Retinal Vascular Disease

1. Retinal Vascular Disease Don Simpson, O.D. St. Louis VA Medical Center

2. WELCOME TO MID-TOWN 915 N GRAND BLVD2 BLOCKS N OF THE FOX THEATER St. Louis VAMC - John Cochran Division

3. St. Louis VA Rotation • 2 divisions • John Cochran – mid town • Jefferson Barracks- south county • Equal time both divisions

4. Case # 1 • 71 yo male pt presents for routine eye exam • No remarkable findings until Fundus examination • Med hx remarkable for htn, ateriosclerosis • Rt eye reveals following:

6. Diagnosis • Retinal embolus- Hollenhorst plaque • What now?

7. Return to history • Anterior circulation TIA SX ? • Amaurosis fugax • Unilateral motor disturbance • Unilateral numbness, tingling • Slurred speech • Momentary confusion • 50-75% of stroke patients have TIAs

8. Return to examination • Additional tests • Auscultation of carotid arteries • What if normal? • What if bruit?

9. Management • ? • TIA sx present • TIA sx absent

10. No TIA Sx • Primary care provider, Neurology • Antiplatelet meds if on none, • ASA contraindications • 81 mg qd • Carotid ultrasound • Echocardiogram

11. TIA SX • Urgent care • Primary care provider • Neurology • ER

12. St Louis VA Neurology • Heading of Neuro consult work sheet at St. Louis VA “ TRANSIENT ISCHEMIC ATTACK IS A MEDICAL EMERGENCY. If TIA is suspected , please refer the patient to the ER or page the Neuro resident on call for an immediate assessment. TIA should also mean: TAKE IMMEDIATE ACTION “

13. Additional signs carotid insufficiency • Hypo-perfusion retinopathy • Ocular ischemic syndrome

14. Hypo-perfusion retinopathy • Peripheral retinal hemorrhages associated with decreased retinal artery perfusion pressure

19. Ocular ischemic syndrome • NVI • Retinal neovascularization • Neovascular glaucoma

22. Surgical management carotid disease • Carotid angiogram • Gold standard to evaluate stenosis • Invasive procedure • Carotid endarterectomy

25. Cardiac sources of emboli • Mitral valve disease • Arrhythmias- a fib , vent tach • Valve replacement thrombi • Sbe

27. Retinal Emboli and Stroke • Beaver Dam study- population based • Looked at risk of CVA with retinal emboli • Results published in Archives of Ophth Vol 117; Aug 99. [1063-68]

28. Findings in Beaver Dam Study • Emboli prevalence 1.3% [3.1%>75yo] • Emboli not present at follow up 90% of the time • With emboli 3x greater risk of fatal CVA in 8 years than if no emboli present

29. TMVL & HTIA • Transient monocular vision loss • Hemispheric TIA • Stroke risk lower if only tmvl v htia sx based on large trials NASCET, ECST • 3yr risk CVA with med tx 10% tmvl • 3yr risk CVA with med tx 20% htia • Why risk different?

30. 6 RISK FACTORS FOR STROKE IN TMVL • MALE • 75yo or > • Hx htia or stroke • Hx intermittent claudication • Internal carotid stenosis of 80-94% • Absence of collateral vessels on angiogram • 3 of these risk factors with TMVL carotid endarterectomy beneficial

31. ASYMPTOMATIC HOLLENHORST PLAQUE • No evidence to suggest that carotid endarterectomy is of benefit

32. Prevalence of Stroke by Age and Sex NHANES: 1999-2002 Source: CDC/NCHS and NHLBI.

33. Estimated Direct and Indirect Costs of Cardiovascular Diseases and Stroke United States: 2005 Source: Heart Disease and Stroke Statistics – 2005 Update.

34. Percentage Breakdown of Deaths From Cardiovascular Diseases United States:2002 Preliminary Source: CDC/NCHS.

35. Case 2 • Sudden vision loss right eye few days duration • 65 yo male • Ocular hx unremarkable • Med hx hypertension, diabetes

36. Examination • Best corrected vision - 10/400 • Right afferent pupillary defect

38. DIAGNOSIS • CRVO • 2 types • Ischemic vs non ischemic • likely ischemic

39. Ischemic CRVO • VA less than 20/200 • APD • Numerous CWS • > 10 disc areas of capillary nonpefusion • 30% of all CRVO- 50-60% develop NVG • NVG 3-4 months [90 day glaucoma]

40. Nonischemic CRVO • VA usually better than 20/200 or better • No APD • Few cotton wool spots • May progress to ischemic CRVO

41. Uncommon Etiologies of CRVO • Polycythemia • Plasma cell dyscrasias

42. Polycythemia • Increased RBC and blood volume • Polycythemia vera- idiopathic • Secondary polycythemia- erythrocytosis • Erythrocytosis can be due to hypoxia or condition causing increased stimulating factor

43. Plasma Cell Dyscrasias • Multiple myeloma • Waldenstrom’s macroglobulinemia • Malignant production of immunoglobulins • Increased serum viscosity

44. Homocystinemia • Elevated homocystine levels associated with atherosclerosis and CRVO • Normal homocystine metabolism, but elevated levels of the amino acid

45. Neovascular glaucoma • Response to ischemia • Difficult to manage • Intractable pain/ enucleation

49. Clinical Management and Natural History of CRVO • Arch Ophth Vol 115, Apr 97, 486-91 • Prognostic value of initial visual acuity • 20/40 or better- likely good outcome • 20/50-20/200- variable prognosis • 20/200 or worse- poor prognosis, likely ischemic, high risk NVI, ANV • 56% of <20/200 had NVI and ANV at one month

50. Follow up CRVO based on Initial Visual Acuity • >20/40 q 1-2 months for 6 months • 20/50-200 q 1-2 months for 6 months • <20/200 q 1 month for 6 months