Retina Grand Rounds Jeffry D. Gerson, O.D., F.A.A.O.

jgerson@Hotmail.com

WWAARRNNIINNGG

• Grand Rounds basically means “license to do whatever you want”

• So, I am going to take that license and be a little random, but hopefully very practical You never know…

• You never know what/who is going to walk in the door

• We need to be prepared for anything

• Some things need treatment….some don’t I’m going to do something a little different

• This Tuesday, I had some really crazy patients. Some were referred, some were not

• I want to get input from YOU on what you think

– Since these all came in the day before I left, I don’t have images, but I will describe to you so that you don’t actually need the “real” images

90 yo returning for VF

• H/o AMD, Central Serous and Glaucoma

• 20/40 and 20/30, doing well, no complaints

• 2/10: Serous fluid, no referral yet, Similar to previous): follow

• 2/24: VF done and shows subtle progression OU, MD: -5.00 OU

• Now what: Treat Glaucoma

Put on AMD supplement Retina Referral for fluid

65 yo Deaf patient

• Recent h/o corneal abrasion OS

• SLOW to heal, and erodes

• Minimal success w bandage CL

• Happy w 20/20 OD but 20/200 OS

• Applied Amniotic Membrane OS and dramatic improvement

– Happy w 20/20 OD and 20/40- OS

• NOW WHAT? 9yo w 1 mo diplopia

• History: Not feeling well along w muscle problems last 1 month

• Observation: Head tilt

• Cover test: Dist EP and Near ET

• Assuming neuro-muscular problem w associated ocular findings, dilate to rule out accomodation problems

• NOW WHAT?? Now What?

35yo told to see a different eye doc

• Had an exam, odd findings, and told to seek further opinion for blurred vision

• Went to PCP and did blood work, did not know results

• Pt appearance and symptoms

• 20/60 and 20/40

• Dilation: Macular edema OU, macular exudates OS>OD, EXTENSIVE CWS and hemes, mild temp ONH Swelling OD

• What now??

• What does this mean to you?

34 yo female

• Need Rx for CL’s (1-800) wouldn’t fill

• 20/20 vision OU

• VF, EOM, Pupils normal

• Med Hx: Normal except overweight

• Meds: None, but going to weight loss “clinic”

• Oc Hx: Normal

• Ant seg: normal

• Post seg: as seen

Follow-up

• 1 month later

• Has lost a few pounds on program

• Still 20/20, refraction unchanged

• Post seg improved

• On meds for HTN

– Prescriber?

1 yr f/u

• Normal retinal exam with exception of tortuous vessels, no hemes or exudates

• Systemic health has been good

– Recently stopped taking BP Med

– Never really lost any weight

• BP checked in office

– 140/92

• Random Blood sugar in office

– 142

• What do you suggest now? What do you think…

• 44yo “healthy”

• Used to have “pre-diabetes” but “cured” w lifestyle modifications

• MD not concerned

Now what do you want to know?

• In office RBG 463

• In office A1c: >13

• Unable to go to PCP today or tomorrow due work schedule

• Went to PCP 2 days later and started on Janumet

• I always try to f/u on this type of pt…

3 months later….

• Came in for “retinal f/u”

• Retina unchanged

• Now on 2 meds for T2DM w dramatically changed outlook on disease

EYE EXAM MADE THE DIFFERENCE! How long has this person had Diabetes?

• They haven’t….new diagnosis

• Vision 20/20

Further information

• Further History: “I get up 3 times a night to get a drink and pee” “I am hungry and eating all of the time”

• Last visit to any doctor: 2 yrs for eye exam. Last MD/physical: >2 yrs, and don’t really have a PCP

• In office A1c:

–>13! New onset floaters

• Healthy 55yo male

• 20/20 OU

• New onset floaters x5days without flashes Posterior Vitreous Detachment

• As seen by different imaging

• Weiss ring clearly seen on OCT

• Partial PVD seen on B-scan

– Dynamic process

• Approx 65% of people >70yo

• Approx 95% of clinical RD’s arise as result of PVD Vitreous Hemorrhage

• If PVD with VH, approx 50-70% have tear

• If no tear seen, look harder until find Retinal Breaks

• Flap or Horseshoe tear

• Operculated hole

• Atrophic hole

• Macular hole

• Dialysis

• Giant retinal tear Retinal Holes

• Can occur anywhere

• Generally no treatment, unless symptomatic

• Rarely progresss to RD

• Pigmentation sign of chronicity

• PVD protective

Retinal Tears

• Up to 15% of symptomatic PVD will develop tear

• **What do you do about symptomatic tear?

