Posterior(Segment(Grand(Rounds( from(the(Bluff(City(11/28/18 1 Posterior(Segment(Grand(Rounds(from(the(Bluff(City(Andrew+Rixon+OD,+FAAO 59713-PS 1 •No+Financial+Disclosures 2 Case+CB

11/28/18

1

Posterior(Segment(Grand(Rounds(from(the(Bluff(City(

Andrew+Rixon+OD,+FAAO59713-PS

1

•No+Financial+Disclosures

2

Case+CB

3

CB• 44+yo WF+c/o+ reduced+ vision+ OS• Slowly+ worsening+ over+ past+8E10+months• CL+examination+ at+outside+ doc+had+VA+ reduced+ to+20/40• Previously+ correctable+ to+20/20• 1+wk ago+covered+up+ OD+and+ couldn’t+ see+cars+ in+ front+of+her+ through+ OS+but+could+ see+ trees+ around+ it

• Tinnitus+ has+worsened+ recently• Hx of+Migraines,+ no+ worsening+ of+ these• Meds:+ Loratidine 10+mg qday, methocarbamol 500+mg qhs prn,+naproxen 250+mg+bid,+ and+promethazine+ 25+mg+q6hours prn.

4

CB(Ocular(findings/Ocular(Hx

• BCVA:+20/20+OD,+20/150+OS• Pupils:+1++APD+OS• Amsler:+normal+OD,++metamorphopsia of+entire+grid+OS• Color+vision:+Unremarkable• Oc Hx:+ONH+drusen OU+c+RNFL+thinning+and+VF+defect• Previous+Photos/OCTs/VF+to+follow….• OCTs+unchanged+at+that+visit• VF+from+this+visit+attached

5

Disc(Photos

6

11/28/18

2

RNFL(OU

7

GCL(OU

8

XCSectional(Scans

9

Historical((VFs

1 0

VF(on(day(of(Exam

1 1

Grayscale(Comp(1yr(prior➡ ️ Day(of(Visit(OS

VFI+71%+ VFI+51%12

11/28/18

3

Is(the(VA(loss(due(to(the(drusen???

J Glaucoma .2009;18(5):373–378 1 3

Unlikely……..

1 4

MRI(c(Contrast(

1 5

Different(MRI(techniques

T1+weighted T2+weighted T1+with+contrastSlide+ Courtesy+ of+ Jess ica+Haynes + OD,+ FAAO 16

Dx…….Planum Sphenoidale(Meningioma• Tx:+Elective+Right+Orbitofrontal+craniotomy+resection+of+planummeningioma“Once+the+tumor+was+identified,+we+looked+along+the+ipsilateral+side+until+

the+ipsilateral+optic+nerve+and+carotid+artery+were+idenitifed.+The+tumor+was+carefully+dissected+off+these.+We+then+worked+across+the+planum.+We+identified+a+significant+number+of+feeders+to+the+tumor.+These+were+carefully+coagulated+and+cut.+We+continued+to+work+across+to+the+other+side,+attempting+to+identify+the+contralateral+optic+nerve.+This+was+somewhat+challenging+as+the+optic+nerve+was+found+to+be+completely+surrounded+by+tumor+and+in+fact+the+tumor+was+invested+into+the+optic+canal.+We+proceeded+to+dissect+the+tumor+out+of+the+optic+canal.+We+also+opened+the+falciformligament+around+the+ipsilateral+side+in+order+to+release+the+optic+nerve+which+was+pinned+laterally+by+the+tumor”

https://vimeo.com/17662043717

Planum Sphenoidale(Meningioma• Account+for+5E10%+of+all+intracranial+meningiomas• Constitute+2%+of+all+primary+intraEcranial+tumors• F>M+predilection• Benign+and+typically+slowEgrowing+tumors• Most+patients+remain+asymptomatic+until+tumor+reaches+>4cm• ~2/3+of+pts+have+monocular+reduced+vision+as+1st symptoms++

Can Fam Phys ician 2017;63:288-9, 291 BMJ$ Case$Reports $ 2011;+ doi:10.1136/bcr.07.2011.45 11+https :/ / radiopaedia.org/cases/plan um Esphe noi daleE me ningio ma E9Romanian Neurosurgery (2013)+ XX+ 1:+ 92+E 99 h ttp s://neup sykey.com/su r gic al E man ag em en tE

o fEmid l in eEan terio rEsku l l Eb aseEm en in giom as /1 8

11/28/18

4

Pre(and(post(tumor(removal

Slide+ Courtesy+ of+ Jess ica+Haynes + OD,+ FAAO19

VF(Pre(and(Post(Tumor(Removal

2 0

OMIC(Claims(2008C2014

• Oncology(claims. There+were+27+claims.+Failure+to+diagnose+melanoma+resulted+in+six+claims+and+two+payments.+Pituitary+tumors+were+allegedly+missed+in+four+claims+but+no+payments+were+made.+A+delay+in+diagnosing+glioma+led+to+three+claims+and+two+payments,+including+a+settlement+of+$2,000,000,+the+largest+ one+in+the+study.+There+were+three+lacrimal+cancer+claims+with+one+payment,+three+optic+nerve+tumors+with+no+payments,+and+one+trigeminal+schwannoma+claim,+which+settled+for+$1,000,000.

https :/ /www.omic.com/diagnosticEe rr or Ety pesEan dEca uses/ 2 1

Optic(Disc(Drusen Diagnostics

• CT• FAF• Ultrasound• OCTEEDI

Retina 2008% Jan)28(1):143 06 .2 2

CT

Turk+ J+Ophthalmol 46;+ 5:+201623

FAF

2 4

11/28/18

5

B(Scan

2 5

SDCOCT(XCsections((Black(on(white

2 6

Ophthalmology 2017)124:66 07 3

EDI(of(ONH(DrusenC3(categories

2 7

J+Neuro+ Ophthalmol2018;38:299–307

28

John son L,+et+al . + Arch $Oph th a lmo l .$2 0 0 9 ;1 2 7 (1 ):4 5 E4 9 .+

Si lverman A,+et+al . + J$Neu ro $ Oph th a lmo l 2 0 1 4 ;3 4 :+1 9 8 E2 0 5 .

