6/12/2019

Optometric Management of Introduction Posterior Segment Pathology  Native Oregonian and Willamette Bearcat

 UC Berkeley School of 2008

 San Francisco VA Residency 2009

 VA Staff Optometrist – teaching

Dave Hicks, OD, FAAO  Regular lecturer at AAO and other meetings

GWCO  No conflicts of interest Portland, OR October 10, 2019

06/11/12 Case 1: Initial Presentation

62 year old Hispanic male, asymptomatic

Ocular Findings: (06/11/12) BCVA: 20/20 OD and OS : ERRL, No APD OU Slit Lamp: 1+ NS OU IOP: 18/18 mmHg @ 1409 : see photos

PMHx: HTN, newly treated Family Ocular Hx: Unremarkable

06/11/12 Differential Diagnosis

 Diabetic  Hypertensive retinopathy  Vascular occlusion (BRVO)  Infectious  Inflammatory

 New or old?

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07/12/12 Case 1: 1 month F/U

No new complaints

Ocular Findings: (07/12/12) BCVA: 20/20 OD and OS Pupils: ERRL, No APD OU Slit Lamp: 1+ NS OU, no NVI OU IOP: 18/18 mmHg @ 1140 Gonio: open to CB 360, no NVA OU

BRVO

07/12/12 07/12/12

08/09/12 Case 1: 2 month F/U

No new complaints

Ocular Findings: (08/09/12) BCVA: 20/20-2 OD, 20/25-1+2 OS Pupils: ERRL, No APD OU Slit Lamp: 1+ NS OU, no NVI OU IOP: 13/14 mmHg @ 0905 Gonio: open to CB 360, no NVA OU

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08/09/12

OD: 1 month progression

08/09/12 BRVO

 Signs/Symptoms: Usually unilateral  Normal or decreased vision  or VF defect Fovea  Intraretinal hemes, respect horizontal raphe  CWS or diffuse  Dilated/tortuous vein(s)  Retinal and/or macular  Retinal neovascularization  Vitreous heme, RD, NV all possible

Superior to fovea

BRVO BRVO Work-Up

 Systemic disease?  Pathophysiology  , DM  A/V crossings with common adventitial sheath  Consider blood tests: BS, CBC, ESR, etc  Artery wall thickening compresses lumen of vein → altered flow and thrombus formation  PCP for cardiovascular disease, BP, etc.  ↑ vascular permeability → hemes/edema ○ Retinal vascular bed organized without collaterals  Anterior segment with gonio  Elevated VEGF levels  NVI or NVA

 180,000 eyes/yr in US have RVO (80% BRVO)  Posterior segment with DFE  NVE or  Consider IVFA

BRAVO Investigators. Ophthalmol 2010; 117:1102-1112.

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BRVO Studies BVOS: Laser for macular edema

 Group 3 study question  Branch Vein Occlusion Study (BVOS)  Is argon laser photocoagulation (ALP) useful  7/1/1977 to 2/28/1985 in improving VA in patients with VA 20/40 or  Multi-center, randomized, controlled worse from macular edema (ME) secondary to  Study Design: BRVO? ○ Group 1 – at risk for neovascularization ○ Group 2 – at risk for vitreous hemorrhage  Yes ○ Group X – at high risk for neovascularization  If ME present & VA is 20/40 ○ Group 3 – at risk for vision loss from ME or worse:  Patients could be in more than 1 group ○ Observe for min 3 months ○ Consider grid ALP ○ 502 patients total

BVOS Group. Am J Ophthalmol 1984; 98:271-282. BVOS Group. Am J Ophthalmol 1984; 98:271-282.

