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Retinal Imaging Conference Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/23/14 Slide 2 Subjective CC: Decreased vision in right eye for several months CC: Decreased vision in right eye for several months HPI: 54 year-old white female presents to Retina clinic for first time in 3 years with gradual painless decrease in vision OD for several months. HPI: 54 year-old white female presents to Retina clinic for first time in 3 years with gradual painless decrease in vision OD for several months. POH: POH: Small choroidal melanocytic tumor OD (nevus vs low grade melanoma) s/p stereotactic radiation therapy (09/2010) Small choroidal melanocytic tumor OD (nevus vs low grade melanoma) s/p stereotactic radiation therapy (09/2010) FNAB: indeterminate due to hypocellularity and degenerated nature of specimen FNAB: indeterminate due to hypocellularity and degenerated nature of specimen Gene expression class 1 (low grade): consistent with nevus vs low grade melanoma Gene expression class 1 (low grade): consistent with nevus vs low grade melanoma Stereotactic Radiation Therapy: 6MeV linear accelerator single target dose of 18 Gy Stereotactic Radiation Therapy: 6MeV linear accelerator single target dose of 18 Gy Slide 3 PMH: HTN, HLD, GERD, DM type II (A1C 5.6), Asthma PMH: HTN, HLD, GERD, DM type II (A1C 5.6), Asthma Medications: Crestor 10mg daily, Lisinopril 10mg daily, Zantac 75mg BID, metformin 500mg BID Medications: Crestor 10mg daily, Lisinopril 10mg daily, Zantac 75mg BID, metformin 500mg BID Allergies: Penicillin, Sulfa, Levaquin Allergies: Penicillin, Sulfa, Levaquin Slide 4 Exam OD OS BCVA20/100-1 20/20 -1 -2.50x0.25x165 -2.50x0.50x180 Pupils: 3 2 3 2 no APD IOP: 14 mm Hg 16 mm Hg EOM: Full OU CVF: Full OU Slide 5 Exam Anterior Segment OD OS L/L: WNL WNL C/S:WNL WNL K:WNL WNL AC: No cell or flare OU I/L: 2+ NS 2+NS Vitreous:WNL WNL Slide 6 Color Fundus Photos: 12/2013 OD OS OD: macular edema, dot hemorrhages temporal to disc, melanotic lesion with central hypopigmentation superotemporally OS: unremarkable Slide 7 Color Fundus Photos OD: 2/2010 OD: 7/2010 Slide 8 Autofluorescence OD: Hyperautofluorescence temporal to macula with areas of hypoautofluorescence temporal to the disc and superotemporal to the macula OS: unremarkable Slide 9 FA OD AV Phase: -Capillary non-perfusion temporal to disc with associated MAs and microvascular remodeling -Capillary nonperfusion superotemporal to macula (area of prior SRT) -Microvascular remodeling juxtafovea (nasal) -Irregular slightly enlarged FAZ Slide 10 FA OD Late AV Phase: expanding hyperfluorescence temporal to the disc and portions of the nasal macula consistent with leakage Slide 11 FA OD Recirculation Phase: -expanded hyperfluorescence with blurred edges (red arrow) -areas of hypofluorescence temporal to the disc and superotemporal to the macula consistent with nonperfusion (white arrow) Slide 12 OCT OD OS Foveal Subretinal Fluid and macular edema Vitreomacular Adhesion Slide 13 ASSESSMENT 54 year old white female presents for 3 year follow up with decreased vision and history of choroidal melanotic lesion s/p stereotactic radiotherapy 54 year old white female presents for 3 year follow up with decreased vision and history of choroidal melanotic lesion s/p stereotactic radiotherapy DDx DDx Radiation retinopathy Radiation retinopathy Diabetic Retinopathy Diabetic Retinopathy BRAO BRAO BRVO BRVO Slide 14 PLAN Avastin OD for macular edema Avastin OD for macular edema Observe melanotic choroidal lesion as no change in size since SRT Observe melanotic choroidal lesion as no change in size since SRT Follow up in 1 month to reassess macular edema Follow up in 1 month to reassess macular edema Slide 15 1 month follow up No change in VA No change in VA Resolution of subretinal fluid but no change in macular edema on OCT Resolution of subretinal fluid but no change in macular edema on OCT Repeat Avastin OD and f/u in 1 month Repeat Avastin OD and f/u in 1 month Slide 16 Radiation Retinopathy Characterized by slowly progressive occlusive vasculopathy Characterized by slowly progressive occlusive vasculopathy Typically has a delayed onset (18 months with external beam and earlier with brachytherapy), and causes microangiopathic changes that clinically resemble diabetic retinopathy Typically has a delayed onset (18 months with external beam and earlier with brachytherapy), and causes microangiopathic changes that clinically resemble diabetic retinopathy Radiation damage to retinal blood vessels causes vascular incompetence and occlusion Radiation damage to retinal blood vessels causes vascular incompetence and occlusion Doses of 30-35 Gy is usually required to induce clinical symptoms, however, retinopathy may develop after as little as 15 Gy Doses of 30-35 Gy is usually required to induce clinical symptoms, however, retinopathy may develop after as little as 15 Gy Slide 17 Clinical Feature Patients may be asymptomatic or may describe decreased visual acuity Patients may be asymptomatic or may describe decreased visual acuity Ophthalmic Signs: CWS, retinal hemorrhages, MAs, perivascular sheathing, capillary telangiectasis, macular edema and disc edema Ophthalmic