Slo tn ick,+ S, +OVS. $ 2 0 1 2 ;8 9 (5 ):+1 E5 .

Evolution(of(Imaging

Slide+ courtesy+ of+ Catherine+ Hogan+ OD,+ FAAO 29

Pros/Cons(of(Drusen Diagnostics

Silverman+ et+ al:+J$ Neuro;Ophthalmol 2014;+ 34:+ 198E20530

11/28/18

6

The(RNFL(problem

Graefes Arch$ Clin Exp Ophthalmol (2014)+ 252:1653–166031

Pseudo(vs(True(EdemaOLD

VS

Arch$ Ophthalmol.+ 2009;127(1):45E49

NEW

Asia-Pac J Ophthalmology 2018;7:271–279 3 2

Serial(OCT(in(Neuro….

Thanks + to+ Jeremy+ W.+Anderson+ OD,+ FAAO 33

DR.B+Case

34

Dr.B

• 45+yo AM+cc:+visual+disturbanceF:+constantO:+suddenL:+OS,+superior+central+fieldD:+24+hrsA:+(E)fortification+scotoma,+(E)HA,+

(E)flashes,R:+None

35

Dr.B

• BCVA:+OD:+20/20+OS:+20/20E D+and+N• PERRL+(E)APD• FROM+OU• CF:+Full+OD,+OS+distortion+of+face+on+FA• TAG;+ 17+mmHg+OD,OS• BP:+118/84mmHg+RAS• SLEx:+Unremarkable• PostPole:+as+follows

36

11/28/18

7

Dr.B

• SysHx:+kidney+stone+sx 1986,+last+med+exam+6+mo+c+comprehensive+blood+work+(E)sleep+apnea• OcHx:+Glaucoma+according+to+retinal+specialist+friend+in+Iran• Meds:+Finasteride 1mg+qd po• Allergies:+Iodine,+(E)anaphylaxis

37

Dr.B

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ 3 8

Phases/Fill( times(of(IVFA

Phases

• Prearterial• Arterial• Arteriovenous• Venous• Recirculation

Fill(times

• InjectionE0+sec• Prearterial/ChoroidalE9E12+sec• ArterialE10E13+sec• ArteriovenousE12E15+sec• VenousE13E17+sec• RecirculationE5+min

Cavallerano,+ Gutner,+ Oshinskie L+Macular$ Disorders 3 9

PreCarterial

Cavallerano A,+Gutner+R,+ Oshinskie L .Macular$Disorders .$ p$48$ Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO 40

Arterial(Characteristics

• Central+retinal+artery+ begins+to+fill• Subsequent+display+of+all+retinal+arterioles• This+is+phase+at+which+arm+to+retina+time+is+calculated• Mean+ART+is+11.2± 3.3+seconds

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO41

Arteriovenous Characteristics

• Retinal+venules and+veins+begin+to+fill• Laminar+flow+in+veins• Definition+to+capillaries

Image+ +Credit:+ Andrew+ Rixon+ OD,+ FAAO 42

11/28/18

8

Arterial/Arteriovenous

Cavallerano,+Gutner,+Oshinskie L+Macular$DisordersImage+ Credit:+ Andrew+ Rixon+ OD,+ FAAO Photo+ Credit:+ Andrew+ Rixon+ OD,+FAAO43

Venous

• Venous+filling+is+now+complete• Intensity+fades+in+the+choroid+and+arterioles

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO 44

Venous/Recirculation

8(minutes


Recirculation 8+minutes

• Mild+residual+staining+of+choroid,+sclera,+and+optic+nerve


IVFA

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+

40+Seconds! 57+Seconds!

47

Dr.BCDx and(Managment• HRVO+OS,+nonischemic• Start+ 81mg+ASA+qd p.o• Comprehensive+bloodwork;

CBC+c+Diff,+Hb1AC,+ANA,+PT,PTT,+Protein+S+and+C,+antithrombin,+FTAEABS,+RPR,+Homocysteine,+lipid+profile,+antiphospholipid+antibodies+• EKG,+carotid+ultrasound• Could+also+have+orderedEprotein+electrophoresis,+factor+V+leiden• RTC+3+weeks+repeat+IVFA+(2’+to+pt+leaving+country)

48

11/28/18

9

HRVO(review

• 5E13%+ of+VOs

• Presumed+ CRV+ does+ not+ become+a+single+entity+ until+ it’s+ posterior+ to+ lamina

• Leaves+ individual+ branches+ more+susceptible+to+ impingement+ at+lamina

• Highest+ age+ incidence+ 65E74yoa• Cardiovascular+ Dz,+ Htn,+ DM,+hyperlipidemia

• Less+ then+ 10%+ occur+under+ age+45• Should+ consider+ thrombophilia+ in+under+ 50

Hay reh SS.% Retina l %v e in %oc c lus ion.%Ind ian%J %Ophthalmol 1994)42:109032Hayreh SS.+Prog Retin Eye$Res .+2005;24:+493–519+Lahey JM,+Tunc M,+Kearney+J,+et+al.+Ophthalmology.$2002;109:126‒131.+ 4 9

Coagulation(Cascade

https :/ /www.researchgate.net/ publica tio n/2369 212 66_U tilizatio n_o f_C oagul atio n_ Assays_in_Cli nical_T hera peu tics

Browning+DJ.+ Retinal+Vein+Occlus ions :Evidence Based+Management+ 2012+ISBN:978E1E4614E3438E2

5 0

Results

• All+testing+normal,+exception+total+protein+S• Protein+S+works+to+inhibit+excessive+clotting• Pts+levels+were+low,+may+have+resulted+in+thromboembolic event• Bloodwork repeated,+total+protein+S+normal

51

Was(I(Zebra(Hunting?

