The document summarizes key findings from two major studies on retinal vein occlusions:
1. The Branch Vein Occlusion Study (BVOS) found that laser treatment was more beneficial for eyes that already had neovascularization, reducing the risk of vitreous hemorrhage. It also provided guidance on the natural history and progression of BRVO.
2. The Central Vein Occlusion Study (CVOS) aimed to define high risk characteristics for proliferation in CRVO, as BVOS did for BRVO. It examined more variables than BVOS to understand relationships between factors linked to progression.
3. Both studies established standards of care for treating complications through randomized controlled trials evaluating
Retinal artery occlusion is an ophthalmic emergency which requires urgent management. Its a vision threatening condition which requires prompt diagnosis.
Retinal artery occlusion is an ophthalmic emergency which requires urgent management. Its a vision threatening condition which requires prompt diagnosis.
Branched Retinal Vein Occlusion (BRVO) for undergraduate MBBS Students.
Covers the basics of Aetiology, pathophysiology, clinical features, types, associated conditions and management of BRVO.
Also encompasses salient points for PGMEE
Retinal vein occlusion (RVO) is an obstruction of the retinal venous system by thrombus formation and may involve the central, hemi-central or branch retinal vein.
The most common aetiological factor is compression by adjacent atherosclerotic retinal arteries.
Other possible causes are external compression or disease of the vein wall e.g. vasculitis.
Branched Retinal Vein Occlusion (BRVO) for undergraduate MBBS Students.
Covers the basics of Aetiology, pathophysiology, clinical features, types, associated conditions and management of BRVO.
Also encompasses salient points for PGMEE
Retinal vein occlusion (RVO) is an obstruction of the retinal venous system by thrombus formation and may involve the central, hemi-central or branch retinal vein.
The most common aetiological factor is compression by adjacent atherosclerotic retinal arteries.
Other possible causes are external compression or disease of the vein wall e.g. vasculitis.
AmeraTex Energy | The American Oil & Gas Industry Is Rescuing The Obama EconomyAmeraTex Energy Inc
On average, weekly wages have increased 40 percent since 2009. With a 3.3 percent unemployment rate statewide, North Dakota is attracting new residents in droves, and the state’s construction, financial, insurance and real estate sectors all grew significantly in the last year.
A group therapy psychoeducational talk on self-care needs of people who care for loved one's that have survived strokes. Focuses on the role changes, coping, self-care and mental health needs of caretakers.
Giving back with GitHub - Putting the Open Source back in iOSMadhava Jay
My experience helping take an in house Swift library and making it into an Open Source framework available on GitHub and Package Management repositories like Cocoapods. Any questions or feedback appreciated @madhavajay
In this case-based presentation, Dr. Lori Myers unscrambles the alphabet soup of Diabetic Retinopathy, providing clear explanations and outstanding images to describe the diagnosis, risk stratification, and treatment of diabetic retinopathy.
This presentation introduces myopia, high myopia, and in more details, pathologic myopia (aka malignant myopia). It is intended for training ophthalmologists, ophthalmology residents, medical students in ophthalmology rotations.
Cscr ( central serous chorioretinopathy )Vinitkumar MJ
What is the difference between disc odema & papillodema ?
Enumerate causes of papillodema ? & management of that ?
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. RETINAL VEIN OCCLUSIONS
• 2nd most common retinal vascular
disease after Diabetic Retinopathy
•3 TYPES (incidence):
1.BRVO (0.6% in 5yr BD study)
2.CRVO (0.2% in 5yr BD study)
3. HEMIRETINAL VO (~0.06% or 10x less
common than BRVO) – not as well
studied
3. Retinal Vein Occlusion
• Pathogenesis
– Incompletely understood
• Clotting mechanism has many PRO and ANTIthrombotic
factors
– thrombus (clot) occurs mostly at site of
arteriolar/artery-venule/vein crossing change
within the common adventitial sheath
Thrombi are caused by: endothelial injury, abnormal
flow, and hypercoagulability.
