What's New in Retinal Vascular Disease? Sherrol A. Reynolds O.D., FAAO Associate Professor NSU College of Optometry COPE ID: PS

Transcription

1 What's New in Retinal Vascular Disease? Sherrol A. Reynolds O.D., FAAO Associate Professor NSU College of Optometry COPE ID: PS COURSE OUTLINE I. What s New with Diabetes/DR/DME: Increasing Prevalence 29.1 million children and adults in the US have diabetes (2012 National Diabetes Fact Sheet) o Diagnosed: 21 million people o Undiagnosed: 8.1 (28%) million people o Pre-diabetes: 86 million o 5%- 30% will develop type 2 diabetes within five years o New Cases: 1.7 million new diagnoses/year Diabetic Retinopathy-Diabetic Retinopathy PPP - Updated 2016 Expected to increase to 11 million Americans by 2030 Initial sign of underlying disease (21% of type 2 DM according ADA) 55 people with diabetes become blind very 24 hours (CDC) 43% to 65% of diabetic patients do not receive a dilated eye examination Risk factors: Duration of diabetes, past glycemic control (HbA1c), medications, medical history (e.g., obesity, renal disease, systemic hypertension, serum lipid levels, pregnancy, neuropathy) and ocular history (e.g., trauma, other eye diseases, ocular injections, surgery, including retinal laser treatment and refractive surgery) DME- Increase risk with systemic medications (Avandia, Actos, and Statins have been reported to increase the risk of DME) SDOCT- DME Pattern o Sponge-like retinal swelling o Cystoid macular edema o Serous retinal detachment OCTA- early identification of microaneurysms Paradigm shifts in patient care: Anti-VEGF agents over macular laser photocoagulation for treatment of DME. Anti-VEGF- alternative therapy for proliferative diabetic retinopathy Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy. JAMA. 2015;314(20): Blood pressure (Hypertension) JNC8: <140/90 Cholesterol (Lipid)- C

2 o Asymmetric DR and carotid artery disease American Academy of Ophthalmology preferred practicepattern/diabetic- retinopathy-ppp-updated Accessed July 13, II. What s new with Hypertension/HTR: HTN is a major public health problem HTN is the most common primary diagnosis. Currently affects 80 million Americans (1 of every 3 adults) o A major risk factor for cardiovascular disease (CVD), strokes, myocardial infarctions, renal failure, early death and disability. o Silent killer - mostly asymptomatic, unless severely elevated, which is associated with headache, shortness of breath, anxiety and epistaxis. 7.1 million deaths per year may be attributable to hypertension Nearly half of people with high blood pressure (47.5 %) do not have it under control. Hypertension is projected to increase about 8 percent between 2013 and 2030 (Heart disease and stroke statistics 2016 update: a report from the American Heart)

3 New 2014 JNC 8 Guidelines on HTN Treatment- What does it say? For patients who have kidney disease and diabetes, the goal is 140/90 mm Hg. Hypertensive Retinopathy (HTR)- an important warning sign Common finding, occurring in 50% -80% of hypertensive patients (Represent target-organ damage) Current literature challenges the prognostic significance of Keith-Wagener- Barker and Scheie classification system, stress the importance of describing retinal appearance rather than assigning a grade Patients with normal blood pressure and early clinical signs of arteriolar narrowing have been found to be 60% more likely to be diagnosed with hypertension within a subsequent three-year period, according the Atherosclerosis Risk in Communities (ARIC) study Early/mild HTR- early signs associated with 2X risk of stroke according to the ARIC study. Early signs: General and focal arteriolar narrowing, Arteriolar/venule (AV) crossing changes: Nicking (Gunn s Sign)- hallmark, Venous deflection (Salus sign), Banking of vein distal to the crossing site (Bonnet s sign). Changes in the arteriolar light reflex- Arteriolar sheathing (known as silver or copper wiring). Take home point: Early clinical findings necessitate referral to PCP for HTN management Moderate HTR-retinal or flame-shaped hemorrhages, microaneurysms, exudates, and cotton wool spots. Two-three times more likely to develop a stroke, according the ARIC study. Malignant HTR (optic nerve swelling, macular edema and exudates) A medical or hypertensive emergency, requiring prompt antihypertensive treatment.

