Post on 26-Jun-2020
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Welcome to SECO 2011
SECO 2011March 2-6, 2011
Essentials in Posterior Segment DiseaseCarlo J. Pelino, OD
Joseph J. Pizzimenti, OD
DISCLOSURE STATEMENT
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At the conclusion of this course, please properlydispose of your trash as you leave this room
Dr. Pizzimenti is CEO of Optometryboardcertified.comDr. Pizzimenti has received honoaraia from Alcon, Reichert,Zeavision, and Carl Zeiss MeditecDr. Pelino has received honoraria from Carl Zeiss Meditec
Goals for This Course
Functional anatomy Recognize and
understand the telltalesigns of posteriorsegment disease.
Case examples New knowledge Interactive!
Identifying Signs of Retinal Disease
The Posterior Segment Functional Anatomy
– Vitreous– Choroid– Retina
Functional Anatomy of Posterior Segment
Clinical Landmark - Equator
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Ora Serrata
Pars Plana
Peripheral vs Central Retina
Approx 6DiscDiameters
CentralRetina
Exit Site ofAmpulla
Cent. R
et. →Equator
Peripheral vs Central Retina
PosteriorPole
“Mid-Periphery”
The Vitreous
Vitreous cavity ~4 ml in volume– 80% of globe’s total volume
Composed of water, proteins, andmucopolysaccharides (MPS).
Protein– Type II c_______________
• Helps support shape
MPS– Hyaluronic acid
• Gives vitreous elastic and viscid qualities
The Vitreous
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AscorbateAscorbate
Cloquet’s Canal
Area of Martegiani
Erggelet’s Space (Berger’s Space)
Vitreoretinal Vitreoretinal interface without PVDinterface without PVD
Posterior vitreous detachment initially occurs in thePosterior vitreous detachment initially occurs in thePerifovea Perifovea with a predilection for superior quadrant.with a predilection for superior quadrant.
Detachment extends widely in the Detachment extends widely in the perifovea perifovea withwithpersistent attachment to fovea and optic nerve head.persistent attachment to fovea and optic nerve head.
Detachment occurs in the fovea, persistentDetachment occurs in the fovea, persistentattachment of the posterior vitreous face to the opticattachment of the posterior vitreous face to the opticnerve head.nerve head.
Detachment is completed in with release of theDetachment is completed in with release of thevitreo-papillary vitreo-papillary adhesionadhesion.
Epiretinal Membrane SD-OCT Images
Fundus ImageFundus Image
ThicknessThicknessMap OverlayMap Overlay
ILM LayerILM Layer
ThicknessThicknessMapMap
Vitreoretinal Interface
Anomalous PVD Epiretinal
Membrane Macular Hole
Case Challenge
65 y/o WF CC: New floater OS x 3 wks
– Floater is bright
BCVA: OD 20/20 OS 20/25 Workup rules out vit cell, retinal breaks Lack of foveal depression OS
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Diagnosis?
What is your plan?
Pharmacologic Pharmacologic vitreolysis vitreolysis - - MicroplasminMicroplasmin
Case Challenge
65 y/o WF CC: New floater OD x 3 wks
– Floater is bright
BCVA: OD 20/20 OS 20/25 Workup rules out vit cell, retinal breaks, but…
NFL or Pre-retinalFlame Hemeat ON 2° toAcute PVD
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What is your plan?
Functional Anatomy: The Retina
RPE Neurosensory 6 million Cones
• Detailed vision• Color vision
120 million Rods• Peripheral retinal
receptors• Great sensitivity to
light
Retinal Pigment Epithelium
120 million cells inmonolayer
T____ junctions– Outer blood-retina
barrier
Functions of RPE– Phagocytosis of
renewable discs of PRs– O-2 diffusion to PRs– Provision of nutrients to
PRs
RPE
Describe That Fundus!
