NEWSLETTER FOR OPTOMETRISTS

Early Detection Saves Sight 2013 | ISSUE 1

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case profile:A 48 year old Chinese male was referred to the Centre for Eye Health for an assessment due to macular changes noted by his optometrist at a recent routine eye test. He reported a history of traumatic injury to his right eye and has had poor vision in this eye since childhood. His medical and family history were unremarkable.

Visual acuities were RE 6/60-2 and LE 6/7.5+2 with a moderate hyperopic prescription. There was no improvement with pinhole. The left eye showed reduced contrast sensitivity but no distortions on the Amsler grid; the right eye was not tested.

Issues to consider:

• Is the macular appearance consistent with the entering tests result?

• What do you think the differentials may be?

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FIGURE 1A: Right eye central photograph

FIGURE 1B: Left eye central photograph

“We are extremely fortunate to have this great service. Thank you.”

Ann, CFEH patient 2013

• The Centre is now distributing all patient reports electronically via Medinexus. If you have not yet set-up your medinexus account please e-mail enquiries@cfeh.com.au for an instruction sheet.

• Virtual consultations are now available for LearningforVision members. Virtual consults allow optometrists with imaging equipment to send their patient data and images to CFEH for interpretation. Visit cfehlearning.com.au for more info.

• Electrophysiology has recommenced at CFEH. Please forward your referrals to the Centre as normal.

• Please remind your patients to take their Medicare card with them to their CFEH appointment, we only bill for optometrist to optometrist referrals (10905).

Early this year the Centre for Eye Health launched its new Continuing Education website LearningforVision (cfehlearning.com.au).

Featuring education on advanced imaging interpretation, the website is available to paying members and offers a variety of CPD activities including; interactive case of the week presentations, live webinars, downloadable video podcasts, an extensive resource library including clinical guidelines, and a more indepth version of Image Newsletter called Image Extra. Multiple choice quizzes are also included for extra CPD points and to test your advanced imaging knowledge.

Together, the courses provide members over 40 points worth of continuing education, including the necessary face-to-face and therapeutic points.

As CFEH is an OAA approved provider of CPD you can see your points on the OAA website, and be sure that all points will be counted towards your registration.

Virtual consults are also available exclusively to LearningforVision members. This resource allows practitioners who have access to their own imaging equipment to forward their patients’ images and data to CFEH over the web for interpretation. Our clinicians will review these images within 5 days and provide you with a report, including management tips and suggestions.

I encourage you to visit the LearningforVision website (cfehlearning.com.au) to learn more about the courses provided, and to consider the benefits that improved knowledge of advanced imaging interpretation and the virtual consults feature could provide both you and your patients. Remember, early eye detection of eye disease is critical to saving sight!

Prof. Michael Kalloniatis Centre Director

• What further tests would you perform to assist you in arriving at the correct diagnosis?

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case profile cont...Results and DiscussionOCT imaging through the lesions in the right eye showed large bullous elevations of the RPE. There are also serous adjacent retinal detachments and regions of outer retinal layer loss.

Imaging throughout the disciform lesion revealed an irregularly elevated retinal profile with fibrotic-type changes within the lesion in addition to alterations to the retinal architecture (Figure 2A).

OCT Imaging through the various macular lesions in the left eye revealed disruptions to the outer retina. These were of a serous, haemorrhagic and/or fibrotic nature (Figure 2B).

Optomap fundus autofluorescence (FAF) showed a focal hypo-autofluorescent area near the centre of the right macula with patchy hypo and hyper autoflurescence surrounding the area. There is a hyper-autofluorescent incomplete ring at the outer borders of the affected area. (Figure 3A).

FAF imaging of the left eye showed a distinct and more uniform area of hyper-autofluorescence, with smaller areas of both hyper and hypo-autofluorescence within this area (Figure 3B).

Given the findings, referral to a retinal specialist was organised for the following day.

The retinal specialist conducted fluorescein angiography on the patient. Haemorrhagic pigment epithelial detachments were found and a diagnosis of bilateral polypoidal choroidal vasculopathy (PCV) made. In the right eye, the PCV was superimposed on a long-standing traumatic maculopathy.

Due to potential complications associated with treatment and considering the patient is monocular, asymptomatic and retains good acuity, a conservative approach was adopted, and the decision made for the ophthalmologist to closely monitor the patient.

