basics to utilizing oct in glaucoma - health.ucdavis.edu · abnormal sap vf on follow up @ earliest...

6/2/17

1

BASICS TO UTILIZING OCT IN GLAUCOMARoma Patel, MD, MBAChief of Eye Care Division – Sacramento VA HospitalAssistant Clinical Professor at UC Davis Eye Center

WHAT IS IT?• Broad bandwidths of long wavelength light

• 1-2 mm below the surface

• Principle of low-coherence interferometry to reject the scattered light

• Differences in Reflected light used to create an A-scan • spatial dimensions and location of structures

• We see a B-scan –combination of serial A-scans – now creating a 2D image

6/2/17

2

OUTLINE

• RNFL Analysis

•Ganglion Cell Analysis

•Artifacts

RNFL

• Circular scans of 3.4 mm diameter centered on nerve head

• OCT quantifies the thinning of the RNFL • Detection and monitoring of pre-perimetric and early-moderate glaucoma

• Compared to age-matched controlled individuals if >18 years of age

> 95th percentile = WHITE 5-95th = GREEN 1-5th= YELLOW <1st percentile = RED

6/2/17

3

EARLIER DETECTION

Ophthalmology 2015;122:2002-2009

75 eyes of 75 patients at UCSD

Initially normal fields à repeatable abnormal SAP VF on follow up

@ earliest VF defect - mean RNFL was 75.09 for glaucomatous eyes & 90.68 for controls

At 95% specificity, 35% of eyes had abnormal mean RNFL 4 years before VF changes.

• 19% of eyes had abnormal results 8 years before field loss

RNFL THICKNESS MAPS• Rule of Thumb to Identify an Abnormal OCT

• Average below the 5th percentile (yellow or red)• Any quadrants below the 5th percentile (yellow or red)• Any clock hour below the 1st percentile (red)

• 12 clock hour map • useful for early disease • assessing optic nerve rim notching

• Compare the two eyes – normal green is a BIG range • >10 micron difference in the superior or inferior quads? LOOK CLOSELY

6/2/17

4

TSNIT CONTOUR

Normal TSNIT contour• Tall rounded peaks of similar heights at the

inferior and superior poles and follow the overall shape of the nomogram closely

• RNFL contours similar between eyes

Abnormal TSNIT contour• Any focal thinning in the superior or inferior

pole, especially if the thickness is at or below the 5th percentile

• Any significant asymmetry between the right and left eye contour, especially located superiorly or inferiorly

RNFL• Excellent intravisit and intervisit reproducibility of measurements

• Cirrus – tolerance limit for average RNFL thickness was 3.89 µm• Suggests reproducible decrease > 4 µm may be statistically significant

• Caution though – 2 µm decrease expected yearly due to aging

• Personally – I look closely for other signs of progression if any quadrant or clock hour has decreased by > 5 µm.

Mwanza JC, Chang RT, Budenz DL, et al. Reproducibility of peripapillary retinal nerve fiber layer thickness and optic nerve head parameters measured with cirrus HD-OCT in glaucomatous eyes. Invest Ophthalmol Vis Sci 2010;51:5724-5730.

6/2/17

5

FLOOR EFFECT

• SD-OCT levels off • Rarely falling below 50 microns • Presence of glial and nonneural (vascular) tissue

• Prone to segmentation error

• Advanced disease? • Serial visual fields are more useful

GANGLION CELL COMPLEX

• Thickest in the perimacular region• Glaucomatous eyes found to have Decreased macular thickness

• Cirrus – Ganglion Cell Layer + Inner Plexiform Layer• Optovue – RNFL + Ganglion Cell Layer + Inner Plexiform Layer

• Development of a Normative database with calculated sectors

6/2/17

6

REFERRED FOR LARGE CDR

• 69 year old male

• No significant ocular history

• IOP OU always <14 with normal CCT

• History of migraines

• Denies trauma, fam Hx, steroid use, Raynaud’s, hypotension, etc.

NEW PATIENT

6/2/17

7

GANGLION CELL COMPLEX PARAMETERS

These 5 correlated the most with RNFL dropout and progression of disease.

MinimumInferotemporal sector

AverageSuperotemporal sector

Inferior sector

Mwanza JC, Durbin MK, Budenz DL, et al. Glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head. Ophthalmology 2012; 1151-1158.

Right Eye Left Eye

• 59 year old Caucasian male• History of Hyperopia and Narrow Angle OD; Closed Angle OS s/p LPI OU 01/2016• IOP elevation to 26 prior to LPI OS in setting of normal pachymetry• Decreased to mid teens after LPI

Clinical Exam May 2017IOP OD 17 OS 22

No evidence of pigmentary or pseudoexfoliation syndrome

Patent LPIs; Open AnglesMild NSC OU

HVF 05/2017 OD WNL

OS with few inferior misses

GLAUCOMA OR NOT?

6/2/17

8

Does this patient have CACG?

Surprisingly OCT RNFL reveals focal superior thinning OU

Ganglion Cell Analysis supports clinical exam

GANGLION CELL PROGRESSION

• Potentially detect structural change sooner than ONH/RNFL changes • Determine if statistically

significant change • Complements ONH/RNFL

Guided Progression Analysis

• Zeiss Software Version 10.0 to be released 2018; Image courtesy of Zeiss

6/2/17

9

GANGLION CELL PROGRESSION

Ganglion Cell

Changes More Visible

Image courtesy of Zeiss

Coming soon:

PanoMapComplete Picture

Zeiss Software Version 10.0 to be released 2018;

Image courtesy of Zeiss

6/2/17

10

ARTIFACTSAsrani et al.1 - Spectralis SD-OCT-related imaging artifacts

Retrospective, cross-sectional study of 277 patients obtaining glaucoma eval scans• 37 of 131 (28.2%) macular thickness scans with artifact • 55 of 277 (19.9%) RNFL scans with artifact

• 14.1 of all artifacts were not evident on final printout• MCC of artifact – ocular pathology such as epiretinal membrane

95% Confidence interval à artifacts in 15.2% to 36.1% of scans

Asrani S, Essaid L, Alder BD, Santiago-Turla C. Artifacts in spectral-domain optical coherence tomography measurements in glaucoma. JAMA Ophthalmol Published online February 13, 2014.

Superotemporal epiretinalmembrane is preventing

collapse of the degenerated RNFL

Artificial inflation of superior rim thickness

Asrani S, Essaid L, Alder BD, Santiago-Turla C. Artifacts in spectral-domain optical coherence tomography measurements in glaucoma. JAMA Ophthalmol Published online February 13, 2014.

6/2/17

11

Partial PVDs – one of

the most common non-

pathologic artifacts

What appears to be

significant progression

over an 18 month interval

is actually the release of

a partial PVD

Asrani S, Essaid L, Alder BD, Santiago-Turla C. Artifacts in spectral-domain optical coherence tomography measurements in glaucoma. JAMA OphthalmolPublished online February 13, 2014.