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Outcome:
• Congenital Hypertrophy of Retinal Pigment Epithelium (CHRPE)
• Photos taken
• Patient referred back to Optometrist
• Monitor 1 year
The Real Deal on CHRPE
Dark black, only slightly raised No malignant potential When present in multiple locations, investigate for
Gardner’s Syndrome– This is familial polyposis coli, which can lead to colorectal
carcinoma.– Autosomal dominant condition– Probe family history, patient GI symptoms– Consider gastroenterology consult if symptomatic or +
family history
CHRPE
The Macula X___________ pigment in
NFL absorbs blue WL,“macula lutea”
Fovea– Shallow depression in middle of
macula, 1.5 DD– Retinal cells displaced exposing
only the PR– Has the highest concentration of
cones– Capillary free zone 500 microns
(FAZ)
Note yellowmacular pigment
Fovea
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OSOSIS/OSIS/OSELMELM RPERPEISIS
NFL: Nerve Fiber LayerNFL: Nerve Fiber Layer OPL: Outer OPL: Outer Plexiform Plexiform Layer Layer IS/OS: Junction of inner and outerIS/OS: Junction of inner and outerILM: Inner Limiting MembraneILM: Inner Limiting Membrane ONL: Outer Nuclear LayerONL: Outer Nuclear Layer photoreceptor segmentsphotoreceptor segmentsGCL: Ganglion Cell LayerGCL: Ganglion Cell Layer ELM: External limiting membraneELM: External limiting membrane OS: Photoreceptor Outer SegmentOS: Photoreceptor Outer SegmentIPL: Inner IPL: Inner Plexiform Plexiform Layer Layer IS: Photoreceptor Inner Segment IS: Photoreceptor Inner Segment RPE: Retinal Pigment EpitheliumRPE: Retinal Pigment EpitheliumINL: Inner Nuclear Layer INL: Inner Nuclear Layer
ILMILM GCLGCLNFLNFL
ChoroidChoroid
IPLIPL INLINL OPLOPL ONLONL
SD-OCT Healthy Macula Retinal VasculatureRetinal Vasculature
2 main sources of blood2 main sources of bloodsupply:supply:Choroidal Choroidal BVBV–– Supplies outer retinalSupplies outer retinal
layers, including layers, including PRsPRs
CRACRA–– 4 branches nourish inner4 branches nourish inner
retinaretina–– Run Run radially radially toward foveatoward fovea
The The ChoriodChoriod
Loose connectiveLoose connectivetissuetissueMelanocytesMelanocytesChoriocapillarisChoriocapillaris–– FenestratedFenestrated
endothelium allowsendothelium allowsdiffusion of proteinsdiffusion of proteins
–– S__________S__________regulationregulation
–– High blood flowHigh blood flow–– Very little O-2Very little O-2
extracted, so highextracted, so highvenous O-2venous O-2
BM
CC
Mel.
