Grand Rounds from the University of Chicago Department of Ophthalmology
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    Grand Rounds from the University of Chicago Department of Ophthalmology Grand Rounds from the University of Chicago Department of Ophthalmology Presentation Transcript

    • Grand Rounds Terry J. Alexandrou, MD Department of Ophthalmology and Visual Science The University of Chicago 9/7/05
    • August 9, 2003
      • HPI: W.A is a 60 y.o A.A. male who presents with a 3 day history of decreased VA and pain in the right eye.
      • Awoke with red, painful right eye.
      • Described decreased VA in right eye as “seeing only black.”
      • C/O bifrontal headache.
      • Denied jaw pain, scalp tenderness, discharge.
    • History
      • PMH: None.
      • POH: s/p cataract extraction with PCIOL OU; “few years back”
      • Meds: None
      • All: NKDA
      • FH: N/C
      • SH: Immigrant from Africa, No EtOH, tobacco or IV drug use.
    • Exam
      • VA: Without correction: OD- Light perception OS- 20/20 (-2)
      • Pupils: + APD
      • EOM: full
      • Anterior Exam:
      • OD: 3+ injection, severe corneal edema, +NVI, PCIOL
      • OS: mild blepharitis, PCIOL
    •  
    • IOP – any guesses?
      • 15
      • 25
      • 46
      • 76
    • 76!!!!!!!!!
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    • Differential???
    • Differential…
      • Diabetic Retinopathy
      • Hypertensive Retinopathy
      • Radiation Retinopathy
      • Ocular Ischemic Syndrome
      • CRVO
      • Hyperviscosity Syndrome
    • Next Step…
      • What do you want to do now?
    • Acute Treatment
      • Alphagan x2
      • Timolol x2
      • Diamox x1
      • Pressure recheck 4 hours later:
      • OD – 45
      • OS - 17
      • Based on the appearance of the fundus photographs, what do you want to check for next?
    • Blood Pressure
      • 202/102
      • -rechecked several times with
      • manual cuff
    • Admitted to Medicine Service
      • Initial B.P in Emergency Department was 206/94
      • Initially treated with Labetalol 5mg IV pushes
      • Overnight, started on Coreg 6.25 mg bid
      • B.P overnight ranged from 155-162/63-71
      • Overnight pt. Received timolol x3, alphagan x3, diamox x2 (in addition to initial treatment)
    • Labs and Tests
      • Chem 10 WNL (glucose of 105)
      • CBC WNL
      • HgBA1C of 6.6
      • All other labs unremarkable
      • Bilateral Carotid U/S - negative
    • Day 2
      • No pain
    • Day 2
      • VA: without correction:
      • OD – LP (but, temporal CF at 2 ft.)
      • OS – 20/20 (-2)
      • IOP:
      • OD – 48
      • OS – 16
      • (after total of timolol x4, alphagan x4, diamox x3)
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      • Diagnosis…….
      • Hypertensive retinopathy with ass. CRVO and secondary NVG
    • Neovascular Glaucoma
      • SYSTEMIC VASCULAR DISEASES
      • *** - Carotid occlusive Disease ***
      • - Carotid artery ligation
      • - Giant cell arteritis
      • - Takayusu disease
      • OCULAR VASCULAR DISEASE
      • *** - Diabetic Retinopathy ***
      • *** - CRVO ***
      • - CRAO
      • - BRVO
      • - Sickle cell retinopathy
      • - Coats Disease
      • - ROP
      • OTHER OCULAR DISEASES
      • - Chronic uveitis
      • - Chronic RD
      • - Endophthalmitis
      • - Retinoschisis
      • INTRAOCULAR TUMORS
      • - Uveal melanoma
      • - Metastatic Carcinoma
      • - Retinoblastoma
      • OCULAR THERAPY
      • - Radiation Therapy
      • TRAUMA
    • Treatment…any thoughts
      • Elevated pressure OD (48) with no view….
    • Cyclocyrotherapy
      • 6 spots of cryo
    • Retinal Cryotherapy
      • 12 spots of cryo
    • Day 3 (still an inpatient)
      • POD # 1 s/p retinal and ciliary body cryotherapy for NVG 2/2 CRVO
      • C/O pain in the right eye
      • VA: OD-HM OS: 20/30
      • IOP: OD-18 OS-12
      • Anterior Exam: OD - edematous cornea (poor view), with hyphema and fibrinous reaction in the AC; NVI
      • Pt. started on PF q1 hour and atropine bid, along with pressure lowering meds
    • Day 4 (outpatient)
      • POD # 2 s/p retinal and ciliary body cryotherapy for NVG 2/2 CRVO
      • Still with pain in right eye
      • VA: OD-HM OS: 20/30
      • IOP: OD-21 OS-16
      • Anterior Exam: OD- edematous cornea, slightly clearer, with 5% suspended hyphema and fibrinous reaction in the AC;
      • PF q2 hours, atropine bid, alphagan, timolol
    • 1 Week
      • VA:
      • OD-HM
      • OS- 20/30
      • IOP:
      • OD-12
      • OS-13
      • AC: resolving fibrin
    • 2 weeks
      • VA:
      • OD- HM
      • OS – 20/30
      • AC: No fibrin, D+Q, No NVI; cornea clear………..FINALLY!!!
