5/21/2014 29 yo white female CC: Decreased VA OD X few days Women of Vision Present Are We PMHx: 5 months pregnant at Risk for Vision Morbidity MODERATOR BVA: 20/30 OD 20/20 OS Pupils: (-) APD Louise Sclafani O.D. Louise A. Sclafani, OD, FAAO CF: FTFC OD/OS Co-instructors: Jill Autry, OD, Melissa Associate Professor Barnett, OD, Susan Cotter, OD, Diana University of Chicago Hospital Shechtman, OD GOALS It’s a BOY… • Our panel will take on this challenge and discuss this population as it relates to the following conditions optic neuritisOCT Women at Risk: Retinal Issues Fetus maculopathy??? evaluation, AMDnutritional controversy, psychosocial issuesmanagement options with strabismus, ocular concerns for common Diana Shechtman, OD systemic pharmaceuticals, safety issues with [[email protected]] ophthalmic drugs, and the hormonal influence Associate Professor of Optometry at on ocular surface disease NOVA Southeastern University College of Optometry Courtesy of Dr. M Rafieetary CASE PRESENTATION SUMMARY So why would’t ICSC (idiopathic central serous chorioretinopathy) WE (female gender) be stressed out? Serous macular detachment due to RBR breakdown • As ODs we need to place a higher priority on those individuals at increased risk for vision- threatening ocular disease. It has been estimated that the female gender represents 23 of all visually compromised individuals due to inherent risk factors and lack of access to healthcare. Diana Shechtman OD FAAO 1 5/21/2014 Hyperpermeability at RPE site is associated with choroidal Which of the following drugs in Not associated CSR in women circulation disruption/vascular congenstion with ICSC? Quillen et al. Ophthlamology jan 103: 72-9 • Viagra (PDE-5 inhibitor) • 51 women w active CSR divided into 3grps: • Steroids (any form) – Idiopathic, steroid use, pregnancy related • Anti-VEGF therapy • Results • Pseudoephedrine (nasal decongestant) – idiopathic: • Cancer medications (i.e. sorafenib) • Clinical findings were similar to those classic MALE • These women tended to be OLDER – Steroid related (exogenous) presentation • tended to be BILATERAL with SUBRETINAL FIBRIN – Pregnancy related FOCAL LEAKAGE but definitive cause is unknown • tended to resolve 1-2M s/p delivery Dxed with possible previous ICSC Clinical characteristic of CSC in females maculopathy 2 yrs ago idiopathic central serous chorioretinopathy • Retrospective study on 78 women w ICSC • Acute No direct cause Affects macular area • Results • Unilateral – 62% had spontaneous COMPLETE recovery within 5M. • Young (20-45) – ~30yo Longer resolution was associated with • Type A personality – Increase age & PED formation – Final VA in 88% >20/40 & more likely associated: A Males DISEASE??? Associated with a • lack subretinal precipitates & a single presentation F:M 2:10 choroidal circulatory dysfunction that – (+)factors associated with COMPLETE recovery included manifests in the neurosensory retina • No HRT, no recurrence, duration <5M, no subretinal Fluid filled detachment precipitates DFE was only performed 2 weeks after given birth (2 yrs ago) Perkins etl al. Ophthal 2002 Which of the following conditions in Not Systemic conditions or medications associated with ICSC? can increase presentation in female The women with ICSC • Tends to me OLDER • Vogt–Koyanagi–Harada syndrome (VKH) – Late 40s-early 50s • Cushing’s syndrome rd More common in 3 trimester • Subretinal precipitates are noted in 30-50% of • Lupus Tends to spontaneously resolve 1-2M sp delivery cases • Organ transplant or conditions requirement use of ling term steroids • Like in MALES, spontaneous resolution & visual recovery >20/40 is common (78-88% of women) • Hypercholesterolemia – Yet, Spaide reported that men and women older than • Sleep apnea 50 with CSC were more likely to have lower vision and • H. Pylori (helicobacter pylori of the stomach) diffuse RPE decompensating at presentation. 2 5/21/2014 BE CAREFUL Take a SLAB 65 HF Decreased vision X 1wk Value of OCT in OD 20/20 OS 20/30 F The classic 2011 A Dx modality Pooling dye superficial deeper Classic “smoke stack” OCT or FA may be required to identify absence of possible CNV As it resolve…OCT images The Classic FA But how many pts have this? vary In ANY older patients with CSC, it is important to consider the possibility of age-related macular degeneration or idiopathic CNV. sneretina.com/retinal-diseases-and-treatments/central-serous-retinopathy.asp Use of diagnostic modalities OCT showing smoke stag The value of OCT in the management of ICSC in 2011 • FA • FAF 20/40 3 wks 1M 2M • OCT 20/40 20/25+ 20/20 3 5/21/2014 Pt with hx of recurrence 20-50% will have at least one recurrence Another dx modality: FAF Within the yr Associated with “sick” RPE 54 WF Decreased vision longstanding Courtesy of Dr. M Dunbar OCT on chronic (>3-6M) or recurrent case may show this appearance EDI…may explain recurrence Choroidal thickness at SITE of ICSC, which correspond to FA leakage Increase vessel permeability due to increase hydrostatic pressure 4 5/21/2014 The image part with relationship ID rId5 was not found in the file. So when to refer? Chronic case have more widespread decompensating RPE (Diffuse Retinal Pigment Epitheliopathy: Variant of ICSC) 1. 