• Refer for treatment

Tear Treatment

• Symptomatic tears require laser treatment

• Before and after

• Why treat symptomatic…

– Approx 50% untreated will develop RD

– Approx 5% treated still develop RD

Retinal Detachments

• 2 day history of inferior blind spot

• 20/30 vision

• Superior tear

• Macula on or off?

• Intervention?

• 1mo after surgery, 20/25

Superior RD with single break

• 25 year old male with no symptoms, superior break, 20/20 vision and clear lens

• Treatment options??

• Principles of treatment

– Retinal coagulation

– Scleral buckle

– Vitrectomy

– Pneumatic retinopexy Pneumatic Retinopexy

• First introduced in late 1980’s

• Indications: Superior 8 clock hours of retina with limited break(s) covering 1 clock hour

• Principle: Gas bouyant upward--tension closes break--RPE pump clears SRF---Laser to seal around tear

• Similar success to scleral buckle

• Importance of positioning

What’s This????

• RD with tear at 930 OD

• Gas Injected day before to tamponade

• Returned next (day of photo) to receive successful laser R.D. cont.

• Superior temporal RD

• Pseudophakic

• Multiple breaks

• Debris in vitreous from inflammation

• Treatment?

Primary Vitrectomy

• Better ineroperative sight of peripheral tears

• Controlled removal of vitreous

• Focused endo-laser

• Very low occurrence of PVR

• Allows for internal drainage

• Air/Fluid/Gas exchange for tamponade

• Excellent outcomes

– 25g Vitrectomy Inferior Detachment

• Healthy 35yo male

• 20/25 vision with recent onset of flashes and superior curtain

• Clear Lens

• Diagnosis??

• Dx: Inferior Detachment with macula on

Retinal Detachment

• Immediate intervention needed since macula on with good vision

• Cryotherapy applied at time of surgery to seal retinal break

• With bullous RD’s, drainage performed Scleral Buckle

• First performed in 1951

• Traction pulls along downslope of buckle to create radial force

• Change in eye contour creates new tangential force to flatten retina

• Different materials can be used for buckle

• Buckle minimally visible externally normally

• Potential complications

– PVR

– Buckle related Scleral Buckle

• Unable to use gas tamponde with inferior break

• Scleral buckle surgery gold standard

• SB alone as effective as SB +PPV in cases of undetected breaks1

• Yellow area is scar from cryotherapy

What’s this?

• Scleral Buckle extrusion

• Can cause diplopia, motility problems, changes to retina appearance, endophthalmitis

• Treatment: removal of buckle, culture, antibiotic treatment To Treat or Not to Treat

• Indications for treatment

– Horse-shoe tear almost always

– Dialysis almost always

– Operculated holes sometimes

– Atrophic holes rarely

– Lattice no holes rarely

– Retinal Detachment

• Macula On Emergent

• Macla Off Not emergent Lattice Degeneration

• No treatment needed if assymptomatic

• Prophylactic laser

– No definitive proof to benefit

• Found in 7-10% of people

• Approx 1% of Lattice patients develop RD

• Approx 2% if Lattice with holes

Why not treat all lattice?

• 20-30% of eyes with RD have Lattice Degen.

• 89% of RD’s from affected eyes occur in areas of normal peripheral retina

– So… How can you treat if you don’t know where RD will occur

• Eyes with risk factors don’t seem to have lower incidence of RD if treated

– 2-4% of treated eyes still have RD1

• Prophylactic laser did not prevent tear or RD in fellow eyes if no PVD present at time of tx:

– 94% still developed tears, 76% developed RD2 “True science teaches us to doubt, and in ignorance to refrain” Claude Bernard

Sudden Painless Loss of Vision

• 75 year old patient with sudden painless loss of vision

• Went to the ER

• Imaging was done

• Systemic testing normal

• Sent to eye doctor Sudden Painless Loss of Vision

• Subluxed lens

• Optomap and B-scan

• Referred for Vitrectomy and lens removal

• Note: RD on bscan Thanks to the DMV

• Pt came in because of DMV “exam”

• No symptoms

• No pertinent history

ERM peel What can SDOCT do for you?

• OS with Stage 4 macular hole. OD with cystic appearance to macla Macular Hole Surgery

• Vitrectomy is performed to relieve any traction

• ERM peeled if present

• Gas or Oil fill of eye to create tamponade

• ILM Peeling?