thicknessRPE
sclera
Anatomic Anomaly #1Anatomic Anomaly #1
Cilioretinal Cilioretinal arteryartery10-30% have it10-30% have it
May spare centralMay spare centralvision in CRAOvision in CRAO
If occluded, centralIf occluded, centralvision lossvision loss
Cilioretinal Cilioretinal Artery in CRAOArtery in CRAO Cilioretinal Cilioretinal ArteryArtery OcclusionOcclusion
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Cilioretinal Cilioretinal ArteryArtery OcclusionOcclusion Venous System AnatomyVenous System Anatomy
Central Retinal VeinCentral Retinal Vein–– Retinal veins join atRetinal veins join at
disc to form CRVdisc to form CRV–– Drains into superiorDrains into superior
ophthalmic v.ophthalmic v. CRA
CRV
Anatomic Anomaly #2Anatomic Anomaly #2
"Dual Trunk" anomaly"Dual Trunk" anomaly–– Retro-laminarRetro-laminar
bifurcationbifurcation–– 2 central retinal veins2 central retinal veins
CV CV DxDx. can lead to a. can lead to aspecial type of sup orspecial type of sup orinf inf hemispheric RVOhemispheric RVO
CRVO AnatomyCRVO Anatomy
Anatomy of HCRVOAnatomy of HCRVO Fluorescein Angiography HCRVOFluorescein Angiography HCRVO
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Identifying Signs ofIdentifying Signs ofRetinal DiseaseRetinal Disease
Signs of vascularSigns of vasculardiseasediseaseSigns of degenerativeSigns of degenerativediseasediseaseSigns of other diseaseSigns of other disease–– InfectiousInfectious–– InflammatoryInflammatory–– Retina/Optic N.Retina/Optic N.–– HereditaryHereditary–– NeoplasticNeoplastic–– TraumaTrauma
69 year old Caucasian Female
CC: Reduced central vision OD x 3 weeks @ distance and near
Ocular History: Unremarkable
Systemic History: Unremarkable ; Last PCP exam 15 years ago
Social History: Smokes ½ pack of cigarettes a day Alcohol 5-10 drinks a day
Meds: Multivitamin
Allergies: +Penicillin
VA: s Rx 20/60 OD 20/20 OS
EOM: Smooth / Full
Pupils: PERRLA - APD
CF: Central blur OD Full Periphery OU
SLE: Unremarkable OU
TA : 20 mm Hg OU
Vitreous: PVD OU
BP: 168 / 98 RAS
Describe That Fundus!
Fluorescein Angiography
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What is your assessment?
Hemispheric Retinal VeinOcclusion
What is your plan?
BRVO
CRVO
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2
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•• Central Retinal Vein Occlusion Central Retinal Vein Occlusion •• Hemispheric Retinal Vein Occlusion Hemispheric Retinal Vein Occlusion•• Branch Retinal Vein Occlusion Branch Retinal Vein Occlusion
•• Ischemic Ischemic •• Non-ischemic Non-ischemic
Outcome:
•Diagnosis: Inferior Hemi-Central Retinal Vein Occlusion OD
•Treated as a non-ischemic CRVO (Why?)
•Follow-Up in 1 month
•Patient sent to PCP to rule out Diabetes, Hypertension, Cholesterol
•Hypertension diagnosed
•Treatment: intravitreal injection of Kenalog at 4 months for CME
•Patient had IOP spike after Kenalog injection – given Alphagan P
•No NVD or NVE occurred
•Vision at 1 year was OD 20/25
Hemi-Central Retinal Vein Occlusion
Uncommon type of hemispheric RVO– Occurs in "Dual Trunk" anomaly
Same pathophysiology as CRVO. May affect either the superior or inferior CRV
before they unite into common central retinalvein.
Usually occurs at or near the optic disc.
The Real Deal on CRVOs
T__________ in CRV at lamina CRVO Study
– Prophylactic PRP did not prevent NVI/NVA in ischemic CRVO• Therefore, wait for development of NVI/NVA before PRP
– No real benefit of macular grid laser for ME Follow-up
– Observe monthly for first 4-6 mon– Angiography when heme, retinal edema reduces– Monitor for NVI/NVA PRP– Medical workup
• CV Dx, DM, hyperviscosity, lipids– Non-ischemic CRVO may convert to ischemic (30%)!
Modern Retinal Specialist Retinal Vein Occlusion
Observe for short period for spontaneousimprovement of ME– 2-4 weeks
Eval. For HTN, DM, Chol, TGs, smoking– Use RVO as life modifier
If patient > 50 y/o and w/o above RF– ESR, CRP
If patient < 50 y/o and w/o above RF– Eval. For hyperviscosity
• Antiphospholipid antibody• Factor V Leiden
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Thrombus vs. Embolus
Thrombus– A hardened clump of blood within a vessel.
Embolus– Sudden blockage of an artery by a blood clot (thrombus) or
a_____________ material. Both are common causes of stroke.
