Swollen macula: Top 5 PROFESSOR FARUQUE GHANCHI AMD u DMO u - - PowerPoint PPT Presentation

Swollen macula: Top 5

PROFESSOR FARUQUE GHANCHI

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AMD

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DMO

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RVO

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CSR

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CMO

How do you identify swollen macula

Symptoms

Minimum acuity

Functioning acuity

Contrast Glare Colour Distortion Central Field

Signs

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SWELLING

u Fluid u Exudates u Fibrosis

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Haemorrhage

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Pigment change

Bradford Ophthalmology Research Network BORN for vision

Optimum treatment

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Tailored/Individualised

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Generic/ Population

• Incipient
• Prodrome

Biological initiation

• Symptoms
• Signs

Disease Detection

• Screening

TESTS

• Diagnostic

First medical Contact

• Service

Design

• Capacity

Treatment Initiation

Patient Delay Seeking healthcare Detection / Referral Delay Service Delay Medical Practitioner Patient Prior M, et al. Br J Ophthalmol 2013;0:1–5. doi:10.1136/bjophthalmol-2013-303813

AMD

Dry

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Drusen

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RPE changes

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Atrophy

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Disciform scar

Wet

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PED

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nAMD

u CNV u RAP u CRA u IPCV

Drusen

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Types of Drusen –

u Soft, hard… but there is more! u Reticular drusen ? Risk for wet AMD

Serous PED

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Wet AMD - but no identifiable CNV

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Conservative management

u Warn for new symptoms

Wet – neovascular AMD

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Retinal haemorrhage

u Deep intraretinal/ subretinal or subRPE u OCT outer retinal and RPE/Bruch’s

changes

Fibrosis- end stage nAMD

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Scar in outer retina

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Usually stable/ non progressive central scotoma

AntiVEGF

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Very good outcomes with antiVEGF injections

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if Timely referral and treatment

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AntiVEGF agents in clinical use in NHS

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LUCENTIS & EYLEA

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Local expereince

u Both probably similar u Outcome data collection

u Average 7 injections in first year u 4+ in second year u Treatment is indefinite

Not all AMD

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In practice look out for signs of nAMD

u OCT can help refine diagnosis

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Macular hole may be confusing

u Watzke’s sign with Volk lens on slitlamp

DMO

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Incidence of diabetes rising globally

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Local diabetic population on the up

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Screening programme helps early diagnosis

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Diaabetic retinopathy is usually continuos –progressive condition

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Background – preproliferative – proliferative stages

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Maculopathy occurs at any stage

DMO

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Definition

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Cliniaclly significant macular oedema

u CSMO – clinical diagnosis

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Centre involving macular Oedema

u CiMO – OCT based u NICE guidance is based on this

Treatment of CiMO

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AntiVEGF

u Lucentis or Eylea

u If >400 micron (NICE)

u Ozurdex or Iluvien implant

u If unresponsive to antiVEGF and eye is

pseudophakic u

Good results with AntiVEGF

u Improvement in vision 5-10 letters

u Multiple injections and visits (monthly) in

the first year

u Reduced number of injections in second

year u

Steroid implants: Ozurdex /Iluvien

u Rescue treatment

RVO

Epidemiology

BRVO > CRVO Prevalence:

0.5–2.0% for BRVO 0.1–0.2% for CRVO

5 year incidence:

1.8% for BRVO 0.2% for CRVO

CRVO – natural history

Spontaneous improvement < 20%

Base line VA 6/60 to 6/18

Young age (<50) more favourable

20% still get severe issues (NV)

Dehydration/ Inflammation

10% BILATERAL @ baseline

5% get second eye involvement in 1 year

BRVO- natural history

Spontaneous improvement 50- 60%

6/12+ at one year

20% worsen 5% bilateral BRVO evident at presentation Most unilateral

10% would get second eye involvement

CRVO treatment

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Risk factor assessment

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Macular oedema

u Lucentis/ Eylea u Ozurdex injections

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Neovascular comlications

u Laser u Glaucoma Rx

BRVO treatment

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Risk factor assessment

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Macular oedema

u Lmacular laser – if view is clear u Lucentis/ Eylea u Ozurdex injections

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Neovascular comlications

u Laser

CSR CSCR

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It was:

u Retinal/ RPE issue u Young man

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Now

u Central Serous Choroido(Retino)pathy

u Leakey choroid u Any age

CSCR Types & management

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Acute

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Recurrent > 2 recurrences

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Persistent >4 months

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Persistent with tracks (Chronic)

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Conservative

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Individualised

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PDT, AntiVEGF, MR Antagonists

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PDT, AntiVEGF, MR Antagonists

CMO

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1-19%

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More with complicated surgery

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Uveitis

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Diabetic eye?

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RVO

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ERM

CMO management

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Treat residual inflammation – steroid drops

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Nonsteroidal anti-inflammatory drops

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Oral Diamox

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Steroids – periocular/ intraocular injections

u Oral?