When to Refer to RETINA

Joseph M. Coney, MD February 17, 2017 Memphis, TN Financial Disclosure

Commercial Interest What was received For what role Aerpio Grant Support Contracted Research Alcon Laboratories Grant Support Contracted Research Alimera Consulting Fee Consultant/Advisor Allergan Consulting Fee Consultant/Advisor Allergan Grant Support Contracted Research Apellis Grant Support Contracted Research Genentech Grant Support Contracted Research Genentech Consulting Fee Consultant/Advisor Hoffman La Roche Grant Support Contracted Research Lowy Medical Research Institute Grant Support Contracted Research Notal Vision Consulting Fee Consultant/Advisor Ohr Grant Support Contracted Research Ophthotech Grant Support Contracted Research Regeneron Equity Ownership Interest Regeneron Consulting Fee Consultant/Advisor Tyrogenex Grant Support Contracted Research Overview – Alphabet Soup

. Endophthalmitis/IOI . VH

. CRAO . CRVO/BRVO

. PVD . NPDR/PDR

. RD . ERM

. NVI/NVA . MH

. CNVM . VMT Endophthalmitis

Hypopyon Hypopyon Bacterial Endophthalmitis

. Types . Acute post-operative . Chronic post-operative . Bleb-associated . Endogenous . Intravitreal injection-related . Post-traumatic Bacterial Endophthalmitis

. Course/Prognosis . Depends on . type of endophthalmitis . duration of time to presentation & Rx . virulence of organism

. Bleb-associated, post-traumatic, endogenous endophthalmitis have poorest prognosis Bacterial Endophthalmitis

. Presenting Symptoms . Decreased vision . Pain . Red eye . Swollen lid . Hypopyon . Most common organisms – Acute Post-op . Staphylococcus epidermidis (70%) . Other gram positives (24.2%) . Staph aureus (10%) . Streptococcus (9%) . Enterococcus (2.2%) Bacterial Endophthalmitis

. Treatment . Prompt intervention critical to restore vision/salvage globe . Vitreous tap & intravitreal antibiotic injections can be done in office with no delays . In very severe or resistant cases, pars plana vitrectomy in operating room Central Retinal Artery Occlusion CRAO

. Incidence . About 1:10,000 general patient visits . Most patients over 60 years . Most patients final VA < 20/400

. Etiology . Usually embolic . Cholesterol emboli suggest carotid atheromatous origin (20% of cases) . Temporal arteritis: 1-2% of cases . If TA suspected, urgent Rx indicated CRAO

. Therapy . Permanent ischemic injury > 90 minutes . Occasional improvement after many hours . Efficacy of therapy questionable . A/C paracentesis . Ocular massage

. Inhalation RX (Carbogen: 95/5% O2/CO2 OR HYPERBARIC OXYGEN CHAMBER) . Oral acetazolamide & ASA . 20% develop rubeosis 1-12 weeks post occlusion . Scatter laser Rx CRAO with Cilioretinal Artery Sparing

Acute Posterior Vitreous Separation

. Prevalence of PVD related to . Axial length of eye . Age . Pts < 50 yrs of age (10%) . Pts ≥ 70 yrs: 63% have PVD

. Incidence of retinal tears . Low in asymptomatic patients . 10-15% of patients with acute symptoms . 50-70% risk in pts with vitreous hemorrhage

Acute PVD

. Management . Symptomatic pts should be seen within 24-48 hours if possible . Pts with VH need close follow-up . Retinal breaks generally should be treated with laser or cryopexy . After initial evaluation, some pts should be seen again within 3-4 weeks as breaks may evolve over time . Esp. myopes, aphakes, pseudophakes, lattice Rhegmatogenous Retinal Detachment

Rhegmatogenous Retinal Detachment

. Predisposing factors . Vitreous liquefaction . Acute PVD . Abnormally firm vitreoretinal adhesion . Lattice degeneration . Cystic retinal tufts . Myopia RRD . Treatment options . Pneumatic retinopexy (PR) . In-office procedure . Cryopexy followed by intraocular gas tamponade . Appropriate for superior breaks . Overall anatomic success: 70% . Key advantages . No delay in treatment . Low morbidity . Low cost

RRD

. Scleral buckling . Circumferential buckles produce permanent indentation that relieves vitreoretinal traction . Relative indications . Localized RDs with small breaks . Multiple breaks in multiple quadrants . Presence of PVR . Overall success rate: 90%

RRD

. Pars plana vitrectomy . Utilization has increased dramatically . Giant retinal tears . Pseudophakes . Posterior breaks . Co-existent macular hole or VH . PVR . Morbidity less than SB, especially 25-gauge . Anatomic success rate 90% RRD RRD

. Barricade laser . Appropriate for . peripheral RRDs . no symptomatic visual field loss . chronic or subacute RRDs . Offers least risk & morbidity . High success rate in selected cases Tractional Retinal Detachment Tractional Retinal Detachment TRD

. Common etiologies . Proliferative diabetic retinopathies . Proliferative vitreoretinopathy . Sickle cell retinopathy . ROP . Penetrating trauma . Retinal vascular disease

. Treatment . Peripheral TRDs can be observed . TRDs involving or threatening macula require PPV

Retinal Detachment

. Timing of surgical intervention . Dependent on several factors: . Type of RD . Status of macula . General medical condition of patient

. Cases amenable to barricade laser or PR should be done on initial visit in the office Retinal Detachment