ARTIFACTS

Eye Movement Blink Decentration

6/2/17

12

ARTIFACTS

• Weiss ring – small localized dropout – dark area on topography map • Localized thinning on clock hour analysis and altered contour on the TSNIT contour

• Segmentation error• Misidentified retinal landmarks• Inspect the images and the delineation marker lines

• Poor signal strength • Media opacity – ocular surface or lens; less commonly - vitreous• If live scan quality and saturation improve temporarily after blinking à artificial tears• A decreased signal usually results in a falsely thinned RNFL with preserved contour

Balasubramanian M et al. Effect of image quality on tissue thickness measurements obtained with spectral-domain optical coherence tomography. Opt Express. 2009;17(5):4019-4036

SPLIT BUNDLES

A) Classic appearance of the superior and inferior RNFL bundles

B) Split superior RNFL bundles

Look for notching in nerve butthis is a case of false thinning

6/2/17

13

HIGH MYOPIA

• Up to 50% will have abnormal scans• Normative database excluded patients with

refractive error of >+8 D and -12 D

• Temporal shift of the ST and IT RNFL bundles

• Focus on changes in Ganglion Cell Maps• Try a vertical volume scan vs the traditional

horizontal volume scan in these eyes

39 year old female, -13.00D myopia

J Glaucoma. 2009 Sep;18(7):501-5.

• RNFL thickness decreases with higher axial length (R = -0.70, p<0.001) and spherical equivalent (R = -0.52, P=0.005)

6/2/17

14

FINAL THOUGHTS

• Earlier detection is becoming easier• Explosive growth in our ability to assess structural changes

• Start treatment earlier to prevent vision loss

• OCT is a tool but cannot diagnose • Clinical judgement is necessary• Risk factors, trauma, color vision, visual field patterns, etc

• Glaucoma is still an art!

Thank you!

Contact information: [email protected]@va.gov

6/8/17

1

Kevin Merrill MDUC Davis Eye Center Resident 2008

June 2nd, 2017

6/8/17

2

6/8/17

3

6/8/17

4

¨ Refers to conjunctivitis during the first month of life

¨ Organism is usually from direct contact through the birth canal

¨ But also be seen in infants delivered via cesarean section

¨ 0-24 hours – Chemical conjunctivitis¡ Usually after instillation of silver nitrate (no longer

used as not effective against TRIC)ú Usually resolves spontaneously by the second day

¨ 1-4 days – Neisseria gonorrhoeae ¡ Chemosis, copious discharge, possible rapid K

ulceration and perforation of the eye¡ Gram’s stain – gram-negative intracellular diplococci¡ Culture on Thayer-Martin and chocolate agar plates¡ Systemic treatment needs to be started immediately

ú Ceftriaxone IV or IM x one week

6/8/17

5

¨ 1 week – Chlamydia trachomatis ¡ The most common cause in the US¡ Mild swelling, redness, papillary reaction with mild

to moderate discharge (follicules don’t develop in infants until ~1 month of age)

¡ Mandated tx b/c of associated systemic involvement with possible pneumonia or GI infection

¡ Tx: oral erythromycin (50 mg/kg/day divided qid) for 10-14 days

¨ 2nd week - HSV

6/8/17

6

6/8/17

7

6/8/17

8

¨ Check pupils/motility/proptosis/optic nerve

¨ Systemic antibiotics/ENT consultation

6/8/17

9

6/8/17

10

¨ Ductions and Versions¨ Forced ductions¨ Oculocardiac reflex

¨ Get Imaging¡ High risk of radiation with CT Orbits

¨ Children are considerably more sensitive to radiation than adults

¨ Children have a longer life expectancy than adults, resulting in a larger window of opportunity for expressing radiation damage.

¨ Children may receive a higher radiation dose than necessary if CT settings are not adjusted for their smaller body size.

6/8/17

11

¨ The first study to assess directly the risk of cancer after CT scans in childhood found a clear dose-response relationship for both leukemia and brain tumors¡ risk increased with increasing cumulative radiation

dose. ¨ A cumulative dose between 50-60 milligray

(mGy - a unit of estimated absorbed dose of ionizing radiation) to the head = threefold increase in the risk of brain tumors¡ Comparison group had cumulative doses <5 mGy

¨ It is important to stress that the absolute cancer risks associated with CT scans are small.

¨ The lifetime risks of cancer due to CT scans, which have been estimated in the literature using projection models based on atomic bomb survivors, are about 1 case of cancer for every 1,000 people who are scanned, with a maximum incidence of about 1 case of cancer for every 500 people who are scanned.

6/8/17

12

¨ Will need sedation¨ Potential risks of sedation based on two types

of research:¡ Animal studies have shown that commonly used

anesthetics can kill brain cells, diminish learning and memory and cause behavior problems.

¡ Retrospective metanalysis showed a possible association between learning problems and multiple exposures to anesthesia early in life (not single exposures)

¨ If an operation requiring anesthesia and sedation can reasonably be delayed, it “should possibly be postponed because of the potential risk to the developing brain of infants, toddlers and preschool children.”

6/8/17

13

¨ Caffey, 1974¨ Infants 18

months or younger¡ No outward

signs of trauma¡ Seizures¡ Retinal

hemorrhages

¨ Cotton wool spots¡ Nerve fiber

layer ischemia¨ Disc edema¨ Retinal

detachment

6/8/17

14

¨ Intraretinal hemorrhages

¨ Preretinal heme¡ Boat-shaped

hemorrhages¨ Circumpapillary

concentration¨ Vitreous

hemorrhages

6/8/17

15

¨ Unilateral or asymmetric hemorrhage not uncommon in abuse cases

¨ Must consider accidental or disease factors

¨ Increased intrathoracic pressure¡ Purtscher’s retinopathy

¨ Acceleration/deceleration injury¨ Intracranial or subarachnoid

hemorrhages extend into retina¡ Terson’s syndrome retinopathy

¨ Infections¡ Meningitis

6/8/17

16

¨ Birth trauma¡ Heme present in 20 - 50% of

vaginally delivered neonates¨ Severe coagulopathies

¡ Hemophilia¡ von Willebrand’s disease¡ Vitamin K deficiency

¨ Blood dyscrasias¡ Leukemia¡ Anemia

¨ Malignant hypertension¨ Bacterial endocarditis¨ Idiopathic thrombocytopenia

6/8/17

17

¨ At risk for occlusion amblyopia or deprivation amblyopia

§ Rx: -steroids-patching-spectacles

_propranolol-Dose usually starts at 1mg/kg/day-monitor BP, heart rate

6/8/17

18

¨ Absent red reflex¨ White spot seen by parent¨ Strabismus¨ Nystagmus¨ Poor visual behavior

6/8/17

19

6/8/17

20

¨ Pre/perinatal history¨ Family history¨ Physical examination – often need B-scan¨ Parent exam

¨ TORCH titers¨ Galactosemia assays¨ Calcium¨ Chromosomes¨ Urine for reducing substances and amino acids

6/8/17

21

¨ PHPV=PFV¡ Small eye¡ Ciliary traction¡ vessels

¨ Nuclear¨ Lamellar¨ Anterior polar¨ Posterior (lenticonus)¨ Total

6/8/17

22

¨ Amblyogenic opacities¡ Greater than 3mm¡ Posterior location¡ Poor view

6/8/17

23

Earlier is bestBUT……

Copyright ©2004 BMJ Publishing Group Ltd.

Vishwanath, M et al. Br J Ophthalmol 2004;88:905-910

For all eyes (A) and for all eyes in patients undergoing bilateral lensectomy (B). Kaplan-Meier plots of glaucoma free survival after early and late lensectomy.

