2/20/2013

1

Retina Workshop

David M. Salib, MD

Virginia Eye Consultants

February 20, 2013

Retina Smorgasbord

1. Evaluation of the peripheral retina

2. Assessing long-term risk in AMD

3. Updates in treatment of retinal diseases

4. Recognizing pathology on OCT

PART 1

EVALUATION OF THE

PERIPHERAL RETINA

Evaluation of the Peripheral Retina

Fundus Photography

Optomap

Binocular Indirect Ophthalmoscopy

Scleral Depression

B-scan Ultrasonography

Fundus Photography

Dilated (up to 130 degrees) or

nonmydriatic (up to 60 degrees) detailed

images, in color or red-free of the retina

Optomap Nonmydriatic

Up to 82% of the retina

Not as detailed as fundus photography

2/20/2013

2

BIO

95% to 100% of the retina is viewed

Dilation is required

View is inverted

Stereopsis

Scleral depression can be performed

Comparing Methods

Optomap provides a good starting point,

and as a screening tool, allows us to see a

majority of the retina simultaneously, using

relatively low light, but

Will miss far peripheral tears and other

lesions

May not provide necessary detail to make a

definitive diagnosis on some identified lesions

Comparing Methods---BIO

Can provides detailed view of entire retina

Can be used to evaluate suspect areas

seen on Optomap or other images

Allows for stereoscopic view

95% sensitivity in diagnosing retinal tears

Provides opportunity for scleral depression

BIO technique

Use least light necessary to achieve

desired view

Be familiar with various lenses

20D is a good basic lens achieving far

peripheral, magnified view through well-

dilated pupil

25D, 28D, or 30D for wider, less magnified

view, useful for less dilated pupil, view

through gas

BIO technique

Have patient look in direction of quadrant

you are trying to examine

Basic exam should include 4 quadrants

If high risk for retinal tear (flashes and

floaters, extensive lattice, very high

myope, etc.), 360 degree exam with

scleral depression recommended

Contact Lens exam

3 mirror lens can be used to view details of a peripheral or macular lesion

Central lens (-64D) provides detailed view of central 30-36 degrees

Equatorial mirror (large, oblong) examines from 30 degrees to equator

Peripheral mirror (intermed. size, square) examines equator to ora serratta

Gonioscopic lens (small, dome shaped) used to see angle

2/20/2013

3

Scleral Depression Allows for view of retina to ora serratta

Highest sensitivity for diagnosing breaks

Indentation allows for raising of occult

flaps

Pressure allows for identification of subtle

or shallow SRF (white WITH pressure)

Scleral Depression--Technique

Apply topical anesthetic

Explain to patient what you’re about to do

Pen or thimble

Usually protruding portion of blunt side (pen)

Scleral Depression--Technique Start at 12:00

May have pt. look away from quadrant of examined to place depressor, then slowly toward that quadrant once in place

Least amount of pressure to view to ora

Proceed around the clock (maintain consistent technique). May slide depressor while maintaining view, or remove and replace depressor, achieving new view.

May need direct conjunctival contact at 3 and 9

May shift eyelid skin down to maintain skin coverage at 3,9

Consider lid speculum

if absolutely necessary

Scleral Depression--

Contraindications

Absolute

Recent intraocular surgery

Recent hyphema

Recent or suspected penetrating injury, or

globe rupture

Relative

Advanced glaucoma

Intraocular lenses (be careful)

Recording Exam

Extended ophthalmoscopy is billable

When findings are not appreciable without the

use of indirect ophthalmoscopy

When there is a new finding

When a detailed drawing is made

4-6 colors, everything labeled (1 color acceptable)

Codes: 92225 (initial), 92226 (subsequent)

Extended Ophthalmoscopy

Report

Why you did it

What you found

What has changed

Management plan

2/20/2013

4

Extended Ophthalmoscopy Color coding for retinal diagrams :

Blue--Retinal vessels, subretinal fluid , detached retina, edema, lattice (blue hatches)