. RRD – Timing of surgical repair . Macula ON & immediately threatened, surgery at earliest opportunity within 24 hrs. . If Rx must be delayed, pt can be positioned to prevent progression of RD (highly effective) . Macula OFF <1 week, surgery should be done <1 week . Macula OFF >1 week, surgery can be done electively in 1-2 weeks . In some cases of PVR, can be advantageous to defer surgery several weeks to allow membranes to “mature” and facilitate peeling Retinal Detachment

. For chronic RRD . Signs include . Non-bullous . Atrophic retina . Subretinal bands, PVR . Demarcation lines . Asymptomatic . Surgery can be scheduled electively . Observation also an option Retinal Detachment

. Tractional RD . Can usually be done electively . Within 7-10 days if macula recently involved . Preoperative laser often helpful in cases of PDR . Anti-VEGF injections also helpful but can increase risk of progression if surgery delayed Rubeosis Rubeosis – Predisposing Conditions

. Systemic vascular disease . Carotid occlusive disease . Giant cell arteritis

. Ocular vascular disease . Diabetic retinopathy . CRAO . CRVO & BRVO . Sickle cell disease

. Other ocular diseases . Uveitis, chronic RD, tumors, trauma Rubeosis

. Prompt treatment indicated, especially in cases of NVA

. Treatment delay can result in synechial angle closure and NVG

. Treatment . Panretinal photocoagulation . Anti-VEGF injections . Rx of underlying condition Rubeosis

CRVO with NVI/NVA CRVO

. Before Avastin . 1 week post IVA . Add surgical video of Ahmed Valve and PPV for NVG Choroidal Neovascularization CNV

POHS Juxtafoveal CNV

. In MPS era, juxtafoveal CNV required immediate referral and Rx before CNV progressed into fovea

. In anti-VEGF era, early Rx important but not an acute emergency

. Pts should be seen at earliest opportunity within 1 week CNV

AMD Subfoveal CNV CNV

. Timing of Rx for subfoveal CNV . Generally non-emergent . More urgent if . rapid progression of vision loss . new heme . monocular or better-seeing eye . functional vision in affected eye . Early intervention will stabilize CNV & maintain useful vision in > 90% of cases

. 8/2015 . CF

. 12/2015 . 20/400

. 4/2016 . 20/40 Vitreous Hemorrhage Vitreous Hemorrhage

. Most common etiologies . PDR . Acute PVD . Trauma . Retinal vascular disease . CRVO & BRVO . CRAO . Ocular ischemic syndrome Vitreous Hemorrhage

. Urgency of evaluation depends on suspected etiology & patient history

. Recurrent VH in PDR – not urgent . New VH in diabetic . More urgent – can potentially apply PRP before localized VH disperses . If fellow eye has no or only mild NPDR, suspect PVD & retinal tear – more urgent evaluation indicated Vitreous Hemorrhage

Retinal Vein Occlusions Retinal Vein Occlusions

. Ischemic CRVO or BRVO . If no NVI/NVA – not urgent . If NVI/NVA present (or increased IOP), pt should be seen ASAP . PRP if view adequate . Anti-VEGF injections also useful . Non-ischemic CRVO or BRVO . Not urgent . Pts with CME may benefit from early Rx Retinal Vein Occlusions

. Bilateral CRVO . Rare . Suggests underlying systemic disease . Malignant hypertension . Blood dyscrasia . Leukemia . Waldenstrom macroglobulinemia

. Urgent systemic evaluation indicated Bilateral CRVO Bilateral CRVO - Case

. 58-year-old black female

. Gradual loss of vision for several weeks

. VA = 20/400 OD & 20/200 OS

. Bilateral CRVO with severe CME

. Found to have multiple myeloma

. Systemic Rx → resolution of CRVOs Diabetic Retinopathy

. NPDR

. PDR

. VH

. DME

. TRD

. Rubeosis Epiretinal Membrane - ERM

20/400 Pre-op Va to 20/60 Post-Op Va Prognostic Factors in Post-op VA Improvement

. Retinal vascular leakage, CME, and RPE disruption of any etiology all have been associated with poorer prognosis Prognostic Factors in Post-op VA Improvement . Eyes with poorer pre-op VA tend to have a greater VA improvement compared with eyes with better pre-op visual levels but also have poorer final VA Prognostic Factors in Post-op VA Improvement

. Removal of traction upon the retina and perifoveal microvasculature allows for gradual resolution of macular edema . Chronic traction results in permanent retinal vascular incompetence, such that persistent vascular leakage and macular edema remain post-op and limit visual gains . Add in ERM video from Dubrovnik . VMT . 20/60

. MH . Ph 20/100-1

. Post-op . Ph 20/40 . NSC Macular Hole Macular Hole 1Apr2014 6Jan2015 9Nov2013 20/30 20/25 20/25

20Sep2016 21Jun2017 22Mar2016 20/50 20/60 20/50

22Nov2017 23Jan201 20/200 8 20/80

Conclusions

. Most common retinal disorders can be evaluated electively

. Endophthalmitis needs emergent Rx

. Retinal detachments: Urgency highly variable and must be tailored to individual patient

. Retinal vascular disease & DR: Usually not urgent unless high-risk PDR or rubeosis present = Satellite offices = Surgery Centers: CELSC = Cleveland Eye & Laser SC CSC = Canfield SC LSC = Lippy SC

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