6/8/17

24

Earlier is bestBUT……

higher incidence of glaucoma if operated < 1 month of age

and post op apnea risk

So…..

¨ Operate age 4 to 6 weeks¨ Prior to 8 weeks

¨ If nystagmus is present, less likely to get 20/20 vision

6/8/17

25

¨ Retinoblastoma¨ Persistent Fetal Vasculature¨ Retinopathy of Prematurity¨ Cataract¨ Coats disease¨ Anatomic anomalies (colobomas, retinal folds)¨ Retinal detachment¨ Toxocariasis

6/8/17

26

6/8/17

27

¨ Congenital Glaucoma ¡ Usually cloudy corneas¡ Usually bigger eyes

6/8/17

28

¨ One of the most common childhood cancers¨ Frequent source of orbital metastasis¨ Usually originates in the adrenal gland or

sympathetic chain of mediastinum

6/8/17

29

¨ ~20% will show ocular involvement¨ Unilateral or bilateral proptosis¨ Eyelid ecchymosis¨ Strabismus, ptosis, Horner syndrome¨ Incisional Bx shows small round blue cells¨ UA for catecholamines is positive in 90-95%

¨ “Raccoon eyes” appearance associated with neuroblastoma and metastasis to the skull is probably related to obstruction of branches of the ophthalmic and facial vessels by tumor tissue in and around the orbits

6/8/17

30

¨ May leave you feeling BLUE

¨ Usually begins between 2-4¨ Usually hyperopic (far-sighted)

6/8/17

31

¨ Remember to perform cycloplegic retinoscopy¨ Don’t always jump to CT/MRI

¡ Risk of radiation and/or sedation

¨ Ophthalmia Neonatorum¨ Trauma – entrapment with orbital fx, NAT¨ Capillary hemangioma¨ Cataracts¨ Rb¨ Glaucoma¨ Neuroblastoma¨ Acute accommodative ET

6/8/17

32

6/8/17

1

Luis Izquierdo Jr. MD. PhD.Universidad Nacional Mayor de San Marcos

Implants Corneal Rings in Ectasia

Luis Izquierdo Jr. MD. PhD.Professor in Ophtalmology UNMSM

President of Peruvian Society of OphthalmologyOftalmosalud Instituto de Ojos

Lima - Peru

No Financial Interest


Intra Corneal Ring: Indications

✓ Primary corneal ectatic disorders

✓ Keratoconus with reduced BCVA and contact lens intolerance✓ Pellucid Marginal Degeneration

✓ Secondary corneal ectatic disorders

✓ (Post LASIK ectasia )✓ Irregular astigmatism after corneal graft✓ Irregular astigmatism after RK✓ Corneal irregularities post-trauma

6/8/17

2

ICR (Segments)

Intacs Ferrara Keraring

Diameter 7.0 and 6.0 6.0 and 5.0 6.0, 5.5 ,5.0

Arc length 100 up 220 90 up 210 90 up 210

Thickness 0,15 to 0,30 0,15 to 0,30 0,15 to 0,30

Base elliptic Flat Flat (Prismatic)


ICR: Circular RingsMyoring(Dioptex)

Keraring(Mediphacos)

Arc Length 360 (complete) 355 and now 340

Thickness 200 and 320 200 and 300

Insertion Pocket 300 m Tunnel channel

6/8/17

3

Gradual Thickness ICRSKeratoconus / Ectasias - ICRS

NEW (Keraring AS ®): Espesor gradual

v Improve UCVA, BCVA an Coma like aberration)


Intra Corneal Ring

v Outcomes ?

v Stop the Progression?

v Best patients for get better results

v Complications?

v How we can improve it ?

6/8/17

4


author Type study ICRS type Follow up UCVA gain/lost CDVA gain/lost

Ameerh et al 2012 retrospective Ferrara-manual 6 Mo 0.48 to 0.62

Ferrara et al 2012 retrospective Ferrara-manual 2 Y 81% gain > 1 line76,4% gain > 1 line

Torquetti et al2009

retrospective ferrara 5 Y 62% gain > 1 line11,4 % lost

74% gain >1 line11,4% lost

Pesando et al. retrospective ferrara 5 Y 93.8% gain>1line1.5% Lost

97,6% gain>1 line0% lost

Hamdi Et al Prospectiveinterventional

Ferrara- manual 6 Mo 64% gained >1 line27% not changed9% lost

Shabayek et al Prospectiveinerventional

Keraring-femto

from 0.06 to 0.3 70% eyes gain>1 line

Gharaibeh et al retrospecctive Keraring-manual

6 Mo 0.10 to 0.32 87.3% gain> 1 linenot change 7.3%Lost 5.5%

Vega -Estrada et al.

Retrospective, multicenter

Keraring, Intacs.manual/femto

6 Mo 37.8% lost (grade I)20.6% lost (grade II)

Vega-Estrada et al retrospective Keraring, Intacs.manual/femto

5 Y Stable during 5 Y follow up

Torquetti et al 2014

Retrospective manual 10 Y 70% gained two or more lines10% lost

66.7% gained 2 or more lines 20,7% lost

Khan et al retrospective Intacs SK. manual

1 Y

Alió et al Retrospectivemulticenter

KeraringManual-femto

5 Y 37.9% (grade I-II). 36% lost82% (grade III-IV). 10% lost


Update surgical ICR

v Best results grade II , III and IV

v Grade I (20/25 or better) 83% showed lossCDVA (p<0.01) *

v Patiets with greatest visual impairment are more benefited with the ICR

Vega Estrada A, Alio J. Outcome Analysis of Intracorneal Ring Segments for the Treatment of Keratoconus Based on Visual, Refractive, and Aberrometric Impairment

Am J Ophthalmol 2013;155:575–584

6/8/17

5


ICR (Femto vs Manual)v In theory FS laser produce more precise and stromal

disecction

v However visual and refractive outcomes are similar in both

v Predictability is still not possible due corneal biomechanics


“Effectiveness of intrastromal corneal ring implantation in the treatment of adult patients with keratoconus: systematic review”.

“Effectiveness of intrastromal corneal ring implantationin the treatment of adult patients with keratoconus: systematic review”.

v Electronic databases until February 20, 2017.

v Including primary research articles evaluating adultswith keratoconus.

v Two independent reviewers assessed themethodological quality, being classified as high risk, low or undefined.

v Measured variables were visual acuity, refraction, ring type, implant depth, channel shape and complications.

Smith J. Izquierdo jr L. Alvaro G. JA. Effectiveness of intrastromal corneal ring implantation in the treatment of adult patients with keratoconus: systematic review

6/8/17

6


“Effectiveness of intrastromal corneal ring implantation in thetreatment of adult patients with keratoconus: systematic review”.

• 346 scientificarticlesInitial search

• 15 selectedInclusioncriteria

• 6 Clinical Trial• 9 Retrospective and

Prospective Cohort

Type of study

• 550 patients and 663 eyes wereanalyzedFinal

data



Experimental studies: 3 of them with high

risk of bias, 1 with lowrisk and 2 undefined.

Observational Studies: 6 undefined risk of bias and 3 with low

risk of bias.