As PCV carries the risk of sub-macular haemorrhage and further retinal exudation, the next ophthalmological review was scheduled in three months.

FIGURE 2A: OCT imaging right eye

FIGURE 3A: Optopmap fundus autofluorescence right eye

FIGURE 3B: Optopmap fundus autofluorescence left eye

FIGURE 2B: OCT imaging left eye

LearningforVisionAcess to virtual consults

Over 40 CPD points from homewww.cfehlearning.com.au

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spotlight on PVC

PCV is a chronic vascular abnormality of choroidal blood vessels with persistent serous leakage and recurrent bleeding. The usual age of onset is between 60 and 70 years.

It is characterised by branching choroidal vessels with aneurysmal dilations which appear as red/orange structures in the macular and/or peripapillary areas. These lesions can be seen in some eyes during fundoscopy, but are more easily visualised with fluorescein angiography (FA) and indocyanine green angiography (ICGA).

PCV lesions in the peripheral fundus have also been reported but are less common.

Epidemiology

The incidence of PCV is high in African Americans, moderately high in Asians, and relatively low in Caucasians.

In African Americans, PCV affects middle-aged women more frequently and the lesions are usually bilateral - occurring in the peripapillary region.

In Asian patients, PCV tends to be more common in males as a unilateral condition affecting the macula.

In Caucasians, the disease is more commonly a bilateral condition with peripapillary lesions and no or female gender predilection.

PCV has been detected in 8-13% of Caucasian and 23% of Japanese patients initially misdiagnosed with neovascular ARMD.

Clinical Presentation

Patients with PCV typically present with good VA despite extensive subretinal exudates and/or haemorrhages in the sub-RPE or subretinal space. Small lesions are more common in early stages of the disease and they often

This version of Image Newsletter has been adapted from our Image Extra series available on our LearningforVision website. To read the full article, see the list of references, and to answer the CPD questions visit cfehlearning.com.au and signup to become a member*.

You will also enjoy over 40 CPD points worth of courses as well as access to virtual consults.

*For membership fees, T&C’s visit cfehlearning.com.au

show a slow rate of progression with good visual prognosis. Large lesions are more likely to appear in later stages.

Pigment epithelial detachment is often associated with polypoidal structures in the choroid beneath the RPE. In some cases, the polypoidal lesions may regress and resolve spontaneously while in other cases there is formation of classic choroidal neovascularisation. In the instance of spontaneous resolution of acute disease, there is development of subretinal fibrosis, retinal pigment hyperplasia and atrophy.

Differential Diagnosis

It remains unclear as to whether PCV is a subtype of neovascular AMD. The clinical appearance of PCV is similar to that of neovascular AMD with haemorrhaging and subretinal exudation, however the natural course and response to treatment differs between the two conditions.

Eyes affected by PCV tend to lack drusen, the characteristic sign of early AMD. Drusen can, however, coexist with PCV and have apparently little effect on the disease course.

The rate of progression tends to be slower and the rate of decline in visual acuity lower in PCV compared with neovascular AMD.

The formation of disciform scarring frequently seen in end-stage neovascular AMD usually does not occur in PCV.

Indocyanine green angiography (ICGA) allows imaging of the choroidal circulation beneath the RPE. The infrared wavelengths used in ICGA penetrates deeper into tissue than visible light so that excitation and imaging through the RPE and any associated exudation is possible. In contrast, fluorescein angiography is less able to show the extent and characteristics of polypoidal choroidal vascular abnormalities as the RPE obscures the inner choroid.

ICGA allows differentiation from persistent and/or recurrent CSR, which have a similar clinical appearance to PCV.

The natural course of PCV is thought to depend on a number of factors including race and systemic disease. Uyama et al. investigated the natural course of PCV by following 12 individuals with PCV for a period of between 2 and 4.5 years without treatment. They found that half of the affected individuals had a favourable outcome and half had a poor outcome due to persistent leakage or recurrent bleeding. A good outcome was associated with a good initial visual acuity. This suggests that some patients with PCV can be initially monitored, depending on presenting VA and ICGA characteristics, with treatment options considered if vision and choroidal vascular status decline. As such, a conservative approach to treatment is recommended unless there is persistent or progressive exudative change that is macula-threatening.

Treatment

Treatments for PCV have included thermal laser photocoagulation, photodynamic therapy (PDT) and anti-vascular endothelial growth factor (anti-VEGF) agents to treat the leaking aneurysm or polypoidal components within the vascular lesion.

