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RETINA UPDATESYannek Leiderman, MD, PhD

University of Illinois Chicago

Illinois Eye and Ear Infirmary

ams NA. Atlas of OCT. Retinal Anatomy in Health & Pathology. Heidelberg Engineering

Stephanie Klemencic, OD

Illinois College of Optometry

Illinois Eye Institute

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taurenghi G, Sadda S, Chakravarthy U et al. Proposed Lexicon for Anatomic Landmarks in Normal Posterior Segmentpectral Domain Optical Coherence Tomography. The IN OCT Consensus. Ophthalmology 2014;121:1572-1578

- (IS/OS Junction)

Choroid
http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://mypro.munawer.in/medical-dictionary.thefreedictionary.com/beta+c%27s&ei=mV5OVJ7SEcy2yAT32ILICA&bvm=bv.77880786,d.aWw&psig=AFQjCNGY_MDBN6qQlZiLUjbkzfwTn8DcLA&ust=1414508536404367

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Case #1: 46 y.o. AAF

BCVA: OD 20/30OS 20/20

Severe visual distortion OD x 2 weeks

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Vitreo-Macular Interface

Stage 1

VMA VMT

Small

Medium

Large

Full thickness

ERM

PVD

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OCT Classification of Macular Holes

ker JS, Kaiser PK, Binder S et al. The international vitreomacular traction study groupssification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013;120:2611-2619

ull Thickness Macular

ole (FTMH) Stages

IVTS Classification

tage 0tage 1: Impending holetage 2: Small holetage 3: Medium holetage 4: FTMH with PVD

VMAVMTSmall or medium FTMH with VMTMedium or large FTMH with VMTSmall, medium or large FTMH witho

VMT

Smaller hole = < 400um

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Vitreo-Macular Adhesion (VMA)

Normal foveal contour and contents/thickness

hthalmology 2013;120:2611-2619

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Stage 1/VMT: 50%spontaneously resolve

20/20 20

20/20/20-

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Stages 2, 3, 4/small, med, large +/- VMT:Full Thickness

20/60

20/200

20/400

/40

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OCT Classification of Macular Holes


ull Thickness Macular

ole (FTMH) Stages

IVTS Classification

tage 0tage 1: Impending holetage 2: Small holetage 3: Medium holetage 4: FTMH with PVD

VMAVMTSmall or medium FTMH with VMTMedium or large FTMH with VMTSmall, medium or large FTMH witho

VMT

Smaller hole = < 400um

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Proportion of VMT Patients withVMA Resolution at Day 28

7.7%

29.8%

0

5

10

15

20

25

30

35

Ocriplasmin

N=188

Placebo

N=78

p

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7.1% 8.9%

21.4%

32.1%

41.1%

0

10

20

30

40

50

Day 7 Day 14 Day 28 Month 3 Month 6

Ocriplasmin (N=56)

A: visual acuity; VMT: vitreomacular traction; VMA: vitreomacular adhesion.

ta on file, ThromboGenics.

Proportion of Patients Gaining 2 Lines VA(Ocriplasmin-Treated VMT Patients with VMA Resolution at Day 28)

Time, Post Injection

%p

atients

Combined Dataset

n = 4 5 12 18 23

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Proportion of Patients Gaining 3 Lines VA(Ocriplasmin-Treated VMT Patients with VMA Resolution at Day 28)

3.6%

5.4% 5.4%

12.5%

14.3%

0

5

10

15


Ocriplasmin (N=56)


%p

atients

A: visual acuity; VMT: vitreomacular traction; VMA: vitreomacular adhesion.

ta on file, ThromboGenics.

