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EMB Case Discussion

EMB Case Discussion. R1 陳錫富 /VS 吳秀琛 June 20, 2011. Chief complaint. 2011/06/01 A 50 y/o man was referred to Dr. Wu’s clinic for poor control of IOP (OD) in recent three months. Past Medical Hx. 2001 2010/8 2011/1 2011/6. OU high myopia (about -8.0D)

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EMB Case Discussion

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  1. EMB Case Discussion R1 陳錫富 /VS 吳秀琛 June 20, 2011

  2. Chief complaint • 2011/06/01 • A 50 y/o man was referred to Dr. Wu’s clinic for poor control of IOP (OD) in recent three months

  3. Past Medical Hx • 2001 • 2010/8 • 2011/1 • 2011/6 OU high myopia (about -8.0D) • Hx of ocular trauma(-), glaucoma(-) Type 2 DM under regular OHA OD poor visual acuity noted accidentally • Cataract was told in LMD OD cataract surgery in Mackay M.H. • Postoperatively, OD ocular HTN and retinal detachment was noted • Diamox 1#TID and Alphagan BID Referred for poor control of IOP(OD)

  4. Ext. photography (OD) • VAcPG OD:light perception(-), OS:0.9 • PT OD:26(23.9)mmHg, OS:15.3(14.5)mmHg • OS  iris:rubeosis(-), lens:NS(1+), fundus: dot hemorrhage

  5. Fundus (OD) • Funnel type retinal detachment

  6. Discussion

  7. How to manage this case?

  8. Question • Pre-op evaluation? cataract 送審? • Improvement in VA after cataract surgery?

  9. Question • The timing of RD? Pre-op? post-op?

  10. One week after IVI of Avastin • PT OD:39.7(38.5) OS:17.3(17.4)mmHg • OD rubeosis regressed keeps Alphagan BID

  11. Introduction • NVG classically carries poor prognosis, typically ending up with severe loss of vision. • Early diagnosis and prompt treatment can prevent visual loss in patients with NVG • glaucomatous optic nerve damage • cataract formation • corneal decompensation • recurrent hyphema with corneal blood staining • phthisis bulbi

  12. Manifestations of NVG • Prerubeosis stage • Normal IOP, rubeosis(-) • Best time to prevent NVG • Preglaucoma stage • Rubeosis starts to develop, IOP is still normal

  13. Manifestations of NVG • Open-angle stage • More prominent NVI and NVA with elevated IOP • May be with Inflammation, hemorrhage, and glaucomatous optic neuropathy

  14. Manifestations of NVG • Angle-closure stage • Conjunctival injection, edematous cornea, hyphema, can be mild pain or absent of pain • Peripheral anterior synechiae, ectropion uveae, pupillary dilation, IOP↑ or ↓→ if phthisis bulbi

  15. Predisposing factors to NVG

  16. Pathogenesis of NVG in this case • Three necessary elements • A hypoxic environment conducive to the production of angiogenic factors • A source of angiogenic factorsischemic retina due to retinal detachment, DM retinopathy and intraocular inflammation due to cataract surgery • A storehouse that allows for the accumulation of angiogenic factors synechial closed angle Seminars in Ophthalmology, 24, 113–121, 2009

  17. Key management to NVG • Treatment of the underlying disease responsible for rubeosis • Retinal ischemic dx PRP: treatment of choice  reduce global retinal oxygen demand and minimize angiogenic stimuli higher success rate for following glaucoma surgery, less rubeosis after cataract extraction • Panretinal cryotherapy, transscleral diode laser retinopexy, or TPPV+lensectomy+endolaser If media opacity • Pure inflammatory causes of NVG topical steroids Seminars in Ophthalmology, 24, 106–112, 2009

  18. Key management to NVG • Treatment of the underlying disease responsible for rubeosis • Goniophotocoagulation on new vessels in the angle to prevent synechial closure of angle • Anti-VEGF therapy adjuvent therapy prior to glaucoma surgery  regression of NV and prevents intraoperative bleeding and inflammation promote successful surgical outcomes Seminars in Ophthalmology, 24, 106–112, 2009

  19. Key management to NVG • Treatment of the increased IOP • Pharmacologic agents limited effects if underlying diseases aren’t eliminated • Cyclodestructive procedures: poor visual prognosis  treatment of choice: TSCP  lower rate progreesed to phthisis than cryotherapy • Glaucoma filtration surgery or aqueous tube shunts  high failure rate Seminars in Ophthalmology, 24, 106–112, 2009

  20. Anti-VEGF therapy in NVG • Prospective multicenter studies are still lacking • In few case reports • IVI of Avastin effectively stabilized NVI activity and controlled IOP in NVG with open angle did not control IOP in those with closed angle Current Opinion in Ophthalmology 2010,21:112–117

  21. Treatment of choice following IVI Avastin • Anti-glaucomatic agents limited effects • Trabeculectomy high failure rate • TSCP progression to phthisis bulbi  cosmetic problems

  22. Thanks for your listening~

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