Ocular Disease III: Exam 2: Lecture 8: Diabetic Retinopathy 3

Question 1

Non-Steroidal Treatments Drug Therapies (Oral Agents)

1. PKC-PKC-B inhib Arxxant (
i don’t think he’ll ask a question on this…more FYI…

Answer 1

1. goal to normalize Retinal BF abnormalities for Pt with DR. and Decrease Risk of Mod. Vision Loss in those w/DME

Question 2

Non-Steroidal Treatments Drug Therapies (Oral Agents)

1. IVT Anti-VEGF Agents (Lucentis, Ranibizumab, Avastin, Bevacizumab)
   a. Advantages over ROIDS?
   b. DISADVANTAGE?

Answer 2

1. a. Better side effect profile than Steroids

b. TEMPORARY IMPROVEMENT of DME ONLY, Recurrent injections

Question 3

Non-Steroidal Treatments Drug Therapies (Oral Agents)

1. New Anti VEGF Drug is AFLIBERCEPT (VEGF Trap-Eye, Eylea)

a. Approved by FDA for Tx of what?
b. Compared to Lucentis?

Answer 3

1. CNV due to AMD! (2011)

b. It’s simply NON-INFERIOR to Ranibizumab. (has Ab based VEGF binding but uses a different BINDING SITE)

Question 4

Non-Steroidal Treatments Drug Therapies (Oral Agents)

1. DA VINCI Study: Phase 2 VEGF Trap-Eye in Pts w/CSME
   a. Looked at DM pts with what?
2. OUTCOME Goal to MEASURE what?
3. Results?
4. What ABOUT LONG TERM CONSEQUENCES?

Answer 4

1. a. with CSME
2. to look at VA and CENTRAL THICKNESS at 6 MONTHS
3. At 24 wks (6 months): The Acuity looks much significantly Better than laser, as well as reduction in Central Retinal THICKNESS!
4. LONG TERM CONSEQUENCES of these ANTI-VEGF THERAPIES FOR DME in DM PATIENTS REMAINS UNDEFINED!

(they can combine this with Focal Laser)

Question 5

Management

1. Mild NPDR w/CSME
   a. FA?
   b. Ret. Con?
   c. FU Months?
   d. Focal Tx?
   e. PRP Tx?
2. Mod NPDR w/CSME
   a. FA?
   b. Ret. Con?
   c. FU Months?
   d. Focal Tx?
   e. PRP Tx?
3. Sev/V Sev NPDR w/CSME
   a. FA?
   b. Ret. Con?
   c. FU Months?
   d. Focal Tx?
   e. PRP Tx?
4. Non-High-Risk PDR w/CSME
   a. FA?
   b. Ret. Con?
   c. FU Months?
   d. Focal Tx?
   e. PRP Tx?
5. HR PDR w/CSME
   a. FA?
   b. Ret. Con?
   c. FU Months?
   d. Focal Tx?
   e. PRP Tx?

Answer 5

1. a. Yes
   b. 0-3 wks
   c. 2-4 months
   d. Yes
   e. No
2. a. Yes
   b. 0-3 Wks.
   c. 2-4 Months
   d. Yes
   e. NO
3. a. Yes
   b. 0-3 wks
   c. 2-3
   d. Yes
   e. Occ After Focal
4. a. Yes
   b. 0-2 wks
   c. 2-3
   d. Yes
   e. Occ After Focal
5. a. Yes
   b. 24-48 hrs
   c. 1-2
   d. YES
   e. YES

Question 6

CLINICAL PEARLS

1. Proper DIAGNOSIS!
   a. MISDIAGNOSIS by 1 LEVEL UNDERESTIMATES RISK for DEVELOPING PDR in 1 YR by AT LEAST what %?
   b. Severe NPDR Pt has % risk

c. PDR in 1 Yr
d. Focal Laser for CSME Decreases Risk for what?
e. ETDRS:

Answer 6

1. a. At least 50%
   b. 52% of development
   c. V. Severe NPDR Pt has 75% risk of developing PDR in 1 yr
   d. for Mod. VA Loss (doubling Visual Angle) from about 30% to 12%.
   e. PRP decreases risk of Sev. VA LOSS (BVA

Question 7

Clinical Pearls

1. Control levels of what in Diabetics?
   a. % that’s Adequate?
   b. Norm?
   c. % of NPDR over 10 years?
   d. Increased risk of progression in PDR over 10 years?
2. For A1c 5-8%
   a. Decrease A1c by what 10% DECREASES RISK of DR PROGRESSION by what %? (Meta-Analysis of what study)?
3. Decrease BP by how much?
   a. this decreases progression of DR by what %? (Study)
4. When VH Obscures Retina or RD Exists: What MAY BE INEFFECTIVE?
   a. What should be done at this POINT and according to what STUDY?