4. BRVOsignificantly increased risk with
-hypertension
-cardiovascular disease
-smoking
-increased Body Mass Index
-higher serum alpha 2 globulin
-like Protein C
other important risk factors
-hyperlipidemia/atherosclerosis
-diabetes (often excluded from VO studies)
-high intraocular pressure
5. CRVO
Increased risk with:
– SYSTEMIC
• BRVO risk factors (mostly systemic vascular)
• Other vascular disease
– vasculitis (sarcoid, syphilis, SLE, other collagen vascular
diseases),
• Abnormal blood flow
– low physical activity (including prolonged bedrest)
– Certain meds MAY: diuretics and oral contraceptives,
– Blood component mutations:
» Homozygous for hyperhomocysteinemia,
» Factor V Leiden and others
6. CRVO
Increased risk with:
–OCULAR
• Certain optic disc area features affecting the
course of the central retinal vessels:
– high cup to disc ratio, ION, tilted nerve head, ON
drusen
• Increased intraorbital pressure
– retrobulbar compression (thyroid eye
disease, orbital tumor),
– head trauma with orbital fracture
7. Retinal Vein Occlusion
In general: Emphasis on controlling
known risk factors in older patients
and investigating potentially unknown
risk factors in younger patients and in
rare simultaneous bilateral cases
8. BRVO
KEY FEATURES:
• Segmental retinal involvement within
distribution of involved occluded vein
– WEDGE SHAPED WITH APEX NEAR SITE OF
OCCLUSION
• Dilated tortuous vessels
• Superficial and deep hemes, CWS’s
• Optic disc swelling
• Macular edema (perfused/nonperfused)
• Optociliary shunt vessels on the disc
• Neovascularization of the retina/post. pole
12. HRVO
-Least common
-~20% of humans have a 2 trunked CRV just
posterior to the lamina cribrosa
-usually superior or inferior half of retina
involved though can be 1/3 or 2/3rd
-distribution of neo distinct from CRVO since
posterior pole > anterior segment
15. Usually Unilateral
• CVOS: 3 of 711 patients had bilateral vein
occlusions
THE OTHER EYE:
• CVOS: 9% of eyes with CRVO’s have had a
prior vascular occlusion in the fellow eye
• After a CRVO the annual risk of any retinal
vascular occlusion in the fellow eye is 1% per
year
17. Major Studies
• Multicenter Randomized Controlled trials
–BVOS (“Luck,” “Branches,” Grid is Good)
–CVOS (“POE,” 20/200, NVGlau)
–FOCUS WILL BE ON THE ABOVE STUDIES
BECAUSE THEY EXAMINE WHAT HAPPENS
IN VOs WITHOUT TREATMENT and “WHO
GETS LASER?”
• Others
– MEDICAL MACULAR TX
18. BVOS: A CLINICAL QUESTION
• The increasing use of photocoagulation therapy in the
late 1960s and early 1970s, along with the increasing
expertise in fluorescein angiography, aided recognition
of the disease, study of the nature and course of the
disease, and small trials of photocoagulation therapy
for the complications of macular edema and
neovascularization, as reviewed in 1978. From these
important studies, it became evident that many
patients who did not undergo laser photocoagulation
did not develop visual loss from macular edema or
neovascularization, which increased the difficulties of
evaluating photocoagulation therapy effect.
Consequently, it became clear that a prospective,
randomized, controlled clinical trial was required to
answer questions about treatment efficacy.
19. BVOS
• "Can peripheral scatter argon laser
photocoagulation prevent the development of
neovascularization?“
• And by extension: "Can peripheral scatter
argon laser photocoagulation prevent vitreous
hemorrhage?"
20. BVOS
• Eyes with vision loss due to conditions other
than BRVO were excluded
BRVO Groups include:
• Group I = pts have had a BRVO with 5DD of
retinal involvement but no neovascularization
at initial visit
• Group II = pts had + NVD/NVE at initial visit or
at some point during study
21. BVOS
Fig 2.—Kaplan-Meier plot of cumulative proportion of group I
eyes that developed neovascularization by follow-up time in
treated and control patients (P = .009, log rank test).
LASER BEFORE NEO
22. BVOS
Fig 3.—Kaplan-Meier plot of cumulative proportion of group II
eyes that developed vitreous hemorrhage by follow-up time in
treated and control patients (P = .005, log rank test).
LASER AFTER NEO
23. BVOS
• Prevention of neovascularization (and by
extension vitreous heme) with laser was not
found
• Neovascularization developed in a smaller
proportion of eyes after laser treatment, so
some did benefit from early laser tx.
24. • The greater benefit of laser tx came to the
eyes that ALREADY HAD NEO and were A LOT
LESS LIKELY to have VITR HEME after laser tx.
