Examining the Retina Assess the optic nerve Clinical Decisions in Retina What is the cup to disc ratio Is there good coloration and perfusion Mark T. Dunbar, O.D., F.A.A.O. Is it flat Choroidal or scleral crescent Mark Dunbar: Disclosure Examining the Retina Consultant for Allergan Pharmn What is the caliber of the retinal vessels Optometry Advisory Board for: Make sure you look and consciously take not of what the caliber is Allergan Carl Zeiss Meditec Narrowing of the vessels requires checking Alcon Nutritional the blood pressure Advisory Board Mark Dunbar does not own stock in any of the above companies Normal A/V ratio is 2/3, ¾ ArticDx What about the arterial light reflex? Examining the Retina Examining the Retina Don’t forget to look at the anterior vitreous The Macula Needs to be done on every dilated patient Is there a foveal light reflex (FLR)? Done at the slit lamp, looking posterior to Is it flat? the lens Is there any fluid, hemorrhage, or exudate Retroillumination may help if you suspect Presence of drusen vitreous cell RPE mottling More on this later Examining the Retina PVD The peripheral retina 65% of individuals > 65 have PVD It has to be done through a dilated pupil More common in women Don’t substitute imaging for indirect ophthalmoscopy More common following intraocular surgery Use Imaging as a compliment, but not substitute More common following Be systematic in your examination inflammation You should be able to see ora on “all” gazes More common in aphakes It’s all about technique 59 y/o White Male PVD Retinal tears occur 8-15% CC of new onset flashes RE X 3 wks of eyes with symptomatic See’s them only at night PVD 90% are superior Does not seem to affect is vision VH occurs in 13-19% of VA: Best-corrected 20/20 (-3.50 OU) symptomatic PVD’s Motility, CVF, Pupils – all normal VH + PVD -> 70% will have a retinal break Anterior Segment – unremarkable PVD No VH -> 2-4% will Posterior Segment - have retinal break Exam of a Pt with 59 y/o White Male Symptomatic PVD Should have a high suspicion of detecting What are you suspicious of? Weis ring What are you looking for? Should have a high index of suspicion of a possible retinal break Posterior Vitreous Detachment Clinical exam should be conducted with these suspicions Clinical Exam of a Patient with Management of Acute PVD A Symptomatic PVD With Symptoms All the testing and procedures that you would normally do with any patient Educate about the Si/Sx of RD Dilated fundus exam Look specifically at the anterior vitreous Note presence or absence of pigment or cells in Return in 4-6 weeks, then 3-4 months, then the anterior vitreous -> tobacco dust, schafer’s annually sign Peripheral extended ophthalmoscopy including scleral depression PVD NOT Seen PVD is Seen but has symptoms… What is your management? What is your management? Do you bring him back for follow up? Return with in 3-4 weeks Management of Acute PVD Lattice Degeneration as a Routine Finding? No Symptoms Educate about the Si/Sx of RD Is this any cause for concern? How do you manage it? Return in 1 yr Indications for Prophylactic Lattice Degeneration Treatment of Peripheral Retinal Tears and Holes in Asymptomatic Patients Present 5-20% of the general population Phakic Highly Fellow Eye Myopic (RD in other) Localized area of Atrophic Holes No No Rarely retinal thinning Operculated No Rarely Rarely associated with a fluid Holes pocket in the overlying Lattice with or No Rarely Sometimes cortical vitreous without Holes Flap Tears Sometimes Sometimes Usually Lattice Degeneration and 48 y/o Asymptomatic Pilot Risk of RD RD develop in 0.7% of eyes with lattice VA 20/15 OU degeneration followed for 10.8 yrs Anterior Segment: Eyes with lattice that developed tractional Unremarkable retinal tears Fundus 40% occurred in areas not associated with lattice…normal-appearing retina Byer NE. Ophthalmology. 1989; 96:1401-1402 Indications for Prophylactic Treatment of Peripheral Retinal Tears and Holes in Symptomatic Patients Treat Horseshoe tears Yes Dialysis Usually Operculated holes Rarely Atrophic holes No Choroidal Nevi Management < 3 mm elevation Flat choroidal nevi: follow < 3 DD in size yearly 95% are less than 2 Suspicious nevi: DD photo Slate gray follow in 6 wks, 3 mo, then 6 mo Drusen evidence of growth -> SRF associated with early melanoma drusen Lesions > 3 mm thickness: CNVM probably early melanoma Features Suggesting Nevi Do any of the medications that Drusen I am taking affect my eyes? Overlying neurosensory detachment Choroidal neovascular membrane Circinate exudate “I am having blurry vision – Bony pigment spiculing could this be from any of the Zones of RPE atrophy medications that I am taking?” Choroidal