Transcript Overview Of Retinal Conditions

Overview Of Retinal Conditions
Clinical and OCT Findings
Central Coast Day Hospital
Inaugural Optometrist Conference
26th February 2012
Anil Arora
What you might rather be doing
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Give your mother a dozen red roses and tell her you love her.
Shower in a waterfall.
Sleep under the stars.
Fart in a crowded space
Give to a charity.
Run a marathon.
Reflect on your greatest weakness, and realize how it is your
greatest strength.
Attend a Sunday morning ophthalmology conference in
Terrigal -especially any lectures on retinal conditions and OCT
OPTICAL COHERENCE TOMOGRAPHY
IN RETINAL DISEASES
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Shows accumulation of fluid within the
retina and below the retina
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Changes in the neurosensory retina
 Cystic
changes
 Alteration
of contour or thickness
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Vitreous – retinal interface abnormalities
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Irregularity or elevation of the RPE
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Quantification of the abnormalities and
measurement of treatment response
Optical coherence tomography
Normal macula
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Foveal depression
Symmetrical contour
Normal thickness of
fovea and perifoveal
tissues
Flat and regular RPE
Important Retinal Conditions
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Age-related macular degeneration
Diabetic retinopathy
Retinal detachment and predisposing
diseases
Central and branch retinal vein occlusion
Macular hole
Epiretinal membrane
Vitreomacular traction syndrome
Central serous retinopathy
Age-Related Macular Degeneration
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Leading cause of blindness in the elderly
Prevalence rate rises sharply with each decade
In Australia there are about 5 million people 50+
~ 15% of these will have
age-related macular changes
 1- 2% or 50-100,000 of these
will have significant vision loss from
geographic atrophy or from
exudative changes
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Exudative Macular Degeneration
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EXAMINATION
Visual acuity
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Variable – depends on size and
location of
haemorrhage/exudation
Amsler grid testing
Fundus examination
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Haemorrhage
Elevation by subretinal
fluid/blood
Drusen
Pigment
changes/atrophy/scarring
Drusen
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Accumulation of
debris between the
RPE and Bruch’s
membrane
Exudative changes –SRF and sub-RPE fluid
Fovea
SRF
RPE
SRF and RPE detachment
RPE thinned and irregular
PED – serous and fibrovascular
Serous PED
dépression fovéale
Fovea
DSR
RD
DEP
PED
b
Fibro vascular PED
Occult
Role of OCT in ARMD
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Evaluation of
exudative changes
Quantification of
retinal thickness
Response to
treatment with
anti-VEGF agents
Role Of OCT In ARMD
Response to treatment
Diabetic Retinopathy
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Presence of diabetic microvascular lesions
Most frequent ocular complication of DM
1/3rd rule – About 1/3rd of all diabetics
have some degree of retinopathy and in
about 1/3rd of these have sightthreatening disease
After 15 years about 70% of people with
diabetes will have some retinopathy
Risk Factors For Retinopathy
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Development of diabetic retinopathy
related to:
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Duration of diabetes
Glycaemic control
Hypertension management
Serum lipids and cholesterol
Other factors eg. pregnancy, nephropathy
Diabetic Retinopathy
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Two types of retinopathy
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Nonproliferative retinopathy (NPDR)
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Early stage diabetic retinopathy
Proliferative retinopathy (PDR)
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Later stage diabetic retinopathy
Nonproliferative Diabetic
Retinopathy (NPDR)
 Also
called background diabetic
retinopathy.
 Earliest stage of diabetic
retinopathy.
 Damaged blood vessels in the
retina leak fluid and blood into
the eye.
 Cholesterol or other fat deposits
from blood, called hard
exudates, may leak into retina.
