Retinal vascular diseaxse - Amazon S3 · –onclusion: Asymptomatic retinal cholesterol emboli is...
Transcript of Retinal vascular diseaxse - Amazon S3 · –onclusion: Asymptomatic retinal cholesterol emboli is...
3/15/2016
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Retinal Vascular Disorders
Mohammad Rafieetary, OD, FAAO
Bring it to the basics!
• In the Era of Nanotechnology getting hung-up
by minutiae and missing the boat is easy….
20/20 vision smokes two
packs/day
Consult to see “eye
injection will help!”
Clinical Challenges (Dx a/o Tx)
• Rushing to Dx– Medical Errors
– Misdiagnosis
– Mismanagement
• Limitation of Testing
• Confusing sign and symptoms
• Limitation of Therapy
• Unresponsive to conventional Therapy
Significance of Retinal
Vascular Disease in
Presence of Comorbid
Conditions often the
Underlying Etiology!
Vascular anatomy
Vascular anatomy
Don’t forget the choroid!
Choroid
• Challenges in
clinical
examination
• Complexity of
the structure
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Patient with loss of vision
Fairly normal retina
End result carotid artery disease
Intricacy of retinal vasculature
• Source of the
image
Mechanism of Retinal Vascular
Disorders
• Conditions that physically alter blood vessels
(Retina a/o choroid)
– Locally or Generalized
• Conditions that alter blood chemistry
• Conditions that do both…
Significance and Relationship Between
Systemic Disease Retinal Vessels And
Retinal Vascular/Background Findings
• Public misconception that all “eye problems
can be fixed by a better pair of glasses”
• (+)Understanding of the significance by the
PCPs
• (+)Attention by the eye-care providers
• What is our role as ODs?
The most common
causes of death in
the United States
All causes 1,989,841 All causes 2,403,351
1Diseases of heart
761,085Diseases of heart
710,760
2
Malignant neoplasms [Cancer of All Types]
416,509
Malignant neoplasms [Cancer of All Types]
553,091
3Cerebrovascular diseases
170,225Cerebrovascular diseases
167,661
4Unintentional injuries
105,718Chronic lower respiratory diseases
122,009
5
Chronic obstructive pulmonary diseases
56,050Unintentional injuries
97,900
6Pneumonia and influenza
54,619Diabetes mellitus
69,301
7Diabetes mellitus
34,851Influenza and pneumonia
65,313
1980 2000
(August 2011)—CDC Data
indicates that the deaths from
CLRD has surpassed CVA as
3rd leading cause of the
death in the US. CLRD=
asthma, chronic bronchitis,
emphysema, others
(CLRD)
Am Lung Assoc.
2009, 21% US
Adults smoke
Is this a normal macula?
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Did the patient know they have a problem?
Long-term outcome?
DX?
Patient was asymptomatic!
Is lack of symptom justify no
TX?
Challenges
• Co-morbidities
How often do we see this? (or ignore it)
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We can easily miss or ignore these!
Should we have a conversation with our
patient beyond the eye finding?
Reasons to miss subtle signs!
How many people that worry about
this have any understanding of
Retinal vascular disease? (lack of PSAs)
But all fear blindness!
Symptoms May Show Overnight! but
these signs didn’t develop overnight!
Association of Retinal Findings and
Systemic Disease (Morbidity, Mortality)
• Wong et al: Prospective cohort study of retinal vessel diameters and risk of
hypertension. (Beaver Dam eye study)
– Conclusions: Narrowed retinal arterioles are associated with long term risk of
hypertension
• Bruno et al: Vascular Outcome in Men With Asymptomatic Retinal
Cholesterol Emboli (Annals of Internal Medicine Feb 1995, V22:4) (VA
Setting)
– Conclusion: Asymptomatic retinal cholesterol emboli is an important risk factor for CVA
independent of commonly recognized vascular risk factors
• Klein et al: Retinal Emboli and Stroke (Beaver Dam Study)
– Higher incidence of CVA in patients with retinal cholesterol emboli
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Hypertensive Retinopathy and Risk of Stroke Yi-Ting Ong, et
al.Hypertension. 2013;62:706-711
“Retinal imaging may someday help assess if you’re more likely to
develop a stroke — the nation’s No. 4 killer and a leading cause of
disability.”
Retinal Hemorrhage
54 Y/O WM
Healthy, vague visual
disturbance.
Referred as Retinal
Hemorrhages, CRVO!
CRVO? Typical Retinal Hemorrhage?
Hemorrhage Characteristics
Roth’s SpotsWhite or pale centers are
composed of coagulated fibrin,
usually caused by immune
complex mediated vasculitis .
May be seen in leukemia,
diabetes, subacute bacterial
endocarditis, pernicious anemia,
ischemic events, and HIV
retinopathy.
Patient dxed with acute
myelogenous leukemia
(AML) and died within a
year.
63 Y/O AfAM F Diabetic
Last seen 2010 recently referred back by
PCP overdue fundus exam
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Referred for Diabetic Retinal Eval
Case of unexpected findings and patient's
disappointment!
• 55 Y/O BF
• DM x20yrs
• Referred as emergency “macular on” RD recent onset vision loss (NPDR OS) Patient arrives end of the day!!!
• OD:HM OS:20/50
• “Wants her vision fixed today need to get back to work!”
-Status of
Fellow Eye
-Coexisting
Disease
-Future of this area
-Mechanism of sight
loss
-What can be done
about it?
