Grand Rounds Conference Tala Kassm DO December 10

Grand Rounds Conference Tala Kassm DO December 10 th, 2015 University of Louisville Department of Ophthalmology and Visual Sciences

Subjective n CC: “I can’t see since last night. ” n HPI: 81 year old male presents to clinic with complaint of sudden painless vision loss in his left eye for one day. Denies headaches, fevers, weight loss, jaw claudication or temporal tenderness. No associated pain, flashes or floaters. n Review of Systems: per HPI.

History POH: - HRVO with CME OD s/p avastin - POHS OU with macular scar OS - PCIOL OU - BRVO OS (2008) - Mild NPDR OU

History PMH: DMII, HTN, hypothyroidism, CVA, HLD Family Hx: noncontributory Meds: insulin, lisinopril, levothyroxine, xarelto, simvastatin Allergies: NKDA

Clinical Exam VA(cc, D): OD 20/40 OS HM (-1. 25+0. 75 x 160) (-1. 00+1. 00 x 180) Pupils: 3 ->2 IOP: EOM: CVF: assess 15 FULL 3 ->2 2+r. APD OS 14 FULL unable to

Clinical Exam Dilated Fundus Exam: OD ON c/d- 0. 4 Macula scar cotton wool spots mild edema perifoveally Vessels Superior HRVO artery, OS c/d- 0. 5 juxtafoveal POHS retinal whitening small emboli in primary superotemporal

OCT Retina - OS

FA OS

FA OS

FA - OS

Assessment n 81 year old male with sudden painless vision loss of left eye. n Diagnosis: Central retinal artery occlusion OS n Differential also includes: n Giant Cell Arteritis

Plan Treatment options discussed at length with patient – 25 gauge pars plana vitrectomy n Patient declined surgery. n Ocular massage attempted. n AC paracentesis performed. n Carotid doppler ultrasound ordered and 2 D echocardiogram n

Follow Up: Three Days Vision: HM OS n Pressure OS: 14 mm. Hg n Vessels appeared narrow with box carring, diffuse retinal edema n Patient reports he ran out of xarelto three weeks ago n Started on a baby aspirin n

Follow up: 5 weeks Vision still HM OS but IOP now 38 mm. Hg OS n Gonioscopy showed NVA n n Diagnosis: n n NVG OS secondary to CRAO Plan: Avastin OS, PRP in the future n Start Cosopt BID OS n

Central Retina Artery Obstruction n Defined as an abrupt decrease of blood flow through the central retinal artery severe enough to cause ischemia of the inner retina n Hallmark symptom: abrupt painless loss of vision in one eye n Initial presenting vision of 20/800 or worse n Light perception to counting fingers in 90% of patients

Presentation Fundus may appear relatively normal in the first few minutes to hours after obstruction n Axonal swelling in the nerve fiber layer results in whitening of the retina and arteries appear attenuated n In severe obstruction, veins and arteries manifest box-carring or segmentation of blood flow n Cherry-red spot: orange reflex from intact n

Epidemiology Accounts for an estimate of 1 in 10, 000 outpatient visits to the ophthalmologist n Incidence of 1. 9 per 100, 000 n Men to women 2: 1 ratio n Mean age 60 years n n n Has been reported to occur from first to ninth decade Bilateral involvement in 1 -2% of cases

Pathogenesis Believed that majority are caused by thrombus formation at or proximal to the lamina cribrosa. n An embolus is visible in the central retinal artery in 20 -25% of cases. n Other causes: n Inflammation in the form of vasculitis (Ie. varicella) n Local trauma to the optic nerve or blood vessels n

Management of CRAO n Reduce IOP n IOP- lowering medications n Anterior chamber paracentesis n Ocular massage n Thought to possibly dislodge emboli 25 gauge vitrectomy n No longer recommended n n Carbinogen vasodilatory inhalation therapy n Hyperbaric oxygen therapy n Catheterization of ophthalmic artery with t. PA infusion n Transvitreal Nd: YAG embolysis

Course and Outcome n Vision loss is permanent due to infarct of inner retina n Irreversible damage to sensory retina after 90100 minutes of complete CRAO Vision of 20/400 or worse in 66% of cases n Complications n Iris neovascularization occurs in 18% of eyes n Less than five percent develop neovascular glaucoma n

Neovascularization of the Iris Also known as rubeosis iridis n Occurs after retinal ischemia – most commonly caused by proliferative diabetic retinopathy (PDR), central retinal vein occlusion (CRVO) or carotid artery occlusive disease (CAOD) n Less commonly: n n n CRAO, sickle cell retinopathy, anterior segment ischemia Can also occur with tumors, uveitis,

Neovascular Glaucoma Neovascularization of the iris and the angle leads to fibrovascular membranes n Obstruct trabecular meshwork -> secondary open-angle glaucoma n With disease progression the fibrovascular membranes mature and contract, tenting the iris toward the trabecular meshwork -> Peripheral anterior synechiae and angle closure-> secondary angle-closure glaucoma n

Neovascular Glaucoma Treatment Indentify and address underlying etiology n Systemic workup for CRVO, PDR, CRAO and carotid artery occlusive disease n Mainstay of treatment and prevention is panretinal photocoagulation (PRP) or cryotherapy n Medical therapy with atropine 1%, topical steroids and antiglaucoma medications n

Mason, John O; Patel, Shyam A; Feist, Richard M; Albert Jr. , Michael A; Huishingh, Carrie; Mc. Gwin Jr, Gerald, Thomley, Martin L. n Investigate the ocular neovascularization rate in eyes with a branch retinal artery occlusion or a central retinal artery occlusion n Study factors that influence ONV rate secondary to CRAO. n Retrospective case series – 83 CRAO’s and 203 BRAO’s.

In the CRAO group, 14. 5% developed ONV n Average time for development of ONV was 30. 7 days n Diabetes mellitus type 2 was a risk factor for ONV development after CRAO – odds ratio of 5. 2 n Patients with DMII should be monitored closely for first 6 months after CRAO for ONV n

References n n n Falkenberry SM, Ip MS, Blodi BA, Gunther JB. Optical coherence tomography findings in central retinal artery occlusion. Ophthalmic Surg Lasers Imaging. 2006; 37(6): 502 -505. BCSC: Retina and Vitreous pages 131 -135 Mason, Jason O. Patel, Shyam A. Feist, Richard M. Albert Jr, Michael A. Huisingh, Carrie. Mc. Gwin Jr, Gerald. Thomley, Martin L. Ocular neovascularization in eyes with a central retinal artery occlusion or a branch retinal artery occlusion. Clinical Ophthalmology 2015 (9): 995 -1000. Ryan SJ. Retina. 4 th ed. Philadelphia: Elsevier/Mosby; 2013. Park SJ, Choi NK, Seo KH, Park KH, Woo SJ. Nationwide Incidence of Clinically Diagnosed Central Retinal Artery Occlusion in Korea, 2008 to 2011. Ophthalmology. 2014 Jun 7. pii: S 0161 -6420(14)00383 -2. doi: 10. 1016/j. ophtha. 2014. 029. [Epub ahead of print]

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