Browning+DJ.+ Retinal+Vein+Occlus ions :Evidence Based+Management+ 2012+ISBN:978E1E4614E3438E2 5 2

Results• Repeat+ IVFA+showed+no+filling+defect• No+neo+on+gonio*• Pt+had+self+d/c+81mg+ASA• Had+decided+not+consult+c+hematology• RTC+4E6mo+DFE• Pt+educated+no+Glaucoma

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+

5 3

Why(Gonio???

Alexander+ L,+ Primary+ Care+ of+ the+ Posterior+ Segment+5 4

11/28/18

10

Was(ASA(impactful?

• 686+ischemic+and+nonEischemic+CRVO+and+nonEischemic+HRVO• All+types+ showed+more+ severe+ hemorrhaging+ in+anticoagulation+group• Initial+VA+and+VF+were+ worse+ in+anticoagulation+ group+ in+nonEischemics• Higher+ visual+acuity+ deterioration+ in+anticoagulation+ group• There+ was+ NO+benefit+ to+existing+ therapy+ or+initiation+of+therapy

Hayreh SS,$et$ al.$ Ophthalmology$ 2011;118:1603–1611$ 5 5

Pathophysiology(of(RVO/Virchow’s(Triad

• Abnormalities+of+the+vessel+wall+• Alterations+in+the+blood+i.e.+

EAbnormalties of+viscosity+and+coagulation

• Alterations+in+blood+flow.+

Hayreh SS.+Prog Retin Eye+ Res +24+ (2005)+ 493–519+Browning+DJ.+ Retinal+Vein+Occlus ions :Evidence Based+Management+ 2012+ISBN:978E1E4614E3438E2 5 6

HypofluorescenceCase

Image+ Credit:+Andrew+ Rixon+ OD,+ FAAO

57


58

XCSection(through(ONH


34(seconds(p(injection


60

11/28/18

11

3(min(p(injection


61

Are(you(on(Warfarin?

• 84yo+WM• Loss+of+vision+OD+x+1week• Painless• LP+vision• “I+sneezed+and+heard+a+pop+in+my+ear+and+then+woke+up+and+couldn’t+see”• Hx of+Htn,+Hld,+CAD,+CHF,+A+Fib• Last+INR+5.1

62

B(ScanPosterior+ Hyaloid+ Face

RetinaChoroid

SuprachoroidalHeme

63

Treatment(Case….

• 67yo+AAM+ cc:+comprehensive+ eye+exam• 2’+cc:+Blur+ and+ haze+OS+x+3E4mo+ ++ ++ ++ ++ +• (E)+flashes/floates ,+ (E)LOV+ ++ ++• Oc Hx:+DED,+NS+cataracts+ (E)surgery+ (E)+Trauma+ + (E)+family+ Hx• Hx of+ reduced+ VA+ OU+without+ organic+ ocular+ etiology,+ past+OCT+ unremarkable+ +and+VF+ ureliable

• Sys+Hx:++(+)+Htn (+)Gout• SysMeds:+ +Amlodipine,+ Atenolol,+ Albuterol,+ Colchicine,+ Enalapril,+ Furosemide,+and+ ibuprofen.+

• NKDA• Social+ Hx:+Unremarkable+ ++

6 4

Fundus(OS


Representative(XCsections

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO

66

11/28/18

12

IVFAs

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Jim+ Williamson+ OD,+ FAAO,+ Michael+ White+ OD 67

45(and(70(sec

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Jim+ Williamson+ OD,+ FAAO,+ Michael+ White+ OD68

Later…..

Image+ Credit:+ Andrew+ Rixon+ OD,+ FAAOJim+ Williamson+ OD,+ FAAOMichael+ White+ OD 69

VEGF(Levels(in(Retinal(Vascular(Disorders

Aiello+ LP,+ et+ al.+N$Engl J$ Med.1994;331:480–148 7 70

BRAVO/RETAIN/BRIGHTER• BRAVO

EExplored+ use+of+monthly+ injections+ of+ ranibizumab for+BRVOEassociated+ CME+ over+6mo+vs+ shamE6mo+resultsE61%+ of+0.5mg+gained+ >3+VA+ lines+ vs+29%+ in+ sham+RETAINEMean+ f/u+49mo+E50%+ had+edema+ resolution+ for+>6mo+ post+ last+ injectionELast+ injection+ within+ 2yrs+of+baseline+ in+ 76%E~80%+ had+ a+final+ BCVA+ of+20/40+ or+betterBRIGHTERERanibizumab vs+Ranibizumab/la ser+ vs+LaserEInjections+ for+3mo,+ then+ prnE24mo+ showed+ Ranibizumab alone+ sufficient,+ addition+ of+ laser+ did+not+ improve+ outcomesTadayon i R ,+et+ al . , +Oph th a lmo lo g y 2 0 1 7 ;1 2 4 :1 7 7 8 E1 7 87 ,+ +C ampoch iaro PA,+et+al . +Oph th a lmo lo g y. 2 0 1 4 ;1 2 :20 9 E1 9