Melanoma Systemic Interactions At least 76 classes of systemic drugs have been >3 mm elevation associated with ocular side effects Drug can interact with and disrupt any step of the Variable pigment biochemical process resulting in deleterious effects to Multiple areas of orange pigment the ocular tissues (lipofuscin) Drugs may incite an exaggerated immune response within the eye Serous fluid (detachment) in absence of drusen Uveitis or retinitis Penetration by certain systemic meds may cause ¾ Unequivocal evidence of growth deposition of the solidified form of the molecule Ethambutol Toxic Systemic Interactions Neuropathy Medications may cause alteration of the pigment st Plaquenil -> Bull’s eye maculopathy 1 described by Leibold in the 1960’s Pharmacologic toxicity can occur leading to cell Dose dependent death and loss of function Can affect the optic nerve Risk is 6-18% for pts with dose > 30 Patient variability may influence and cause mg/kg/day (18% at 35 mg/kg/day) unexpected effects Develops in 1-3% at dose 15-25 mg/kg/day Pharmaceutical studies provide statistical evidence supporting appropriate dosage for meds, however individual variation can result in unexpected results 57 y/o White Female What are your/our obligations in Presented on 2/29/08 with decreased vision, deciding if certain medications that near > distance 2o CC: can my medicine affect my eyes? a patient is taking are affecting the LEE: 1970’s patients vision? Ethambutol Patient History TB regimens begin at either 50 mg/kg/day Meds Social Hx (maximum 4 grams) for 2 weeks or 25-30 1 pack/day tobacco mg/kg/day (maximum 2 grams) for 3 weeks, Pegasys and then maintained at 15-20 mg/kg/day (max usage X 40 yrs Copegus 2 grams) Visine prn For MAC regimens the maintenance dose is 15 20 drinks/day x 40 yrs, mg/kg/day (maximum 2.5 grams). quit 2007 in AA Depending on the species of mycobacteria pts, Family Hx may be treated with a loading dose of 25 IV drug usage X 10 yrs, mg/kg/day for the first two months of therapy None (Mandell et al., 2005; Micromedex 2007). quit 1970 What are your obligations for Interferon Retinopathy managing a patient on plaquenil? 1990: Ikebe reported the first case What is the risk of having ocular problems from plaquenil? 1992: IFN therapy widely used in Japan for hepatitis C patients What testing is necessary? How often do you need to follow her? 1993: Ocular complications from IFN increasingly reported from Japan 1998: Review of early reports by Hayasaka Review of Early Reports Plaquenil Typical Findings (Hydroxychloroquine) Prescribed in 200 mg tablets CWS Dose is 200mg or 400mg daily Hemorrhages: flamed shaped or white centered Risks for macular damage include Posterior pole or around the optic disc Cumulative dose of 1000g 5-7 years or more of use Occurred alone or together ¾1% risk after 1000g total dose (7 years) Unilateral or bilateral Renal or hepatic dysfunction (both) Subjective complaints are uncommon Pre-existing macular pathology Visual acuity not usually impaired Short stature / obesity Age Plaquenil Screening: 57 y/o Hispanic Female Traditionally Was told by her rheumatologist to have Baseline macula photos her eyes checked Color vision testing He wants to put her on a new medication but told her it can affect her eyes. Amsler grid Medical history of severe rheumatoid 10-2 Visual fields arthritis Yearly exams Currently on Prednisone 20 mg/day Wants to start her on plaquenil Revised Recommendations on Feb 2011 Screening for Plaquenil Toxicity • SD-OCT can show localized thinning of the parafoveal retinal layers confirming toxicity – May be unable to see with TD-OCT – Changes maybe visible prior to VF defects • FAF may reveal subtle RPE defects with reduced autofluorescence • MF-ERG can objectively document localized paracentral ERG depression in early retinopathy Revised Recommendations on Revised Recommendations on Screening for Plaquenil Toxicity Screening for Plaquenil Toxicity • Amsler grid testing removed as an acceptable Parafoveal loss of visual sensitivity may appear screening technique before changes are seen on fundus evaluation – NOT equivalent to threshold VF testing Many instances where retinopathy was • Strongly advised that 10-2 VF screening be unrecognized for years as field changes were supplemented with sensitive objective tests dismissed as “non-specific” until the damage such as: was severe – Multifocal ERG 10-2 VF should always be repeated promptly when central or parafoveal changes are observed – Spectral domain OCT to determine if they are repeatable – Fundus autofluorescence Revised Recommendations on Mild Retinopathy Screening for Plaquenil Toxicity Tests Not Recommended for Screening: Fundus photography