oct in optom practice ho - weo media · • csme od noted on clinical exam widefield re4na clinic...
TRANSCRIPT
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OCTintheOptometricPrac4ce
StevenFerrucci,OD,FAAOChief,OptometrySepulvedaVA
Professor,SCCO/MBKU
Disclosure Statement
• Speakers bureau/Advisory Board – Alcon – B&L – Centervue – Genentech – MacuLogix – Optovue – Science Based Health
OCT
• AMD• DME• ERM/VMT• CSR• MaculaedemafromBRVO/CRVO• Plaquenilscreening• MacularHoles• Glaucoma
Newstuff
• Morescans– Upto70K
• Widefield– 12x9mmvs.standard6x6mm
• OCTangiography• Anteriorsegment
– Angles– Pachymetry– Epithelialmapping
RETINA AMD
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DryAMD
• 83yomale• Followed>13yearsfordryAMD
– VA20/25OUsince2013• AREDS2BID:reportsgoodcompliance• Notesvisionhasgo]enblurrier• MetamorphosiaOUx2mos
Widefield
Assessment/plan
• DRYAMDOS>OD• Stage3OU
– Mul4pleconfluentdrusenOU
• NofluidonOCT• Con4nueAREDS2BID• HAG• RTC3mosforrepeatOCT
WetAMD
• 81yearoldmale• h/oPOAGforyears
– T½andLatanaprost• h/odryAMDOUforyears
– LastVA:20/40OD,20/30OS– RarelydoesHAG
• Type2DMforyears– Nore4nopathyorCSME
WetAMD
• Infor3mosfollow-up• Reportslostglasses• VAToday:
– 20/40OD– 20/70OS– Didnotno4ceachangeun4lcheckedinclinic– Again,rarelydoesAmsler
OCT-Widefield
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OCT-AOS Re4naClinic
• WetAMDOS• Avas4nseriesx3OS.• RepeatOCT/OCT-Aafer3rdinjec4on
AMD• ChangeinVAormetamorphopsiashouldalwaysbetakenseriously– OCTtoruleoutfluid– FA/OCT-Aifneeded
• EvidenceofhemeorfluidshouldbereferredASAPfortreatment– Earliertreatment/smallerlesionsizecorrelateswithbe]erfinalvisualacuity
CHANGEINVAORMETAMORPHPSIAINDRYAMDPTISCONVERSIONTOWETUNTILRULEDOUT!!!
DIABETES/DME
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DMcase1
• 47yoAAmale• Type2DMx10years
– Glipizide,mejormin– LastA1c9.9
• LEE:5yearsagoatLenscrafers• VA20/20OU• CSMEsuspectedODtemporaltomacula
Widefield
Assessment/plan
• MildNPDROU• Mildnon-centralDMEOD,noDMEOS• PtedreBScontrol
– Ptstatesadjus4ngmedswithPCPaswespeak
• RTC3-4mosrepeatOCTOD• Refertore4naifincreasingedemaordecreasingVA
DMcase2
• 63yearoldmale• Type2DMx10years
– Insulinx3years– LastA1c9.7(h)
• VA20/30-OD,20/25+OS• CSMEODnotedonclinicalexam
Widefield Re4naClinic
• CenterinvolvedDMEOD• Discusswithre4naclinic• An4-Vegfx3• RepeatOCTafer3rdinjec4on• PtedreBS/BPcontrol
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DMcase3
• 50yearoldmale• Type2DMx20years
– LastA1c8.7– Insulinandliraglu4de(Victoza)
• ReducedVAODx9mos• h/oinjec4onsODlastyear• Toldearlierthisyearnomoreinjec4onsneeded.• UnclearwhyVAdecreasedOD• ScheduleFA
DMcase3
• ModerateNPDROU• NocenterinvolvedDMEOD• MacularischemiaOD>>OSonOCTA
– NoneedtodoFA– Notreatmentavailable
• Op4mizeacuity• Op4mizeBP/BScontrol• RTC3mos.RepeatOCT/OCTA
DM/DME
• ReferifcenterinvolvedDME/CSMEevidentonOCTin1-2weeks
• Ifnotcenterinvolved,followcloselyin3-6mos
• OCTifunexplainedvisionlossinptwithdiabetes– Lookforischemia
• PtedreroleofBS/BPcontrol• Treatment:FMLvs.serialan4-VEGF
ERM
ERM