Campoch iaro PA,+Oph th a lmo lo g y. +2 0 1 0 ;+1 1 7 (6 ):+1 1 0 2 –1 1 1 2.7 1

VIBRANT

• EIVTEAflibercept (IAI)+vs+Grid+ laser+ on+macular+ edema+2’+ to+BRVOEIAI+group;+ sham+ laser+ baseline,+ injection+ q4wks+ through+ 24wks,+ then+q8wks+ through+ 48EGrid+ group;+ baseline+ laser,+ sham+ injections+ q4wks+ through+ 24wks,+ rescue+IAI+after+ week+24+ if+needed

24+wk Results:E %+of+eyes+ improving+ >15+ letters+ was+ 52.7%+ in+ IAI,+26.7%+ in+ laserEReduction+ in+ central+ macular+ thickness+ was+ 280.5um+ vs+128.0um52+wk results+E Equivocal+ due+ to+ rescue+ IAI+after+24wksE8wk+ injection+ intervals+ post+ initial+ 24wks+ maintained+ VA+and+ mac+thickness

Clark+ WL,+et+ al.+Ophthalmology.+ 2016;123:+ 7 2

11/28/18

13

GENEVACMean( BCVA(change(from(Baseline

Slide+ courtesy+ of+ Allergan73

Ozurdex

7 4

Good+or+Bad+Compensation???

75 Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD76

IVFA(OD20(sec 34(sec

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD77 Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD

64+sec 120+sec

78

11/28/18

14

IVFA(OS150+sec 150+sec

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD79

OCTCA( Color(

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD80

OCTCA( Superficial(vs(Deep

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD 81

Collateral(vs(Neo(on(OCTCA

Sogawa K,% et% al.% Int Med2 Case2 Rep2 J.% 2015 Oct 23)8:26306.Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ 8 2

Pachychoroid

https :/ /blog.goodaudience.co m/t heE eosEel eph ant EinE the Er oo mE3 5fb 9bd 1e94 83

Choroidal(Thickness1,3

• Affected+ by+a+multitude+of+factors

At(Birth Age(90 Subfoveal Thickness What( is(thick?

200+um 80+um 220+to 350+um >+390+um

Slide+Courtesy+Meagan+Williams+ OD,+FAAO84

11/28/18

15

Factors(Affecting(Choroidal(Thickness2,4,5

• Age*• Choroidal+thickness+decreases+by+15+microns+per+decade+• 4+micron+decrease+per+year

• Axial+length• Decrease+ in+15+microns+for+every+1D+increase+in+myopic+refractive+error

• Gender• Thicker+in+men+by+18+%

Slide+Courtesy+Meagan+Williams+ OD,+FAAO 85

Factors(Affecting(Choroidal(Thickness2,4,5

Other+Factors

Sympathetic+Tone

Pregnancy

Metabolic+Disease

SmokingSystemic+

Inf lammatory+Disease

Tumors

Neurological+Disease


Increased(Choroidal(Thickness

• Pachychoroid• >300+microns

• Characteristics• Increased+choroidal+thickening• Pathologically+dilated+veins+in+Haller’s+layer+(pachy veins)• Thinning+in+Sattler’s+layer+and+choriocapillaris

Akkaya S.++Spectrum+ of+pachychoroid+ disease.+ +Int Ophthalmol.$ 2017;+ 1E8


Increased(Choroidal(Thickness

• Pachychoroid+“phenotype”

• Pachychoroid+vascular+changes+cause+focal+disruptions+in+RPE+and+Bruch’s+membrane

Choroidal+hyperpermeability

Dilated+choroidal+vessels

Focal+or+diffuse+choroidal+ thickness+increase



Pachychoroid(Disease(Spectrum3

Pachychoroid+Pigment+Epitheliopathy(PPE) Central+Serous+

Chorioretinopathy (CSR)

Pachychoroid+Neovasculopathy

PolypoidalChoroidal+Vasculopathy (PCV)



Pachychoroid(Pigment(Epitheliopathy6,7• “Form+fruste”+or+incomplete+version+of+CSR• No+SRF

• Pachychoroid+phenotype• Reduced+fundus+tessellation• Unilateral+or+bilateral• RPE+abnormalities• Small+RPE+detachments• Absence+of+SRF+and+drusen

• Commonly(confused(with(ARMD,(macular(dystrophies,(choroiditis

Slide+Courtesy+Meagan+Williams+ OD,+FAAO

Retina 2013;33:1659E1672Retina 2016;36(3);499E516

90

11/28/18

16

Case(Example:(PPE

9 1

Case(Example:(PPE

439(um

9 2

JG(Case

9 3

JG(Case(details• 82yo+WM+for+Dr+directed+f/u+of+Dry+AMD,+unspecified+stage• Dx AMD+in+2008+in+our+clinic• Uses+AREDS2+x2yrs+(inconsistent+recommendations)• Sys+Hx:+DM+Type+II,+Htn,+Chronic+Ischemic+Heart+Disease,++• Smokes+rare+cigar,+ no+Hx of+cigarette+smoking• OcHx:+Amarosis fugax+5mo+previous,+CT,+CTA,+Carotid,+EKG+unremarkable,++1++NS+OU• (E)metamorphopsia

94

Color(Fundus(Photos

9 5

FAF

9 6

11/28/18

17

XCsections(OD

9 7

XCsections(OS

9 8

AMD(vs(PachychoroidCAll(age(82yo(WMs

Intermediate+AMD Advanced+AMD

Our+Patient99

Choroidal(Thickness(and(AMD???• Proposal+that+choroidal+thinning+and+insufficiency+contributes+to+outer+retinal+ischemia• If+choroid+cannot+supply+oxygen+and+remove+waste+from+photoreceptors+and+RPE+it+may+contribute+to+AMD+worsening• Although+physiologic+aging+diminishes+choroidal+thickness,+further+decrease+ is+observed+in+dry+and+wet+AMD+independent+of+controls• RPD+associated+with+choroidal+thinning• Choroidal+thickness+change+associated+with+resultant+GA• Debate+ in+the+literature+continues…..

