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.