Answer 7

1. HbA1c
   a. 5-7%
   b. 4-6%
   c. 44%
   d. 145%
2. a. 43% (of DCCT, and UKPDS)
3. 10/5 mmHg
   a. 34% (UKPDS)
4. PRP
   a. Vitrectomy and RD Repair (DRVS)

Question 8

Venous Occlusive Disease

1. How prevalent is this retinopathy?
2. STRONGLY ASSOCIATED with what?
3. Very prominent what 2 things?
4. Most COMMONLY seen in Pts over what?
5. can you laser Exudates?

Answer 8

1. 2nd Most Prevalent Retinopathy (Behind DM retinopathy)
2. with SYSTEMIC DISEASE
3. morbidity and mortality
4. > 45 yrs.
5. NO! even if you have CSME, they will NOT LASER it, cuz (slide 9) there’s nothing to laser. So they will probably do an INJECTION of Avastin or something like that (they are moving AWAY from Steroids these days) or Lucentis or Eylea

Question 9

Anatomy

1. Central Retinal Vein
   a. Single trunk in Nerve, but may Bifurcate w/in what?
   b. Constricts w/in LAMINA CRIBROSA in order to enter what?
   c. Drains the Retina thru what?
2. CRA
   a. Feeds what part of the Retina
   b. Branch of what artery?
   c. Parallels what?

Answer 9

1. w/in the substance of the nerve to a DUAL TRUNK

b. to enter the Globe
c. Thru 4 Tributaries

2. a. Inner 2/3rds of the Retina
   b. of Ophthalmic Artery
   c. the Venous Arcades

Question 10

Venous Occlusive Disease

1. What 4 did we talk about?

Answer 10

1. CRVO
2. HRVO (Hemi-Retinal)
3. BRVO (Branch Retinal)
4. Papillophlebitis

Question 11

CRVO: Background

1. Age of people this is seen in?
2. Incidence b/w men and Women?
3. Prevalence?
4. USUALLY Uni/Bi?
5. 3 Risk Factors for CRVO?

Answer 11

1. ELDERY (50-70 yrs)
2. Same
3. 0.1%-0.4%
4. UNILATERAL (BUT: Estimated up to 7% of persons may develop CRVO in the other eye w/in 5 YEARS!)
5. a. HYPERTENSION (47-57%)
   b. Diabetes
   c. POAG

Question 12

CRVO: Pathogenesis

1. Physical Blockage
   a. Lumina of CRA and CRV are narrower where?

b. Vessels are bound by what?
c. Lamina Limits Expansion and Displacement of what?

2. Hemodynamic Factors
   a. Results in what?

Answer 12

1. a. at the LAMINA CRIBROSA
   b. by a Common Sheath
   c. of ON and Vessels!
2. a. Results in an Obstruction to BLOOD FLOW!

Question 13

CRVO

1. THROMBOTIC/ATHEROSCLEROTIC PHENOMENON
2. What is the NIDUS for Occlusion?
   a. Why?
3. WHAT External Factors MAY Cause FURTHER COMPRESSION and Contribute to OCCLUSION? (2)

Answer 13

1. Some property of the blood and CRV act in Concert to Cause Occlusion.
2. The LAMINAR CONSTRICTION SITE!
   a. Due to Intraluminal Pressure of the Vein decreases, leading it to being susceptible to Collapse. Compression by an Arteriolosclerotic CRA further Affects Flow and Thrombus Formation
3. Increased IOP in POAG and Papilledema (causing increased pressure in the optic nerve sheath)
   * Other factors that can cause Occlusion: Many: orbital tumor, abscesses, Cavernous Sinus Thrombosis, Retrobulbar Intranerve sheath Injection

Question 14

CRVO: Symptoms

1. What happens to Vision?
2. What other two things?
3. Asymptomatic. IT’s RARE. What 2 Occlusive diseases ARE MORE LIKELY to be ASYMPTOMATIC?
4. What is the KEY SYMPTOM (HALLMARK)?!