Methodological analysis


6/8/17

7



The improvement of UCVA pre and postoperative was 0.26 LogMAR ([SD]: 0.24)

and BCVA was 0.052 LogMAR ([SD]: 0.15 ) At 6 months follow up.

The sphere improved 2.21 D([SD]: 2.28), the cylinder improvedby 2.15 dp ([SD]: 1.1) and keratometry improved by 4.02 dp[(SD]: 2,3) within six months of the procedure.


Anterior perforation:

0,87%(4)

Extrusion: 2,19%(10)

Epithelialdefect:

6,79%(31)

White deposits: 7,89%(36)

Migration of the segment:

0,87%(4)

Descentration: 1,31%(6)

Neovascularization: 0,21(1)

6/8/17

8


Review Conclusion

v The studies analyzed show refractive and visual improvement of patients treated withICR

v However the evidence is limited due to thelack of studies with low methodological bias.


Phakic IOL in keratoconus

v Izquierdo et at. Artiflex Phakic Intraocular Lens Implantation After Corneal Collagen Cross-linking in Keratoconic Eyes.

v Navas, Graue E. et al. Implantable collamer lensesafter ICR for keratoconus.

v Qin et al. Clinical application of TICL implantationfor ametropia following DALK for keratoconus: A CONSORT-compliant article.

Izquierdo L Jr, Henriquez MA, McCarthy M. Artiflex Phakic Intraocular Lens Implantation After Corneal Collagen Cross-linking in Keratoconic Eyes. J Refract Surg. 2011 Jul;27(7):482-7

6/8/17

9


author Type study ICRS type Follow up Mean K reduction

Steep K reduction

Min Kreduction

Ameerh et al retrospective Ferrara-manual 6 Mo 3,71 D 4,59 D 2,54 D

Ferrara et al retrospective Ferrara-manual 2 Y 3,46 D (160)3,82 D (210)

Torquetti et al2009

retrospective ferrara 5 Y 3,98 D 4,7D 3,22D

Pesando et al. retrospective ferrara 5 Y 3,59 D

Henriquez, Izquierdo Jr.

Prospectiveinterventional

Ferrara- femtoCXL before ICRS

4.6 D 5.58 D 4.17D

Shabayek et al Prospectiveinerventional

Keraring-femto

HO aberration

60% significant decrease in HO

Coma and comalike

Grades II,III with RMS> 3.0

Gharaibeh et al retrospecctive Keraring-manual

6 Mo 4,56 D 5,75 D 3,37 D

Vega-Estrada et al.

Retrospective, multicenter

Keraring, Intacs.manual/femto

6 Mo From 1,55 D (grade I) to 5,61 D (grade plus)

Vega-Estrada et al

retrospective Keraring, Intacs.manual/femto

5 Y 3,24 D 3,08 D 3,26 D

Torquetti et al Retrospective Intacs -manual 10 Y 3,13 D 4,41 D 1,95 D

Khan et al retrospective Intacs SK. manual

1 Y 6,13 D 6,7 D 5,92 D

Alió et al Retrospectivemulticenter

KeraringManual-femto

5 Y 3.24 D 3.01 D 3.26 D


Treatment: Central vs Asymmetric keratoconus

v Central (nipple-type) keratoconus is better treated with long-arc ring segments

Ferrara G el al. Clin Exp Ophthalmol 2012; 40: 433–439.

v In asymmetrical cornea , asymmetrical implantation may provides better results

Shabayek MH,. Ophthalmology 2007;114:1643–1652

6/8/17

10

Circular (Myoring) Rings

• 22 eyes 1 year follow up• Average 8.13 D of flattening effect• Corneal asphericity decrease significantly.• Improving in the BCVA was better in central keratoconus than assimetryc

Izquierdo Jr,Henriquez , Rodriguez A. Circular intrastromal ring assisted by femtosecondlaser: outcomes and complications . ESCRS 2013

6/8/17

11

v 22 years old, male

v RE: UCVA: 20/200- : -4.00-6.00 X 50 = 20/50

355 ICR Keraring (tunnel channel)

6/8/17

12


1 month postop:UCVA 20/40= +0.50 -2.00 X 30= 20/30-

(improve 7 lines UCVA and 2 BCVA)

Preop:UCVA: 20/200- : -4.00-6.00 X 50 = 20/50

Circular Ring (355 femto tunnel aproach)

6/8/17

13


Progression with ICRS ??


KC Progression in ICRSv In progressive cases, regression effect of 3.36 D

between 6 months and 5 years postoperatively.

Alio JL, et al. Mid East Afr J of Ophthalmol, 2014 (21) 1:3-9

v ICRS in very advanced phase may require a subsequent surgery (DALK or PK) due to progression or bad visual Outcome.

6/8/17

14

KC Progression in ICRS?v Relation between Advanced keratoconus and very young

age

Ferrara G, Almeida F, et al. J Refract Surg. 2014;30(1):22-26.

v The initial flattening effect may regress with time (Post Lasik ectasia)

Browley JG, Randleman JB. Curr Opin Ophthalmol. 2010 Jul; 21(4): 255-8

v No published data with available preop information about progression in ICRS treated patients

v Gain 3 or more lines UCVA, no BCVA loss

v Average reduction 4.17 D. for the K

v Similar than ICRS alone

v So we may halt the progression (CXL) and not loose ICRS effect.

v Additive effect of CXL after ICRS **

Coskunseven E et al.Effect of treatment sequence in combined intrastromal corneal rings and corneal collagen crosslinking for keratoconus. J Cataract Refract Surg 2009; 35:2084–2091

6/8/17

15


Complications


Complication Ferrara et al

Shabayeket al

Kwitkoand Severo

Khanet al.

Piñero et al Miranda.Campos et al

Ertanet al

GharaibehEt al

Extrussion 0,56% 0% 19,6% 19,35%

8,3% manual10,5% femtosecond

13.8 % 2,32%

incision opacification

38%

Epithelial plugs 24,6%

Channel deposits

neovascularization

0,18% 6,45%

infectious keratitis 4,8 % 1,9% 3,22% 2.7% 4,65%

Segmentmigration

5 % 4.5%

Descentration 0% 3,9% 5%

Incomplete chanel 2,6%

Endothelialperforation

0,6%

6/8/17

16


Causes of ICRS explantations

v Extrusion (48.2% of explanted segments)

v Poor refractive outcome (37.9%),

v Keratitis (6.8%;),

Ferrer C, Alio JL, Montañes A, et al. J Cataract Refract Surg 2010; 36:970–977

Luis Izquierdo Jr. MD. PhD.Universidad Nacional Mayor de San MarcosLuis Izquierdo Jr. MD. PhD.Universidad Nacional Mayor de San Marcos

6/8/17

17



6/8/17

18



How can we improve itmigration and extrusion ??

6/8/17

19


New technique (Izquierdo ICR)


6/8/17

20

Double incision

6/8/17

21


Adaptative corneal Rings for improve

refractive outcomes

Patient: 27 yo, : -0.75 -3.25 x 50 = BCVA: 20/30-2

6/8/17

22


1 MONTHS POSTOP: RE: 20/100: +1.50 -1.75 X 10= 20/30

PreOp:RE: 20/100: -0.75 -3.25 X 10 = 20/30

6/8/17

23

Initial positionAfter mobilization

30 Days of Post op ICR mobilization: RE: UCVA 20/25 = - 0.50 X 90º =20/20

1 Month Postop : RE: 20/100: +1.50 -1.75 X 10= 20/30

Journal: American Journal of Ophthalmology Case ReportsTitle: Modulation of Intrastromal Corneal Ring according to post surgical outcome: Reportof two cases.