Graefe's Archive for Clinical and Experimental Ophthalmology (2018) 256:511–518Am J Ophthalmol. 2018;191:23-33 Surv Ophthalmol 2016; 61:+ 521–37Am$ J$ Ophthalmol 2015;159:617E626 10 0

CC(Case

1 0 1

CC:• 36+yo• Cc:+new+patient+presents+with+cc:+of+a+brown+spot+in+central+vision+OD+x+1wk

EReports+it+is+like+he+is+looking+through+a++“coffee+stain"+EReports+the+spot+is+located+in+his+central+vision+and+does+not+move;+EDenies+any+flashes,+floaters,+or+LOV+OU.+EDenies+any+associated+signs+and+symptoms

• Pertinent+Hx:+Recent+divorce,+PTSD,+works+in+engineering

102

11/28/18

18

Fundus(Photos

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO103

November

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO+ 1 0 4

CSCR(Type(I(and(II

Cavallerano,+ Gutner,+ Oshinskie Macular$ Disorders $ 199710 5

OS(is(great!

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO 106

December=Elplerenone Time


CSCR(Review• Pathogenesis+multifactorial,+poorly+understood+• Characterized+by+serous+detachment+of+the+neurosensory+retina• Additionally;+focal+detachments+of+RPE,+angiographic+leakage+at+level+of+RPE,+choroidal+hyperpermeability,+pachychoroid• Associated+with+endogenous+hypercortisolism,+type+A+behavior+and+pregnancy,+administration+of+ACTH+or+exogenous+administration+of+corticosteroids• Most+resolve+spontaneously+with+minimal+sequelae• 30E45%+of+patients+have+recurrent+disease+and+a+poorer+visual+prognosis.+

Nicholson+ BP,+ et+al.+ Surv Ophthalmol 2018;63(1):1E8Daruich A,+ et+ al.+Prog Retin Eye$Res .+ 2015:48:82e118+

1 0 8

11/28/18

19

Mineralcorticoid Pathway(Hypothesis• Endogenous+cortisol+metabolism+disturbances+have+also+been+associated+with+CSCR+• Suggests+glucocorticoids+paradoxically+favor+the+accumulation+of+fluid+under+the+retina+in+CSCR,+instead+of+acting+on+its+absorption+as+observed+in+macular+edema+of+other+origins+• Primary+adrenal+cortical+steroid+hormones,+aldosterone+and+cortisol,+act+through+binding+to+the+structurally+similar+mineralocorticoid+(MR)+and+glucocorticoid+(GR)+receptors+• Proposed+that+MR+antagonists+could+be+used+to+treat+CSCR+with+persistent+subretinal fluid+

Daruich A,+ et+ al.+Prog Retin Eye$Res .+ 2015:48:82e118+1 0 9

Mineralcorticoid Antagonists• EplerenoneEFDA+Approved+for+HTN+and+CHF

EHigher+affinity+and+selectivity+than+spironolactone+for+the+MR+E Limited+binding+to+progesterone+and+androgen+receptors+ETypical+dosing;++25mg/day+x+1wk,+then+50mg/day+x+1mo

• SpirnolactoneEFDA+approved+for+hypertensionEInteracts+with+progesterone+receptorsES/E+like+gynecomastia,+ED,+menstrual+irregularitiesEHyperkalemia+in+renal+failure+patients

• Head+to+head+equivalent,+spironolactone+more+s/e

Yang+ D,+Eliott D.+ Semin Ophthalmol. 2017;32:36E42 11 0

January


XCSections


IVFAs

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Jim+ Williamson+ OD,+ FAAO 113

IVFA(cont….

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Jim+ Williamson+ OD,+ FAAO114

11/28/18

20

Intermediate(Form

Cavallerano,+ Gutner,+ Oshinskie Macular$ Disorders $ 1997 11 5

IVFA(cont….


IVFA(cont….


Multimodal


FAF(and(

Gravity

Shah+ V.+IOVS.2013;54(15):316 4.$

1 1 9

CSCR(Management

• Observation• Eplerenone• Sprinolactone• Conventional+photocoagulation+(OffEfovea+confirmed+by+ICGA)• Subthreshold+Micropulse/PDT• Intravitreals

Goldhagen BE,+ Goldhardt R.+ Curr Ophthalmol Rep$ 2017+ Jun;5(2):141E14812 0

11/28/18

21

CP(Case

1 2 1

CP(2010

• 60yo+AAF+presents+for+postop• s/p+phaco/IOL+OD+x+1day• BCVA++20/30+OD,+20/25E OS• Heart+ disease,+diabetes,+HTN,+Protein+C+Deficiency,+HLD• High+BS+led+to+hospitalization+3yrs+earlier• Meds:+triamterene,+ atenolol,+norvasc,+coumadin,+Insulin,+gabapentin,+coreg,+simvastatin• Oc Hx:++Phaco/IOL+OS+x+2+month

122

RetinalReview

Image+ Courtesy:+Heidelberg

1 2 3

GrayScale is( better!