Answer 14

1. Blurred (unilateral)
2. Scotoma, and Photopsia (rare cases)
3. in BRVO or HRVO
4. SUDDEN (Keyword) PAINLESS LOSS OF VISION!!!!

Question 15

CRVO: SIGNS

1. WHAT WILL YOU SEE in the FUNDUS?
2. Veins?
3. MAIN CAUSE FOR VISION REDUCTION?
4. What White stuff do you see?
5. What will you SEE LATER oN?

Answer 15

1. BLOOD AND THUNDER!! All 4 Quadrants!
2. DILATED, TORTUOUS VEINS!
3. MACULA EDEMA!
4. COTTON WOOL SPOTS (cuz it’s an INFARCT. Rarely see exudates in CRVO)
5. COLLATERAL VESSELS (as body tries to correct itself) and Post and Ant Segment NEO
   * Collaterals form b/w CRV and Vortex Vein thru Unopened Telangiectatic Vessels (they’re already there…but open at this point)

Question 16

Collateral Vessels

1. Why is it good to see these?
   a. They still HAVE WHAT in THEM (will BE ON TEST?!)
2. When will you see them?
3. Present in what % of CRVOS?
4. CRVO with IRIS/ANGLE NV is how MANY TIMES LESS LIKELY to have Collaterals?

Answer 16

1. BECAUSE its NOT NEO! (You WANT TO SEE THEM. It’s the body’s response to fix the problem in a GOOD WAY)
   a. THEY DO NOT LEAK because they still have ENDO LUMEN with TIGHT JUNCTION!
2. 3-14 MONTHS AFTER OCCCLUSION (you WILL NOT SEE THEM INITIALLY…if you think what you see is that, then it isn’t Collaterals)
3. 58% of CRVO’s WITHOUT IRIS/ANGLE NV
4. 25x’s LESS LIKELY!

Question 17

CRVO: Classification

1. Perfused (Non-Ischemic)
   a. Refers to what?
   b. % of all CVOs?
2. Non-Perfused (ISCHEMIC)
   a. Refers to what?
   b. % of CRVO?
   c. To be CALLED Non-Perfused (ISCHEMIC): YOU NEED TO HAVE HOW MANY DISC DIAMETERS?

Answer 17

1. a. Min. to Moderate. Capillary Non-Perfusion (LESS than 50%)
   b. 70-80% of ALL CVO’s
2. a. More than 50% Non-Perfusion
   b. 19-30%
   c. MORE THAN 10 DD of NONPERFUSION to be considered NON-PERFUSED!

Question 18

CRVO: Perfusion vs. Non-Perfusion

1. What is the MAJOR COMPLICATION of CRVO?
   a. THIS IS CORRELATED WITH THE DEGREE OF WHAT?
2. Alternate Classification
   a. PERFUSED
   b. NON PERFUSED
   i. Problem with this method?
3. How do you check Non-perfusion?

Answer 18

1. NEOVASCULARIZATION
   a. with the DEGREE OF CAPILLARY NON-PERFUSION
2. a. 10 DD of NONPERFUSION
   i. May not be able to classify due to too many Hemorrhages and you can’t adequately visualize it.
3. with an FA, but WAIT until BLOOD has CLEARED UP!

Question 19

CRVO: Natural History of it

1. Visual Acuity
   a. If 20/40 or Better?
   b. 20/50 to 20/200?
   c. 20/200 or worse?
2. % of CRVOs that are ISCHEMIC?
   a. APD?
3. If you have an APD is that good or bad?
4. % of all CRVOs that DEVELOP NVI/NVA? (What study?)
   a. % risk of Vascular occlusion (any kind) in the other eye?