Adaptative ICR (new concept)

Femto Tunnel is enlarged thinking in the need for Ring moving after surgery in assimetriyc Cones with not good visual outcomes

6/8/17

24


Conclusion

v Progressive KC before ICRS implantation are at risk to progression after ICR.

v Circular Rings: have greater flattening effect than segments

v Asymmetrical keratoconus may need more enhacements.

v Double inverted incision avoid contact or overlap rings

v Modulation of ICR position can improve refractive outcome specially in asymmetrical KC.


6/8/17

25



6/8/17

26


Thanks Maria A. Henriquez MDAna Maria Roriguez MD

Alejandra Orozco MD

A Popurrí of Fallen Lenses

Huck Holz MD (Still Dr Mannis’ Resident)

UC Davis Eye Center

Financial DisclosureI have no financial interest in vitreous or any of the following material

What’s NOT working well • Iris sutured IOL fixation

Late dislocations 2%

Inflammation and CME

IFIS = image instability

Aggarwal glued IOL

Dislocation rate 3% - some very late

What’s Working Well ✊• If you need to remove an ACIOL - Use a CZ70BD

lenses with 8-0 Gore-tex scleral suturing

• For treatment of aphakia or replacing a lens you can bisect and remove through a small incision- Use an Akreos AO60 lens with 8-0 Gore-tex scleral suturing

• Dislocated IOL in the capsule bag - Lasso suture fixation through Hoffmann pocket

• Dislocated three piece that is not in the capsule bag- Yamane technique

Exception: I always use GoreTex sutured lenses in patients with atopy

Yamane Technique Akreos AO60 with 8-0 Gore-Tex

Manipulation hole fixation

CZ70BD 8-0 GORE-TEX Iris Repair Techniques

Iris trauma Thank you!

6/8/17

1

Neuro-OphthalmicEmergenciesUCDNapaSymposiumJune2nd 2017

KimberlyGokoffski,MD/PhDNeuro-OphthalmologyFellowUSCRoski EyeInstituteA MADDOX ROD

Top5chiefcomplaints1. “Ican’tsee”2. “Ican’tsee…sometimes”3. “Iseedouble”4. “Ihaveheadaches”5. “Ican’tseeandIhaveheadaches”

6/8/17

2

CC:“Ican’tsee”HPI:73y/oArmenianMrecentlys/popenheartsurgery.- Duringrecovery:Persistentheadacheonrighttemple.- POW3:diplopiaandblurryvisionOD® gastricbleed- POW4:totallossofvisionOD- POW5:startedtolosevisionOS® referraltoophthalmology

ROS:Templetendertopalpation.Jawgoesnumbwithchewing.

OD OS

VAcc NLP 20/70

Pupils 6® 4Amaurotic pupil

6® 4

6/8/17

3

ESR:99(age/2,+5iffemale)CRP:53.4(<5)Plts:325

Whyorderlabs?

RIGHTTEMPORALARTERYBIOPSY:- Granulomatousnecrotizingarteritisconsistentwithgiantcellarteritis

Shouldwebiopsy?

Managementforpatientswithvisionloss:80mgPOinclinicIVsolumedrol 750mg(usually1g)x3days®POprednisone80mg

q1mPlts/ESR/CRP/DFE® taper10mgq1mifstable/noCWS

CC:“Ican’tsee…outofmyothereye”After3daysofIVsolumedrol,nowon80mgprednisone……patientlossvisionOSexceptforsmallsliver

1)IVwasinsufficient?2)Thrombosisinnarrowedlumen

Roleforheparin/warfarin?WegaveIVsolumedrol 750mgx1thenprednisone80mg

OD OS

VAcc NLP CF 1’

6/8/17

4

GiantCellArteritis(5%)• Suddenonsetpainful visionloss,TVOs• OcclusionofSPCA® chalkywhitepallidedema,CWS® excavation• Female,70s,Caucasian>>>Blacks,rarelyAsians/Latinos• BX(2.5cmsegment):giantcells,patchylossoflaminaelastica• 97%specificityifESR>47,CRP>2.45• CNS:7:1vertebrobasilar infarct;cardiacinfarctions

200um 20um

PositivebiopsyVision loss/CWS

PositivebiopsyNovisionloss/CWS

Negativebiopsy

IVsolumedrol 1g/dx3d®PO prednisone80mgqday®Taperqmonth

PO prednisone80mgqday®Taperqmonth

PO prednisone80mgqdayuntilbiopsyresults®Taperover1week

WhendoIbiopsy?Visionloss,>60yrsold,compellingstory/ROS,elevatedCRP,hx ofPMRWhendon’tIbiopsy?StorynotcompellingandnormalESR/CRP,<50yrsold

Non-arteritic ArteriticFrequency 95% 5%

Average age 60yrs 70yrs

Gender M=F F >>M

Pain Rare Common (claudication)

VA >20/200 <20/200

TVO Rare Common

Cup:Disc Discatrisk Normalcup

Pallor/excavation Pallor withoutexcavation Chalky pallorwithexcavation

CWS Rare Common

NaturalProgression Max improvementVA3m,noimprovementinVF

NoImprovement

6/8/17

5

CC:“Ican’tsee…sometimes”Transientvisualobscurations

Secs:papilledema,drusen,dryeye1-10Minutes:amaurosis

ASA81mgECHOCartoid ultrasound48hrHolterCTAorMRA

20Minutes:Migraineaura

CC:“Iseedouble”HPI:76y/oMwithHTN,DMIIpresentswithsuddenonsetdiplopia.Thenextdayhisdiplopiaresolved…

6/8/17

6

Microvascular 2235

Aneurysm 1016

Trauma 1016

Tumor 58

Congenital 11

Other 1524

Total 63100%TAkagi etal.Jpn JOphthalmol 52:32-35,2008

CauseTotal%

CausesofisolatedCranialNerve3palsies

6/8/17

7

CourtesyofCarlosTorres,MD

Whentoimage?

EmergentCTAorMRI/AinanyadultwithoutischemicriskfactorsorINCOMPLETEinvolvementofEOMSinCNIIIterritory

Any pupillaryinvolvementorifpupilisnotreliable

Whenyoumightnot imageandwatchcloselyoveraweek:

– Age50to70– DM,HTN,Chol– Suddenonset– Complete– normalpupil

NEEDALL

6/8/17

8

CC:“Ihaveheadaches”HPI:65y/oMradiologistdevelopedsuddenonsetptosisandblurryvisionOD.Wasdoingcross-fityesterday.

6/8/17

9

Anisocoria

BIGpupilisbad SMALLpupilisbad

Worseinlightordark?