Combined Dataset

n = 2 3 3 7 8

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Macular Hole Subgroup*Responder Analysis

ost-hoc analysis

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Proportion of Patients with FTMH Closure(without vitrectomy)

10.6%

17.0%

40.6% 40.6%

0

10

20

30

40

50 Placebo (N = 47) Ocriplasmin (N = 106)

6 MonthsDay 28

p

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4.5%

13.6%

24.6% 24.6%

0

10

20

30

40

50

60

p250 m

p=0.002p=0.200p=0.031

16.0%20.0%

58.3% 58.3%

0

10

20

30

40

50

60

n = 22 57 22 57

%p

atients

%p

atients

Combined Dataset

Day 28 6 Months

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17.0%

40.6%

0

10

20

30

40

50

Placebo (N = 47) Ocriplasmin (N = 106)

p=0.004

Proportion of Patients with FTMH Closure at Month 6

(without vitrectomy)

n = 43%p

atients

H: full thickness macular hole

on file, ThromboGenics

Combined Dataset

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14.0%

32.6%

58.1%65.1%

76.7%

0

20

40

60

80


Ocriplasmin (N=43)


visual acuity, FTMH: full thickness macular hole

a on file, ThromboGenics

Proportion of Patients Gaining 2 Lines VA(Ocriplasmin-Treated Patients with FTMH Closure at Month 6 without Vitrectomy

Combined Dataset

n = 6 14 25 28 33

%p

atients

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2.3%

14.0%

30.2%

41.9%

51.2%

0

10

20

30

40

50

60


Ocriplasmin (N=43)


visual acuity; FTMH: full thickness macular hole

a on file, ThromboGenics

Proportion of Patients Gaining 3 Lines VA(Ocriplasmin-Treated Patients with FTMH Closure at Month 6 without Vitrectomy

Combined Dataset

n = 1 6 13 18 22

%p

atients

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FTMHVitrectomy vs. Ocriplasmin

Pros

High (>85%) success rate

Known long-term side effects

Cons

Surgical risks

Face down positioning(+/-)

Cataract formation

Pros

In-office procedure Less $ if successful

Avoid surgery/earlier cataractformation if successful

No face down positioning

Cons

Lower (~40%) success rate Surgery needed if fails

Long term side effects notknown

Risks: tears, dyschromatopsias Avoid in high risk RD patients

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Lamellar HolesAborted macular hole

Partial thickness

Criteria:1. Irregular foveal contour

2. Defect/break inner fovea

3. Intra-retinal split (schisis) can be variable

4. Intact photoreceptors


20/30

20/30

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Macular Pseudohole Criteria

1. ERM

2. No loss of tissue3. Heaped foveal edges

4. Near normal foveal thickness

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Stage 0/Impending Macular Hole

FTMH one eye + VMA/VMT in fellow eye

Fellow eye at increased risk for FTMH

OD: FTMH OS: Impending mac hole

20/60 20/25

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Ocriplasmin (Jetrea)

Symptomatic Vitreo-macular Adhesion

FDA Approved 2012

MIVI-TRUST Trials FTMH closure (~40%) vs. placebo (~10%)

VMT resolution (~29%) vs. placebo (~8%) Smaller holes/more focal adhesion did better

Cant have ERM

Recommend treatment for: Symptomatic VMT or smaller macular holes (

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Back to our patient: Case #1: 46 y.o. AAF

BCVA: OD 20/30OS 20/20

Severe visual distortion OD x 2 weeks

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OD: 8/2/2014 20/30 OD: 9/5/2014 20/25

Back to our patient

She chose: MONITOR

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Case #2: 80 y.o. AAFRequesting Cataract Extraction

20/60 20/40

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OD OS

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1 y.o. attorney decreased visionX 3 weeks

VA 20/50 OD20/20 OS

Case #3

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EarlyMid Late

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Notice Please do not quote, cite, copy, or distribute without permission from the author.

Question 1

A 31 y/o attorney complains of decreased vision

OD (VAcc20/50) for 3 weeks. Examination andimaging findings are most consistent with centralserous chorioretinopathy. Select the mostappropriate course at this time:a) Inquire about steroid-containing medication use and observe

b) Perform fluorescein-angiography-guided thermal laserphotocoagulation

c) Perform fluorescein-angiography-guided photodynamic therapy

d) Initiate oral therapy with mefipristone

e) Recommend lifestyle modificationconsider career change

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Central Serous Chorioretinopathy

Serous macular

detachment Idiopathic

>>9:1

Possible hyperopic shift

Risk factors: stress(type-A personality)

Exogenous/endogenoussteroids

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May have serous RPE

detachment (PED) CSCR characteristicfluorescein angiography:exspansile pinpointleakage