Macula
On vs.
OFF
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Unmet Expectations Spectrum of DR (#Ways to failure) 31 Y/O BF Referred by OD for diabetic retinal exam … DM X 20 yrs A1C 8—daily
average 180-230 Blurred vision on going…
OD 20/30 OS 20/100 (wears spectacles)
7/24/2013 IVA OU
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8/14/2013 IVA OU Sch SX OS
RBA including high% of post-op VA loss
OD 20/20---- OS PH 20/400
Sep 11, 2013 – IVA OD Sch SX (Discussed RBA including further vision loss )
-Progression of RD
-Regression of SRH and NV
-Post-op VA loss as expected and
discussed with patient
-Not all cases obvious a/o symptomatic but will not
remain that way
-Not all cases have obvious underlying etiology
-Variation in presentation
Not all cases due to an underlying
systemic dieases
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Not all cases present with similar
severity but this had an early stage in the past !
Can’t always find why?
Canary in the coalmine
59 Y/O M Excess Factor XII
When OS involved MRV showed blockage in left transverese and sigmoid
sinuses
Further Anti-coagulation Therapy
Not all cases due to one group of
underlying disease (Systemic Lupus)
Sarcoidosis
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Had missed follow-up care. Returns with New-Onset Symptoms (small floater OS)
She is also on plaquenil
Surprising Findings (Retinal Vascular Disease)
60 Y/O WM, Difficulty near vision lately, has stopped his BP meds
Referred for Hemorrhage and Exudates OS
VAs OD: 20/25, OS: 20/30 (1+ NS)
Surprising Findings (Retinal Vascular Disease)
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Surprising Findings (Retinal Vascular Disease)
Following a long debate, patient agreed to revisit PCP, and to eye tx!
Challenges 8/20/2013 8/23/2013
81 Y/O WM
4/200, 20/50
Photo sent by referring doc
Challenges
Photo sent by referring doc
Challenges
Challenges IOP OD 25, OS 14 Now OD NLP, OS doing well post cataract sx
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VOD Unpredictable changes
Case of rapid vascular alteration
July 2010
IVA OS and No Show for follow-up
Case of rapid vascular alteration March 2011 OD VA loss X 1month
Case of rapid
vascular
alteration
July 2010 March 2011
Case of
rapid
vascular
alteration
VOD predictable changes (noncompliant patient)
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Predictable changes
over time
(complaint patient)
PDR Progression
April 2011
PDR Progression
April 2012 by June 2012 Vas 20/40 OD/OS Ongoing Treatment and much improved.
PDR Progression
Missed Jul 2012 appt shows Late sep HM OU (Now on kidney dialysis)
PDR Progression (following first IVA)
PDR Progression (following second IVA)
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PDR Progression (OD following PPV)
1 Day Post-op 20/200
PDR Progression (OD following PPV)
3 wks s/p VA 20/100
New View of Fundus Sch for PPV
PDR Progression (OS following PPV)
OS 1 Month 2 Months S/P PPV
Eventually
20/30
20/400
I have no problems with my LE don’t
want treatment!
I have been blinded by treatment!(should not have had it, will tell everyone laser blinds you!!!)
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Diabetic Retinopathy
2.5 years is it really getting better?
Focal for ME
More Pitfalls
Diabetes
• A group of metabolic diseases associated with
high serum glucose level, either due to body’s
inability to produce sufficient insulin, or cells do
not respond to the produced insulin
• Incidence/Epidemiology (www.diabetes.org)
– >25 million children and adults in US (8.3% of
the population)
• Type 2: primarily lifestyle factors
• Type 1: Multifactorial
Diabetes
• Morbidity and Mortality
– In 2006 diabetes was the seventh leading cause of death listed on U.S. death certificates
• Complications
– Nephropathy, Neuropathy, Retinopathy
– Heart disease and stroke
– Hypertension
• In 2003–2004, 75% of adults with also had hypertension.
– Amputation
• More than 60% of nontraumatic lower-limb amputations
Diabetic Retinopathy
• Classification
– NPDR
• Mild: Microaneurysms only
• Moderate: More than mild less than “Severe”
• Severe: any of the following
– > 20 IRH in 4 quads
– Definitive venous beading in 2 or more quads
– Prominent IRMA in 1 or more quad and no NV
– PDR: Definitive NV, PRH or VH
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Systemic Hypertension
• Definition
– A chronic condition in which the arterial (blood)
pressure is elevated
• Types
– Primary or Essential(90-95%)
– Secondary (5-10%)
• Caused by other conditions that affect the kidney,
arteries, heart or the endocrine system.
– White coat, Isolated Systolic, Labile, Malignant
Systemic Hypertension
• Complications
– Hypertension is the most important risk factor
for morbidity and mortality in the industrialized
world
• CVA, Hypertensive encephalopathy
• Cardiac: MI, CHF
• Nephropathy
• Retinopathy
HTN and Posterior Segment
• Retinopathy
– Hypertensive, and exasperating diabetic and other
vascular retinopathies
• Choroidopathy
• Macroaneurysm
• RVOs
• RAOs
Others … e.g., ION
Arteriolar narrowing
• Arterio-venous ratio
• Generalized and focal
arteriolar narrowing
Arteriolar light reflex
• Arteriolosclerosis, with
thinning of the blood
column
– Copper wiring
– Silver wiring
AV crossing changes• Gunn sign
• Salus sign• Precursors to
BRVOs