Light Dark

Physiologic

SamePARASYMPATHETIC SYMPATHETIC

Pre:CN3Pharm Post:Adie

NOco

nstrictio

nc

1%pilocarpine

YESconstrictio

nc

1%pilo,N

OT0.1%

YESconstrictio

nc

0.1%

pilocarpine

Central

PharmHorners

Pre Post

Dilatestohydroxyamph

NotoCocaineYestoApraclonidine

Nototropicamide

Sympatheticpathway

6/8/17

10

CC:“Ihaveheadaches”Reassuringsigns- Normalvisualfield- (+)Familyhistory- positiveandnegativescintillationsthatspreadacrossthevisualfield,~20mins

Worrisomesigns- Abruptonset,laterinlife- Progressiveworsening- Homonymousscotoma- Localizingsignsonneuroexam- Worsewithvalsalva/straining/supine- UnderlyingHIV,pregnancyorrecentlypost-partum

6/8/17

11

CC:“IhaveheadachesandIseedouble”HPI:16y/ohealthy,non-obeseFwithdoublevisionandheadachex3weeks- Posturalheadache(worsewhensupine)- UsedMinocycline50mgBID3monthsago

ROS:Binocularhorizontaldiplopia,pulsatiletinnitus,transientvisualobscurations(30secs).

InitialLP30,repeatLP50

6/8/17

12

OD OS

VAcc 20/25 20/60

Pupils 5® 4 No RAPD 5® 4NoRAPDColor 8/8 8/8

25ET 25ET 25ET

0 0 0

-1 0

0 0 0

0 0 0

0 -1

0 0 0

OD OS

6/8/17

13

StartedonDiamox500mgBIDx1week® 1000mgBID…

FT30 FT33326 159

60 60

1monthlater:improvedheadaches,pulsatiletinnitus,diplopiabut…

- hervisualfieldsareworsening- herRNFLisgettingthickerwithconcurrentGCCthinning

FT32 FT35473 364

44 54

…ONSF

6/8/17

14

OD OS

1weekafteropticnervesheathfenestration

FT35 FT36

36 43

318 374

3monthslater:- Improvedvisualfields- StabilizedRNFL/GCC- ResolvedbilateralCN6palsies- Improvedheadaches,taperingdiamox

6/8/17

15

Malignant/fulminantPseudotumor Cerebri1) ElevatedICP(>25cmH2Oadults,>28cmH2Ochildren)2)Nohydrocephalus3)NomassorCVTonMRI® needMRV4)NormalCSF® needLP5)CN6+/- CN7palsy(canbeb/l)

Incidenceoffulminant2.3-2.9%Risk:M,Black,>40yrs,anemia

Fulminant idiopathicintracranial hypertension

Madhav Thambisetty, MD, PhD; Patrick J. Lavin, MD; Nancy J. Newman, MD; and Valerie Biousse, MD

Abstract—Objective: To describe the incidence and characteristics of acute and rapidly progressive visual loss in idio-pathic intracranial hypertension (IIH). Methods: We reviewed the medical records of all patients with IIH seen at twoinstitutions. “Fulminant IIH” was defined as the acute onset of symptoms and signs of intracranial hypertension (lessthan 4 weeks between onset of initial symptoms and severe visual loss), rapid worsening of visual loss over a few days, andnormal brain MRI and MR venography (or CT venogram). Results: Sixteen cases with “fulminant IIH” were included (16women, mean age 23.8 years [range 14 to 39 years]). All were obese. One patient had iron-deficiency anemia, four hadsystemic hypertension, and none had known sleep apnea syndrome. Acute or subacute headache, nausea and vomiting,and visual loss were present in all patients. The first lumbar puncture performed for the diagnosis showed a mean CSFopening pressure of 54.1 cm H2O (range 29 to 60 cm H2O). In addition to the initial lumbar puncture, medical treatmentincluded acetazolamide (1 to 2 g/day) in all patients, and IV methylprednisolone in four patients. Repeat lumbar punctureswere performed in 11 of the 16 patients. Surgical treatment (optic nerve sheath fenestration in five cases, lumboperitonealCSF shunting procedure in nine cases, and ventriculoperitoneal shunting procedure in two cases) was performed becauseof ongoing visual loss in all cases. The median delay between evaluation in neuro-ophthalmology and surgery was 3 days(range a few hours to 37 days). All patients reported dramatic improvement of headaches and vomiting following surgery.Visual function improved in 14 cases, although 8 patients (50%) remained legally blind. Visual fields remained severelyaltered in all cases. Conclusion: Severe and rapidly progressive visual loss suggests “fulminant idiopathic intracranialhypertension” and should prompt aggressive management. Urgent surgery may be required in these patients, andtemporizing measures such as repeat lumbar punctures, lumbar drainage, and IV steroids considered.NEUROLOGY 2007;68:229–232

Idiopathic intracranial hypertension (IIH) is in-creased intracranial pressure (ICP) with normal CSFcontents, in the absence of an intracranial mass, hy-drocephalus, or other identifiable cause.1,2 The majormorbidity of IIH is progressive, insidious visual lossfrom chronic papilledema.1,3-9 Although progressivevisual loss is common in poorly managed or noncom-pliant patients, acute presentation with rapidly pro-gressive visual loss is rare and usually points tosecondary causes of intracranial hypertension suchas a meningeal process or venous sinus thrombo-sis.1,3,6,7 Rapid recognition of acute IIH, also de-scribed as “fulminant” or “malignant” IIH, isimportant, as it may prompt emergent surgicaltreatment.1,8-16 We present a series of 16 patientswith “fulminant IIH” who developed early, severe,

and rapidly worsening visual loss and evaluate theincidence of this disorder at two institutions.

Methods. The medical records of all cases with IIH seen in theNeuro-Ophthalmology Clinics at Emory University between 1996and 2006 and Vanderbilt University between 2003 and 2006 werereviewed. Only cases with definite IIH according to the recentlyupdated modified Dandy criteria2 were selected, including 1)symptoms and signs of generalized intracranial hypertension suchas headache, papilledema, sixth nerve palsies; 2) documented ele-vated ICP; 3) normal CSF composition; 4) no evidence of hydro-cephalus, mass, or structural or vascular lesion on brain MRI;specifically, no evidence of cerebral venous thrombosis. All IIHcases were reviewed in detail to identify patients with “fulminantIIH,” defined as follows: 1) acute onset of symptoms and signs ofintracranial hypertension; 2) less than 4 weeks between onsetof initial symptoms and severe visual loss; 3) rapid worsening ofvisual loss over a few days. Only patients who underwent brainMRI and MR venography (MRV) or CT venogram to rule outcerebral venous thrombosis were included. The study was ap-proved by the Emory and Vanderbilt Institutional Review Boards.Patients’ characteristics were recorded, including age, gender,obesity (body mass index criteria), associated factors such as med-ications, systemic hypertension, anemia, and sleep apnea. Pre-senting features, visual acuity and visual fields, presence oftransient visual obscurations, tinnitus and diplopia, time betweenthe onset of symptoms and worst visual loss, time between the

Additional material related to this article can be found on the NeurologyWeb site. Go to www.neurology.org and scroll down the Table of Con-tents for the January 16 issue to find the title link for this article.