RanibizumaB for the Treatment of Sustained Benefits from Ranibizumab Macular Edema following for BRAnch Retinal Vein Occlusion: Macular Edema Following Branch Retinal Vein Occlusion: Evaluation of Efficacy and Safety 12-Month Outcomes of a Six-Month Primary End Point Results Phase III Study of a Phase III Study

BRAVO: 12 Month Results BRAVO: 12M Results

 Treatment period – initial 6 months  “As-needed” Lucentis  Lucentis or sham every month  0.3mg group: 2.8 injections, 79.1% needed  Grid laser considered at month 3  0.5mg group: 2.7 injections, 76.3% needed  Sham/0.5mg: 3.6 injections, 82.1% needed  Observation period – months 6-12  “As-needed” Lucentis (0.3 or 0.5mg)  Rescue grid laser received  Grid laser considered at month 9  0.3mg group: 30.6%  0.5mg group: 23.7%  Sham/0.5mg: 23.5%

BRAVO Investigators. Ophthalmol 2011; 118:1594-1602. BRAVO Investigators. Ophthalmol 2011; 118:1594-1602.

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Visual Acuity Macular Edema

BRAVO Investigators. Ophthalmol 2011; 118:1594-1602. BRAVO Investigators. Ophthalmol 2011; 118:1594-1602.

BRAVO: 12M Summary

 Ranibizumab (Lucentis) works  Unprecedented gains in BCVA & CFT at 6 months  As-needed dosing can maintain BVCA & CFT  Does not alter underlying pathophysiology of vein blockage

 Earlier treatment is better  Sham group didn’t do as well overall  Unclear effect if BRVO >12 months

BRAVO Investigators. Ophthalmol 2011; 118:1594-1602.

Optometric Management Case 2: Initial Presentation

63 year old Caucasian male, asymptomatic  Patient education Ocular Findings: (06/23/11)  Contact primary care physician BCVA: 20/20 OD and OS Pupils: ERRL, No APD OU  Lab testing Slit Lamp: 1+ NS OU IOP: 21/22 mmHg @ 1340  Monitor for neo/retinal edema  Monthly then extend PMHx: white coat HTN w/o tx, pernicious , hyperlipidemia, psoriasis, Vit D deficiency, IFG, smoker  Refer to BP Left Arm Sitting at 1535: 169/95, 67

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06/23/11 06/23/11

Differential Diagnosis Case 2: 1 Month F/U

Remains asymptomatic  Hypertensive retinopathy  Ocular Findings: (07/27/11)  Ischemic BCVA: 20/20 OD and OS (NAION/AAION) Pupils: ERRL, No APD OU  Infectious Slit Lamp: 1+ NS OU IOP: 16/19 mmHg @ 1538  Inflammatory Gonio: open to CB 360, no NVA OU  Vascular occlusion

07/27/11 CRVO

 Signs/Symptoms: Typically unilateral  Painless loss of vision, (+)RAPD  Retinal hemes in 4 quads (Blood & Thunder)  Dilated/tortuous retinal veins  edema, hemes, shunt vessels  CWS, retinal and/or macular edema/ischemia  Retinal//Angle neovascularization  Vitreous heme, RD, NV Glaucoma all possible

CRVO

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CRVO CRVO

 Ischemic and non-ischemic types (historical)  Pathophysiology  Non-ischemic:  Thrombus forms in central retinal vein ○ No RAPD  Occlusions primarily at or posterior to lamina ○ Mild fundus findings cribrosa (partial) ○ VA usually better than 20/400  Reduced outflow → increased venous pressure ○ Up to 1/3 become ischemic  VEGF production  Ischemic: ○ RAPD  Macular edema ○ Multiple CWS, extensive hemes and nonperfusion  Impedance of arterial flow ○ VA usually worse than 20/400

 Incidence: 30,000 in US (0.5% population)  Newer studies: variable ischemia in all pts

CRUISE Investigators. Ophthalmol 2010; 117:1124-1133.

CRVO Work-Up Case 2: 2.5 Month F/U

 Systemic disease? Remains asymptomatic  Hypertension, DM  Blood tests: BS, CBC, ESR, ANA, FTA-ABS Ocular Findings: (08/16/11)  PCP for complete eval BCVA: 20/20 OD and OS  Anterior segment with gonio Pupils: ERRL, No APD OU  NVI or NVA Slit Lamp: 1+ NS OU IOP: 16/12 mmHg  Posterior segment with DFE Gonio: open to CB 360, no NVA OU  NVE or macular edema/ischemia  Consider IVFA

08/16/11 06/19/12 07/24/13 CRVO Studies

 Central Vein Occlusion Study (CVOS)  8/1/1988 to 8/31/1992  Multi-center, randomized, controlled  714 eyes of 725 patients  Followed every 4 months for 3 years

 Eligibility  Retinal hemorrhage in all 4 quadrants  Dilated retinal veins  No diabetic retinopathy  No retinal disease in study eye

CVOS Group. Arch Ophthalmol 1997; 115:486-491.