Retina Quiz
In an ischemic CRVO, which is false?
a. it carries high risk of NVI/NVAb. complications may include ME,
ischemic damagec. risk of NVG is 5%d. it carries some risk for NVD, NVE,
leading to vitreous heme
Retina Quiz
In an ischemic CRVO, which is false?
a. it carries high risk of NVI/NVAb. complications may include ME,
ischemic damagec. risk of NVG is 5%d. it carries some risk for NVD, NVE,
leading to vitreous heme
Non-ischemic vs. Ischemic CRVO
Functional Tests
VA Pupil testing Visual fields Electroretinography
Structural Tests
Ophthalmoscopy– SL Fundoscopy– BIO
Fluoresceinangiography
Ischemic CRVO
• Note disc edema, several CWS
• Capillary non-perfusion on FA
• VA < 20/200, +APD, retinal/macular edema
• More likely to result in NVI/NVA than non-is
• 45% of cases result in NVG
Should Ischemic VenousOcclusions be Referred to a
Retinologist Before NVI/NVA?
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Macular Edemain CRVO
The Real Deal on BRVOs
Caused by a______________of overlying artery BRVO Study
– Observe monthly for first 6 mon• DFE, (OCT)• Gonio
– Chronic findings include ME, collateral BVs– Macular grid laser helpful for ME > 6 mon– Lucentis/Avastin off-label for ME– After initial 6 mon, observe q 3-4 mon for RNV, NVI/A– Scatter laser for RNV, VHeme
Medical workup• CV Dx, DM, hyperviscosity, lipids
Arteriosclerosis with calcification ofvessel wall
Emerging Treatments forEmerging Treatments forBRVO/CRVOBRVO/CRVO
Intravitreal KenalogIntravitreal Kenalog–– Intravitreal injection for MEIntravitreal injection for ME–– The The SStandard Care versus tandard Care versus COCOrticosteroid forrticosteroid for
REREtinal Vein Occlusion (SCORE) Study: tinal Vein Occlusion (SCORE) Study: TwoTwoRandomized TrialsRandomized Trials to Compare the Efficacy and to Compare the Efficacy andSafety of Intravitreal Injections(s) ofSafety of Intravitreal Injections(s) ofTriamcinolone Acetonide with Standard Care toTriamcinolone Acetonide with Standard Care toTreat Treat Macular EdemaMacular Edema
–– One for One for CRVOCRVO and One for and One for BRVOBRVO–– IVK found useful for ME in CRVO, IVK found useful for ME in CRVO, notnot BRVO BRVO
when compared to CRVOS/BRVOS standardwhen compared to CRVOS/BRVOS standard
SCORE84 clinics and sponsored by the National Eye Institute
One group received the standard clinical care for the conditionOne group got 4 milligramOne group got 1 milligram
Results: SCORE (CRVO) – 27%(1milligram) group and 26%(4milligram) groupExperienced a substantial visual gain of 3 or more lines. The results up to 2 years.
The 4 milligram group had the highest rates of cataract formation, cataractSurgery, and elevated pressure. The 1 milligram dose is safer for patients.
SCORE (BRVO) – 29%(laser), 26%(1mg), 27%(4mg) gained 3 or more lines. 3 yr.Laser treatment may have fewer side effects for patients.
