3/15/2016

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Retinal Vascular Disorders

Mohammad Rafieetary, OD, FAAO

mrafieetary@charlesretina.com

Bring it to the basics!

• In the Era of Nanotechnology getting hung-up

by minutiae and missing the boat is easy….

20/20 vision smokes two

packs/day

Consult to see “eye

injection will help!”

Clinical Challenges (Dx a/o Tx)

• Rushing to Dx– Medical Errors

– Misdiagnosis

– Mismanagement

• Limitation of Testing

• Confusing sign and symptoms

• Limitation of Therapy

• Unresponsive to conventional Therapy

Significance of Retinal

Vascular Disease in

Presence of Comorbid

Conditions often the

Underlying Etiology!

Vascular anatomy

Vascular anatomy

Don’t forget the choroid!

Choroid

• Challenges in

clinical

examination

• Complexity of

the structure

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Patient with loss of vision

Fairly normal retina

End result carotid artery disease

Intricacy of retinal vasculature

• Source of the

image

Mechanism of Retinal Vascular

Disorders

• Conditions that physically alter blood vessels

(Retina a/o choroid)

– Locally or Generalized

• Conditions that alter blood chemistry

• Conditions that do both…

Significance and Relationship Between

Systemic Disease Retinal Vessels And

Retinal Vascular/Background Findings

• Public misconception that all “eye problems

can be fixed by a better pair of glasses”

• (+)Understanding of the significance by the

PCPs

• (+)Attention by the eye-care providers

• What is our role as ODs?

The most common

causes of death in

the United States

All causes 1,989,841 All causes 2,403,351

1Diseases of heart

761,085Diseases of heart

710,760

2

Malignant neoplasms [Cancer of All Types]

416,509

Malignant neoplasms [Cancer of All Types]

553,091

3Cerebrovascular diseases

170,225Cerebrovascular diseases

167,661

4Unintentional injuries

105,718Chronic lower respiratory diseases

122,009

5

Chronic obstructive pulmonary diseases

56,050Unintentional injuries

97,900

6Pneumonia and influenza

54,619Diabetes mellitus

69,301

7Diabetes mellitus

34,851Influenza and pneumonia

65,313

1980 2000

(August 2011)—CDC Data

indicates that the deaths from

CLRD has surpassed CVA as

3rd leading cause of the

death in the US. CLRD=

asthma, chronic bronchitis,

emphysema, others

(CLRD)

Am Lung Assoc.

2009, 21% US

Adults smoke

Is this a normal macula?

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Did the patient know they have a problem?

Long-term outcome?

DX?

Patient was asymptomatic!

Is lack of symptom justify no

TX?

Challenges

• Co-morbidities

How often do we see this? (or ignore it)

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We can easily miss or ignore these!

Should we have a conversation with our

patient beyond the eye finding?

Reasons to miss subtle signs!

How many people that worry about

this have any understanding of

Retinal vascular disease? (lack of PSAs)

But all fear blindness!

Symptoms May Show Overnight! but

these signs didn’t develop overnight!

Association of Retinal Findings and

Systemic Disease (Morbidity, Mortality)

• Wong et al: Prospective cohort study of retinal vessel diameters and risk of

hypertension. (Beaver Dam eye study)

– Conclusions: Narrowed retinal arterioles are associated with long term risk of

hypertension

• Bruno et al: Vascular Outcome in Men With Asymptomatic Retinal

Cholesterol Emboli (Annals of Internal Medicine Feb 1995, V22:4) (VA

Setting)

– Conclusion: Asymptomatic retinal cholesterol emboli is an important risk factor for CVA

independent of commonly recognized vascular risk factors

• Klein et al: Retinal Emboli and Stroke (Beaver Dam Study)

– Higher incidence of CVA in patients with retinal cholesterol emboli

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Hypertensive Retinopathy and Risk of Stroke Yi-Ting Ong, et

al.Hypertension. 2013;62:706-711

“Retinal imaging may someday help assess if you’re more likely to

develop a stroke — the nation’s No. 4 killer and a leading cause of

disability.”

Retinal Hemorrhage

54 Y/O WM

Healthy, vague visual

disturbance.

Referred as Retinal

Hemorrhages, CRVO!

CRVO? Typical Retinal Hemorrhage?

Hemorrhage Characteristics

Roth’s SpotsWhite or pale centers are

composed of coagulated fibrin,

usually caused by immune

complex mediated vasculitis .

May be seen in leukemia,

diabetes, subacute bacterial

endocarditis, pernicious anemia,

ischemic events, and HIV

retinopathy.

Patient dxed with acute

myelogenous leukemia

(AML) and died within a

year.

63 Y/O AfAM F Diabetic

Last seen 2010 recently referred back by

PCP overdue fundus exam

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Referred for Diabetic Retinal Eval

Case of unexpected findings and patient's

disappointment!

• 55 Y/O BF

• DM x20yrs

• Referred as emergency “macular on” RD recent onset vision loss (NPDR OS) Patient arrives end of the day!!!

• OD:HM OS:20/50

• “Wants her vision fixed today need to get back to work!”

-Status of

Fellow Eye

-Coexisting

Disease

-Future of this area

-Mechanism of sight

loss

-What can be done

about it?

Macula

On vs.