Smoke stackconfiguration in 5-10%

Multifocal patterns More common in

medication-induced orsystemic disease

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90% of patients exhibit spontaneous resorption of

subretinal fluid and recovergood

vision without

treatment

Complaints of metamorphopsia and objective defects in contrast

sensitivity are common ~ 1/3 will experience recurrence

Laser speeds recovery, does not change visual outcome

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CSCR Therapeutic Interventions

Thermal laser photocoagulation

Speeds recovery..does not change visual outcome

Photodynamic therapy with verteporfin (PDT)

Subthreshold diode micropulsephotocoagulation

Intravitreal bevacizumab (Avastin)

Mifepristone

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Br J Ophthalmol. 2010 Jul 19. Lim JW et al.

Comparative study of patients with central serouschorioretinopathy undergoing focal laser

photocoagulation or photodynamic therapy

Compared with focal laser, half-dose PDT may facilitateearlier resolution of macular detachment and earlierrecovery of central retinal function

However, at 3 months after treatment and thereafter, nodifference in anatomical and functional recovery wasnoted between the two modalities of treatment

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Ophthalmology. 2008 Oct;115(10):1756-65. Chan WM, Lai TY, Lai RY, Liu DT, Lam DS.

Half-dose verteporf in photodynamic therapy for acute centralserous chorioretinopathy: one-year results of a randomizedcontrolled trial

Thirty-seven (94.9%) eyes in the verteporfin group compared with11 (57.9%) eyes in the placebo group showed absence of subretinalfluid at the macula at 12 months (P = 0.001)

CONCLUSIONS: Photodynamic therapy with half-doseverteporf in is effective in treating acute symptomatic CSC,resulting in a higher proportion of patients with absence ofexudative macular detachment and better visual acuitycompared with placebo.

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Question 1

A 31 y/o attorney complains of decreased vision OD (VAcc20/50) for3 weeks. Examination and imaging findings are most consistent with

central serous chorioretinopathy. Select the most appropriate courseat this time:

a) Inquire about steroid-containing medication use andobserve

b) Perform fluorescein-angiography-guided thermallaser photocoagulation

c) Perform fluorescein-angiography-guided

photodynamic therapyd) Initiate oral therapy with mefipristonee) Recommend lifestyle modificationconsider career

change

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Initial presentation 1 month

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Enhanced Depth Imaging

Increased visualization of choroidal anatomy

Normal

Outer border of RPEBruchs complex

Choroid/sclera junction

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Enhanced Depth Imaging CSCR

rejen S. OCT: Imaging of the choroid and beyond. Surv Ophthalmol 2013;58:387-489

OD

OS

Choroidal hyperpermeability/thickening in BOTH eyes

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Central Serous Chorio-Retinopathy(CSCR)

Treatments Observation Laser photocoagulation

PDT

Referral if:

3-4 months duration Recurrent with reduced VA

VA other eye reduced from CSCR

Vocation/visual needs willing to take risk

permanent scotoma

CNV

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OD: 20/25 OS: 20/25

Case #4: 73 y.o. AAF

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s/p Avastin injection x 1

20/25 20/25

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Exudative AMD polypoidal variant

Early CNV detection/referral imperative DONT DELAY

Typically within within 1 week or less

2005* 2006 2011 Current Clinical Trials

(Additive to Anti-VEGF

Avastin

~$50

Lucentis

~$1800

Eylea

~$1800FoVista

Squalam

eye drop

Anti-VEGFAnti-VEGF&-PIGF

Anti-PDGFAnti-VEGPDGF, bF

vastin not FDA approved

999

DT

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THANK YOU!!!!!

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10/21/20

GlaucomaUpdate

Fall2014ContinuingEducation

AhmadA.Aref,MD

AssistantProfessorofOphthalmology

October27,2014

Chicago,IL

JaniceMcMahon,OD,FAAO

AssociateProfessorof

Optometry

Disclosures Dr.McMahon

Nodisclosures.

Disclosures Dr.Aref

C:NewWorldMedical,Inc.