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ 1 2 4

PEDCHemorrhagic( vs(Serous(

Cavallerano,+ Gutner,+ Oshinskie Macular$ Disorders $ 1997 1 2 5

CP((OS


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CP


CP


Dx/Management

• Hemorrhagic+PED/PCV• IOA+x+3• Continue+Taper+PF1%+OD+2:1+by+week,+Bromday• Start+ PF1%+qid,+Bromday….consider+IOK+if+NI

129

PCV(Review• AMD+subtype+first+described+in+the+1990s• No+universally+accepted+definition• Initially+considered+Dz of+middle+aged+AA+females• Occur+in+both+sexes,+all+ethnicities,+higher+in+asian vs+caucasian• Characterized+by+recurrent+ serosanguineous maculopathy+and+presence+of+orange+nodules+• Most+base+diagnosis+of+PCV+on+ICGA+findings+that+demonstrate+presence+of+polypoidal dilatations.+(Criterion+differ+per+study)• OCT+structural+and+OCTA+have+not+been+shown+to+supplant+ICGA• Pachychoroid role+in+pathogenesis????

Cheung+ CMG+ et+ al.$Ophthalmology 2018;125:708E724+ 1 3 0

PCV(Problems

Image+credit:+Andrew+ Rixon+OD,+FAAO,+Jim+Williamson+OD,+FAAO,+Michael+White+OD131

OCT(structural(example

Cheung+ CMG+ et+ al.$Ophthalmology 2018;125:708E724+

SD OCT scan (right) with corresponding fluorescein angiography (left) showing a double-layer s ign (black arrowhead), pigment epithelial detachment notch (black arrow), and a thumb-like polyp containing hyperreflective rings with internal hyporeflective lumen (white arrow).

1 3 2

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23

EVEREST/PLANET/DRAGON(• Compared+ efficacy+and+ safety+of+antiEVEGF+ to+combo+ PDT/AntiEVEGF

• Found+ that+antiEVEGF+ monotherapy+(IVTER+ or+ IVTEAFL)+ showedESignificant+ VA+ gainESignificant+ polyp+ closure+ ratesESignificantly+ reduced+ disease+ +activity

• Combo+ PDT/AntiEVEGF+ more+effective+than+ monotherapy

• Combo+ required+ fewer+ injectionshttp s://en .wikip ed ia.o rg/wiki/Moun t_ E ve re st #/ med i a/ Fi le:Moun t_ E ve re st _a s_ s een_from_Drukair2 _P LW _ ed it.jp g

1 3 3

Big(Heart(Case

1 3 4

9/2014• 46yo+AAM+who+presents+with+the+loss+of++vision+to+his+left+eye+over+the+last+24+hours.+• Denies+any+pain.++• Patient+states+that+he+was+in+an+MVA+3+days+ago+and+had+some+soreness+to+the+left+side+of+his+body+that+brought+him+into+the+ER+yesterday.++• Patient+left+the+ER+before+his+encounter+was+complete.++Patient+states+that+progressively+over+the+night+he+lost+his+eyesight+at+11:08+PM.+• Denies+any+other+complaints

135

Past(Hx• 5’6”++228lbs• Ischemic+Cardiomyopathy+Dx as+30yo• Htn x+16+yrs (BP+on+first+exam+at+age+33+was+175/122+)• DM+x+15+yrs Avg HbA1C+9%• Hyperlipidemia• (E)+cocaine• CABG+at+41yo+2’+to+80%+stenosis• TIA+c+R+sided+numbness+and+weakness+2013• MRI+2013+Left+thalamic+infarct+noted,+old+CVA

136

3/2014(Photos


9/2014(Photo(OS


11/28/18

24

IVFA/OCT(OD

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Michael+ White+ OD,+ Jim+Williamson+ OD,+ FAAO

139

OCT(OS

Image+ cred i t:+And rew+R ixon +OD,+FAAO,+M ichael +Wh ite+OD,+ Jim+Wi l l iamson +OD,+FAAO1 4 0

Middle(Maculopathy(Example

Temporal Nasal


1min(13(sec(in,(Attention(CRA!!!


142

IVFAs(OS

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Michael+ White+ OD,+ Jim+ Williamson+ OD,+ FAAO143

38(sec….

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Michael+ White+ OD,+ Jim+ Williamson+ OD,+ FAAO 144

11/28/18

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OS(cont….


OS(cont…..

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Michael+ White+ OD,+ Jim+ Williamson+ OD,+ FAAO

12+min+9min+

14 6

IVFA(advice?(Ask(Dr.Williamson

23Video+ credit:+ Jim+ Williamson+ OD,+ FAAO 147

CRAO(Review• Causes+infarction+of+the+inner+retina+• Acute,+painless,+catastrophic+vision+loss• 80%+>20/400• Cherry+ red+spot+in+fovea• RGC+infarction+followed+by+progressive+axonal+degeneration+with+pale+optic+atrophy+evident+after+ some+weeks+• NonEarteritic and+arteritic forms• Cause+for+1+in+10,000+outpatient+OMD+visits

Tobalem et+al.+ BMC$ Ophthalmology.+ 2018;18:101Biousse V,+et+ al+Neurol Clin 35+ (2017)+ 83–100

Varma+ DD,+ et+ al.+ Eye (2013)+ 27,+688–697+1 4 8

Retinal(Survival(Time/Heroic(Measures

• Retinal+infarct+likely+to+occur+after+ only+12E15min1

• Historically+between+90E240+min1

• NO+strong+evidence+based+therapy+ exists+for+CRAO+• If+no+retinal+arterial+flow+after+15min+heroic+measures+likely+futile