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CVOS: Natural Hx Study CVOS: Natural Hx/Mgmt

 Outcome measures  Initial VA largely predictive of VA at 3 yrs  Iris neovascularization (INV)  Initial 20/40 or better → 65% maintain VA  Neovascular glaucoma (NVG)  (VA)  Initial 20/50 – 20/200 → variable ○ 19% improve  Findings and recommendations ○ 44% maintain  Prompt PRP only after INV/ANV develops ○ 37% decrease to < 20/200 ○ Non-perfusion developed fastest in first 4 months   No treatment for macular edema Initial <20/200 → 80% remain or worse ○ Highest risk for NVI or NVA (54%)  VA more important than FA for prognosis

CVOS Group. Arch Ophthalmol 1997; 115:486-491. CVOS Group. Arch Ophthalmol 1997; 115:486-491.

70 y/o Caucasian M

20/150 Ischemic CRVO Old CRVO OD s/p extensive laser

CVOS – edema improves with laser CRVO Studies treatment but VA does not

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Collaterals on ONH are common after CRVO Optometric Management 03/06/11 10/02/14

 Patient education

 Contact primary care physician  Lab testing

 Monitor for neo/retinal edema  Monthly then extend

 Refer to ophthalmology

Ranibizumab for the Treatment of Visual Acuity Macular Edema after Central Retinal Vein OcclUsIon Study:

Evaluation of Efficacy and Safety

Six-Month Primary End Point Results of a Phase III Study

CRUISE Investigators. Ophthalmol 2011; 118:2041-2049.

Macular Edema

CRUISE Investigators. Ophthalmol 2011; 118:2041-2049.

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10/02/14 Retinal Emboli

 Cholesterol (Hollenhorst plaques)  Bifurcation of retinal arteries  Carotid arteries  Calcific  Near ONH  Heart valves  Fibrinoplatelet, fat, air also possible

 1% of population over age 40, 3% over 75  Associated with carotid artery plaque and stenosis, HTN, smoking, and DM

Retinal Emboli Work-Up Case 3

 Symptomatic – ER 64 year old Caucasian male  Asymptomatic – PCP CC: Black spot OS, central, some wavy lines, no decrease in vision, sudden onset  All – CVD risk assessment, carotid imaging?, labs Ocular Findings:  Some – EKG BCVA: 20/20 OD and 20/20 OS Pupils: ERRL, no RAPD OU Slit Lamp: unremarkable OU Stroke: ~6x risk IOP: 16/16 mm Hg @ 1433 Fundus: see photos Death: ~2x risk h/o oral prednisone, anxiety

BDES. Arch Ophthalmol 1999; 117:1063-1068.

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04/12/12 Differential Diagnosis

 ERM  CSR  PED  CNV  White dot syndrome

20/20 OU

05/11/12

Referred to specialist

20/100 CNV – pt gets Lucentis

Exudative (Wet) AMD 06/22/12

 Can be difficult to detect with 90D  Grey-green membrane  Subretinal or sub-RPE hemorrhage  Exudates  Subretinal fluid  Retinal thickening

 Listen to symptoms  Amsler grid  Retina referral

Zayit-Soudry et al. Surv Ophthalmol 2007; 52 (3):227-243 20/40+ Pt gets Lucentis again

