25/02/2014 Disclosure  Retina in Your Chair: Treat if or Out of There?? I have been on advisory boards/a consultant to/received honoraria from/ or been on speakers bureau list of the following:  Allergan, Alcon, Arctic Dx, Bausch & Lomb, Carl Zeis Meditec, Essilor, Optos, Optovue, Reichert, VSP, ZeaVision Jeffry D. Gerson, O.D., F.A.A.O. Shawnee, KS [email protected]  What does this mean to you? 34yo female Need Rx for CL’s (1-800) wouldn’t fill 20/20 vision OU  VF, EOM, Pupils normal  Med Hx: Normal except overweight  Meds: None, but going to weight loss “clinic”  Oc Hx: Normal  Ant seg: normal  Post seg: as seen   Follow-up      1 month later Has lost a few pounds on program Still 20/20, refraction unchanged Post seg improved On meds for HTN  What next? BP: 150/94 Prescriber? FBG in office: 134 1 25/02/2014 Disaster Strikes 1 yr f/u   Normal retinal exam with exception of tortuous vessels, no hemes or exudates Systemic health has been good   Recently stopped taking BP Med Never really lost any weight  BP checked in office  Random Blood sugar in office    140/92 142 What do you suggest now? Disaster…..       Pt called PCP yesterday w sx and unable to speak w Dr or nurse, told may want to go to urgent care or ER Instead, came to me next day: still w sx of dizzy, nausea, malaise and faint Complaining of blurred vision OD>OS, FBS OD OcHx: CE OS 6yrs ago Meds: Lantus (6units TID), Statin, HTN med SMBG: never Exam Findings Entering VA: 20/400 OD 20/200 OS Refract: -4.00 20/80 +3.75-4.25x125 20/30Anterior Segment: see photo below Posterior segment: OD: unable to see OS: mild NPDR, no CSME RBG: 554mg/dL A1c: >13   The Talk… I WANT HER OUT OF MY CHAIR But Where to??    Discussed grave nature of situation..cataract surgery can wait! Had husband drive her to the hospital** She returned 2 wks later for Cataract eval  Had been in hospital for 1 wk, Dx w CHF Was home for 3 days, than back for 3 days  Released 2 days before appt w me  The EMERGENCY ROOM!!!   CT/MRI and ultrasounds, full cardio w/u Now has new PCP….new lease on life! 2 25/02/2014 What would you do with this… 1 yr f/u    Has had CE on and YAG in other eye 20/25 OU BCVA New PCP, on Metformin and Byetta    A1c between 6 and 6.5 No NPDR present A completely different person In this case, no “wrong” answer…. Your worst patients… 65yo male  Occupation: retired, but used to be field medic in military  “My optometrist referred me because of my right eye, I am not sure what is wrong”  “Good general health, my blood pressure runs low”  My exam…  Hypertension??        Vision: 20/400 OD Anterior Segment: normal Blood Pressure: 196/120 What next…. Sent to PCP directly from office Started on HTN meds Returned for laser 2 wks later Hypertension     50-60 million Americans have systemic HTN (by today’s standards) Usually asymptomatic, but can lead to MI, PVD, CVA, renal disease, retinopathy Significant CVD risk at 140/90, and risk doubles with every increase of 20/10mmHg Risk factors include smoking, dyslipidemia, DM, age, family history, race, sedentary, obese, sodium… Hypertension  Category* Systolic Diastolic Normal <120 <80 Pre-HTN 120-139 80-89 Stage 1 140-159 90-99 Stage 2 >160 >100 HTN Malignant   >120  Refer to PCP in timely manner Goal of BP reduction to as low as tolerated Most patients will require 2 medications Lifestyle modification   30 minutes of physical activity >4 days/wk can lower SBP by up to 9mmHg Weight loss of 10kg can lower SBP by 5-20mmHg *The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH 3 25/02/2014 Branch Retinal Vein Occlusion  ME and 20/25-…What would you have done in 2008 and now in 2014? Major BRVO  1st order temporal branch at ON or 1st order away from ON but involving macula  Minor BRVO  Peripheral BRVO   Only macular branch No macular involvement So pt presents with VO & ME THESE are TODAY’S FDA approved options Anti-VEGF  First and foremost: Any ME from VO is no longer an “optometric” management: There is proven benefit to Tx that are implemented earlier than before  Which treatment is best?  