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Emerging Treatments forEmerging Treatments forBRVO/CRVOBRVO/CRVO
Dexamethasone Dexamethasone Drug Delivery SystemDrug Delivery System–– OZURDEX (OZURDEX (intravitreal intravitreal implant) 0.7mgimplant) 0.7mg
((AllerganAllergan))–– Intraocular, biodegradable implant for theIntraocular, biodegradable implant for the
treatment of persistent MEtreatment of persistent ME–– Clinical trial validatedClinical trial validated OzurdexOzurdex
for ME in CRVOfor ME in CRVO
DR: CSME DR: CSME TreamentTreament
Iluvien Iluvien (formerly known as(formerly known asMedidureMedidure))–– Tube 3.5mm x 0.37mmTube 3.5mm x 0.37mm
containing containing fluocinolonefluocinolone–– Implanted into vitreousImplanted into vitreous w/ w/ 25g25g
(~0.5mm) inserter(~0.5mm) inserterSuturelessSutureless
–– Designed to provideDesigned to provide sustained sustainedeffect up to 24 monthseffect up to 24 months
–– FAMEFAME ( (fluocinolone acetonidefluocinolone acetonidein DME)in DME) results favorableresults favorable
Emerging Treatments forEmerging Treatments forBRVO/CRVOBRVO/CRVO
BRAVO and CRUISE studies BRAVO and CRUISE studies –– Lucentis Lucentis clinical trials for RVOclinical trials for RVO
BRAVOBRAVO –– Phase III study (12 month study) 0.3 or 0.5 mg of Phase III study (12 month study) 0.3 or 0.5 mg of LucentisLucentis
Safety and effectiveness of Safety and effectiveness of Lucentis Lucentis in macular edema secondary to BRVOin macular edema secondary to BRVO
CRUISECRUISE –– Phase III study (12 month study) 0.3 or 0.5 mg of Phase III study (12 month study) 0.3 or 0.5 mg of LucentisLucentis
Safety and efficacy of Safety and efficacy of Lucentis Lucentis in macular edema secondary to CRVOin macular edema secondary to CRVO
An analysis of the 6 month data from both studies showed a safety profileAn analysis of the 6 month data from both studies showed a safety profileconsistent with previous consistent with previous Lucentis Lucentis Phase III trials in wet ARMD.Phase III trials in wet ARMD.
As early as seven days after the first injection, patients who received monthlyAs early as seven days after the first injection, patients who received monthlyinjections of injections of Lucentis Lucentis had, on average, a statistically significant improvementhad, on average, a statistically significant improvementin their vision that lasted 6 months.in their vision that lasted 6 months.
Final thoughts on CRVOFinal thoughts on CRVOWhen NV occurs in ischemic CRVO, it most often occursWhen NV occurs in ischemic CRVO, it most often occursin the anterior segment.in the anterior segment.Neovascular Neovascular glaucoma is seen in ~ 45% of eyes withglaucoma is seen in ~ 45% of eyes withischemic CRVO.ischemic CRVO.M______ e_____ may occur in either ischemic or non-M______ e_____ may occur in either ischemic or non-ischemic CRVO, leading to permanent central scotoma.ischemic CRVO, leading to permanent central scotoma.–– Referral for steroid or Anti-VEGFReferral for steroid or Anti-VEGF
Non-ischemic CRVO may convert to ischemic (30%)!Non-ischemic CRVO may convert to ischemic (30%)!2/3 of non-ischemic CRVO will have 20/40 or better w/o2/3 of non-ischemic CRVO will have 20/40 or better w/oocular ocular TxTx..
Questions and Comments?Questions and Comments?
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Arterial Occlusive Disease
Central Retinal Artery (CRAO)– CRAO with retinal whitening and “cherry-red” spot in the fovea– May be embolic, “ischemic”, thrombotic (GCA), or due to NVG
Retina Quiz
In CRAO of < 24 hrs duration, best initialmanagement is:a. digital ocular massage, STAT retinal
consultb. IV methylprednisonec. po steroidd. observe without treatment; prognosis
excellent for visual recovery
Retina Quiz
In CRAO of < 24 hrs duration, best initialmanagement is:a. digital ocular massage, STAT retinal
consultb. IV methylprednisonec. po steroidd. observe without treatment; prognosis
excellent for visual recovery
The Real Deal on CRAO
CRAO can be embolic or thrombotic– Atherosclerotic changes, inflammatory endarteritis– BP, carotid auscultation
Acute management (< 24 hours)– Ocular Massage: 10 seconds/release Retinal consult **
• AC paracentesis (<24 hr)• IV Acetazolamide• Carbogen (95% O-2, 5% CO-2)
– Medical evaluation to ID and treat underlying cause• Carotid, cardiac studies• ESR if > 55 y/o, no visible emboli• If suspect GCA, hi-dose steroids
Follow-up– Monitor for NVI/NVA PRP
Arterial Occlusive Disease
Branch Retinal Artery (BRAO)– Almost always embolic
Color (left) and red-free (middle) photographs with retinal whitening.Fluorescein angiography (right) with delay in A-V transit time alonginferior arcade.