• 68yearoldmale• h/oochtnongenericlatanprostqhsOUx3years
– PretxIOPs≈30– Posttreatmentmidteens– VFfullOU
• InforIOPcheck.• Doingwell,goodcompliance,butnotesmilddecreaseVAODwithmetamorphosiawhenreadingsmallprint
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EnFace ERM#2
• 83yearoldmale• Catarctsxoux2015• NotesOSblurrierthanOD• HTN• BCVA20/20OD,20/25Os
ERMCase#3• 70yoHispanicmale• NotesdecreasedVAODsincepreviousexam
– Lastyear20/20OU• MildHTN,earlycataracts• BCVA
– 20/30OD– 20/20OS
ERM#3
• Assessment– ERMOD
• Plan– WillmonitorduetogoodVA– RTC6mos
ERM
AGE INCIDENCE
<60 1.7%
60-69 7.2%
70-79 11.6%
80+ 9.3%
BLUEMOUNTAINEYESTUDY,AUSTRALIA
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ERM
• Consider surgery if: – VA 20/40ish or worse – Symptomatic – Visual need of patient
• Make sure you have an experienced surgeon!!
VMT
VMTcase
• 82yearoldmale• Inforyearlyexam
– Notesnochangeinvision– h/omildtomoderatecataracts,VA20/30OU
• VAtoday– 20/40OD-onelinedecrease– 20/30OS-stable
VMTCASE
• VMTOSwith20/40acuity
• Discussionreop4ons– Surgery– Monitor
• Ptelectstomonitor,asnotbotheredbyvisionandwouldliketoavoidsurgery
• RTC3moswithrepeatOCT.Ptagreeswithplan
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VMTCASE2
• 70yearoldmaleinforrou4neexam• Notesmildchangeindistancevision,botheyes,sincelastexam1yrago
• Thinksheneedsnewglasses• 20/20OD,20/50OS
– PtsurprisedthatVAOSwasdecreased.Didnotno4ceun4lexamtoday
VMTCASE2
• VMTOSwith20/50acuity
• Discussionreop4ons– Surgery– Monitor
• Ptelectstomonitor,asnotbotheredbyvisionandwouldliketoavoidsurgery
• RTC3moswithrepeatOCT.Ptagreeswithplan
VMT: when to refer • Natural progression of disease is rather
variable – Slow progression possible with near
normal acuity – Approx 10% will have spontaneous PVD
and resolution within 30 days • Therefore, close monitoring my be advised
for some patients
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VMT: when to refer
• In patients with poor vision, or symptomatic, a pars planar vitrectomy (PPV) may be considered – Duration, severity should also be
considered • Jetrea (ocriplasmin) as option? • Literature reports up to a 75% success rate
and improvement of vision following PPV MACULARHOLES
LMH
• 78yearoldmale• HadcataractsurgeryOS5yearsagoandunhappywithresults– FeelsvisionOSisworsenowthanbeforesurgery– Nopreopdataavailable– Unclearifeverexplainedtocataractsurgeonordiscussedwithhimreasonforvisionloss
– Unclearwhattes4ngwas/wasnotdone
LMH• BCVA20/20OD,20/30OS• MildNSCOD• PCIOLOS.Clearandwellcentered• Postpole:
Widefield LMH• LamellarMaculaHoleOS
– Alsocalledpar4althicknessmacularhole• Pted.• Monitorin3mos.• RepeatOCT• Considerre4nareferralifworsens
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CSR
CSR
• 37yearoldmale• BlurredvisionOSx5days
– BlackspotcentrallyOS– Spotseems“warped”
• BCVA– 20/80OD– 20/20OS
• Medhx:albuterolPRNforasthma
CSR
• CSROD• Askaboutsteroids
– Albuterol?• Askaboutstress?• RTCforFAn/a
Followup
• Ptpresents1moslaterforFA• FeelsVAhasimprovedODsignificantly
• 20/20!!• FAcancelled!
