6/12/2019
Optometric Management of Introduction Posterior Segment Pathology Native Oregonian and Willamette Bearcat
UC Berkeley School of Optometry 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 Pupils: ERRL, No APD OU Slit Lamp: 1+ NS OU IOP: 18/18 mmHg @ 1409 Fundus: see photos
PMHx: HTN, newly treated Family Ocular Hx: Unremarkable
06/11/12 Differential Diagnosis
Diabetic retinopathy Hypertensive retinopathy Vascular occlusion (BRVO) Infectious Inflammatory
New or old?
1 6/12/2019
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
2 6/12/2019
08/09/12
OD: 1 month progression
08/09/12 BRVO
Signs/Symptoms: Usually unilateral Normal or decreased vision Scotoma or VF defect Fovea Intraretinal hemes, respect horizontal raphe CWS or diffuse ischemia Dilated/tortuous vein(s) Retinal and/or macular edema Retinal neovascularization Vitreous heme, RD, NV Glaucoma all possible
Superior to fovea
BRVO BRVO Work-Up
Systemic disease? Pathophysiology Hypertension, 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 macular edema Consider IVFA
BRAVO Investigators. Ophthalmol 2010; 117:1102-1112.
3 6/12/2019
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.
4 6/12/2019
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 anemia, hyperlipidemia, psoriasis, Vit D deficiency, IFG, smoker Refer to ophthalmology BP Left Arm Sitting at 1535: 169/95, pulse 67
5 6/12/2019
06/23/11 06/23/11
Differential Diagnosis Case 2: 1 Month F/U
Diabetic retinopathy Remains asymptomatic Hypertensive retinopathy Papilledema Ocular Findings: (07/27/11) Ischemic optic neuropathy 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 Optic nerve edema, hemes, shunt vessels CWS, retinal and/or macular edema/ischemia Retinal/Iris/Angle neovascularization Vitreous heme, RD, NV Glaucoma all possible
CRVO
6 6/12/2019
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.
7 6/12/2019
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) Visual acuity (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
8 6/12/2019
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.
9 6/12/2019
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.
10 6/12/2019
04/12/12 Differential Diagnosis
ERM CSR PED CNV White dot syndrome
20/20 OU
05/11/12
Referred to retina 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
11 6/12/2019
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
12 6/12/2019
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.
13 6/12/2019
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 Geographic atrophy
90 y/o Caucasian M
Atrophy
20/40 Drusen Geographic atrophy, drusen
14 6/12/2019
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 macular degeneration and vision loss – AREDS report no.8. Arch Ophthalmol 2001;119:1417-1436.
15