Branch Retinal Artery Occlusion
• Monitor for NV
• Carotid Studies
• Echocardiogram
• “Baby Aspirin”
• Lower the Cholesterol
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81 year old Caucasian female
CC: Decreased vision OU but OS getting much worse
Ocular History: + “Dry”AMD OU x 15 years, +Cataracts OU
Medical History: + Hypertension x 27 years (controlled with meds)
Allergies: +Sulfa drugs Meds: Ocuvite
VA: 20/100 OD 10/400 FB OS
EOMS: smooth/full TA: 12 mm Hg OU
Pupils: PERRLA – APD BP: 135/90 RAS
CF: Full periphery OU Central scotoma OU, confirmed w/Amsler
SLE: Unremarkable Vitreous: PVD OU
Describe That Fundus!Describe That Fundus!
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Fluorescein AngiographyFluorescein AngiographyOutcome:
• Diagnosis:• Geographic Atrophy (End-stage Dry AMD) OD• Choroidal Neovascularization (Wet AMD) OS
• FA ordered
• Avastin injections OS
• Subsequent PDT (“double therapy”)
• 20/200 VA (OD) 20/200 (OS) at 1 year
• Low Vision Referral
• D/C Ocuvite; switch to BS MV w/L & Z
Soft DrusenSoft Drusen
Soft, confluent more inclined to lead toSoft, confluent more inclined to lead to_______________ AMD *_______________ AMD *
soft drusen
Stages of AMD
EarlyAMD
Intermed.AMD
AdvancedAMD
“wet”
“dry”
Retina QuizRetina Quiz
The clinical feature of Wet AMD thatThe clinical feature of Wet AMD thatdistinguishes it from Dry is:distinguishes it from Dry is:a.a. Geographic atrophy of the RPEGeographic atrophy of the RPEb.b. soft, confluent soft, confluent drusendrusenc.c. vision 20/60 or worsevision 20/60 or worsed.d. Choroidal neovascular Choroidal neovascular membranemembrane
(CNVM) formation(CNVM) formation
Retina QuizRetina Quiz
The clinical feature of Wet AMD thatThe clinical feature of Wet AMD thatdistinguishes it from Dry is:distinguishes it from Dry is:a.a. Geographic atrophy of the RPEGeographic atrophy of the RPEb.b. soft, confluent soft, confluent drusendrusenc.c. vision 20/60 or worsevision 20/60 or worsed.d. Choroidal neovascular Choroidal neovascular membranemembrane
formationformation
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AMD Risk FactorsAMD Risk FactorsAgeAge
Gender - Gender - F > MF > M
SmokingSmoking
Iris Color - Iris Color - lighter irislighter iris
ObesityObesity
CV DiseaseCV Disease
AMD Family HistoryAMD Family History
Poor nutritionPoor nutrition
Low Macular PigmentLow Macular Pigment
Dietary and Serum Levels -Dietary and Serum Levels -Complex analyses (most, butComplex analyses (most, butnot all) show a relationship.not all) show a relationship.
MPOD-MPOD- Most (but not all)Most (but not all)studies have shown reducedstudies have shown reducedMPOD in AMD (by multipleMPOD in AMD (by multiplemeasurement techniques).measurement techniques).
Nutritional Factors
AREDSAREDS 2
AREDS 1 and 2Formulations
Vitamin C: 500 mg* Vitamin E: 400 IU* Beta-carotene: 15 mg (May be listed on the label as
“25,000 IU vitamin A as beta-carotene”) (eliminated) Why?