Top: Healthy retina
Bottom: NPDR with
hard exudates
Proliferative Diabetic Retinopathy
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Characterised by the growth of new blood
vessels in response to tissue hypoxia
NVD – new vessels at or within 1 DD of
the optic disc
NVE – new vessels elsewhere in the retina
Can lead to:
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Vitreous haemorrhage
Tractional retinal detachment
Proliferative Diabetic Retinopathy
Proliferative Diabetic Retinopathy
With PDR, vision is affected
when any of the following
occur:
 Vitreous haemorrhage
 Traction retinal detachment
 Neovascular glaucoma
Vitreous
haemorrhage
Diabetic Macular Oedema
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Most common cause of decreased vision
and blindness in diabetic retinopathy
Indicated by findings of microaneurysms,
haemorrhages or hard exudates within
2DD of the fovea
CSME (Clinically significant macular
oedema) Complicated definition, but
basically retinal thickening or hard
exudates within 500 um of the fovea
Macular oedema
OCT scan showing macular oedema
Diabetic macular oedema –
focal, cystoid and diffuse
Role of OCT in Diabetic Retinopathy
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Confirm clinical suspicion of macular oedema
Quantification of extent of oedema
Diagnosis of macular traction and localised
macular tractional retinal detachment in
cases of proliferative retinopathy
Evaluation of response to treatment – laser
and /or intravitreal Avastin/Triamcinolone
Retinal Detachment
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Often preceded by a vitreous detachment
with patient seeing flashes and floaters
Usually starts as a blurring or loss of
peripheral vision in one area that progresses
centrally
More likely in those with a history of
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Myopia
Ocular trauma or surgery
Retinal Detachment
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Most commonly due to a posterior vitreous
detachment with a retinal tear developing
About 10% of PVD
develop a retinal tear
Risk of tear much higher
if blood or pigmented
cells present in vitreous
Retinal Detachment
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If a retinal tear is
found before the retina
detaches, it can often
be treated with laser
photocoagulation or
cryotherapy or a
combination of these.
Retinal Detachment
Retinal Detachment
Retinal Detachment
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Surgical Management
Scleral buckle/cryotherapy
Vitrectomy
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+/+/+/+/+/-
buckle/cryotherapy
endolaser
intraocular gas
silicone oil
perfluorocarbon liquid
Pneumatic retinopexy
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In-rooms procedure
Gas injection and positioning
Role of OCT in Retinal Detachment
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Very limited role as the diagnosis is clinical
and treatment in most cases is surgical
Useful in assessing reason for poor vision
following retinal detachment repair with
anatomical reattachment of the retina.
May show:
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Persistent macular oedema/subretinal fluid
Damage to photoreceptors
Thinned and atrophic retina
Epiretinal membrane
Central Retinal Vein Occlusion
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Common cause of visual loss
Usually history of hypertension
Two main forms
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Non-ischaemic
Ischaemic
75-80% non-ischaemic at presentation
15% non-ischaemic may convert to ischaemic
50% of ischaemic -->neovascular glaucoma
Central Retinal Vein Occlusion
Cause Of Visual Loss In CRVO
 In non-ischaemic CRVO vision reduction due
to macular oedema &/or haemorrhage
 In ischaemic CRVO vision reduced from
macular ischaemia or later
by retinal neovascularization
with vitreous haemorrhage or
from neovascular glaucoma
Central Retinal Vein Occlusion
Management
 Macular oedema
 Intravitreal Avastin
 Intravitreal triamcinolone / dexamethasone
 Macular grid laser in younger patients
(<60)
 Ischaemia and neovascular complications
 Panretinal photocoagulation
 Anti-VEGF drugs
 Management of hypertension and other
cardiovascular risk factors
Branch Retinal Vein Occlusion
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Usually occurs in patients 50 – 70 yo
Hypertension is the main risk factor (70%)
Occurs at an A-V crossing where vein and
artery have a common adventitial sheath
Visual loss from macular
oedema, haemorrhage or
ischaemia
Branch Retinal Vein Occlusion
Late Complications
 Retinal or optic disc neovascularization
with vitreous haemorrhage
 Epiretinal membrane
 Chronic macular oedema with formation
of a foveal cyst or lamellar hole
 “Atrophic maculopathy” from prolonged
macular oedema or ischaemia
Branch Retinal Vein Occlusion
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Management
Intravitreal Avastin
Intravitreal triamcinolone or dexamethasone
Retinal laser