1)+ Tobalem et+ al.+BMC$ Ophthalmology.+ 2018;18:101+ 1 4 9

AHA/ASA(Definitions

• The+2009+revised+(and+current)+definition+of+a+TIA+“a+transient+episode+of+neurological+dysfunction+caused+by+focal++brain,+spinal+cord,+or+retinal(ischemia,+without+acute+infarction”+

• 2013+(and+current)+Stroke+definition+“Central+nervous+system+infarction+is+defined+as+brain,+spinal+cord,+or+retinal(cell(death(attributable+to+ischemia,+based+on+neuropathological,+neuroimaging,+and/or+clinical+evidence+of+permanent+injury”+

Easton+ JD,+ Stroke.+ 2009;40:2276–2293+Sacco RL,+ Stroke.+ 2013;44:2064–2089+

1 5 0

11/28/18

26

CRAO(and(CVA• 5+year+risk+of+death+from+cerebral+ischemia+post+CRAO+is+11.7%1

• Rate+of+CVA+upwards+of+70x+greater+in+1st week+after+CRAO2

• Acute+ischemic+stroke+detected+in+24%+of+subjects+with+RAO3

• Patients+with+acute+CRAO+should+be+promptly+evaluated+for+stroke+and+stroke+prevention4

• Patients+with+MVL;+TMVL,+CRAO,+BRAO+may+have+up+to+19.5%+risk+of+concurrent+ischemic+stroke5

ENo+concurrent+focal+neurological+s/s• Recommended+to+do+DWI+on+MRI,+CT+misses1) Biousse V,+et+ al+Neurol Clin 35+ (2017)+ 83–100+ 2)Park+ SJ,+ et+ al. Ophthalmology 2015;122:2336E2343+ +3)+ Lee+J,+ et+al.+ Am$ J$Ophthalmol 2014;157:1231–1238+ 4)French+ DD,+ et+al.+ +Ophthalmol Ther.+ 2018+ Mar+ 245)+ Zhang+ +LY,+et+ al.+J+ NeuroEOphthalmol 2018;0:1–6 15 1

So(what’s(the(recommendation?• “Based+on+the+currently+available+literature,+the+treatment+ of+CRAO+should+be+focused+on+identifying+a+concomitant+acute+cerebral+infarction,+which+is+a+medical+emergency;+optimization+of+all+cardiovascular+risk+factors;+and+a+thorough+investigation+for+undiagnosed+cardiovascular+risk+factors,+with+the+ultimate+goal+being+prevention+of+subsequent+ischemic+events,+such+as+an+acute+MI,+vascular+death,+and+acute+cerebral+ischemia.”+• “Optimal+management+of+these+patients+requires+collaboration+between+ophthalmologists+and+stroke+neurologists”+• Note+65%+of+programs+in+a+national+survey+of+teaching+hospitals+routinely+referred+ patients+to+a+general+ER

Biousse V,+et+ al+Neurol Clin 35+ (2017)+ 83–100Youn TS,+J$ Neurol.+ 2018;265:330E335 15 2

Do(you(have(a(Cilioretinal?

1 5 3

CC:

• 59+yo presents+with+c/o+black+spot+in+center+of+vision+x+1+year• Describes+black+spot+as+constantly+being+there• Pt+tilts+head+up+to+see+it• Notes+got+roofing+tar+in+eye++10yrs+previous• Loss+was+sudden• Social:+2packs/day,+homeless• Systemic:

154

Fundus(Photos


ONH(Photos(

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+1 5 6

11/28/18

27

VFs

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+ 1 5 7Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+

1 5 8

Macular(Thickness

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO+1 5 9

XCSections


IVFA


IVFA(cont…


11/28/18

28

Case(RK

1 6 3

Case(Hx/Details

• 73yo+WM+for+6mo+eval of+Dry+AMD• Uses+AREDS2+bid• AMD+Dx in+2014• Denies+visual+changes• SysHx:+Smoked+3+packs/day+x+30yrs,+quit+in+1996• SysHx:+Htn,+Obesity• Meds:+HCTZ,+colchicine

164

FP(4/2018(OD

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD165

FP(4/2018 ???


OCTCA(OvervueOS

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO167

Default(Outer(RetinaCThick(Slices

Images + credit:+ Andrew+ Rixon+ OD,+ FAAO+ 1 6 8

11/28/18

29

Custom(Outer(Retinal(Slice


IVFAs(OS

Images + credit:+ +Andrew+ Rixon+ OD,+ FAAO+ and+ Michael+ White+ OD170

IVFAs(OS


ICGs(OS


ICGs(OS(cont….


Case+RG

174

11/28/18

30

Case(History/Exam(details• 74yo+WM+presents+for+annual+doctor+directed+followEup+for+Type+II+DM• No+ocular+complaints• Last+HbA1c=6.9%• Systemic+Hx:+Type+II+DM+x+15yrs,+Hld• Smoker+x+20yrs+ago• Meds:+Glipizide,+Metformin,+Simvastatin,+OmegaE3s• OcHx:+Non+visually+significant+cataracts+(E)retinopathy• BCVA+OD:+20/20,+OS:+20/25• SLE:++2++NS,+2++Cortical• Images+to+Follow………

175

Representative(PhotoCNot(our(Patient

1 7 6

XCsections(OD

1 7 7

XCsections(OS

1 7 8

EDI(XCSections ELM PIL/Ellipsoid+Line

RPEBruch’s Subretinal???179

FAF

1 8 0

11/28/18

31

Reticular(Pseudodrusen (RPD)