Zinc oxide: 80 mg (40 mg) Copper: 2 mg (needed to prevent Cu deficiency caused by
high dosage of zinc)* Lutein & Zeaxanthin (10 mg & 2 mg) Omega-3 fatty acids (1 gram)
Retina Quiz The AREDS 1 study found that in subjects with
intermediate AMD, or advanced AMD in one eye(but not the other):a. Zinc alone lowered risk of advanced AMD by about 25
percent.b. Lutein alone lowered risk of advanced AMD by about 25
percent.c. Antioxidants increased risk of advanced AMD by about 25
percentd. Antioxidants + zinc lowered risk of advanced AMD by
about 25 percent.
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Retina Quiz The AREDS 1 study found that in subjects with
intermediate AMD, or advanced AMD in one eye(but not the other):a. Zinc alone lowered risk of advanced AMD by about 25
percent.b. Lutein alone lowered risk of advanced AMD by about 25
percent.c. Antioxidants increased risk of advanced AMD by about 25
percentd. Antioxidants + zinc lowered risk of advanced AMD by
about 25 percent.
AREDS Grading Scale
1. No drusen or a few small drusen.2. Pigment abnormalities or non-extensive small
or intermediate drusen.3. Extensive intermediate drusen or any large
drusen or non-central atrophy.4. Good acuity and no advanced AMD in the
study eye. Advanced AMD in the fellow eye(choroidal neovacularization or geographicatrophy).
Intermediate Stage AMD
•• AREDS Category 3 AREDS Category 3• Extensive intermediatedrusen (63-124µ indiameter)
• At least one large druse(>125µ in diameter)
• Geographic atrophy notinvolving the foveal center
Is There a Strategy ?Is There a Strategy ?USDA Food TriangleUSDA Food Triangle5+ daily portions of fruits5+ daily portions of fruits& veggies& veggies–– at least 1 dark green, leafyat least 1 dark green, leafy
veg (spinach, kale)veg (spinach, kale)Low fat, low cholesterolLow fat, low cholesterolAntioxidant forAntioxidant for““nutritionally-challenged nutritionally-challenged ““Address CardiovascularAddress CardiovascularDisease, exerciseDisease, exerciseAvoid smoking, UVAvoid smoking, UV
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Available technologies for earlyAvailable technologies for earlydetection and monitoring of AMDdetection and monitoring of AMD
Non-invasive MethodsNon-invasive MethodsMacular Pigment Optical DensityMacular Pigment Optical Density–– MPODMPOD
Preferential Preferential Hyperacuity Hyperacuity PerimetryPerimetry–– PHPPHP
Optical Coherence Tomography Optical Coherence Tomography–– OCTOCT
Management of Dry AMDManagement of Dry AMD
Repeat Exams q3-4 Repeat Exams q3-4 monmonUV/blue WL Protection, Home AmslerUV/blue WL Protection, Home AmslerAntioxidants/Nutrition/Diet/SmokingAntioxidants/Nutrition/Diet/Smoking–– Contrast Sensitivity FunctionContrast Sensitivity Function–– AmslerAmsler–– Photostress Photostress RecoveryRecovery–– DFE, PhotosDFE, Photos–– MPODMPOD–– OCTOCT–– Hyperacuity PerimetryHyperacuity Perimetry(PHP)(PHP)
LV consultLV consult
Retina QuizRetina Quiz
Approximately what percentage of dryApproximately what percentage of dry((non-exudativenon-exudative) AMD eyes progress to wet) AMD eyes progress to wet((exudativeexudative) AMD?) AMD?