– More likely to close hole, but not as good of vision 1 S/P Mac Hole Surgery

• Face down positioning to create tamponade

– From 0-14 days

– Oil may prevent need for face down

• Hole closure does not ensure improved VA

– Months to recovery

• Slow migration of retinal cells Are there other treatments for VMT / Macular holes?

• 1. Observe

• 2. Injection….of what What if this patient were 20/50?

What is this even called???? Are they more likely to develop macular hole? Can this be fixed without surgery?

Data on file. ThromboGenics, Inc. 2013 Who knows what Jetrea is?

Jetrea Results Resolution of VMA at Day 28

By Predictors of Response * 400 μm with VMA Data on file. ThromboGenics, Inc. 2013.

I know…we won’t be doing this treatment

• But…

– Your patient may need it.

– We need to be aware of it

– We need to make patient aware of options

– By the way, it is not cheap….. TRIVIA

• What Vegas resort owner is legally blind due to RP?

• ANSWER LATER

What supplement do you think of when you think of RP?

• Probably Vitamin A in HIGH doses!

` TODAY’s thought: Lutein & RP

More current thought O3 + RP = better function

• Vit A palmitate 15,000 IU/d + Diet rich in O3 slows the rate of VA decline in pts with RP Berson Arch Ophthal 2011

– Calculated dietary intake of pts taking taking Vit A X 4-6yrs

• Data pool from 3 prev studies (1984-1991, 1996-2001 & 2003-2008) = 350 pts

– Neuroprotectin D1 Answer to trivia

• Which Las Vegas resort owner if legally blind from RP??

Acute care in the office…

• 34yo cauc female

• Got hit in eye last night w volleyball

• No f/f noted

• Vision is good but blurred spot above

• No pain

• Ant seg normal

Keep in chair, or out of there? Uveitis…

• 36yo w multiple recurrences

• 20/20 Vision

• Retina unaffected

• Systemic: ?? What if macula looked like this??

What if….

• The last patient is 78yo

• Ant seg clear

• PCIOL OU

• CE was 5 mos ago?

• Treat or refer? What would you do about ‘postpost op’ CME??

Normal Macula with h/o Uveitis

• 39 yo AA female

• H/o uveitis

• H/o previous sub-tenons steroid for CME

• Just finishing PF Taper and initially 20/20

• Then returned with 20/30 Change over time analysis

Another view of change over time ARE WE ALMOST DONE!!!

My trip to Romania All is good until…

• 74 yo male

• h/o glc on Xalatan

• 20/50, 20/60

• IOP: 26, 20

• Pupils: ERRL, -APD

• Ant seg: OD: Lens has mild ant. Cap pig and shallow angle OU

• DFE: What now?

• IOP post dilation: 66/64

• Treatment?

– Oral

• Osmoglyn

• Isosorbide

• Diamox

– Topical

• Pilo?

• Steroid

– Surgical

• Corneal indentation (beneficial in short term1)

• PI

• Outcome:

How to predict?

• Shadow test

• Visualization of angle

– Externally

– Von Herrick

– Gonioscopy Incidence

• RARE occurrence

– Patel et al. AJO 12/05 part of BES

• 4870 DFE with 0 AAC

• Prediction by shadow and h/o glc determined who was occludable, but still overestimated

– Croatia 2.9/100,000 Leung et al. Aug 04

– Israel 0/148,000 Avshalom. J Israel Med Assoc 1966

The next day…

• 72 yo with h/o glc

• Dilate?

• Still possible to have AAC after PI1

– Up to 55% still closed or occludable

• TAKE HOME MESSAGE: My trip to Romania

All is good until…

• 74 yo male

• h/o glc on Xalatan

• 20/50, 20/60

• IOP: 26, 20

• Pupils: ERRL, -APD

• Ant seg: OD: Lens has mild ant. Cap pig and shallow angle OU

• DFE: What now?

• IOP post dilation: 66/64

• Treatment?

– Oral

• Osmoglyn

• Isosorbide

• Diamox

– Topical

• Pilo?

• Steroid

– Surgical

• Corneal indentation (beneficial in short term1)

• PI

• Outcome:

How to predict?

• Shadow test

• Visualization of angle

– Externally

– Von Herrick

– Gonioscopy Incidence

• RARE occurrence

– Patel et al. AJO 12/05 part of BES

• 4870 DFE with 0 AAC

• Prediction by shadow and h/o glc determined who was occludable, but still overestimated

– Croatia 2.9/100,000 Leung et al. Aug 04

– Israel 0/148,000 Avshalom. J Israel Med Assoc 1966

The next day…

• 72 yo with h/o glc

• Dilate?

