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Retinal Imaging Conference. Shivani V. Reddy, MD University of Louisville Department of Ophthalmology and Visual Sciences 6/5/2014. Patient Presentation. CC : Blurry vision OS x 1month

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Retinal imaging conference

Retinal Imaging Conference

Shivani V. Reddy, MD

University of Louisville

Department of Ophthalmology and Visual Sciences

6/5/2014


Patient presentation

Patient Presentation

CC: Blurry vision OS x 1month

HPI: 52 y/o AAF presenting to the eye clinic for her first diabetic exam c/o occasional blurry vision OS x 1 month. Denies flashes, floaters, scotomas or episodes of vision loss.


Medical history

Medical History

POHx:none

PMH: DMII (diagnosed 3 months prior, A1c: 8.9%)

HTN with HTN urgency episode in 2012

secondary to cocaine abuse

Meds: metformin, lantus insulin, norvasc, gabapentin

Allergies: NKDA


Retinal imaging conference

3 ->2mm

14

3 ->2mm

17

Exam

BCVA P TTP

EOM: Full OU

CVF: Full OU

Anterior Segment: mild NS cataracts OU, otherwise WNL

20/20-1 (sc)

(-) RAPD

20/60-2 (-1.00+1.00x180)


Oct photos

OCT Photos


Retinal imaging conference

OCT

OD

OS

OS: retinal thickening with cystic spaces temporal to fovea, subfoveal disruption of ELM and ellipsoid region lines


Autofluorescence os

Autofluorescence OS

OD: Area of central hyperautofluorescence , hypoautofluorescense concentrated superiorly


Fa photo os

FA Photo OS

00:19:53

Arterial phase : normal arterial filling


Fa photo os1

FA Photo OS

00:23:28

Mid AV phase : delayed superotemporal venous arcade filling, scattered areas of hypofluorescence, pinpoint hyperfluorescent areas


Fa photo os2

FA Photo OS

00:30:33

Late AV phase: persistent filling defect in superior temporal arcade, prominent macular collateral vessel, hypofluoresentares scattered throughout the sup-temp segment


Fa photo os3

FA Photo OS

00:38:65

Venous Phase: Late filling of superotemporal venous arcade, increasing hyperfluorescence surrounding original pinpoint areas with persistent intervening hypofluorescent regions, hyperfluorescence temporal to the fovea, appearance of venous collaterals


Fa photo os4

FA Photo OS

01:44:39

Recirculation phase: increasing hyperfluoresnce around pinpoint leakages, decreasing fluorescence of collateral vessels. Increasing hyperfluorescence temporal and superior to the fovea


Fa photo os5

FA Photo OS

02:39:10

02:24:13


Assessment and plan

Assessment and Plan

A: 52 yo AAF with CME OS secondary to old branch retinal vein occlusion.

P: Avastin OS, follow-up pending


Branch retinal vein occlusion

Branch Retinal Vein Occlusion

  • Vein occlusion that occurs most commonly at an AV crossing

  • Mean age of presentation: 7th decade

  • Risk factors

    • HTN

    • Cardiovascular disease

    • Glaucoma history

    • Increased BMI at age 20

  • Most commonly effected area: supero-temporal quadrant


Branch retinal vein occlusion1

Branch Retinal Vein Occlusion

  • Acute Phase

    • Segmental intraretinal hemorrhage with apex near obstructed vein

    • Subretinal hemorrhages less common

    • Cotton wool spots scattered throughout the occluded segment

    • CME with layering intraretinalheme within the cysts

    • If CME present, round yellow spot can occur centrally that later disappears


Branch retinal vein occlusion2

Branch Retinal Vein Occlusion

  • Chronic Phase

    • Resolution of subretinalheme at 9-12 months

    • Underlying retinal vascular abnormalities seen on FA

      • Collateral vessel formation around blockage site

      • Capillary telangiectasia

      • Capillary non-perfusion areas within involved segment


Branch retinal vein occlusion3

Branch Retinal Vein Occlusion

The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282.2001;21:416-434.

Branch Vein Occlusion Study (BVOS)

Questions asked:

  • Can scatter laser prevent neovascularization?

  • Can peripheral scatter laser prevent vitreous hemorrhage?.