a. 37 %a. 37 %b. 50 %b. 50 %c. 2 %c. 2 %d.d. 15-20 %15-20 %
Clinical Features of Clinical Features of ExudativeExudative(Wet) AMD(Wet) AMD
______________________*______________________*________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Available technologies for earlyAvailable technologies for earlydetection and monitoring of AMDdetection and monitoring of AMD
Non-invasive MethodsNon-invasive MethodsMacular Pigment Optical DensityMacular Pigment Optical Density–– MPODMPOD
Preferential Preferential Hyperacuity Hyperacuity PerimetryPerimetry–– PHPPHP
Optical Coherence Tomography Optical Coherence Tomography–– OCTOCT
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Optical Coherence Tomography
Subfoveal Subfoveal CNVM w/ret thick, serous RDCNVM w/ret thick, serous RD
TD-OCTTD-OCT
CysticCysticchange inchange inWet AMDWet AMD
SD-OCTSD-OCT
Wet AMDWet AMD
Management of Exudative AMDManagement of Exudative AMDUV/blue WL protectionUV/blue WL protectionHome AmslerHome AmslerAntioxidants/Nutrition/Diet/Antioxidants/Nutrition/Diet/Smoking/ExerciseSmoking/ExerciseFA - Stat ! (ICG - as indicated) *FA - Stat ! (ICG - as indicated) *Retinal Consult and TreatmentRetinal Consult and Treatment–– Laser PhotocoagulationLaser Photocoagulation–– Photodynamic TherapyPhotodynamic Therapy–– Anti-angiogenic Anti-angiogenic TherapyTherapy–– Surgical or Other MedicalSurgical or Other Medical
InterventionInterventionLow Vision ConsultLow Vision Consult
Antiangiogenic Antiangiogenic Drugs: VEGFDrugs: VEGFInhibitorsInhibitors
VEGF binds to receptorVEGF binds to receptor
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Targeting Vascular EndothelialGrowth Factor (VEGF)
• Macugen
• Lucentis
• Avastin
Lucentis
• Lucentis ™ (ranibizumab) .5 mg injection monthly treatment x 4 mon
• Genentech• Antibody-based• VEGF-A inhibition• (low) risk of thromboembolism• Requires re-treatments• $2,000.00
Lucentis
• Lucentis approved for treatment ofneovascular AMD in June 2006
• MARINA – 12 mon results, Min. classic 95% of patients treated maintained vision 40% of patients treated improved their vision
by at least 3 lines (or 15 letters) on the studyeye chart
• ANCHOR: Predom. Classic• Similar results to MARINA
Treatments for Wet AMD VEGF Inhibitors
• Bevacizumab- Avastin (Genentech) $40.00 Intravitreal injection “off-label” for Wet AMD 1 injection/mon x 3 mon Is being compared w/Lucentis in CATT
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VA 55 L
VA 78 L
Pre and Post Avastin Treatment Antiangiogenesis
• Corticosteriods Kenalog
• Intravitreal triamcinolone combined withPDT showed mean VA improvement(Spaide 2004).
• Anti-VEGF agents
• Steroids
• PDT
Triple TherapyWhich therapy(ies) is/are“off-label” for Wet AMD?
a. Argon Laser Photocoagulationb. Visudyne Photodynamic Therapyc. Intravitreal Ranibizumab (Lucentis)d. Intravitreal Bevacizumab (Avastin)e. Intravitreal Triamcinolone (Kenalog)
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VEGF Inhibitor not yetapproved
• VEGF-Trap (Regeneron) Intravitreal injection completed Phase II
• No adverse effects
Now entering Phase III Binds tightly to VEGF receptors Rapid decrease in foveal thickening,
improved VA Also in trials for DME
Conclusions
We have an importantrole in the diagnosis and(co-)management ofposterior segmentvascular, degenerative,and other diseases.
Don’t miss the telltalesymptoms and signs.
Used evidence-basedmanagement.
Questions?
????
Thank youFor spending your precious time with us!
Carlo J. Pelino
Cpelino@salus.edu
Joseph J. Pizzimenti, OD
pizzimen@nova.edu