Post on 28-Dec-2020
transcript
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
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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
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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
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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
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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
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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
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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.
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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
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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
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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?
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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