Signs: CWS, retinal hemorrhages, MAs, perivascular sheathing, capillary telangiectasis, macular edema and disc edema Capillary nonperfusion and extensive retinal ischemia can lead to neovascularization of the retina, iris, disc. Capillary nonperfusion and extensive retinal ischemia can lead to neovascularization of the retina, iris, disc. Visual prognosis is related to the extent of macular involvement with CME, exudative maculopathy, or capillary nonperfusion Visual prognosis is related to the extent of macular involvement with CME, exudative maculopathy, or capillary nonperfusion Slide 18 Treatment Focal laser to reduce macular edema and PRP to treat zones of ischemia and neovascularization. Focal laser to reduce macular edema and PRP to treat zones of ischemia and neovascularization. Intravitreal triamcinolone or anti-VEGF drugs can stabilize or improve visual acuity in some patients with CME Intravitreal triamcinolone or anti-VEGF drugs can stabilize or improve visual acuity in some patients with CME Hyperbaric oxygen has been proposed as treatment but benefits remain unproven Hyperbaric oxygen has been proposed as treatment but benefits remain unproven Situations that exacerbate radiation retinopathy: Situations that exacerbate radiation retinopathy: Pre-existing microangiopathy: more likely to develop severe changes Pre-existing microangiopathy: more likely to develop severe changes Diabetic patients: likely to show changes at lower doses of radiation Diabetic patients: likely to show changes at lower doses of radiation Chemotherapeutic agents (5-FU) Chemotherapeutic agents (5-FU) Slide 19 Literature Review Retrospective case series of 159 patients with radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with intravitreal bevacizumab Retrospective case series of 159 patients with radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with intravitreal bevacizumab Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased vision Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased vision 81 of 159 (50.9%) demonstrated 20/50 or better vision at mean follow up of 34.6 months 81 of 159 (50.9%) demonstrated 20/50 or better vision at mean follow up of 34.6 months Slide 20 Literature Review Slide 21 Retrospective case series of 25 patients with severe radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with combination of intravitreal triamcinolone and bevacizumab Retrospective case series of 25 patients with severe radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with combination of intravitreal triamcinolone and bevacizumab Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased Va Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased Va Cases of severe radiation maculopathy or cases refractory to bevacizumab monotherpay were given IV triamcinolone Cases of severe radiation maculopathy or cases refractory to bevacizumab monotherpay were given IV triamcinolone Mean number of injections: Bevacizumab 8.8 (1-26) and Triamcinolone 2 (1-6) Mean number of injections: Bevacizumab 8.8 (1-26) and Triamcinolone 2 (1-6) Clinical Ophthalmology September 2013 Slide 22 Literature Review 36% with BCVA of 20/50 or better at last follow-up visit Patients refractory to bevacizumab monotherapy may benefit from combination therapy with triamcinolone Slide 23 References BCSC: Retina and Vitreous. Radiation Retinopathy. Pgs 151-153 BCSC: Retina and Vitreous. Radiation Retinopathy. Pgs 151-153 Maguir AM, Schachat AP. Radiation Retinopathy. Retina Vol II 4 th Ed. Chapter 83:1483-1489. Maguir AM, Schachat AP. Radiation Retinopathy. Retina Vol II 4 th Ed. Chapter 83:1483-1489. Patel SJ, Schachat AP. Radiation Retinopathy. Albert and Jakobiecs Prinicples and Practice of Ophthalmology. 3 rd ed. Philadelphia: Saunders; 2008:chap 175 Patel SJ, Schachat AP. Radiation Retinopathy. Albert and Jakobiecs Prinicples and Practice of Ophthalmology. 3 rd ed. Philadelphia: Saunders; 2008:chap 175 Shields CL, Demirci H, Dai V, et al. Intravitatreal triamcinolone acetonide for radiation maculopathy after plaque radiotherapy for choroidal melanoma. Retina. 2005;25(7):868-874 Shields CL, Demirci H, Dai V, et al. Intravitatreal triamcinolone acetonide for radiation maculopathy after plaque radiotherapy for choroidal melanoma. Retina. 2005;25(7):868-874 Shah NV, Houston SK, Markoe A, Murray TG. Combination therapy with triamcinolone acetonide and bevacizumab for the treatment of severe radiation maculopathy in patients with posterior uveal melanoma. Clinical Ophthalmology. 2013;(7):1877-82 Shah NV, Houston SK, Markoe A, Murray TG. Combination therapy with triamcinolone acetonide and bevacizumab for the treatment of severe radiation maculopathy in patients with posterior uveal melanoma. Clinical Ophthalmology. 2013;(7):1877-82 Shah NV, Houston SK, Markoe A, Murray TG. Early SD-OCT diagnosis followed by prompt treatment of radiation maculopathy using intravitreal bevacizumab maintains functional visual acuity. Clinical Ophthalmology. 2012;(6):1739 - 1748 Shah NV, Houston SK, Markoe A, Murray TG. Early SD-OCT diagnosis followed by prompt treatment of radiation maculopathy using intravitreal bevacizumab maintains functional visual acuity. Clinical Ophthalmology. 2012;(6):1739 - 1748