Manage hypertension and other risk factors
Role of OCT in RVO
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Assessment of macular oedema
Quantification of retinal thickness
Response of macular oedema to treatment
with intravitreal agents and/or laser
Assessment of late complications –
epiretinal membrane, lamellar hole
Macular Hole
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Central visual loss in elderly
VA usually 6/36 – 6/60
5 – 10% bilateral
Treatment consists of vitrectomy,
peeling of the cortical vitreous +/internal limiting membrane peeling
and intravitreal gas injection with
one to two weeks of face-down positioning
Macular Hole
Macular hole
OCT showing a
macular hole before
and after surgery
Stages of a macular hole on OCT
Epiretinal Membrane
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Usually idiopathic, seen in patients over 60
Sometimes after vein occlusion, inflammation
Variable effect on vision - blurring, distortion
May have associated cystoid macular oedema
Pseudohole – may look like macular hole
Retinal vessels irregular and tortuous
Vitrectomy and peeling if VA 6/18 or worse
or even with better vision but troublesome
distortion
Epiretinal Membrane
Epiretinal Membrane With
Pseudohole
Epiretinal membrane
Without pseudohole
With pseudohole
Role of OCT in Macular Hole and
Epiretinal Membrane
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Clearly shows hole morphology
Differentiates full-thichness hole from
lamellar hole or pseudohole
Demonstrates associated conditions such
as macular oedema, macular cyst and
vitreoretinal traction
Shows response to treatment eg. closure
of macular hole, successful peeling of ERM
Vitreomacular traction syndrome
Vitreomacular traction syndrome
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Traction on the retina by taut or contracted
vitreous gel
May be part of a spectrum – VMT may be
the result of antero-posterior traction while
macular hole may be from tangential
traction
Shows up well on OCT, sometimes in an
asymptomatic patient with a normal retina
OCT in VMT
More questions than answers?
The more you know the less you
understand – LAO TSE
The more I learn, the more I learn
how little I know - SOCRATES
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Possible precursor to lamellar
hole or macular hole/cyst ?
Possible precursor to epiretinal
membrane formation?
Spectrum of vitreretinal interface
disorders – VMT, ERM, macular
cyst, lamellar hole, full-thickness
macular hole
VMT
Treatment
 Usually vitrectomy with
removal of as much
cortical vitreous as
possible
 ERM peel if ERM present
 Intraocular gas fill and
face down positioning
 OCT useful to demonstrate
post-op macular structure
and release of traction
Central Serous Retinopathy
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CSR
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Usually middle-aged male
Central visual
blur/distortion
Micropsia
Association with “stress”
Can be subtle and easily
missed on clinical
examination
Vast majority recover
OCT in CSR
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Shows extent of SRF
very well – able to show
patient
Can monitor progress of
disease with serial OCT
Does not show leakage
site in RPE. Need
fluorescein angiography
Conclusion
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Multitude of common and important
retinal conditions
Clinical diagnosis and an understanding of
the potential severity of the condition are
vital to good outcomes
OCT adds to our ability to diagnose and
manage retinal diseases and is increasing
our understanding of these conditions
Question 1
OCT is useful in exudative (“wet”) ARMD for
all the following reasons EXCEPT:
A. Confirming the presence of subretinal or
sub-RPE fluid
B. Assessing and quantifying the amount of
fluid present
C. Assessing the size and activity of the
choroidal neovascular membrane
D. Assessing response of the exudative
changes to treatment
Question 2
OCT is useful in diabetic retinopathy to:
A. Assess the size and number of diabetic
microaneurysms
B. Assess hard exudates and cotton-wool
spots
C. Assess retinal and/or optic disc new
vessels
D. Assess diabetic macular oedema
Question 3
Retinal detachment:
A. Is most commonly due to a posterior
vitreous detachment with a retinal tear
B. Is best managed by monitoring with
regular OCT examinations
C. Is most common in those with a history
of hypertension
D. Usually resolves without treatment over
several months
Question 4
The following are true about epiretinal
membranes EXCEPT:
A. Can result in blurring and distortion of
central vision
B. If visually symptomatic they should be
treated with laser photocoagulation
C. May be associated with cystoids macular
oedema
D. May spontaneously separate from the
retina
Question 5
Central serous retinopathy:
A. Results in loss of central vision if not
treated
B. Is managed by using OCT to find the
leakage site
C. Is usually due to a leak at the level of the
RPE
D. Is typically a disease of elderly females