Embed Size (px)
Citation preview
Swollen macula: Top 5PROFESSOR FARUQUE GHANCHI
u AMD
u DMO
u RVO
u CSR
u CMO
How do you identify swollen macula
Symptoms
Minimum acuityFunctioning acuity
Contrast GlareColourDistortionCentral Field
Signs
u SWELLINGu Fluid
u Exudates
u Fibrosis
u Haemorrhage
u Pigment change
Bradford Ophthalmology Research Network BORN for vision
Optimum treatment
u Tailored/Individualised
u Generic/ Population
•Incipient•Prodrome
Biologicalinitiation
•Symptoms•Signs
DiseaseDetection
•Screening
TESTS
•Diagnostic
FirstmedicalContact
•ServiceDesign
•Capacity
TreatmentInitiation
PatientDelaySeekinghealthcare
Detection/ReferralDelay ServiceDelay
MedicalPractitionerPatient
PriorM,etal.BrJOphthalmol 2013;0:1–5.doi:10.1136/bjophthalmol-2013-303813
AMD
Dryu Drusen
u RPE changes
u Atrophy
u Disciform scar
Wetu PED
u nAMDu CNV
u RAP
u CRA
u IPCV
Drusen
u Types of Drusen –u Soft, hard… but there is more!
u Reticular drusen ? Risk for wet AMD
Serous PED
u Wet AMD - but no identifiable CNV
u Conservative managementu Warn for new symptoms
Wet – neovascular AMD
u Retinal haemorrhageu Deep intraretinal/ subretinal or subRPE
u OCT outer retinal and RPE/Bruch’s changes
Fibrosis- end stage nAMD
u Scar in outer retina
u Usually stable/ non progressive central scotoma
AntiVEGF
u Very good outcomes with antiVEGF injections
u if Timely referral and treatment
u AntiVEGF agents in clinical use in NHS
u LUCENTIS & EYLEA
u Local expereinceu Both probably similar
u Outcome data collectionu Average 7 injections in first year
u 4+ in second year
u Treatment is indefinite
Not all AMD
u In practice look out for signs of nAMDu OCT can help refine diagnosis
u Macular hole may be confusingu Watzke’s sign with Volk lens on slitlamp
DMO
u Incidence of diabetes rising globally
u Local diabetic population on the up
u Screening programme helps early diagnosis
u Diaabetic retinopathy is usually continuos –progressive condition
u Background – preproliferative –proliferative stages
u Maculopathy occurs at any stage
DMO
u Definition
u Cliniaclly significant macular oedemau CSMO – clinical diagnosis
u Centre involving macular Oedemau CiMO – OCT based
u NICE guidance is based on this
Treatment of CiMO
u AntiVEGFu Lucentis or Eylea
u If >400 micron (NICE)
u Ozurdex or Iluvien implant
u If unresponsive to antiVEGF and eye is pseudophakic
u Good results with AntiVEGFu Improvement in vision 5-10 letters
u Multiple injections and visits (monthly) in the first year
u Reduced number of injections in second year
u Steroid implants: Ozurdex /Iluvienu Rescue treatment
RVO
EpidemiologyBRVO > CRVO
Prevalence:
0.5–2.0% for BRVO
0.1–0.2% for CRVO
5 year incidence:
1.8% for BRVO
0.2% for CRVO
CRVO – natural historySpontaneous improvement < 20%
Base line VA 6/60 to 6/18
Young age (<50) more favourable
20% still get severe issues (NV)
Dehydration/ Inflammation
10% BILATERAL @ baseline
5% get second eye involvement in 1 year
BRVO- natural historySpontaneous improvement 50-60%
6/12+ at one year
20% worsen
5% bilateral BRVO evident at presentation
Most unilateral 10% would get second eye involvement
CRVO treatment
u Risk factor assessment
u Macular oedemau Lucentis/ Eylea
u Ozurdex injections
u Neovascular comlicationsu Laser
u Glaucoma Rx
BRVO treatment
u Risk factor assessment
u Macular oedemau Lmacular laser – if view is clear
u Lucentis/ Eylea
u Ozurdex injections
u Neovascular comlicationsu Laser
CSR CSCR
u It was:u Retinal/ RPE issue
u Young man
u Nowu Central Serous Choroido(Retino)pathy
u Leakey choroid
u Any age
CSCR Types & management
u Acute
u Recurrent > 2 recurrences
u Persistent >4 months
u Persistent with tracks (Chronic)
u Conservative
u Individualised
u PDT, AntiVEGF, MR Antagonists
u PDT, AntiVEGF, MR Antagonists
CMO
u 1-19%
u More with complicated surgery
u Uveitis
u Diabetic eye?
u RVO
u ERM
CMO management
u Treat residual inflammation – steroid drops
u Nonsteroidal anti-inflammatory drops
u Oral Diamox
u Steroids – periocular/ intraocular injectionsu Oral?