• Still possible to have AAC after PI1

– Up to 55% still closed or occludable

• TAKE HOME MESSAGE: Schisis

• Schisis vs RD

– Schisis is partial splitting of neurosensory retina

– VF will give relative scotoma with schisis

– B scan can be helpful

– OCT definitive

– Schisis is splitting of retinal layers between inner and outer layers

– Schisis generally benign and does not progress posteriorly

– With more bullous schisis, may develop inner and outer layer holes, which may predispose to RD

** Treatment needed when RD, otherwise no treatment

Combined retinoschisis with RD OD P200 Retinoschisis with RD Lines represent OCT orientation Bullous schisis

Retinoschisis

• Top OCT

– Red arrow: Full thickness sensory RD

– Green arrow: RPE still attached

• Bottom OCT

– Red: Thin inner layer of retinoschisis

– White arrow: Split in sensory retina

– Green: Outer retinal layer still attached to RPE

Thanks to the DMV

• Pt came in because of DMV “exam”

• No symptoms

• No pertinent history

Sometimes, all you have to do is look…

• 86yo female, loss of vision 3wks ago

• History of dry AMD

• Went to primary eyecare provider, and told to use artificial tears for Dry eyes

BMI

How do you talk to your pts about exercising? My Diabetes is diet controlled

What would be your top 3 ingredients for… What is a food’s GI?

Factoid: L/Z make you Smart!

• Xanthophyls (lutein & zeaxanthin) are good for brain health and cognition • MPOD related to indices that evaluate Processing speed,Accuracy, Completion1

• More L/Z in brain = better cognitive function2 • More AMD and worse VA = worse cognitive function3

• More green veges associated w less cognitive decline w age4

20 HM

• CC: Decreased VA X few weeks OS

– World looks like a “FISH bowl”

• PMHx: Unremarkable

– LME 6M (never told to get an “EYE exam”)

– CT at age 1 & sees PCP q12M

• POHx: Unremarkable

– Last CEE was at age 1

• Amsler: (+) metamorphopsia OS

• BCVA 20/20 OD 20/30 OS

`

Is it only associated neurosensory detachment? Things may be lurking that you are not aware of

Do you think the glaucoma is related to the maculopathy? Sturge Weber Syndrome (SWS)

Encephalotrigeminal (facial) angiomatosis Neuro-oculo-cutaneous congenital vascular hamartomas

• Need not affect ALL 3 systems

– CNS angioma

– Choroidal hemangioma (Ipsilateral to PWS)

• 50% of CH are associated with SWS

• Most commonly DIFFUSE pattern

• Various associated complications

– PWS

• Distribution along trigeminal nerve

• Choroidal hemangioma is more common with lid involvement

– Also increased likelihood of glaucoma

SWS and association with glaucoma Pathophysiology:

• Abnormal development of anterior chamber

– Abnormalities within the angle structures may be associated with decrease aqueous drainage (like in other congenital glaucoma)

• Mechanical pressure from CH causes increase episcleral venous pressure

Management of OUR patient

• SWS

– Glaucoma

• Glaucoma work-up (including gonioscopy)

• Cosopt BID initiated

– PG work well with THIS 2nd glaucoma but why is it NOT an ideal med in THIS case?

– Retinal detachment/Choroidal menangioma

• Ultrasound/FA CONFIRMED the Dx

– FA: hyperFL of large choroidal vessels with Fl staining entire lesion

Dr. Gerson & The Gas station story…

A few survey questions

• How many in the room sell supplements from their office?

• How many measure MPOD in office?

• How many do genetic testing in the office for AMD?

• Who has OCT in their office? Eye Vitamins Own 2 of the Top 10 Vitamin Category SKUs

Nutrition

• The best intake is through diet/food

– Not always realistic:

– Average American gets only 2mg Lutein

– Leading antioxidants for average American is coffee

– French fries account for 25% of all vegetable intake in US

– Importance of healthy lifestyle

• But only 3% of Americans follow 4 basic health practices Nonsmoking (76 %) BMI 18.5 – 25 (40%) 5 or more F &V daily (23%) > 30 minutes physical activity 5 times per week (22%)

Reality….

Take Home Message -Average patient -”Worried well” Patient with early AMD or Family history and worried -Intermediate or advanced AMD

• Value of Lutein

– Not in AREDS, studies have shown benefit (LAST)

• Either by supplement or green leafy vegetables

DISCUSS DIET and SMOKING!