Optometric Management

Although in some cases PCV can be postulated from fundoscopic and/or OCT appearance (and in some instances FAF), in most cases it will not be possible to differentiate PCV from other conditions such as neovascular AMD or chronic central serous retinopathy (CSR). ICGA imaging is needed for a definitive diagnosis. Hence individuals presenting with macular exudation and/or serosanguinous PEDs should be referred to a retinal specialist within the recommended two week time frame.

Centre for Eye Health is an initiative of Guide Dogs NSW/ACT and The University of New South Wales

our contact detailsThe University of New South Wales, Rupert Myers Building (south wing), Kensington NSW 2052

Ph: (02) 8115 0700/1300 421 960 Fax: (02) 8115 0799 Email: enquiries@cfeh.com.au Website: cfeh.com.au

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Many of your patients may already need assistance.

It’s never too early for Guide Dogs NSW/ACT to show a person how to adapt to life with low vision – especially when all training and equipment is provided completely free of charge.

Best known for its amazing Guide Dogs, the organisation offers many other services which include:

• Low Vision Services: tailored one-on-one training in the home to maximise remaining vision. There is also a low vision clinic at Chatswood, delivered in partnership with UNSW School of Optometry.

• Children’s Services: working with schools and pre-schools to provide advice on the needs of children with impaired vision, and review the environment to identify any hazards or barriers to learning and inclusion.

• Programs for people with neurological vision impairment.

• Provision of electronic mobility aids and optical aids, and free training in their use.

• Orientation and Mobility (O&M) training to help people independently move safely around their own community.

Guide Dogs instructors travel to all parts of NSW/ACT.

It’s easy to refer someone. With your patient’s permission, call (02) 9412 9300 or fill in an online referral form at guidedogs.com.au.

Printed June 2013

clinical staffDirector Professor Michael Kalloniatis BSc Optom, MSc Optom, PhD, PGCertOcTher

Consultant Ophthalmologists South Eastern Sydney and Illawarra Area Health Service

Chief OptometristMichael Yapp BOptom (Hons), MOptom, GradCertOcTher

Principal OptometristsAnna Delmadoros BOptom (Hons), MOptom

Paula Katalinic BOptom (Hons), MOptom, GradCertOcTher

Dr Andrew Whatham BOptom (Hons), DPhil, GradCertOcTher

Senior OptometristsAgnes Choi BOptom, MOptom, GradCertOcTher

Carol Chu BOptom (Hons), GradCertOcTher

Clinical ScientistPenny Chen DipClinNeuroph

OptometristsJaclyn Chiang BOptom, MOptom, GradCertOcTher

Angelica Ly BOptom (Hons)

Rebecca Milston BOptom (Hons), GradCertOcTher

Elizabeth Wong BOptom (Hons), GradCertOcTher

Nayuta Yoshioka BOptom (Hons), GradCertOcTher

Support the Centre

The Centre for Eye Health needs your support to continue providing this great service.

By becoming a LearningforVision member you can directly support the Centre and the services it provides.

In return you will be provided the opportunity to complete over 40 CPD points in advanced imaging education and given exclusive access to our virtual consults service.

For more information on the LearningforVision program visit cfehlearning.com.au.

Thank you to our valued referrers for your continued support.

did you know?A Referrer Hotline is available for registered optometrists.

REFERRER HOTLINE: 8115 0777

Disclaimer: This newsletter is not intended to provide or substitute advice through the appropriate health service providers. Although every care is taken by CFEH to ensure that this newsletter is free from any error or inaccuracy, CFEH does not make any representation or warranty regarding the currency, accuracy or completeness of this newsletter. Patient names and details have been changed to protect privacy. Copyright: © 2012, Centre for Eye Health Limited. All images and content in this newsletter are the property of Centre for Eye Health Limited and cannot be reproduced without prior written permission of the Director, Centre for Eye Health Limited.

This edition of Image Newsletter has been prepared by Andrew Whatham, Principal Staff Optometrist and Carol Chu, Senior Staff Optometrist at CFEH.

This edition has been adapted from the CFEH’s ‘Image Extra’ series on the LearningforVision website (www.cfehlearning.com.au).

To access previous editions of Image Newsletter, or to download additional resources and references, please visit www.cfeh.com.au.