Answer 19

1. a. Good likelihood of keeping good VA
   b. Varies
   c. 80% stay at that LEVEL or WORSE!
2. 20-33%
   a. + APD, poorer VA, non-perfusion on FA, +CWS
3. It’s NOT GOOD!
4. 16% (according to CVOS study)
   a. 1%/year risk

Question 20

CRVO: Non-Ischemic

1. % of ALL CASES
2. ACUITY >20/200: Risk for NEO?
3. Low or Deep Hemorrhage?
   a. Type?
4. Prognosis?
5. SHOULD BE TREATED as what?
6. % of “INTERMEDIATE” CRVO that convert to Ischemic CRVO over 4 Months?
7. Over 3 Years, % of perfused eyes that progressed to Ischemic CRVO?
8. Dynamic Phenomenon: What is this?
9. VA: usually what?
10. How common are CWS in this?

Answer 20

1. 70-80%
2. Low risk
3. Deep
   a. Dot/Blot
4. Good. Most have Final VA of 20/40 or BETTER!
5. the TIP of the SYSTEMIC ICEBURG
6. 83%
7. 34%
8. Pt Recovers Vision very well. SPONTANEOUSLY!
9. Normal to Finger count, but MOST have 20/50 or better.
10. They’re RARE!

Question 21

CRVO: Perfusion vs. Non-perfusion

1. VAs?
2. Pupils?
3. What exams are done?
4. What is seen on ERG?

Answer 21

1. 20/200 or worse
2. APD
3. Dilated Fundus, VF, FA
4. a/b wave Reduction

Question 22

Non-Perfused (Ischemic) CRVO

1. Presentation more severe compared to Perfused CRVO?
2. AVG age?
3. Symptoms?

Answer 22

1. MORE SEVERE
2. 68
3. Pt usually aware of SUDDEN, PAINLESS, DECREASE in VISION

Question 23

Non-Perfused (Ischemic) CRVO: Clinical Features

1. VA RANGE?
2. BIG THING YOU SEE?
3. What is seen in the PUPIL?
4. Prognosis?
5. Why would NVI Happen?

Answer 23

1. Range from 20/400 to HM
2. MULTIPLE CWS’s
3. POSITIVE APD!
4. POOR! *Very HIGH RISK of NEO of the IRIS and ANGLE and Low/Mod risk of DISC or RETINAL NEO!!!!!
5. CRVO stimulates VEGF: FINDS POSTERIOR IRIS and forms NEO into the ANGLE! (When you have CRVO, YOU ARE LOOKING AT THE IRIS for NEO!!
   * Because of the look of the Fundus, you probably DONT HAVE TO DO AN FA!

Question 24

NEO:

1. Ischemic CRVO: NEO
   a. NVG % ? KNOWN AS WHAT?
2. Tx of NEO Complications thru what?
3. PREVIOUS THINKING?
4. RETINAL NEO in CRVO is common/RARE?
5. WHAT ABOUT ANTERIOR (NVI, NVG)

Answer 24

1. a. 47% (90 DAY GLAUCOMA: usually occurs w/in 90 days Post Occlusion)

• If pt has NVI but has CRVO: what is the TX? (PRP!!)
• WHEN DO YOU DO IT? WHEN YOU SEE NEO! AND ONLY THEN!

2. thru PRP to destroy Ischemic RETINA and REDUCE O2 NEED.
3. Prophylactic laser.
   * MUST ALWAYS WAIT UNTIL COMPLICATIONS DEVELOP
4. RARE
5. COMMON (Iris 58% and NVG 47%)
   * Non-Ischemic CRVO: NEO IS RARE!

Question 25

Iris/Angle NEO of CRVO 1. What is the MOST COMMON SERIOUS COMPLICATION of CRVO? a. Proportionate to level of what? 2. & of Ischemic CRVO? a. % that Progresses to NVG?! 3. Initial NEO Location? 4. Onset? a. Critical Period?

Answer 25

1. IRIS/ANGLE NEO!! a. of ISCHEMIA (>10 DD) 2. 60-70% a. 45% AT LEAST 3. IRIS in 88-94%, then Angle (6-12%) 4. 2 weeks-2.5 years a. 3 Month-1 Year

Question 26

CRVO: NEO (Ischemic) 1. ALWAYS DO WHAT TEST ON ALL PATIENTS WITH CRVO TO RULE OUT NVI? 2. If PATIENT HAS NVI, what % will DEVELOP NEO GLAUCOMA?