Laser before neo vs Laser after neo
LESS BENEFICIAL vs MORE BENEFICIAL
AS A RESULT: LASER FOR NEO FROM BRVO
BECAME THE STD OF CARE
25. BVOS
• Although the Branch Vein Occlusion Study was
not designed to determine whether peripheral
scatter treatment should be applied before
rather than after the development of
neovascularization, data accumulated in this
study suggest that peripheral scatter
treatment should be applied after the
development of neovascularization rather
than before the development of
neovascularization.
26. BVOS
• What other guidance is provided by the data?
• Natural History of BRVO – “Approximately
50% rule” - important for management and pt
education because it answers a clinical
question that initiated the study
27. BVOS: Natural History of BRVO
Approximately 50% of all eyes with at least 5DD of
involvement (a Gr I entry criteria) will have at least 5DD
of capillary nonperfusion (ischemic BRVO). (the other
50% will be nonischemic BRVOs – did not find
conversion rate from nonischemic to ischemic)
28. A NEW GROUP, GROUP X:
Group X (5DD nonperfusion, nontreated): Of the
eyes in this group, 41% developed
neovascularization.
• (study text does not match graphed data well)
• Approximately 50% of eyes with 5DD of
nonperfusion will develop neovascularization
• (the other ~50+% will not develop neo)THIS
ANSWERS A CLINICAL QUESTION THAT INITIALLY
PROMPTED THE STUDY NAMELY WHY DO SOME
BUT NOT ALL PTS BENEFIT FROM LASER
BVOS: Natural History of BRVO
29. Going back to Group II:
Group II (+ NVD/NVE): Of the 41 (nontreated)
eyes, 61% developed vitreous hemorrhage.
• Approximately 50++% of eyes with
neovascularization from BRVO will develop
vitreous heme
BVOS: Natural History of BRVO
30. Fig 4.—Visual acuity
distribution for all
group II eyes with
vitreous hemorrhage
that were never treated.
Boxes indicate
first visit and acuity at
which first vitreous
hemorrhage was noted;
LP, light perception; and
mi, missed visit.
31. BVOS
• “Can macular argon laser photocoagulation
improve visual acuity in eyes with macular
edema reducing vision to 20/40 or worse?”
(LAST BUT NOT LEAST,… GROUP III)
• Summary recommendations reflect the
importance of macular perfusion to the
success of grid laser tx.
• GRID LASER BECAME THE GOLD STD OF
TX’ING CERTAIN TYPES OF ME FROM BRVO
AFTER THIS STUDY
32. Summary of change in visual acuity since initial visit for eyes
that were evaluated at the 3rd year visit
Group III Control (No. =35) Treated (No. = 43)
Percent gaining two or
more lines at two
consecutive visits
37% (13) 65% (28) ↑
Percent losing two or
more lines at two
consecutive visits
17% (6) 12%(5) ↓
Percent with VA 20/40
or better at 3rd yr visit
34%(12) 60%(26) ↑
Percent with Visual
acuity 20/200 or worse
at 3rd year visit
23%(8) 12%(5) ↓
Avg VA at 3rd year visit
20/70 20/40-20/50
Avg number of lines
gained at 3rd year visit
0.23 1.33 ↑
33.
34. Now turning to CVOS
• CVOS examines more variables than BVOS
• CVOS isolates and explores the relationship
between those variables linked to
progression in order to DEFINE HIGH RISK
CHARACTERISTICS FOR PROLIFERATION – AS
WAS DONE IN BVOS
35. CVOS: GROUP P
• The first CVOS pt group is Group P (P for
PERFUSED CRVO)
• TABLE 6 (Next Slide) shows the PROPORTION
OF PERFUSED PTs PROGRESSING by
VARIABLES WHICH MAY BE INVOLVED IN
THEIR PROGRESSION
• Table 6 was published in the preliminary
report. A similar table was not published in
the final report, but the final report added
that moderate to severe venous tortuosity IS
associated with progression out of Group P
36. CVOS GROUP P: LIST OF VARIABLES
Progression is defined as the presence of any of the
following by the 4-month visit: 10 disc areas of
nonperfusion, transfer to group I, 2 clock hours of
iris neovascularization, or angle neovascularization.
37. CVOS GROUP P: LIST OF VARIABLES
Progression is defined as the presence of any of the
following by the 4-month visit: 10 disc areas of
nonperfusion, transfer to group I, 2 clock hours of
iris neovascularization, or angle neovascularization.