Red--hemorrhage (preretinal, retinal or subretinal), retinal tears, microaneurysm, retinal neovascularization, attached retina, thin retina (red hatches)

Yellow--exudate, inflammation (retinal), amelanotic mass lesions, cotton wool spots, drusen,subretinal fibrosis, atrophic areas (paving stone) flecks or white deposits (i.e stargardt’s disease, talc retinopathy)

Green Media opacity--vitreous debris or heme, retinal fibrosis or preretinal membranes, vitreous detachment (weiss ring)

Brown--Melanocytic lesions, geographic atrophy

Orange--Orange pigment

Black--pigment clumping, lattice degeneration, melanocytoma, laser burns

ALTERNATIVE: ONE COLOR WITH DETAILED LABELING

Extended

Ophthalmoscopy

B-Scan

Indications

Media opacity

Elucidate characteristics of masses

Internal reflectivity

Elucidate nature of choroidal detachment

Serous vs. hemorrhagic

Elucidate nature of RD

Rhegmatogenous vs. tractional vs. PVD

Locate and identify intraocular FBs

B-Scan -- Technique

Anesthetic applied

Methylcellulose applied to probe

Probe can be applied to lids or globe

Longitudinal scan most common

ONH in view

Marker toward top of scan

Can have pt. look in direction of scan for far periph

Transverse scan

Marker parallel to limbus, pointing N or S

B-scan

Vitreous hemorrhage

B-scan

PVD

2/20/2013

5

B-Scan

RD

B-Scan

Traction RD

B-Scan

Choroidal detachment

B-Scan

Choroidal tumors

Peripheral Evaluation--Summary

Many techniques available to you

Tailor your exam to the pathology you

suspect

Don’t be afraid to dilate

If complete peripheral evaluation is

warranted but not practical in your setting,

or if diagnosis is uncertain, seek a second

opinion

PART 2

ASSESSING LONG

TERM RISK IN AMD

2/20/2013

6

AMD—Assessing Risk

Age and lifestyle related factors

Clinical predictors

Role for genetic testing?

AMD risk factors

Age

10% of 66-74 age group

30% of 75-85 age group

Family

50% risk if family member has it

12% risk if no family member has it

Smoking

250% more likely to develop AMD

330% more likely in men

AMD—Clinical predictors

Simplified scale for evaluation of 5-year risk of developing advanced AMD

1 point for large druse(n) in each eye

1 point for medium druse(n) in both eyes if no large drusen in either eye

1 point for pigmentary changes in each eye

0 points: 0.5% risk

1 point: 3% risk

2 points: 12% risk

3 points: 25% risk

4 points: 50% risk

AMD—Genetic Testing

Many genes implicated

CFH

CF1

C2FB

C3

ARMS2

TIMP3

COL8A1

LIPC

LPL

CETP

ABCA1

Genetic Testing

50% of those with affected family member

will develop AMD vs. 12% with no family

history.

Genetic Testing Macula Risk procedure

Forms completed

Avoid food or coffee for 30 minutes

Cheek swab, avoiding gums—airdry swab

Place swab into biohazard bag

Repeat for other cheek

Label bags

2/20/2013

7

Genetic Testing

Macula Risk claims:

5 year predictive power of test: 88.5%

10 year predictive power: 89.5%

Sensitivity and specificity >80%

Genetic Testing

According to Macula Risk

50% of population are MR1—low risk for

advancing AMD

30% are MR2 (low risk)

16.8% are MR3

2.2% are MR4 (high risk)

1% are MR5 (highest risk)

Macula Risk

0

10

20

30

40

50

60

70

80

MR1 MR2 MR3 MR4 MR5

Percentage(%)

RiskofVisionLoss(5year-10year)

RiskofProgressionfromearly/intermediateAMDtoadvancedAMDwithvisionloss

Genetic Testing

Macula Risk recommends:

MR1 and 2: monitor every 12-24 months

MR3: monitor twice per year

MR4: monitor up to 3x/ year

MR5: monitor up to 4x/ year

VEC Current Practices

Dry AMD pts seen (average) every 6

months, unless very mild disease (annual

exam) or more severe disease (3-

4X/year).

