grand rounds
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Grand Rounds. Shivani V. Reddy, M.D. 7/18/14 University of Louisville Department of Ophthalmology and Visual Sciences. Patient Presentation. CC : Blurry Vision OD - PowerPoint PPT PresentationTRANSCRIPT
Grand RoundsGrand Rounds
Shivani V. Reddy, M.D.Shivani V. Reddy, M.D.
7/18/147/18/14
University of LouisvilleUniversity of Louisville
Department of Ophthalmology and Department of Ophthalmology and Visual SciencesVisual Sciences
Patient PresentationPatient Presentation CCCC: : Blurry Vision ODBlurry Vision OD
HPIHPI: : 80 y/o AAF presents for yearly 80 y/o AAF presents for yearly Plaquenil check She states that her vision Plaquenil check She states that her vision had been stable until 1 month ago when had been stable until 1 month ago when she noticed some blurriness and dimming she noticed some blurriness and dimming of vision OD. She denies experiencing of vision OD. She denies experiencing metamorphopsia, flashes, floaters or metamorphopsia, flashes, floaters or scotomas. scotomas.
HistoryHistoryPOHx: POHx: refractive error refractive error
PMHx:PMHx: Rheumatoid Arthritis, Hypertension, Rheumatoid Arthritis, Hypertension, Hypothyroidism Hypothyroidism
FAMHx:FAMHx: uknown uknown
ROS: ROS: joint painjoint pain
MEDS:MEDS: Plaquenil ( 3.04 mg/kg/day (65.7kg weight), Plaquenil ( 3.04 mg/kg/day (65.7kg weight), 200mg daily x 5 years)200mg daily x 5 years)
Toprol, MTV, triamterone, synthroid Toprol, MTV, triamterone, synthroid
ALLERGIESALLERGIES: : NKDA NKDA
ExamExam
VA TP P
20/50-2 (+0.75 +0.50 x 005)
20/20-2 (-0.25 +0.50 x 175)
8
12 no RAPD
EOM: full OU CVF: full OU
4→3
4→3
Exam Exam
OD OS LIDS/LASHES WNL WNL
CONJ WNL WNL
CORNEA WNL WNL
IRIS WNL WNL
LENS 2+NS, 1+CC 2+NS, 1+CC
Fundus Photos Fundus Photos
OD photo demonstrates orangish-red faintly circumscribed lesions in the peripapillary region
OD OS
FAF Photos FAF Photos OD OS
1. Nasal pigment epithelial detachment with associated neurosensory detachement with sub-neurosensory fluid accumulation, some loss of foveal contour
2. Nasal pigment epithelial detachment with overlying heme and fluid
1.OD
2.OD
3.OS
FA/ICG FA/ICG Early AV Phase
Peripapillary staining, supero-nasal hypofluorescence of dye
Superonasal hypofluorescence, network of dilated peripapillary vasculature with terminal bulb
00:19:45
FA/ICG FA/ICG AV Phase
Increasing peripapillary hyperfluorescence
circular of hyperfluorescence at end of vascular network
00:29:45
FA/ICG FA/ICG Recirculation Phase
continual demonstration of peripapillary dye leakage, increasing over area of polyp
Hyperfluorescence of polypoid lesion and demonstration of surrounding vascular network
1:21:45
FA/ICG FA/ICG Late Phase
Persistent peripapillary dye pooling representing leakage
2:00:45
Decreased hyperfluorescence of polyp with surrounding area of hypofluorescence
SummarySummary
DDx:Polypoidal Choroidal Vasculopathy Other entities causing subretinal neovascularization
AMD CSCR (central serous
chorioretinopathy) Pathologic myopia Choroidal tumors or Mets Infection
80 y/o AAF presents for routine plaquenil check with 1 month history of blurriness and dimming of vision OD. BCVA OD is 20/50-2. ICG angiography demonstrates choroidal polyps with surrounding vascular network and corresponding leakage on FA. OCT demonstrates PED’s OD with overlying neurosensory retinal detachment
Treatment Treatment
First Visit20/50-2
1 month post Avastin #1VA 20/50
1 month post Avastin #2VA 20/40-2
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
Also known as posterior uveal bleeding syndrome
First described by Dr.Yannuzzi in 1982
Characterized by sub-retinal vascular lesions associated with serous and hemorrhagic detachments of the RPE
Named for its network of branching, choroidal vessels with terminal polyp-like aneurysmal dilations
First described in middle -aged African American woman
Most commonly seen in 50-65 age group
Occurs 23-55% in Asian patients presenting with neovascular AMD
4% to 9.8% prevalence reports in Caucasian patients with presumed AMD
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
Diagnosis based on ICG angiography high definition OCT and fundus photography
FA not helpful as it demonstrates too much dye leakage
Classification based on imaging characteristics Branching vascular network vs. feeder vessel
supplying polyps Cluster of polyps vs. single polyp Juxtafoveal vs. extrafoveal polyps
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
CNV or Not?