38. CVOS
THE PROPORTION
OF PATIENTS THAT
PROGRESSED
FROM THE
PERFUSION
GROUP TO OTHER
MORE ADVANCED
GROUPS WAS 0.16
THEREFORE ALL OF
THE
PROPORTIONS
FOR ALL OF THE
VARIABLES ARE
COMPARED TO
0.16 TO SEE
WHICH ARE THE
MOST DIFFERENT.
39. CVOS
too few pts < 50
more males in study
too few patients
not sign. different proportion
pt’s with DR excluded
“MARGINAL SIGNIFICANCE”
HIGH CORRELATION
not sign. different proportion
HIGH CORRELATION
not sign. different proportion
not sign. different proportion
not sign. different proportion
not sign. different proportion
not sign. different proportion
not sign. different proportion
not sign. different proportion
not sign. different proportion
41. CVOS: ↑ # of Risk Factors ↑ Risk of Progression
Figure 3. Group P progression (INV and/or ANV, group I, or nonperfusion) by number
of risk factors present at entry. Risk factors are duration of central vein occlusion
of less than 1 month, visual acuity of worse than 20/200, and five to nine disc
areas of nonperfusion. Error bars represent 95% confidence intervals. See the text,
introductory section, and Table 1 for explanation of groups.
ADDITIVE
INTERACTION
BETWEEN HIGH RISK
CHARACTERISTICS/
VARIABLES
42. CVOS A SHORT SUMMARY SO FAR
• So an initially perfused CRVO is more at risk of
progressing to a nonperfused CRVO if
– visual acuity worse than 20/200 AND
– 5-9DD of capillary nonperfusion AND
– (moderate to severe venous tortuosity) are present
than any one alone.
• THE RELATIONSHIP BETWEEN VISUAL ACUITY AND
AMOUNT OF NONPERFUSION IS EASIER TO EXPLORE
BECAUSE IT IS MORE QUANTIFIABLE
• THE RELATIONSHIP BETWEEN VISUAL ACUITY AND
AMOUNT OF NON PERFUSION IS NOT ONLY ADDITIVE
BUT ALSO “HIGHLY CORRELATED” (next slide)
MEANING THEY BOTH INCREASE TOGETHER SOMEHOW
43. CVOS
Figure 1. Proportion of patients developing iris neovascularization (INV)
and/or angle neovascularization (ANV) (2-clock hours of INV or any ANV)
during the study period by number of disc areas of nonperfusion
measured at baseline.
44. CVOS
Figure 2. Proportion of patients developing iris neovascularization (INV)
and/or angle neovascularization (ANV) (2-clock hours of INV or any ANV)
during study period by Snellen visual acuity measurement at baseline.
45. CVOS – HIGHLY CORRELATED
• GREATER CAPILLARY NONPERFUSION AND A
WORSE INITIAL VISUAL ACUITY ARE EACH
RELATED TO AN INCREASE IN PROPORTION OF
EYES DEVELOPING INV/ANV ( NVGlau)
THIS PART OF BOTH GRAPHS ARE THE SAME
46. CVOS
• THE CORRELATION BETWEEN VISUAL ACUITY
AND CAPILLARY NON PERFUSION WAS NOT
EXPLORED IN MORE DETAIL PERHAPS
BECAUSE THE MECHANISTIC DETAILS ARE NOT
AS RELEVANT TO CLINICAL PRACTICE AS IS THE
ABILITY TO LEGITIMATELY GUESSTIMATE
CAPILLARY NONPERFUSION BY A VISUAL
ACUITY MEASURE
47. A CLOSER LOOK AT 20/200
• CVOS states that 20/200 is the level
of acuity that is most concerning; but
why?
48. CVOS – evidence for 20/200 marker
<1mo since
onset
subgroup:
At ≤ 20/200
majority are
ischemic
CRVOs &
large rise in
proportion of
eyes with
INV/ANV
The
tippin
g
point
49. CVOS
NOW WE KNOW WHICH EYES ARE MOST AT RISK. WE
KNOW HOW THE RISK FACTORS INTERACT. WE
KNOW THE SIGNIFICANCE OF 20/200. BUT WE STILL
NEED TO MENTION THE MAIN CONCERN.