      • Treatment – PRP right eye
      • F/U Next week
    • Hypertensive Retinopathy
      • JNC lists retinopathy as 1 of several markers of target-organ damage in hypertension
      • First described by Marcus Gunn
      • Gunn noticed:
      • - arteriolar narrowing
      • - arteriovenous nicking
      • - flame-shaped and blot-shaped retinal hemorrages
      • - cotton-wool spots
      • - swelling of the optic disc
    • Pathophysiology
      • 1) Vasoconstrictive Stage – initially, seen as generalized narrowing of retinal arterioles
      • 2) Persistently Elevated BP – more severe generalized and focal areas of arteriolar narrowing; AV nicking, and alterations in arteriolar light reflex (copper wiring)
      • 3) Exudative Stage – microaneurysms, hemorrhages, hard exudates, cotton-wool spots, swelling of the optic disc (if severely elevated blood pressure)
    • Epidemiology
      • > 50 million people in the US affected by hypertension
      • Prevalence of 2-15 % for various signs of retinopathy
    • Classification of Hypertensive Retinopathy
      • Grade 0 No changes
      • Grade 1 Barely detectable arterial narrowing
      • Grade 2 Obvious arterial narrowing with focal irregularities
      • Grade 3 Grade 2 plus retinal hemorrhages and/or exudate
      • Grade 4 Grade 3 plus disc swelling
    • Treatment
      • Blood pressure Control
      • Chronic hypertensive retinopathy alone rarely, if ever, results in significant vision loss.
      • Evidence of hypertensive retinopathy can be used for risk stratification of other systemic diseases associated with hypertension
    • Atherosclerosis Risk in Communities Study
      • Multisite cohort study
      • 5 year risk of stroke of participants with both hypertensive retinopathy and cerebral lesions on MRI (compared to those with neither of these 2 findings) was 18.1.
      • - Among participants with only cerebral lesions on MRI only, the RR of stroke was 3.4.
      • CRVO
    • Pathogenesis
      • Thrombus in the central retinal vein at the level of the lamina cribosa, often secondary to atherosclerosis of the neighboring central retinal artery.
    • Risk Factors
      • Age > 50
      • DM
      • Htn
      • Hyperviscosity syndromes
      • Glaucoma
    • Classification of CRVO
      • 1) Non-ischemic – ~75-80% have this milder form
      • 2) Ischemic - ~20-25% have this severe form
    • Non-Ischemic CRVO
      • Symptoms – 1) mild to moderate decrease in VA (can range from normal to CF however); 2) intermittent blurring; 2 pain is rare
      • Signs – 1) APD is rare; 2) dot and flame hemorrhages in all 4 quadrants; 3) optic nerve head swelling; 4) engorgement and tortuosity of retinal veins; 5) macular hemorrhage or edema; 6) rarely is there neovascularization of either the anterior or posterior segment (<2%)
    • Progression of Non-Ischemic to Ischemic CRVO
      • Central Vein Occlusion Study
      • - 34 % of eyes initially diagnosed with non-ishemic CRVO progressed to ischemic variant within 3 years; (15% converted within first 4 months)
    • Ischemic CRVO
      • 1) Symptoms – 1) Acute, markedly decreased visual acuity (usual presenting complaint, VA ranges from 20/200 to LP) ; 2) Pain (if neovascular glaucoma has already developed)
      • 2) Signs – 1) APD is common; 2) Extensive 4 – quadrant retinal hemorrhages and edema; 3) Marked venous Dilation; 4) Anterior Segment Neovascularization (60 % or higher) 5) Neovascular glaucoma – can occur within 3 months of disease onset (90 day glaucoma), often resulting in intractably elevated IOP’s; 6) Neovascularization of optic disc and retina may be seen, but not as common;
    • Diagnosis
      • 1) Characteristic fundus photos –
      • 2) FANG in ischemic CRVO– most useful ancillary test; Eyes with 10 disc areas or greater of non-perfusion are classified as ischemic
      • - demonstrates marked hypofluorescence – secondary to blockage from extensive retinal hemorrhages or to capillary non-perfusion
      • - optic nerve head leakage
      • - macular edema
      • 2) FANG in non-ischemic CRVO –
      • - staining along retinal veins
      • - microaneurysms
      • - dilated optic nerve head capillaries
      • - minimal or absent retinal capillary non-perfusion
    • Treatment
      • If Neovascular Glaucoma – CVOS demonstrated PRP was recommended in eyes where iris neovascularization was present, however prophylactic PRP did not show statistical significance in prevent neovascularization.
      • If Macular Edema – CVOS showed that macular grid laser reduced angiographic evidence of macular edema, however there was no difference in VA of treated vs. untreated eyes; Recent study demonstrated intravitreal kenalog effective in reversing CME and improving VA in recent-onset non-ischemic CRVO at 6 months, but results not maintained at 1 year
      • Laser – induce Chorioretinal Venous Anastomosis
      • Radial neurotomy
    • Typical Course of CRVO
      • 50 % of non-ischemic CRVO patients deteriorate to 20/200 or worse
      • 90 % of ischemic CRVO patients have VA of 20/200 or worse
      • 7% of CRVO patients develop a venous occulsion in the fellow eye within 2 years (risk ~ .9 % per year)