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Retinal Imaging Conference Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/23/14

Retinal Imaging Conference

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Retinal Imaging Conference. Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/23/14. Subjective. CC : “ Decreased vision in right eye for several months ” - PowerPoint PPT Presentation

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Retinal Imaging Conference

Eddie Apenbrinck MDUniversity of Louisville School of

MedicineDepartment of Ophthalmology & Visual

Sciences1/23/14

Subjective 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.

POH: 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 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

PMH: HTN, HLD, GERD, DM type II (A1C 5.6), Asthma

Medications: Crestor 10mg daily, Lisinopril 10mg daily, Zantac 75mg BID, metformin 500mg BID

Allergies: Penicillin, Sulfa, Levaquin

Exam OD OS

BCVA 20/100-1 20/20-1

-2.50x0.25x165 -2.50x0.50x180

Pupils: 3 2 3 2 no APDIOP: 14 mm Hg 16 mm Hg EOM: Full OU

CVF: Full OU

Exam Anterior Segment

OD OSL/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

Color Fundus Photos: 12/2013

OD OS

OD: macular edema, dot hemorrhages temporal to disc, melanotic lesion with central hypopigmentation superotemporally

OS: unremarkable

Color Fundus PhotosOD:

2/2010OD:

7/2010

Autofluorescence

OD: Hyperautofluorescence temporal to macula with areas of hypoautofluorescence temporal to the disc and superotemporal to the macula

OS: unremarkable

FA OD

AV Phase: -Capillary non-perfusion temporal to disc with associated MA’s and microvascular remodeling-Capillary nonperfusion superotemporal to macula (area of prior SRT) -Microvascular remodeling juxtafovea (nasal)-Irregular slightly enlarged FAZ

FA OD

Late AV Phase: expanding hyperfluorescence temporal to the disc and portions of the nasal macula consistent with

leakage

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)

OCT OD

OSFoveal Subretinal Fluid and macular edema

Vitreomacular Adhesion

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 DDx

Radiation retinopathy Diabetic Retinopathy BRAO BRVO

PLAN

Avastin OD for macular edema

Observe melanotic choroidal lesion as no change in size since SRT

Follow up in 1 month to reassess macular edema

1 month follow up

No change in VA Resolution of subretinal fluid but no

change in macular edema on OCT

Repeat Avastin OD and f/u in 1 month

Radiation Retinopathy 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

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

Clinical Feature Patients may be asymptomatic or may describe

decreased visual acuity

Ophthalmic Signs: CWS, retinal hemorrhages, MA’s, perivascular sheathing, capillary telangiectasis, macular edema and disc edema

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

Treatment 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

Hyperbaric oxygen has been proposed as treatment but benefits remain unproven

Situations that exacerbate radiation retinopathy: Pre-existing microangiopathy: more likely to

develop severe changes Diabetic patients: likely to show changes at lower

doses of radiation Chemotherapeutic agents (5-FU)

Literature Review

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

81 of 159 (50.9%) demonstrated 20/50 or better vision at mean follow up of 34.6 months

Literature Review

Literature Review

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 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)

Clinical Ophthalmology September 2013

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

References BCSC: Retina and Vitreous. Radiation Retinopathy. Pgs

151-153 Maguir AM, Schachat AP. Radiation Retinopathy. Retina

Vol II 4th Ed. Chapter 83:1483-1489. Patel SJ, Schachat AP. Radiation Retinopathy. Albert and

Jakobiec’s Prinicples and Practice of Ophthalmology. 3rd 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

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