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Retinal Imaging Conference
Shivani V. Reddy, MDUniversity of Louisville
Department of Ophthalmology and Visual Sciences
6/5/2014
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 HistoryPOHx: 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
Exam
BCVA P TTP
EOM: Full OU CVF: Full OU
Anterior Segment: mild NS cataracts OU, otherwise WNL
20/20-1 (sc) 3 ->2mm
3 ->2mm
14
17(-) RAPD
20/60-2 (-1.00+1.00x180)
OCT OD
OS
OS: retinal thickening with cystic spaces temporal to fovea, subfoveal disruption of ELM and ellipsoid region lines
Autofluorescence OS
OD: Area of central hyperautofluorescence , hypoautofluorescense concentrated superiorly
FA Photo OS 00:23:28
Mid AV phase : delayed superotemporal venous arcade filling, scattered areas of hypofluorescence, pinpoint hyperfluorescent areas
FA Photo OS 00:30:33
Late AV phase: persistent filling defect in superior temporal arcade, prominent macular collateral vessel, hypofluoresent ares scattered throughout the sup-temp segment
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 OS
Recirculation phase: increasing hyperfluoresnce around pinpoint leakages, decreasing fluorescence of collateral vessels. Increasing hyperfluorescence temporal and superior to the fovea
01:44:39
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
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
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 intraretinal heme within
the cysts If CME present, round yellow spot can occur
centrally that later disappears
Branch Retinal Vein Occlusion
Chronic Phase Resolution of subretinal heme 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 Occlusion
Branch Retinal Vein Occlusion
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 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 Retinal Vein Occlusion
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
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.
Branch Retinal Vein OcclusionBRAVO 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 Occlusion
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
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.
Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, 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
Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusionFrancesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, 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
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.James W Heroman, M.D. Shlomit Schaal, 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 bevacizumab monotherapy 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)
ReferencesRetina-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.