IsthisCSR?
• Ptnotesacuteonsetofbent/crookedlinesOD.• Norealchangenvision• Lastexam4yearsagoatCOSTCO
CSR• Whentoworry/refer
– IfVAworsethan20/70– Ifptdemographicsdonotsupport– Ifdoesnotresolvein6mos– Ifgetsworseratherthanbe]er– FA/OCTdoesnotsupportdiagnosis– “Justdoesn’tfeelright”– Ptisunabletoacceptvision/prognosis
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VEINOCCLUSIONS
CRVO• 75yearoldmale• Presentsfor3mosglccheckand24-2
– NTGx2010– LatanaprostqhsOU– Hasnotusedx1mos.IOP19mmOU(14ishwhentreated)
• ReportsnotedblurredvisionOSabout2weeksago– OD20/20– OS20/200
• Type2DMandHTN– A1C7.4– BP134/84
Raster Re4naClinic
• CRVOOSwithgrossmacularedema• Avas4nseriesOSx4• RepeatOCT1mosaferlastinjec4on
BRVOcase
• 69yohispanicmale• PresentsforyearlyDMexam.
– Nocomplaints
• HTN,DM,Obesity– A1c5.4– BP154/81– BMI43.61
• VA20/20OU
BRVOcase
• IncreasingedemaODonOCT– Approachingmacula
• VAremains20/20• Ptgivenop4onoffollowingvs.injec4on,Ptelectstofollow
• RTC4mosforrepeatOCT
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CRVO/BRVO• Referifmaculaedemawithin1week
– Laservs.injec4oninBRVO– Injec4onCRVO– Steroids?
• Systemicworkuprecommended– DM– HTN– Cholesterolpanel– Caro4dDoppler
• LookforNV/NVI/NVA/NVGesp.inCRVO,esp.ifischemic
PLAQUENIL
Plaquenil
• 31yoAAfemale• SentfromRheumatologyclinic
– “ptonplaquenil.Pleasedore4nalscreenincludingOCT”
• +Lupus• 200mgHCQBIDx7years• 20/20OU
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Case
• Normalre4nanoevidenceofplaquenilmaculopathy
• Le]erbacktorheumatologyclinic• Pted• RTC1yr
Plaquenil• Beawareofnewguidelines
– Rheumatologyclinic/PCPsaware– HD-OCT,FAFrecommended– 1stscreeningwithin1styear,thenafer5years
• Riskfactors– >10years– Concurrenttamoxifenuse– Concurrentkidneydisease– Doseabove5mg/kgofREALbodyweight
• Incidencesilllow,probably≈1%
GLAUCOMA
Glaucoma
• 70yoAAmale• FollowedasGlCsuspectx4years• Posi4vefamilyhistory
– Mom,maternalGM
• C/D:OD0.45;OS0.50• IOPs:18-23OD;19-23OS• Ini4al24-2VF:nodefects
Ini4al24-2VF:August2012 Todaysexam
• NoComplaints• VA20/20OU• IOP22mmOD,23OS• 1+NSCOU
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24-2 RightEye
Assessment/Plan
• POAGOD>OS• StartgenericlatanoprostQHSOU
– Goal≈16mmOU(30%reduc4on)– Ptedresideeffectsofg]s
• RTC6weeksforIOPcheck
ANTERIORSEG
Normalangleanatomy Angleclosure