intact OS o OCT: intraretinal fluid OD, normal contour OS o IVFA: diffuse leakage in macula, no active neovascularization OD, clear OS o Assessment/Plan: ▪ IDDM w/ PDR OD s/p PRP OD, CSME OD; focal laser OD same day ▪ DME vs. Irvine Gass Syndrome; Trial of topical Diclofenac 0.1% QID OD and RTC in 2 weeks and continue Eylea OD ▪ POAG OU; Switch Latanoprost QHS OU to Cosopt BID OU, concern of prostaglandin contributing to macular edema • Follow up on 8/10/2017 o VA sc: 20/50+2 OD (improved) PH: NI; 20/20 OS (stable); IOP: 12 OD, 12 OS o Pertinent Findings: ▪ ONH C/D: 0.60/0.60, distinct margins OU ▪ Macula: Improved macular edema OD; clear, flat OS ▪ Posterior Pole: dot/blot hemes, MAs, IRMA, venous beading OU ▪ Periphery: PRP scars OD; clear/intact OS o OCT: improved intraretinal fluid OD, normal contour OS o Assessment/Plan: ▪ IDDM w/ PDR OD s/p PRP OD and focal OD; improving CSME OD; Eylea OD same day. RTC in 4-6 weeks for OCT macula and possible Eylea OD ▪ POAG OU; Continue with Cosopt BID OU III. Differential diagnosis • Primary/leading o Diabetic macular edema o Irvine Gass syndrome (cystoid macular edema) s/p surgery • Others: Exudative age related , CRVO, BRVO Amy Zhang

IV. Diagnosis and discussion • Elaborate on the condition o Macular edema has many causes such as DME or Irvine Gass syndrome. Macular edema is a build-up of subretinal or intraretinal fluid resulting in decreased vision. Treatment options include focal laser and anti-VEGF or steroid injections. o Irvine Gass syndrome (cystoid macular edema) is the most common cause of decreased vision following . It is characterized by cystoid areas of fluid in the macula that result in macular thickening and decreased vision. Treatment options include topical steroids, anti-VEGF or steroid injections. • Expound on unique features o Macular edema associated with diabetic was not improving after multiple injections o Macular edema complicated by use of Latanoprost. Risks of Latanoprost include CME (especially in post-op cataract surgery) and increased inflammation. V. Treatment, management • Treatment and response to treatment o Lucentis x 3 with no improvement. Switched to Eylea injections x 2 with no improvement. Switched to Triescence injection x 1 with improvement. Triescence also led to an increase in IOP. o Re-initiated Eylea x 4 and edema worsened o Focal laser OD in combination with discontinuation of Latanoprost and trial of topical Diclofenac 0.1% QID OD resulted in improved macular edema • Refer to research where appropriate o Lucentis is a good first line treatment for DME and Irvine Gass o Topical NSAIDs and steroids are used for prophylaxis and treatment of Irvine Gass s/p cataract surgery o Steroid injections are an effective treatment for Irvine-Gass syndrome o Eylea is a good alternative when patients are unresponsive to Lucentis injections • Bibliography, literature review encouraged o "Intravitreal for the treatment of cystoid macular edema in Irvine- Gass syndrome." o "A review of Ranibizumab for the treatment of ." o "Topical for prevention and treatment of cystoid macular edema following cataract surgery: a review." o " implant as an effective treatment option for macular edema due to Irvine-Gass syndrome." o "Switch to in diabetic macular edema patients unresponsive to previous anti-VEGF therapy." VI. Conclusion • Clinical pearls, take away points if indicated o This case illustrates the challenges in diagnosing and treating macula edema. o Be careful in prescribing Latanoprost to a patient with macular edema and cataract post op patients. o Remember Latanoprost side effects: increasing the risk of macula edema and increasing inflammation o Remember macular edema in diabetic patients is not always DME