Current clinical method of evaluating risk,

combined with pt. use of Amsler grid, is

very effective in identifying advancing

AMD, resulting in early detection and rapid

treatment of wet AMD

Role for genetic testing?

The most accurate way to predict risk

Appropriate for a subset of the AMD population

Those that are interested in gaining more knowledge as

to their precise risk, given their family history

Should be available as an adjunct in risk

assessment in the ophthalmologist’s and

optometrist’s office

Decision not to adopt this routinely in our practice is

based on Dr. Salib’s opinion, which also mirrors the

opinion of the great majority of retina specialists

worldwide.

2/20/2013

8

PART 3

RETINA UPDATE

What’s new in Retina?

•Calendar

Jetrea

Approved for treatment of:

1. symptomatic vitreomacular adhesions

2. small macular holes associated with VMA

Jetrea--Mechanism

Ocriplasmin (recombinant, truncated

human plasmin) has proteolytic activity

against protein components of the vitreous

body and vitreoretinal interface (laminin,

fibronectin, collagen, thereby dissolving

the protein matrix responsible for the VMA

Jetrea—The evidence 2 clinical trials: Jetrea vs. vehicle injection

Trial 1: 27.9% vs. 13.1% had VMA resolution

Trial 2: 25.3% vs. 6.2% had VMA resolution

(measured at day 28 in 6 months trial)

Jetrea—The evidence

Total PVD induced in

16% vs. 6% (Study 1)

11% vs. 0% (Study 2)

Closure of small macular holes (<400u)

associated with VMT

40% closure rate with Jetrea

2/20/2013

9

Jetrea—The evidence

Significantly more 3-line gainers with Jetrea

12.8% vs. 8.4% (Study 1) at month 6

11.8% vs. 3.38% (Study 2)

Significantly more 3-line losers with Jetrea

5.6% vs. 3.2% at month 6**

**majority of 3-line losers were from progression of disease rather than from adverse effects

Jetrea—The evidence

Greater success was achieved in

releasing VMA in cases where the are of

VMA adhesion was not wide

Jetrea—Adverse Effects

Intraocular inflammation (7.1% vs. 3.7%)

Intraocular hemorrhage (2.4% vs. 3.7%)

Increased IOP (4.1% vs. 5.3%)

Lens subluxation (in 1 case of overdose, and in animal studies that were injected twice, 28 days apart)

Dyschromatopsia—yellowish vision—2% of all pts. injected with Jetrea, with ERG changes in 50% of these

Jetrea—Adverse Effects

RD (0.9% vs. 1.6%)**

Retinal tear (1.1% vs. 2.7%)**

**most RDs and RTs occurred during

vitrectomy;

RD pre-vit was 0.4% Jetrea vs. 0% vehicle;

RT pre-vit was 0% Jetrea and 0.5% vehicle

Jetrea--Summary

Useful and promising tool, providing a way to

avoid surgery and all of its potential risks,

post-op face down positioning, etc.

Far lower success rate than surgery (100%

VMA resolution and 95%+ resolution of small

macular holes with surgery vs. 26%, 40%)

$3950 per vial

PART 4

MYSTERY OCT

2/20/2013

10

3 weeks post CE with decrease in

vision 3 weeks post-op CE, vision didn’t

improve as much as pt expected

3 weeks post-op, vision improved

in first week, but not great, then

decreased after that Treatment options?

Dx? Dx?

2/20/2013

11

79 y.o. sees wavy lines 79 y.o. sees wavy lines

84 y.o. with wet AMD, s/p multiple

injections. Re-treat?

79 y.o. with gray area in central

vision

48 y.o. sees wavy lines

Thank You

Thank You