68 WF 20/50 (visual disturbances) May be associated with worse prognosis than TYPICAL presentation. Cases may benefit from PDT…may be seen in FEMALES Over 39k women health professionals 2 w/o AMD were evaluated The treated grp was given 600 IU Vit E every other day (Higher than AREDS) No difference in the development of AMD observed after 10 yrs b/t groups CONTROVERSIES Christen WG, et al. Vitamins E and C and Medical Record-Confirmed Age-Related Macular Degeneration in a Randomized Trial of Male 3. CHRONIC (persistent for 3-6M) or recurrent Physicians. Ophthalmology. 2012 & Christen et al. Ophthalmology. 2010 Jun;117(6):1163-8 The image part with relationship ID rId5 was not found in the file. 1. Increase Calcium requires… ` 2. High dose Vit A is associated with hip fractures in the elderly because… 3.Shouldn’t supplement lutein & beta- carotene together because… 4. Affects on liver/kidney have to be 1M f/u considered Initial 1M F/u s/p laser 20/25 20/50 20/30 20/50 TX INITIATED “Downright dangerous!” A. Observation (>60% recover w/i 4-8 wks with good outcomes) B. Laser photocoagulation RESOLVED ON ITS OWN C. PDT D. Anti-VEGF therapy E. ASA Can anything we take OTC be a problem? Referral: Doesn’t follow typical natural hx, visual needs, recurrent Laser still commonly implemented More controversies WOMEN & AMD when tx is required 2011 • Who is MORE at risk for N=>30K women AMD: Female or males? • Is there a correlation MV , Vit B6, folic acid, Mg, zinc , iron & copper may be associated with increase mortality rate b/t MPOD & gender? • PDT works on chronic cases • Note that 5% of pts can experience LONG term severe permanent VL; due to long term affect on photoreceptors 5 5/21/2014 Vitamin D Hormones Women loose Vit D as they AGE • Increased Vit D consumption leads to less (severe) • Hormone change during menopause could worsen DES AMD • Thought sex hormone replacement therapy (SHRT) may relieve DES – Monozygotic twin study w asym. AMD: those w • Epidemiologic studies indicate DES incidence in women on SHRT is Hormone Influence on greater than women not on SHRT less severe AMD had more Vit D intake: 200 vs • Specifically, higher incidence of DES of older women on SHRT, 170 IU Ocular Surface Disease especially using estrogen alone. With longer SHRT use, DES frequency and symptomology increased • Seddon et al. Ophthalmology . 2011;118:1386–1394 • • Findings disagree with other studies • Higher 25OH-VitD leads to less AMD – Menopause found to be a risk factor for DES, but SHRT was instead some benefit Melissa Barnett, OD, FAAO – highest vs lowest quintile in <75yo WOMEN • Other studies show estrogen therapy in women triggered or Department of Ophthalmology & Vision Science worsened DES and of Sjogren’s syndrome • Millen et al. Arch Ophthalmol . 2011;129:481–489 University of California, Davis Vitamin B complex and Prevalence of Dry Eye Disease SHRT relationship to AMD 7.3yrs f/u w 5205 women • An estimated 25 million Americans report suffering from dry • Theory for conflicting conclusions eye. • Outcome of SHRT depends on Treatment group: • 12.76 million postmenopausal women 1. Estrogen dosage • 3 million men age 65 and older 2. Age of the individuals when therapy is first initiated folic acid (2.5 mg/d) • Estrogen may only benefit younger women vitamin B6 (50 mg/d) • Estrogen detrimental and / or pro-inflammatory in postmenopausal women vitamin B12 (1 mg/d) 3. Type and combination of SHRT applied • Estrogen at physiological doses supportive of lacrimal gland function and preservation of anterior ocular surface health at early Rx grp had a lower AMD ages association • At higher doses and / or in combination with other hormonal supplements would be harmful and / or induce inflammation. B-Complex and incident AMD in women. • Elderly women would be more susceptible WAxFACS: Arch Intern Med. 2009 Feb Dry Eye Syndrome Hormones and Dry Eye • Ocular surface homeostasis is altered by hormone changes • Dry eye syndrome • Contribute to dry eye The great deBate: • Androgens impact structure and function of meibomian and lacrimal • Prevalence is much higher among women glands do you recommend O3 for AMD • Androgen deficiency is associated with the etiology of dry eye • Aging is a risk factor • In contrast, reports of the effects of estrogen and progesterone for the ocular surface are contradictory Particular women prone to DES • Sex hormones are key factors • Mechanisms of action of these female-specific sex hormones in the eye are not well understood. Best to be selective in choosing the • Changing hormone levels / decreased • Conflicting reports of relationship between hormone replacement therapy RIGHT pt androgens are contributory and signs and symptoms of dry eye • New research – Average results may not apply to • Sex hormone influences the immune system, suggesting that estrogen the individual pt may modulate a cascade of inflammatory events, which underlie dry eye.