L:AlconLaboratories,CarlZeissMeditec

R:Akorn Pharmaceuticals

CasePresentation

67yearoldfemale

Followingfor3yearswithearlyPOAG

IOPpretreatmentmid20s

Achievedhighteens,OD>OS

Singlemedication,prostaglandinqhs OU

ONH Visualfields

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10/21/20

CasePresentation

VA20/40OD,OS

Mildcataractwithglarecomplaint BATVA

Managementoptions

Addsecondtopicalmedication

Considerlaser

Considersurgicalintervention

MedicalTherapy

Advantages

Noninvasive

Betterperceivedby

patient

Efficacious

Disadvantages

Sideeffects

DosingSchedule

Contraindications

Druginteractions

AdjunctiveMedicalTherapy

Nearly40%ofpatientsinOcularHypertension

TreatmentStudyrequired> 2medstoreach

targetIOP

Options

Betablockers

Alphaagonists

Carbonicanhydraseinhibitors

Resultsof10prospective, randomized,parallelorcrossoverclinicaltrialscompiledandanalyzed

Primaryoutcome:MeanIOPreductionfrombaseline

Peak,intermediate, andtroughIOPloweringefficacyalsocompared

Adverseeventsinvestigated

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10/21/20

IOPloweringfrombaselineequivalentamongalladjunctivetherapies(p=0.22)

IOPloweringefficacyatintermediateandtroughtimepointslesswithalphaagonists

Greaterriskofadverseeventswithalphaagonists

Prospective,openlabel,crossovertrialof26patientswithglaucomaorocularhypertensionwhowerereceivingtreatmentwithlatanoprost qhs

IOPmeasuredq2hrs postrandomizationtotimolol vs.brinzolamide

IOPsmeasuredinsittingandsupinepositionsduringdiurnaltimeperiodsandinsupinepositionduringnocturnaltimeperiod

Posthocevaluationofdatafromprospective

clinicaltrialscomparingbrimonidine and

timolol

Timolol treatedsubjectsconcurrentlytaking

systemicBblockersexperiencedlessIOP

loweringeffect(P

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10/21/20

WhichisbetterALTorSLT?

Similarefficacy1

Similarsafetyprofile1

SLTrepeatable2,butALTisnot3

ALT

SLT

1BovellAM,etal.CanJOphthalmol.2011;46:408413.2RiansuwanL,etal.Poster77.AGS,2007.3RichterCU,etal.Ophthalmology.1987;94(9):10859.

Microinvasive GlaucomaSurgery

Ab interno microincisional approach

Minimallytraumatictotargettissue

AtleastmodestIOPloweringefficacy

Highsafetyprofile

Rapidrecoverywithminimalimpactonqualityoflife

Saheb H,AhmedII.Curr Opin Ophthalmol 2012;23:96104.

GlaucomaTreatmentParadigm

Disease Stage

T

h

e

r

a

p

y

FDAApprovedMIGSProcedures Trabectome

AblationoftrabecularmeshworkandinnerwallofSchlemms canal

FDAapprovedin2004

IndicationsAllstagesofglaucoma

Requiresadequatevisualization oftrabecularmeshwork

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10/21/20

Trabectome Video

MeanIOPreducedfrom20+6.3mmHgto

15.5+2.9mmHgatyearwithmeanmedicine

reductionof1.44+1.29meds

iStent TitaniumLshapedstentimplantedabinterno

BypassestrabecularmeshworkbyconnectinganteriorchamberwithSchlemms canaltoenhanceaqueousoutflow

FDAapprovedin2012 Indicatedfortreatmentofmildtomoderate

glaucomainconjunctionwithcataractsurgery

iStent video

Ophthalmology 2011;118:459-467.

1yearresults:

72%intreatmentgroupvs.50%inphaco alonegroup

withunmedicated IOP

< 21mmHg(P

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10/21/20

PostoperativeTrabectome

Topicalantibioticx1week

Topicalcorticosteroidx4weeks Maintainglaucomamedsx46weeks

Pilocarpine qid x68weeks

Followupat1day,1week,3weeks,2months

PostoperativeiStent

Topicalantibioticx1week

Topicalcorticosteroidx4weeks Maintainglaucomamedsx46weeks

Followupat1day,1week,3weeks,2months

Goal

AchievelowerIOPwithminimalriskandless

significantimpacttothepatient.

Thankyou

oct.pdf

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