PCV is? More likely to occur in pigmented
races, although also demonstrated in Caucasians
lesions more likely to be peripapillary ICG in late phases shows ‘wash-out’ of
polyp in contrast to late staining seen in occult CNV
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
Treatment
Anti- VEGF treatment alone not helpful
EVEREST TRIALCompared PDT monotherapy and PDT + ranibizumab to ranibizumab alone Significantly higher proportion in the first 2 groups showed regression at 6 months
Surgical intervention based on complications such as break-through vitreous hemorrhage
Polypoidal Choroidal Polypoidal Choroidal VasculopathyVasculopathy
Prognosis
Clinical outcomes in literature vary considerably 35-68.2% of patient with reported poor
outcomes
Larger polyps, juxtafoveal location of polyps and clustering of polyps are risk factors for massive subretinal and subsequent vitreous hemorrhages
In patients with large detachments, subretinal fibrosis can lead to eventual vision loss
PDT can lead to subretinal hemorrhage in upto 31% of eyes, VH in 6-12.5% post treament, 8.9% of bleeding post anti-VEGF
Retrospective chart review
17 patients with massive subretinal hemorrhages (SRH) secondary to PCV (16.7+/- 7.1 DD) and associated vitreous hemorrhage (VH) enrolled
Patients underwent 20G Pars Plana Vitrectomy +/- bevacizumab injection for new heme, PED or CME
Main outcome measure: BCVA at end of follow-
up period
Mean post-op follow up of 25.2 months
Mean duration from SRH to VH was 3.5 +/- 1.2 weeks Time from VH to PPV 1.3 +/- 0.7 months
BVCA (LogMar)Pre VH : 0.95 +/- 0.60Pre PPV: 2.65 +/- 0.57 3 months post-op: 1.62 +/- 0.67Final Visit: 1.43 +/- 0.82 VA > 20/400 in 16.7% of juxtafoveal polyp patients,
87.5% of extraoveal polyp patients
THANK YOU
References References 1.Retina and Vitreous, BSCS 2. Retina, Vitreous and Macula , David R. Guyer MD, Lawrence A. Yannuzzi MD, Stanley Chang MD and Jerry A. Shields MD 3.Yannuzzi LA, Sorenson J, Spaide RF, Lipson B. Idiopathic polypoidal choroidal vasculopathy (IPCV). Retina 1990; 10(1): 1–8.4.Koh et al. EVEREST STUDY: Efficacy and Safety of Verteporfin Photodynamic Therapy in combination with Ranibizumab or Alone Versus Ranibizumab Monotherapy in Patients with Symptomatic Macular Polypoidal Choroidal Vasculopathy. Retina 2012; 32:1453-1464.5. Uyama M, Wada M, Nagai Y, et al. Polypoidal choroidal vasculopathy: Natural history. Am J Ophthalmol. 2002; 133(5):639-48.6. Lim TH, Laude A, Tan CS. Polypoidal choroidal vasculopathy: An Angiographic discussion. Eye (Lond) 2010; 24:483–4907.Kamaeda T, Tsujikawa A, Otani A, et al. Polypoidal choroidal vasculopathy examined with en face optical coherence tomography. Clin Experiment Ophthalmol. 2007; 35(7):596-601.8.Sato T, Kishi S, Watanabe G, et al. Tomographic features of branching vascular networks in polypoidal choroidal vasculopathy. Retina. 2007 27; 589-594.9.Park DH, Shin JP, Kim IT. Association of plasma malondialdehyde with ARMS2 genetic variants and phenotypes in polypoidal choroidal vasculopathy and age-related macular degeneration. Retina 2013; 0:1–10.