From the Departments of Neurology (M.T., N.J.N., V.B.), Ophthalmology (N.J.N., V.B.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA;Departments of Neurology (P.J.L.) and Ophthalmology (P.J.L.), Vanderbilt University, Nashville TN; and MRC Centre for Neurodegeneration Research(M.T.), Institute of Psychiatry, King’s College London, UK.Supported in part by a departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, NY, and by core grantP30-EY06360 (Department of Ophthalmology) from NIH, Bethesda, MD. Dr. Newman is a recipient of a Research to Prevent Blindness Lew R. WassermanMerit Award.Disclosure: The authors report no conflicts of interest.Received June 13, 2006. Accepted in final form October 10, 2006.Address correspondence and reprint requests to Dr. V. Biousse, Neuro-ophthalmology Unit, Emory Eye Center, 1365-B Clifton Rd. NE, Atlanta, GA 30322;e-mail: [email protected]

Copyright © 2007 by AAN Enterprises, Inc. 229

MinocylineTetracylineDoxycyclineRetinoicacidSteroidwithdrawalBeta-HCGwithdrawalGrowthhormone

TruePapilledema

Freisen GradingHyperemiaofRNFLObscurationofmarginObscurationofvesselsObliterationofcup(latesign)

NotpartofFreisenAbsentSVP(ICP>20cmH2Obut20%don’thaveSVP)

Peripapillary hemorrhages® ACTIVEVenouscongestion® ACTIVECWSPatton’sLinesChorioretinal folds

ChronicGliosisExudatesShuntvessels® ACTIVE

6/8/17

16

Refractivescotomas

Badthingswillgetworse!

Pseudo-Papilledema

40TH ANNUAL UC DAVIS EYE CENTER SYMPOSIUM

OPHTHALMOLOGY THROUGH

THE GENERATIONS

X34

It’s hard not to think about the time that has past when thinking anniversary

34 years since finishing my residency is a long time

32 years in practice is ½ of my life (now 64)

I’m thinking about those who are gone & thankful that most of us are still here and thriving

I have certainly worked hard, but also feel i’ve been so lucky….

Lucky to have matched at UC Davis

Lucky to have had enthusiastic & collaborative co-residents I still call friends today

Lucky to have had great faculty & mentors who helped steer me

Then I got really lucky - joining one of my friends & mentors in practice in 1985

….time has passed :)

I thought a walk down the memory lane of Macular Hole Surgery would be fun

Touch on how the care is changing today

The first ophthalmology texts all the residents bought had this brief comment regarding macular holes

During the mid 80’s interest in macular holes was “peaking’. Dr Gass at Bascom Palmer established a clinical classification of macular holes based on slit lamp examination (No OCT)

AJO APRIL, 1988

And a randomized trial of vitrectomy to prevent macular hole formation was underway

Remember -> OCT was developed in 1991 and the first time a patient was imaged with OCT outside of the laboratory took place at Tufts NEEC in 1994

The first commercially available device was in 1996

CollaborationNeil presented our first few cases of macular hole surgery at the Squaw meeting in Feb ’89 -> 7 years before OCT was available

During Oct ’89 we presented our first 20 cases of macular hole surgery at the AAO

MACULAR HOLE SURGERY

Vitrectomy

Peel vitreous cortex (usually attached)

Peel membranes (ERM if present and ILM)

Gas-Fluid exchange typically SF6

Face Down for 5-7 days

In 1989 surgery on macular holes immediately became a controversial subject

Well know SF retinal specialist (now having more fun as a successful NY photographer) sent us a challenging letter

He suggested we were not operating on macular holes

I felt that your three middle cases (the ones that did well) were not macular holes

…your last case on which you didn’t have a follow-up was definitely a macular hole, and although I don’t know …..I would bet that….case has not done well

Tell me exactly what it is you do when you do a vitrectomy on these cases…..

Had the audacity to add:

OCT 1989

Dr S Fine reviewed our paper and left the audience with the nursery rhyme: Humpty Dumpty sat on the wall, Humpty Dumpty had a great fall

We submitted an abstract describing 10 consecutive eyes, but presented data on our first 20. Our results were only so so … The AAO sent our paper back to us and said don’t send it

back - even with edits

In preparation for this talk I reached out to the AAO and Dr Fine for historical documentation

Unfortunately, our old database no longer has any record of you and Dr Kelly submitting a paper circa 1989. The database records have been purged since it was an old submission. I am sorry we no longer have a record.

From: Fine, Stuart [email protected]: Re: AAO talk in New Orleans 1989

Date: April 10, 2017 at 7:32 AMTo: Robert Wendel [email protected]

Idon’tthinkIhavethatdiscussion,butIwilllook.IfthatpaperwaspublishedinOphthalmology,then

mydiscussionshouldhavebeenpublishedaswell.Funny,Ihavenorecollec>onofdiscussingthatpaper

andIsurelydon'trecallanyHumptyDumptyopening.IdorecalldiscussingapaperbyBertGlaserin

whichheclaimedsuperiorresultsinholeclosureusingTGFbeta.ThatdiscussionwasattheAAO

mee>nginChicago.Ialsorecallwri>nganeditorialaboutmacularholesurgerywithArgyeHillis,PhD,a

seniorbiosta>s>cian,asmyco-author.Inanycase,I'lllookfortheHumptyDumptywhenIreturnto

Coloradoinmid-Junewhichiswheremanyofmyfilesremain.

Cheers,

Stuart

From:RobWendelMD<[email protected]>

Date:Sunday,April9,20179:10PMTo:StuartFine<[email protected]>

Subject:Re:AAOtalkinNewOrleans1989

YoureviewedthepaperthatDrKellyandIgavereMacularHolesinNewOrleansin1989.Youstarted

yourreviewwith“humptydumpty”…..wouldbefuntohavetheactualtext.

Nowre>nalsurgeonsaretalkingaboutallsortsofwaystorepairlargeandlongstandingmacularholes

withpoorvisualpoten>al……justbecausetheycan“closethehole”andsomesurgeonsneedsomething

to“talkabout”atmee>ngs.(inmyopinion)

Hopealliswell!

best,

Rob Wendel [email protected] iPhone

www.retinalmd.com

OnApr9,2017,at8:52AM,Fine,Stuart<[email protected]>wrote:

HiRob,

Goodtohearfromyou.

IknowthepaperbutIdon'trecallthetalk.DidIdiscussit?Isthatwhatyou'rereferringto?Ifso,let

meknowandI'lllook.I'vebeenpurging/declujeringoverthelasttwoyears.It'spainfultothrowout

slides,lectures,papers,journals,etc.butIsimplyranoutofroom.Inanycase,letmeknowexactly

Dear Dr S Fine

…You started your review with “Humpty Dumpty” …would be fun to have the actual text

Funny, I have no recollection of discussing that paper and I surely don’t recall any Humpty Dumpty opening

It took us until May 1991 (1 ½ yrs) to get our first publication regarding Macular Hole Surgery

The editorial made the cover, but our article did not!

SEPT 1991

We did make the cover of the Spanish language addition

ARCHIVES MAY 1991

Pts with macular hole usually are in the seventh decade of life, an age at which elective surgery should be performed only when there is clear likelihood of substantial benefit

…it is not clear that the benefits of this operation outweigh the risks.

EDITORIAL BY DR S FINE

ARCHIVES MAY 1991Conclusion of editorial:

The following year one of our patients who had undergone bilateral Macular Hole Surgery died. The family called us and arranged to have her eyes donated for pathological examination.