Not exactly up to us…But sort of ….you choose! Steroid implants Ozurdex for BRVO and CRVO Bravo/cruise For BRVO/CRVO VEGF-trap Galilelo/copernicus For CRVO Laser for BRVO/ME BVOS Retinal specialists preferred tx option & when they decide to tx may remain controversial in regards to what is standard of care. Yet, many employ AVT more frequently & start treating earlier than before What about ASA / Anti-platelet use?  Historically thought to be beneficial especially in light of likely systemic Dz  When Sohan Singh Hayreh speaks..people listen ASA does not improve (actually worsens) outcomes in CRVO and HRVO pts Ok to cont if needed, but don’t start because of   So, what is the new standard for BRVO and/or CRVO Bottom line: Options available and no clear RIGHT answer. The wrong answer now seems to be: DO NOTHING So, when do they need to be out of your chair?? S.S. Hayreh: CRVO/HRVO and anticoagulants. Ophth. 8/11. 4 25/02/2014 Central “Spot” Central Serous Choroidopathy   Characterized by breakdown of the outer retinal barrier, with leakage of fluid through a defect in the RPE into the subretinal space, resulting in a neurosensory detachment Often times associated with high stress +/      50yo female referred in with a “spot” in the center of her vision Present for 1-2 wks Referring OD noticed abnormality VA 20/20 OU Denies High stress or type “A” personality      ED (Emotional Distress) may be related1 FA or OCT must be done to rule out CNVM Other systemic associations Use of corticosteroids* (Well documented in literature), pregnancy, increased adrenaline level, hemodialysis, collagen vascular disease, and hypertension Treatment? Letter of diagnosis to PCP to make aware 1. Conrad et al. Alexithymia and emotional distress in ICSC. Psychosomatics. 2007 Nov-Dec;48(6):489-95 ICSC    What would “FA” look like? Proposed Treatments?  You fill in the blank  Anti-VEGF Is it too easy to be successful with new treatments?? Can this be treated “Optometrically”? Classic “smoke stack” These are not FA’s: They are en-face OCT scans PDT for RPE leaks in CSC. Ober, M et al. Ophthalmology. Dec. 2005. ISCS…getting all the facts… Was this the initial presentation…and how would we know??? Hyperautofluorescence: Metabolically overactive: Dying Hypoautofluorescence: Metabolically inactive: Dead * 5 25/02/2014 New Guidelines per AAO (the other one) Plaquenil Screening: A HOT TOPIC!!  Historical screening tests: Baseline macula photos  Color vision testing  Amsler grid  10-2 Visual fields  Yearly exams  Very rare to find plaquenil toxicity   We now know that if we use these techniques, we will be too late!! Risk increases sharply to 1% at 5-7yrs or cumulative dose of 1000g (usual dose 400mg/d HCQ or 250mg/d CQ)  New screening guidelines include baseline exam and then annually at 5yrs  Objective tests: mfERG or FAF or SDOCT  Subjective test: 10-2  Fundus exam still important, but findings are generally late stage  Recommendations screening for CQ and HCQ Retinop.Marmor et al. Ophthalmology 2/11 So what about this pt on Plaquenil? Color Optomap: Note macular change Fundus Image OD What do you think? What next?? Case 5: Optomap® FAF OD PAF images reveal a peri-foveal ring of hypo AF in each eye. 6 25/02/2014 So, Plaquenil in your chair….??? 62yo Female 20/20 OU When do you want these patients in your chair?  When do you want them out?  How if at all do you communicate?  20/20 OU Anterior seg normal  IOP, VF, pupils WNL  What else do you want to know?  ???What is this   Debbie…a patient for over 10yrs   With Patient With Rheumatologist  So, What is the true standard of care??  Can we utilize fellow OD’s to perform necessary scans? Stargardt’s Dystrophy • Vision approximately 20/100 and stable for years • Always wondering if vision will get worse • Some difficulties w job, but nobody at workplace knows of visual difficulties • Drives w Bioptic and has for years What is the dx and can we tell if she is getting worse? In your chair or out of there??  38 yo male Dangers of Addiction  Healthy • Does a patient with Stargardt’s need to be referred out for treatment?  No meds, but…  Viagra PRN  Frequent Alcohol • What is the treatment?  20/20 OD, 20/30 OS • What about Low Vision rehab when needed?  Ant Seg healthy  Retina OS as seen  Diagnosis? 7 25/02/2014 Valsalva Would you refer this patient out??  Not generally associated with systemic disease, but…  More common in people with DM, HTN, and sickle cell  Typical ocular findings:  Pre-retinal heme, sub-hyaloid heme  Caused by sudden raise in intrathoracic pressure, which leads to Increased intraocular venous pressure  Causes break in macular capillary “Drunken Pumpkin” Valsalva Maculopathy Uveitis…  Common causes:  Vomit, cough, sneeze, constipation, exertion  Often seen with alcoholism, • 36yo w multiple recurrences bulemia and GI problems  Tend to resolve on own • 20/20 Vision  No long lasting damage • Retina unaffected  What caused condition in this patient? • Systemic: ?? What if macula looked like this?? What if…. • The last patient is 78yo • Ant seg clear • PCIOL OU • CE was 5 mos ago? • Treat or refer? 8 25/02/2014 What would you do about ‘postpost op’ CME?? Normal Macula with h/o Uveitis 4/08 • 39 yo AA female • H/o uveitis • H/o previous subtenons steroid for CME • Just finishing PF Taper and initially 20/20 • Then returned with 20/30 Same patient, later recurrence 5/8/08 5/15/08 5/27/08 Change over time analysis Foveal lift Threshold of 350microns Timeline Intraretinal cysts Does this patient need to be referred? Ultimately retinal thinning upon resolution Clearly defined cyst walls Change in thickness over time: ultimate foveal thickness 219 Another view of change over time Just 2 mos ago • 42yo healthy Caucasian 2 mos ago female • Work-in appt for “flashes in vision” • 2 mo ago exam, completely normal exam 9 25/02/2014 2 wk F/u: All normal blood work What is it?? Ophthalmologist Dx: Capillary Periphlebitis, no further testing necessary Has now had normal carotid, cardio echo and more blood work Normal CBC, PT, PTT, ANA, SED, CRP, B12, A1c, Ferritin,VWF, factor 5, high LDL and Cholesterol, BP 118/84 What about the periphery? • When do you send patients out for second opinion to an ophthalmologist? Retinal picture has changed some, but not “better” Yesterday in the office • 34yo cauc female • Got hit in eye last night w volleyball • No f/f noted 1. Peripheral retinal hemorrhage 2. Lattice degeneration 3. Lattice degeneration with holes 4. Asymptomatic retinal break • Vision is good but blurred spot above • No pain • Ant seg normal 5. Symptomatic retinal break Now What??? Keep in your chair or out of there? 10 25/02/2014 1 week later..complete resolution of retinal signs and VF defect Keep in chair, or out of there? A quick preview for Grand Rounds: WWYD Retina in your chair 18 yo male Serious soccer player No sx upon questioning Healthy fellow eye • It is often a fine line between what you will keep in your chair and what will be “out of there” • Each of us has to set that line for each condition that we might see (before we see it) • There may not be a “right” answer, but there are some WRONG answers • Utilize clinical exam, technology AND critical thinking to make reasonable decisions THANK YOU! Jeffry D. Gerson, O.D., F.A.A.O. [email protected] 11