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08/20/14 78 y/o Caucasian M

20/80-2 s/p Lucentis x 10 20/400

Hemes, disciform scarring, SRF Hemes, disciform scarring, SRF

Optometric Management Case 4

58 year old Caucasian male  Careful assessment CC: blurry vision OU x 1 year, distortion OD  Time of onset? Ocular Findings: (06/30/10)  Patient education BCVA: 20/50+2 OD and 20/30- OS  Smoking cessation, ocular multivitamins Pupils: ERRL, no RAPD OU  Available treatments (Anti-VEGF) Slit Lamp: unremarkable OU IOP: 15/15 mm Hg @ 1415 Fundus: see photos  Refer to ophthalmology Long h/o smoking 1/2 ppd, HTN

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6/30/10 6/30/10

20/50+ 20/30-

12/01/10 OD: 1 year progression

20/200- 20/50- to FC @ 2 ft

Non-exudative (Dry) AMD

4757 pts

AREDS Group. Arch Ophthalmol 2001; 119:1417-1436.

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Non-exudative AMD Optometric Management

 AREDS Ocular multivitamins  Patient education  Vitamin C 500mg, Vitamin E 400 IU, Beta Carotene  Smoking cessation 15mg, Zinc 80mg, Copper 2mg  Ocular multivitamins – side effects, benefits

 25% risk reduction by taking antiox + zinc  AREDS2 Formula vs. other OTC  20-28% risk of progression to advanced AMD (includes  Lutein 10mg, Zeaxanthin 2mg, DHA 350mg, categories 2 thru 4) EPA 650 mg

 Category 3: 6-27% risk of developing  Monitor for CNV advanced AMD at 5 years Vitamins for categories 3-4  Refer to ophthalmology if CNV develops  Category 4: 43% risk at 5 years

AREDS Group. Arch Ophthalmol 2001; 119:1417-1436.

72 y/o Caucasian M 72 y/o Caucasian M

20/150+ Drusenoid PED vs. CNV 20/200

90 y/o Caucasian M

Atrophy

20/40 Drusen Geographic atrophy, drusen

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Disciform scarring, SRF

Conclusions

 Primary care optometrists often encounter retinal condition that require intervention

 Additional testing or referring to specialty care may be necessary

 Optometrists can and should play a large role in managing retinal pathology (and systemic health)

Thank you! References

 BVOS Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol 1984; 98:271-282.  BVOS Group. Argon laser scatter photocoagulation for prevention of neovascularization and vitreous hemorrhage in branch vein occlusion: a randomized clinical trial. Arch Ophthalmol 1986; 104:34-41.  CVOS Group. Natural history and clinical management of central retinal vein occlusion. Arch Ophthalmol 1997;115:486-491.  CVOS Group. Evaluation of grid pattern photocoagulation for macular edema in central vein occlusion: the CVOS Questions? group M report. Ophthalmology 1995;102:1425-1433.  CVOS Group. A randomized clinical trial of early panretinal photocoagulation for ischemic central vein occlusion: the CVOS group N report. Ophthalmology 1995;102:1434-1444. [email protected]  Heier JS, Campochiaro PA, Yau L, Li Z, et al. Ranibizumab for macular edema due to retinal vein occlusions: Long- term follow-up in the HORIZON trial. Ophthalmol 2012; in press.  Campochiaro PA, Heier JS, Feiner L, et al. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology 2010;117:1102-1112.  Brown DM, Campochiaro PA, Bhisitkul RB, Ho AC, et al. Sustained benefits of ranibizumab for macular edema following branch retinal vein occlusion: 12-month primary end point results of a phase III study. Ophthalmology 2011;118:1594-1602.  Brown DM, Campochiaro PA, Singh RP, et al. Ranibizumab for macular edema following central retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology 2010;117:1124-1133.  Campochiaro PA, Brown DM, Awh CC, Lee SY, et al. Sustained benefits from ranibizumab for macular edema following central retinal vein occlusion: 12-month primary end point results of a phase III study. Ophthalmology 2011;118:2041-2049.  Hayreh SS. Prevalent misconceptions about acute retinal vascular occlusive disorders. Prog Retin Eye Res 2005;24:493-519.  AREDS Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with References available upon request vitamins C and E, beta carotene, and zinc for age-related and vision loss – AREDS report no.8. Arch Ophthalmol 2001;119:1417-1436.

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