• the primary concern is prevention of neovascular
glaucoma by careful attention to the
development of INV and prompt treatment if it
occurs. There is concern that the patient with a
visual acuity worse than 20/200 is likely to have a
nonperfused occlusion.
• THIS OUTCOME IS MUCH MORE SERIOUS THAN
THE VITREOUS HEME CAUSED BY BRVO NEO
50. Figure 3. Kaplan-Meier survival curve showing cumulative proportion of
patients who had developed iris neovascularization (INV) and/or angle
neovascularization (ANV) by study month.
CVOS
Anterior segment
neovascularization and therefore
Neovascular Glaucoma can develop
very quickly initially and then less
quickly (but never zero slope) as
time goes on – frequent f/u early
and long term f/u necessary
51. ADDITIONAL CVOS NATURAL HX
• Number with ischemia: In the first 4 months of
follow-up, 81 (15%) of the 547 eyes with
perfusion converted to ischemia… a total of 34%
after 3 years.
• Rate of ischemia: The development of ischemia
was most rapid in the first 4 mos and progressed
continuously throughout the entire duration of
follow-up.
– MAY ALWAYS NEED TO LOOK FOR NEO IN OLD CRVO
• A result of ischemia: Iris neovascularization of at
least 2-clock hours, and/or angle
neovascularization (ANV) developed in 117 (16%)
of the 714 eyes.
52. CVOS - LOOKING FOR NEO
Necessary Clinical information upon diagnosis of
Central Retinal Vein Occlusion
Best Corrected Visual Acuity
Intraocular pressure
Undilated slit-lamp examination
Gonioscopy
Fluorescein Angiography*
*If the perfusion status is not clinically obvious and if the media and retinal
hemorrhage do not obscure retinal capillary detail, then a fluorescein
angiogram would be a useful clinical adjunct
53. BVOS vs CVOS
BVOS CVOS
concern for posterior segment
neovascularization and
vitreous hemorrhage
concern for anterior segment
neovascularization and
neovascular glaucoma/blind
painful eye
high risk characteristic for
proliferation is 5 DD of
capillary nonperfusion
high risk characteristics for
proliferation including 5-9 DD
of capillary nonperfusion and
VA worse than 20/200
certain macular edemas are
treatable with grid laser.
grid laser should not be used
for macular edema for
reasons unknown.
54. Ischemia and Neovascularization
• Ischemia is often but not always or
immediately a prelude to neovascularization
therefore PRP for neo is performed not PRP
for ischemia
55. A Brief Word on Other Studies
RELATE TO TX OF MACULAR EDEMA (ME)
• SCORE
– Steroid injections for certain ME’s from CRVO
• OSURDEX steroid implant for ME’s from VO
• CRUISE and BRAVO
– Lucentis (Anti-VEGF agent) for ME’s from VO
(Eyelea (VEGF Trap) approved for ME after CRVO)
THE ABOVE STUDIES and the OCT MAY HAVE
CHANGED THE STD OF CARE SO THAT
FLUORESCEIN’s are LESS RELIED UPON FOR MGT
56. Management
• VO
– Consult for Macular edema
• BRVO
– Monitor at 2-4 month intervals for first year and
less often thereafter looking for signs of
neovascularization (usually posterior) (PRP for
neo)
– Possible Fluorescein angiography to confirm neo
or to assess perfusion status of macular edema in
anticipation of grid laser
57. Management
• CRVO
– Monthly monitoring looking for earliest signs of
neovascularization (usually anterior) (PRP for neo)
for first 6-8 months, less often thereafter for next
2 to 3 years
– Possibly no Fluorescein angiography needed
unless the outcome impacts treatment decisions
58. CVOS Q&A
• WHO WILL GET WORSE?
• HOW DO WE ADVISE PATIENTS?
• WHAT’S AT RISK VISIONWISE?
59. CVOS
• WHO WILL GET WORSE?
– Over time 1/3 will get worse
– Pts with worse VA (and greater capillary
nonperfusion and mod to sev venous tortuosity)
• HOW DO WE ADVISE PATIENTS?
– Frequent F/u especially in 1st 4 months
– Long term f/u for long term risk of progression
• WHAT’S AT RISK VISIONWISE?
– Potential for a blind painful eye
60. References
• Stephen J. Ryan’s Retina
• Albert & Jakobiec's Principles & Practice of
Ophthalmology, 3rd ed.
• CVOS
• BVOS
• Dr. Edward Deglin