  • Can grid laser improve visual acuity in eyes with macular edema with vision <20/40?

    Conclusions:

  • Grid laser is beneficial for macular edema with vision <20/40 for 3 months

  • Scatter laser is beneficial for prevention of vitreous hemorrhage


Branch retinal vein occlusion4

Branch Retinal Vein Occlusion

Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128.

SCORE (BRVO) Study

  • Question asked:

    • Is triamcinolone beneficial in the treatment of macular edema when compared to standard of care?

  • Patients were divided into 3 groups: grid laser, 4mg , 1mg group. Visual acuity changes were compared at 1 year

  • Conclusions:

    • 3 groups with similar VA improvement BUT more complications in the steroid group. Therefore, Grid laser was the benchmark against which future treatments should be compared


Branch retinal vein occlusion5

Branch Retinal Vein Occlusion

BRAVO Study

Purpose: to determine the safety and efficacy of Lucentis in treating macular edema

  • Design:

    • 3 groups – 0.3mg , 0.5mg ranibizumab and sham

    • Patients received monthly injections

  • Number of patients with >15 letters gained at 6 months:

    0.5mg group: 61.1%, 0.3mg group: 55.2%, sham group: 28.8%

  • Conclusion: Intravitreal ranibizumab is effective for treatment of macular edema following BRVO

Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.


Branch retinal vein occlusion6

Branch Retinal Vein Occlusion

Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24.

GENEVA Study

  • Purpose: to evaluate the efficacy and safety of Ozurdex for visual loss secondary to macular edema associated with BRVO

  • Design: patient injected with intravitreal implant 0.7mg, 0.35mg or sham

  • Conclusion: Dexamethasone intravitreal implant can reduce the risk of vision loss and improve speed and incidence of visual improvement


Retinal imaging conference

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San RaffaelePierluigiIacono, Fondazione GB Bietti, Roma Maurizio ParodiMacula Society, 2014

Purpose: to evaluate the effects of dexamethsone implant for the treatment of macular edema secondary to ischemic retinal vein occlusions over a 12 month follow-up

Methods: - prospective, open-label, interventional, case series.

- each patient received a comprehensive exam, FA & OCT imaging followed by

a dexamethasone implant

- retreatment based on presence of macular edema at month 4

primary outcome measure: ETDRS letter score

secondary outcome measure: CME, number of injections during followup


Retinal imaging conference

Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San RaffaelePierluigiIacono, Fondazione GB Bietti, Roma Maurizio ParodiMacula Society 2014

Results: 24 patients enrolled (11 CRVO, 13 BRVO)

- mean ETDRS letter score changed:

BRVO 75,3 to 95,6

CRVO 44,3 to 60,8

- CMT change

BRVO 544um to 321um

CRVO 776um to 444um

- mean #injections

BRVO: 1.7

CRVO: 1.8

Conclusions: Dexamethasone implant reduces ME in eyes with ischemic RVO’s, leading to a slight visual acuity improvement


Retinal imaging conference

The OMAR study: Comparison of Ozurdex and Triamcinolone Acetonide for Refractory Cystoid Macular Edema in Retinal Vein OcclusionAhmet Ozkok, M.D.,*Omar A Saleh, M.D.,* Douglas K. Sigford, M.D.JamesW Heroman, M.D. ShlomitSchaal, M.D., Ph.D.

Purpose: To compare the risks and benefits of adding either intravitreal dexamethasone implant (DEX) or preservative free triamcinolone acetonide (TA) to bevacizumabmonotherapy in refractory CME due to RVO

Design: interventional, comparative study of

74 patients received bevacizumab, then later DEX (35) and TA (39)

outcome measures: BCVA, CMT, frequency of injections

Results: no significant change in BCVA

significant improvement in CMT

significant decrease in number of injections per month, more so in

DEX group (from 0.66 to 0.26 inj/mo)


References

References

Retina-Vitreous Macula. Guyer, Yannuzzi, Chang, Shields, Green

BCSC. Chapter 12 Retina and Vitreous. 2012-2013:Chapter 6:121-127.

The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282.2001;21:416-434.

Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128.

Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24.

Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.

The Eye Disease Case-control Study Group. Risk factors for branch retinal vein occlusion. Am J Ophthalmol 1993;116(3):286-96.


Retinal imaging conference

Thank You


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