Return of the anxiety -> were we operating of full thickness macular holes or not? (as suggested by one of our colleagues) (Still no OCT exams)

1992 PRESENTED AT THE PRE AAO - RETINA SUBSPECIALTY DAY 1992 PUBLISHED IN RETINA 1992

Clinicopathologic examination did disclose anatomical repair of the full-thickness macular holes…..

PRESENTED AAO 1992 & PUBLISHED 1993

170 consecutive eye with macular hole

We showed that small holes were easier to close and had better post-op vision

Recall - these macular hole patients were just “waiting in the wings” & only referred as the word got out that we were trying to repair these eyes with surgery

OPHTHALMOLOGY PUBLICATION NOV 1993

TOM WEINGEIST MD PHD…macular holes occur most commonly in women in their seventh decade…..I believe treatment of an elderly person…..should not be done unless results from a randomized clinical trial demonstrate its value.

PS I Googled Seventh Decade -> as I thought it applies to a bunch of us

AAO PRESENTATION NOV 1993 JAN 1997

In 1997 results from the Multi-centered Randomized Clinical Trial of macular hole surgery were published

.…some benefit of vitrectomy surgery …. exists, despite a notable incident of adverse events

JAN 1997Editorial that accompanied the results of the randomized trial concluded:

It is not yet possible to counsel patients adequately about the results of vitrectomy for macular holes

JAN 1998

JULY 2001

The AAO has published Technology Assessments for 51 ophthalmic diseases since 1994 - macular hole was the 5th subject covered

HTTPS://WWW.AAO.ORG/GUIDELINES-BROWSE?FILTER=OPHTHALMICTECHNOLOGYASSESSMENT

JULY 2007

SO WHAT’S NEW?

Staining the ILM to facilitate the visualization & removal = easier and safer

We recognized the need to remove the ILM

“THE FORCE”

FDA approval 2012 for symptomatic VMA

Cleaves fibronectin and laminin

Pre and Post op Jetrea

2 weeks post injection the vitreous has detached and the hole closed

Vision improved from 20/50 to 20/40 two weeks post treatment

Good result - in some patients

PRE JETREA

PVD

POST JETREA

Scary complications post injection

Loss of IS/OS junction (usually transient)

Acute Retinal Dysfunction post Jetrea injection - acute visual loss, VF constriction, pupillary abnormalities, attenuated retinal arteries, reduced ERG - possibly due to intra-retinal laminin cleavage

Limits our usage

PRE JETREA

1 DAY POST JETREA

OOPSMost controversial is “face down”. We still routinely recommend “eye down’ for 5-7 days

So what has changed?

Self promotional web site

Some surgeons don’t require prone positioning

I guess I am old fashion

Still recommending “eye down”

We typically use SF6 which lasts 2 weeks. Most of these non-supine patients are likely treated with C3F8 which lasts 2 months

The patients still have to stay off their backs!

NO KIDDING!

9-10–2014 PRE-OPPatient with few week hx of visual loss OD

Advised to have macular hole surgery by one of my partners

Did a Google search - found the website advertising “no facedown”

Had surgery not once, but twice with no facedown! by a Bay Area surgeon

2-2016Returned to see me - (also found my name on the internet as a doctor who knew something about macular holes) 16 months later

I tried to talk him out of more surgery, but he wanted to try face down at least once

Had surgery one more time - facedown for 2 weeks with long-acting gas

Hole closed, but he is aware of central visual loss

Another approach is to inject intra-vitreal gas in the office as opposed to going to surgery

Still need to be face down

66.7% anatomic success (compared to > 92% with surgery)

AT MEETINGS TODAY THERE IS MUCH CHATTER ABOUT HOW TO MANAGE

LARGE PRIMARY & MYOPIC MACULAR HOLES - MUCH LESS COMMON

PROBLEMS (BUT SOMETHING TO TALK ABOUT)

Inverted Flap of ILM to cover the macular hole

WHAT ABOUT MANAGEMENT OF PRIMARY SURGICAL FAILURE OR RECURRENT MACULAR HOLES?

DH 3-15-16 PRE-OP

DH PO #1 FAILED 5-19-16

DH PO #2 9-27-16 SILICONE OIL - OPEN HOLE

DH PO #3 S/P MAC RD CREATED 2-14-2017

THANX FOR LISTENING

6/8/17

1

UCD Eye CenterNapa Symposium

2017

Sam Abbassi, M.D., M.S.PGY-4Susanna S. Park, MD PhD

A Case of Unexplained Vision

Loss

HPI:50yearoldwomanhereforsecondopinion- 1yearhistoryofprogressivevisionlossOU,(especiallyatnight)

PMH:CongenitalRubellawithhearingloss

POH:Unremarkable

FHx:-Parentwhodiedoflungcancerfromsmoking-Noretinaldegenerationorblindness

History

6/8/17

2

SocialHx:Non-contributory

Medications:None

ROS:Unremarkable:

Nohistoryofphotopsia,oculartrauma,travel,toxicmedicationuse,weightlossorcancer.

History

OD OS

VA sc 20/70+2 20/25+1

VA ph 20/25

IOP 19 18

Pupils 4 -> 3, no RAPD 4 -> 3, no RAPD

Examination

6/8/17

3

OD OS

L/L MGD, telangiectasia

MGD, telangiectasia

C/S White and quiet White and quiet

K Clear Clear

AC Deep/quiet Deep/quiet

Iris Pharmacologically dilated

Pharmacologically dilated

Vitreous Normal, no cells Normal, no cells

Examination

ExaminationOD

6/8/17

4

ExaminationOS

ODOCT Macula

T1

MRA

6/8/17

5

OSOCTMacula

T1

MRA

OD OS

FundusAutofluorescence

T1

MRA

6/8/17

6

ODFluorescein Angiography

T1

MRA

1 2

3 4

50yearoldwomanwithcongenitalrubellainfectionwhopresentswitharecentoneyearhistoryofprogressivevisionloss,andexaminationaswellasretinalimagingconsistentwithretinalatrophyOU

Summary

Whatisourdifferentialdiagnosis?

Whatshouldwedonext?

6/8/17

7

50yearoldwomanwithcongenitalrubellainfectionwhopresentswitharecentoneyearhistoryofprogressivevisionlossandexaminationaswellasretinalimagingconsistentwithretinalatrophyOU

Summary

Whatisourdifferentialdiagnosis?-DDx:RetinaatrophyduerubellaretinopathySyphilisHereditaryRetinalDegeneration

e.g.Usher’ssyndromeChoroideremiaGyrateAtrophy

Whatshouldwedonext?

mfERGOD OS

6/8/17

8

ffERG

T1

MRA

1 2

3 4

OD OS

ffERG

T1

MRA

1 2

3 4

OD OS

6/8/17

9

LaboratoryEvaluation

T1

MRA

1 2

3 4

PerReferringEyeMD Records,negativefor:

-Syphillis-Bartonella H.-Lyme-ToxoplasmaG.-HLA-B27

GeneticTestingnotapprovedbyInsuranceRecommendSerumOrnithine

Diagnosis:

Chorioretinal degenerationfromcongenitalrubellavs.Choroideremia,carrier-state

Summary

6/8/17

10

THANKYOU

basics to utilizing oct in glaucoma - health.ucdavis.edu · abnormal sap vf on follow up @ earliest...

Documents