OFF

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Unmet Expectations Spectrum of DR (#Ways to failure) 31 Y/O BF Referred by OD for diabetic retinal exam … DM X 20 yrs A1C 8—daily

average 180-230 Blurred vision on going…

OD 20/30 OS 20/100 (wears spectacles)

7/24/2013 IVA OU

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8/14/2013 IVA OU Sch SX OS

RBA including high% of post-op VA loss

OD 20/20---- OS PH 20/400

Sep 11, 2013 – IVA OD Sch SX (Discussed RBA including further vision loss )

-Progression of RD

-Regression of SRH and NV

-Post-op VA loss as expected and

discussed with patient

-Not all cases obvious a/o symptomatic but will not

remain that way

-Not all cases have obvious underlying etiology

-Variation in presentation

Not all cases due to an underlying

systemic dieases

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Not all cases present with similar

severity but this had an early stage in the past !

Can’t always find why?

Canary in the coalmine

59 Y/O M Excess Factor XII

When OS involved MRV showed blockage in left transverese and sigmoid

sinuses

Further Anti-coagulation Therapy

Not all cases due to one group of

underlying disease (Systemic Lupus)

Sarcoidosis

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Had missed follow-up care. Returns with New-Onset Symptoms (small floater OS)

She is also on plaquenil

Surprising Findings (Retinal Vascular Disease)

60 Y/O WM, Difficulty near vision lately, has stopped his BP meds

Referred for Hemorrhage and Exudates OS

VAs OD: 20/25, OS: 20/30 (1+ NS)

Surprising Findings (Retinal Vascular Disease)

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Surprising Findings (Retinal Vascular Disease)

Following a long debate, patient agreed to revisit PCP, and to eye tx!

Challenges 8/20/2013 8/23/2013

81 Y/O WM

4/200, 20/50

Photo sent by referring doc

Challenges

Photo sent by referring doc

Challenges

Challenges IOP OD 25, OS 14 Now OD NLP, OS doing well post cataract sx

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VOD Unpredictable changes

Case of rapid vascular alteration

July 2010

IVA OS and No Show for follow-up

Case of rapid vascular alteration March 2011 OD VA loss X 1month

Case of rapid

vascular

alteration

July 2010 March 2011

Case of

rapid

vascular

alteration

VOD predictable changes (noncompliant patient)

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Predictable changes

over time

(complaint patient)

PDR Progression

April 2011

PDR Progression

April 2012 by June 2012 Vas 20/40 OD/OS Ongoing Treatment and much improved.

PDR Progression

Missed Jul 2012 appt shows Late sep HM OU (Now on kidney dialysis)

PDR Progression (following first IVA)

PDR Progression (following second IVA)

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PDR Progression (OD following PPV)

1 Day Post-op 20/200

PDR Progression (OD following PPV)

3 wks s/p VA 20/100

New View of Fundus Sch for PPV

PDR Progression (OS following PPV)

OS 1 Month 2 Months S/P PPV

Eventually

20/30

20/400

I have no problems with my LE don’t

want treatment!

I have been blinded by treatment!(should not have had it, will tell everyone laser blinds you!!!)

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Diabetic Retinopathy

2.5 years is it really getting better?

Focal for ME

More Pitfalls

Diabetes

• A group of metabolic diseases associated with

high serum glucose level, either due to body’s

inability to produce sufficient insulin, or cells do

not respond to the produced insulin

• Incidence/Epidemiology (www.diabetes.org)

– >25 million children and adults in US (8.3% of

the population)

• Type 2: primarily lifestyle factors

• Type 1: Multifactorial

Diabetes

• Morbidity and Mortality

– In 2006 diabetes was the seventh leading cause of death listed on U.S. death certificates

• Complications

– Nephropathy, Neuropathy, Retinopathy

– Heart disease and stroke

– Hypertension

• In 2003–2004, 75% of adults with also had hypertension.

– Amputation

• More than 60% of nontraumatic lower-limb amputations

Diabetic Retinopathy

• Classification

– NPDR

• Mild: Microaneurysms only

• Moderate: More than mild less than “Severe”

• Severe: any of the following

– > 20 IRH in 4 quads

– Definitive venous beading in 2 or more quads

– Prominent IRMA in 1 or more quad and no NV

– PDR: Definitive NV, PRH or VH

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Systemic Hypertension

• Definition

– A chronic condition in which the arterial (blood)

pressure is elevated

• Types

– Primary or Essential(90-95%)

– Secondary (5-10%)

• Caused by other conditions that affect the kidney,

arteries, heart or the endocrine system.

– White coat, Isolated Systolic, Labile, Malignant

Systemic Hypertension

• Complications

– Hypertension is the most important risk factor

for morbidity and mortality in the industrialized

world

• CVA, Hypertensive encephalopathy

• Cardiac: MI, CHF

• Nephropathy

• Retinopathy

HTN and Posterior Segment

• Retinopathy

– Hypertensive, and exasperating diabetic and other

vascular retinopathies

• Choroidopathy

• Macroaneurysm

• RVOs

• RAOs

Others … e.g., ION

Arteriolar narrowing

• Arterio-venous ratio

• Generalized and focal

arteriolar narrowing

Arteriolar light reflex

• Arteriolosclerosis, with

thinning of the blood

column

– Copper wiring

– Silver wiring

AV crossing changes• Gunn sign

• Salus sign• Precursors to

BRVOs