4 This stage is associated with poor prognosis for survival. The mortality rate is 50% at 2 months and 90% at one year if untreated. Complications of severe untreated HTR include hemorrhagic detachment of the internal limiting membrane of the retina, subhyaloid and vitreous hemorrhage Hypertensive Choroidopathy- YOUNG patients with acute severe HBP. Poor perfusion of the choriocapillaris lead to: Elschnig s spots-focal area of RPE atrophy with associated pigmentations Siegrist s line- Linear RPE pigmented changes that develop over sclerotic choroidal arteries Focal pigment epithelium detachment, leading to exudative retinal detachment III. Retinal Vascular Occlusion (RVO)- Second most common retinal disease Being increasingly recognizing this as a cerebral vascular accident that shares the same risk factors commonly associated with stroke: hypertension, hyperlipidemia, diabetes, and tobacco use. Central Retinal Vein Occlusion (CRVO)-Thrombotic occlusion Non-ischemic (83% of cases) Acuity >20/200 Good prognosis 5-20% progress from non-ischemic to ischemic CRVO Ischemic - greater than 10-disc areas of capillary non-perfusion observed on fluorescein angiography Acuity < 20/200 (+) RAPD Poor Prognosis Risk for neovascularization Extensive hemorrhages/cws Branch retinal vein occlusion (BRVO)- Occurs at arteriovenous crossing Share a common adventitial sheath-virchow s triad- compression of the veins by arteries, degenerative changes within venous walls, and hypercoagulability. Commonly in superior temporal quadrant Major BRVO, when one of the major branch retinal veins is occluded, and (2) macular BRVO, when one of the macular venules is occluded. Major BRVO Non-ischemic Ischemic- 5 DD or more of capillary non-perfusion on FA, neovascularization. Macular edema (this is the most common cause of vision loss in BRVO)

5 Treatment of Central Retinal Vein Occlusion: Where Are We in 2016? Anti-VEGF first line therapy 2 FDA approved anti-vegf ( ranibizumab and aflibercept) 1 off-label (bevacizumab) Second-line therapy 1FDA approved Corticosteriod (Dexamethasone) 1 off-label (triamcinolone) IV. Retinal Arterial Occlusion (RAO) Emboli (62% of eyes): Cholesterol (hollenhorst), calcific and platelet-fibrin, or other emboli from tumors, migraines, parasitic or fungal injections, Susac syndrome or impurities injected into the bloodstream from intravenous drug use. Non-embolic causes, such as thrombosis and atherosclerosis, Central retinal artery occlusion (CRAO) Acute profound painless unilateral vision loss (20/400-counting fingers or worse) o Sparing of the cilioretinal artery, a branch of the posterior ciliary artery, which occurs in about 25 % of CRAOs results in visual acuity of 20/50 or better. Positive APD Significant visual field defect Cherry-red spot (presence of choroidal circulation) Pale or whitened edematous retina Narrowed retinal artery Segmental arterial blood flow ( boxcarring or cattle-trucking ) Retinal emboli o Lodge at artery bifurcations/detectable in up to 23% of CRAO patients Branch Retinal Artery Occlusion (BRAO) -A wedge-shaped area of superficial retinal whitening in the affected retina (commonly in the temporal arcade) Ophthalmic Artery Occlusion NLP vision Cherry red spot not present More severe retinal whitening Systemic associations (associated with GCA) Cilioretinal Artery Occlusion- central acuity with preservation of peripheral field Treatment (1-24 hour window of opportunity)-retina can only survive minutes of ischemia prior to permanent damage. Digital massage Breathing into a brown paper bag in order to increase blood CO 2 levels Fibrinolytic agents (clot-busters)/ Hyperbaric oxygen (HBO2) has demonstrated promise

6 Ocular Ischemic Syndrome (OIS): ocular hypoperfusion or venous stasis retinopathy Common (CCA) or internal (ICA) carotid arteries stenosis. May cause ipsilateral ocular signs and symptoms. Occurs bilaterally 20% of cases Clinical Signs and Symptoms o Mid-peripheral dot/blot hemorrhages o Dilated retinal veins o Uveitis and NVI/NVA Treatment and Management o PRP, anti-vegf o Carotid Artery Endarterectomy Conclusion: Retinal Vascular Disease is on the rise in the United States. Early diagnosis and treatment has significantly improved the patient visual prognosis and outcome.