• 1st described+in+1990+as+yellowish+and+illEdefined+interlacing+network+on+clinical+examination+and/or+fundus+photography• Now+known+as+subretinal drusenoid deposits+• Appear+as+an+orderly+array+ of+relatively+white,+dotElike+accumulations+• RPD+give+a+4E8x+increased+risk+of+5yr+progression+to+late+AMD• Risk+is+independent+of+conventional+drusen and+focal+pigmentary+abnormalities.+

IOVS. 2016;57:1310–1316 Surv Ophthalmol 61 (2016) 521e537

Surv Ophthalmol 61 (2016) 521e537 1 8 1

RPD(vs(Drusen

IOVS. 2016;57:1310–1316

RPE 1 8 2

RPD(stages

Surv Ophthalmol 61 (2016) 521e537 1 8 3

AutofluorescenceCRPD


Other(Eye


Drusen Regression

Opthalmology 2016;123:39E50 Image+ Credit:+ Drew+ Rixon+ OD,+ FAAO186

11/28/18

32

Construction(Case

1 8 7

Case(details( CH• 55yo+WM• Cc:+Constant+ blur+ at+distance+ and+near+ OD>>OS• Vision+ started+ worsening+ over+ last+ year+but+ has+been+ bad+ at+near+ for+11+ +years

• OcHx:+Pt+notes+ hit+ head+ frequently+ when+ worked+ construction• SysHx:+(+)MI+2mo+ previously,+ (+)DVT+ Dx 2mo+previously• Social:+ ½+pack+per+day• BCVA:+ 20/50E OD,+ 20/20+ OS• Trace+APD+ OD• SLE+unremarkable• Posterior+ attached

188

Fundus(Photography

Courtesy+ Mohammad+ “The+ great+ one”+ RafieetaryOD,+ FAAO+ +Charles + Retina+ Institute

1 8 9

Shields(B(Scan…..

Shields + CL,+et+ al.$ Ophthalmology$ 2001;108:2237–2248$1 9 0

Our(Patient’s(B(Scan• “3.0+mm+apically+elevated,+8mm+basal+diameter+choroidal+lesion+with+high+internal+reflectivity,+homogenously+hyperechoic/acoustically+solid”

191

FAF

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO,+ Michael+ White+ OD,+ Jim+ Williamson+ OD,+ FAAO Ramasubramanian A,+ et+ al.+Retina.+ 2010;30:16E22

19 2

11/28/18

33

EDI(XCsection

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO 193

EDI(XCsection


FAs


Fas cont….


FAs(cont….


ICGs


11/28/18

34

Dx and(Management• Circumscribed+Choroidal+Hemangioma+• Referral+ to+Retina• Patient+has+since+undergone;

EIOA+x+4EPDT+x+2EFocal+photocoagulation

• Last+retinal+eval showed+“Minimal+improvement+on+repeated+PDT+and+antiEVEGF”• BCVA+20/80E• Referral+ to+oc oncology+for+possible+low+dose+plaque+brachytherapy

199

Choroidal(Hemangioma(Review• Rare+ Vascular+tumor+(5%+of+pseudomelanomas)+• Unknown+cause• Likely+congenital,+• Typically+asymptomatic+until+4thE6th decade• Unknown+prevalence/Most+asymptomatic• No+correlation+with+systemic+disease• Composed+of+choroidal+vessels+but+spares+choriocapillaris• Slow+to+no+progression+in+size+over+time• Within+1+to+3+DD+of+the+macula• Ranges+from+3E19+mm+in+diameter+and+1E8mm+in+thickness

Berry+ M,+ Lucas +L.+Journal$ of$ Optometry$ (2017)+ 10,(79E83+Karimi S,+et+ al.+J$Ophthalmic$ Vis $Res $2015;+ 10+(3):+ 320E328.+

Shields + CL,+et+ al.+ Ophthalmology$2001;108:2237–2248$

2 0 0

What(would(Carol(Shields(Do?• Not+sure+but+the+options+are…..

EObservation+in+asymptomatic+s+SRFEPDTETx of+choice+for+symptomatic+c+detachmentELaser+photocoagulationEPlaque+brachytherapyEExternal+beam+and+proton+beam+radiationESterotactic radiosurgeryETranspupillary thermotherapyEOral+propranolol+EEnucleation

http s://twitter.com/sea rch ?q=%2 3 ch iefs round s

Karimi S,+et+ al.+J$Ophthalmic$ Vis $Res $2015;+ 10+(3):+ 320E328Berry+ M,+ Lucas +L.+Journal$ of$ Optometry$ (2017)+ 10,(79E83+ 2 0 1

Metastatic(Tumor(on(Ultrasound

Image+ credit:+ Andrew+ Rixon+ OD,+ FAAO


Metastatic(Melanoma

Image+credit:+Andrew+ Rixon+OD,+FAAO

203

XCRay/MRI

Image+credit:+Andrew+ Rixon+OD,+FAAO204

11/28/18

35

Melanoma/Melanoma( on(B(scan

Myelination

RPE+Reactive+Hyperplasia

Choroidal+Mass

Shields CL, et al. Curr Opin Ophthalmol 2014, 25:177 – 185

Clinical$ Ophthalmology$ 2017:11+ 1557–1564+Neuroimag Clin N$Am$ 25+ (2015)+ 327–365+

2 0 5 2 4 6

Documents

Posterior(Segment(Grand(Rounds( from(the(Bluff(City(11/28/18 1 Posterior(Segment(Grand(Rounds(from(the(Bluff(City(Andrew+Rixon+OD,+FAAO 59713-PS 1 •No+Financial+Disclosures 2 Case+CB