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Retinal Imaging Conference

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 ”

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Retinal Imaging Conference

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  1. Retinal Imaging Conference Eddie Apenbrinck MD University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/23/14

  2. Subjective • CC: “Decreased vision in right eye for several months” • HPI: 54 year-oldwhite female presents to Retina clinic for first time in 3 years with gradual painless decrease in vision OD for severalmonths. • 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

  3. 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

  4. Exam OD OS BCVA 20/100-1 20/20-1 -2.50x0.25x165 -2.50x0.50x180 Pupils: 3 2 3 2 no APD IOP: 14 mm Hg 16 mm Hg EOM: Full OU CVF: Full OU

  5. Exam Anterior Segment OD OS L/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

  6. OS Color Fundus Photos: 12/2013 OD OS: unremarkable OD: macular edema, dot hemorrhages temporal to disc, melanotic lesion with central hypopigmentationsuperotemporally

  7. OD: 7/2010 Color Fundus Photos OD: 2/2010

  8. Autofluorescence OD: Hyperautofluorescence temporal to macula with areas of hypoautofluorescence temporal to the disc and superotemporal to the macula OS: unremarkable

  9. 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

  10. FA OD Late AV Phase: expanding hyperfluorescence temporal to the disc and portions of the nasal macula consistent with leakage

  11. 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)

  12. OCT OD OS Foveal Subretinal Fluid and macular edema Vitreomacular Adhesion

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Treatment • Focal laser to reduce macular edema and PRP to treat zones of ischemia and neovascularization. • Intravitrealtriamcinolone 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)

  19. Literature Review • Retrospective case series of 159 patients with radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with intravitrealbevacizumab • 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

  20. Literature Review

  21. Literature Review Clinical Ophthalmology September 2013 • Retrospective case series of 25 patients with severe radiation retinopathy and macular edema secondary to I-125 brachytherapy, treated with combination of intravitrealtriamcinolone 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 bevacizumabmonotherpay were given IV triamcinolone • Mean number of injections: Bevacizumab 8.8 (1-26) and Triamcinolone 2 (1-6)

  22. Literature Review • 36% with BCVA of 20/50 or better at last follow-up visit • Patients refractory to bevacizumabmonotherapy may benefit from combination therapy with triamcinolone

  23. 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’sPrinicples and Practice of Ophthalmology. 3rd ed. Philadelphia: Saunders; 2008:chap 175 Shields CL, Demirci H, Dai V, et al. Intravitatrealtriamcinoloneacetonide 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 triamcinoloneacetonide 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 intravitrealbevacizumab maintains functional visual acuity. Clinical Ophthalmology. 2012;(6):1739 - 1748

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