retinal imaging conference
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Retinal Imaging Conference. Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/23/14. Subjective. CC : “ Decreased vision in right eye for several months ” - PowerPoint PPT PresentationTRANSCRIPT
Retinal Imaging Conference
Eddie Apenbrinck MDUniversity of Louisville School of
MedicineDepartment of Ophthalmology & Visual
Sciences1/23/14
Subjective CC: “Decreased vision in right eye for several
months”
HPI: 54 year-old white female presents to Retina clinic for first time in 3 years with gradual painless decrease in vision OD for several months.
POH: Small choroidal melanocytic tumor OD (nevus vs
low grade melanoma) s/p stereotactic radiation therapy (09/2010) FNAB: indeterminate due to hypocellularity
and degenerated nature of specimen Gene expression class 1 (low grade): consistent
with nevus vs low grade melanoma Stereotactic Radiation Therapy: 6MeV linear
accelerator single target dose of 18 Gy
PMH: HTN, HLD, GERD, DM type II (A1C 5.6), Asthma
Medications: Crestor 10mg daily, Lisinopril 10mg daily, Zantac 75mg BID, metformin 500mg BID
Allergies: Penicillin, Sulfa, Levaquin
Exam OD OS
BCVA 20/100-1 20/20-1
-2.50x0.25x165 -2.50x0.50x180
Pupils: 3 2 3 2 no APDIOP: 14 mm Hg 16 mm Hg EOM: Full OU
CVF: Full OU
Exam Anterior Segment
OD OSL/L: WNL WNL
C/S: WNL WNL
K: WNL WNL
AC: No cell or flare OU
I/L: 2+ NS 2+NS
Vitreous: WNL WNL
Color Fundus Photos: 12/2013
OD OS
OD: macular edema, dot hemorrhages temporal to disc, melanotic lesion with central hypopigmentation superotemporally
OS: unremarkable
Autofluorescence
OD: Hyperautofluorescence temporal to macula with areas of hypoautofluorescence temporal to the disc and superotemporal to the macula
OS: unremarkable
FA OD
AV Phase: -Capillary non-perfusion temporal to disc with associated MA’s and microvascular remodeling-Capillary nonperfusion superotemporal to macula (area of prior SRT) -Microvascular remodeling juxtafovea (nasal)-Irregular slightly enlarged FAZ
FA OD
Late AV Phase: expanding hyperfluorescence temporal to the disc and portions of the nasal macula consistent with
leakage
FA OD
Recirculation Phase: -expanded hyperfluorescence with blurred edges (red arrow)-areas of hypofluorescence temporal to the disc and superotemporal to the macula consistent with nonperfusion (white arrow)
ASSESSMENT
54 year old white female presents for 3 year follow up with decreased vision and history of choroidal melanotic lesion s/p stereotactic radiotherapy DDx
Radiation retinopathy Diabetic Retinopathy BRAO BRVO
PLAN
Avastin OD for macular edema
Observe melanotic choroidal lesion as no change in size since SRT
Follow up in 1 month to reassess macular edema
1 month follow up
No change in VA Resolution of subretinal fluid but no
change in macular edema on OCT
Repeat Avastin OD and f/u in 1 month
Radiation Retinopathy Characterized by slowly progressive occlusive
vasculopathy
Typically has a delayed onset (18 months with external beam and earlier with brachytherapy), and causes microangiopathic changes that clinically resemble diabetic retinopathy
Radiation damage to retinal blood vessels causes vascular incompetence and occlusion
Doses of 30-35 Gy is usually required to induce clinical symptoms, however, retinopathy may develop after as little as 15 Gy
Clinical Feature Patients may be asymptomatic or may describe
decreased visual acuity
Ophthalmic Signs: CWS, retinal hemorrhages, MA’s, perivascular sheathing, capillary telangiectasis, macular edema and disc edema
Capillary nonperfusion and extensive retinal ischemia can lead to neovascularization of the retina, iris, disc.
Visual prognosis is related to the extent of macular involvement with CME, exudative maculopathy, or capillary nonperfusion
Treatment Focal laser to reduce macular edema and PRP to treat
zones of ischemia and neovascularization.
Intravitreal triamcinolone or anti-VEGF drugs can stabilize or improve visual acuity in some patients with CME
Hyperbaric oxygen has been proposed as treatment but benefits remain unproven
Situations that exacerbate radiation retinopathy: Pre-existing microangiopathy: more likely to
develop severe changes Diabetic patients: likely to show changes at lower
doses of radiation Chemotherapeutic agents (5-FU)
Literature Review
Retrospective case series of 159 patients with radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with intravitreal bevacizumab
Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased vision
81 of 159 (50.9%) demonstrated 20/50 or better vision at mean follow up of 34.6 months
Literature Review
Retrospective case series of 25 patients with severe radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with combination of intravitreal triamcinolone and bevacizumab
Patients monitored with SD-OCT at 2-4 month intervals and treatment with IV bevacizumab was initiated at first signs of macular edema associated with decreased Va Cases of severe radiation maculopathy or cases
refractory to bevacizumab monotherpay were given IV triamcinolone
Mean number of injections: Bevacizumab 8.8 (1-26) and Triamcinolone 2 (1-6)
Clinical Ophthalmology September 2013
Literature Review
• 36% with BCVA of 20/50 or better at last follow-up visit
• Patients refractory to bevacizumab monotherapy may benefit from combination therapy with triamcinolone
References BCSC: Retina and Vitreous. Radiation Retinopathy. Pgs
151-153 Maguir AM, Schachat AP. Radiation Retinopathy. Retina
Vol II 4th Ed. Chapter 83:1483-1489. Patel SJ, Schachat AP. Radiation Retinopathy. Albert and
Jakobiec’s Prinicples and Practice of Ophthalmology. 3rd ed. Philadelphia: Saunders; 2008:chap 175
Shields CL, Demirci H, Dai V, et al. Intravitatreal triamcinolone acetonide for radiation maculopathy after plaque radiotherapy for choroidal melanoma. Retina. 2005;25(7):868-874
Shah NV, Houston SK, Markoe A, Murray TG. Combination therapy with triamcinolone acetonide and bevacizumab for the treatment of severe radiation maculopathy in patients with posterior uveal melanoma. Clinical Ophthalmology. 2013;(7):1877-82
Shah NV, Houston SK, Markoe A, Murray TG. Early SD-OCT diagnosis followed by prompt treatment of radiation maculopathy using intravitreal bevacizumab maintains functional visual acuity. Clinical Ophthalmology. 2012;(6):1739 - 1748