Answer 26

1. GONIOSCOPY!! | 2. 2/3-3/4 will develop Neo Glaucoma!

Question 27

Ischemic Vs. Non-Ischemic CRVO Characteristics: Ischemic 1. Clinical Impressions 2. FA 3. Pupil Defects 4. VA

Answer 27

1. a. Retinal Details obscured by Flame-shaped hemes b. CWS c. Orange, Turbid, Edematous and Sick looking Retina 2. 10+ DD of Retinal Non-Perfusion on FA 3. + APD 4. <20/200 (Finger count at 2 Ft)

Question 28

Ischemic Vs. Non-Ischemic CRVO Characteristics: Non-Ischemic 1. Clinical Impressions 2. FA 3. Pupil Defects 4. VA

Answer 28

1. a. Dot/Blot Hemes b. Still looks like Blood and thunder w/Flame-shaped hemes 2. 0-9 DD of Retinal Non-Perfusion 3. - APD 4. >20/200

Question 29

Vision Loss due to CRVO 1. Macular Edema 2. RPE Atrophy 3. Macular Ischemia 4. Retinal Hemorrhage? 5. NEO Glc? 6. Vitreous Hemorrhage? 7. Tractional RD?

Answer 29

1. MAIN CAUSE of VISION REDUCTION in CRVO 2. happens 2ndary to Chronic Macular Edema --> PERMANENT VISION REDUCTION 3. Severe, Irreversible Vision Loss. Often the cause when the vision loss is MUCH MORE DRAMATIC than the CLINICAL PICTURE! 4. Common 5. Common 6. Rare 7. Rare

Question 30

CRVO tip of SYSTEMIC ICEBURG Systemic Considerations 1. What things?

Answer 30

1. HTN (more detailed evals reserved for special cases like Bilateral Cases) 2. DM Many other things..Syphillis, AIDS, Collagen Vascular Disease

Question 31

CRVO Treatment and Management 1. First thing to do? 2. In Office Management 3. ProphyLACTIC LASER? 4. Use of Beta Blockers? 5. REFERRAL TO RETINOLOGIST FOR WHAT?

Answer 31

1. Treatment of Underlying Systemic Condition (rarely REVERSES VEIN OCCLUSION but may prevent it in the other eye) 2. a. FA (not in early course) b. Pupil testing c. Retinal Photography d. Gonio to R/o Angle NEO e. Measure IOP f. F/U q 1 month for 4 Months, then periodically until complete Resolution (or Blindness) 3. NOT INDICATED 4. Not WELL THOUGHT OF Tx (reduce pressure elevations and re-establish BF) 5. PRP IF there's NVD, NVE, NVI, NVG or MACULAR EDEMA

Question 32

Central Retinal Vein Occlusion Study (CVOS): Questions they ASKED. 1. Looked at NATURAL HISTORY of what? 2. Is PHOTOCOAGULATION BENEFICIAL for what? 3. Is PRP effective in Preventing what in Pts w/Non-Perfused CVO

Answer 32

1. of CRVO 2. Macular Edema (VA 20/50 or worse) 3. INV/ANV in Pts w/Non-Perfused CVO

Question 33

Central Retinal Vein Occlusion Study (CVOS): Progression 1. % PERFUSED that Progressed to Non-Perfused? a. % w/in 1 Month of Onset 2. Risk Factors a. DD of Retinal Non-Perfusion b. VA of what or worse? 3. Indeterminate Eyes a. % Progressed to non-perfused b. % in 6 Months?

Answer 33

1. 16% a. 24% 2. a. 5-9 DD b. 20/200 or worse 3. a. 83% b. 92%

Question 34

CVOS study: Did Macular Grid Laser Tx help improve the vision in eyes w/CRVO and VA 20/50 or worse DUE TO MACULAR EDEMA 1. Did Macular Laser have a SIGNIFICANT EFFECT ON VA? 2. What is the STANDARD of CARE if you have CRVO AND MACULAR EDEMA?

Answer 34

1. NO! so MACULAR GRID LASER is NOT INDICATED!! | 2. YOU DO NOTHING!!!!!!

Question 35

CVOS Study Group: N Study 1. Is PROPHYLACTIC PRP EFFECTIVE in reducing NVI and NVA in cases w/10 DD Areas or more of capillary non-perfusion? a. Results: Both groups (no Tx early on and Early Prophylactic PRP) DEVELOPED WHAT? 2. So what is Early Prophylactic Tx Indicated here?

Answer 35

1. NEO!! 2. NO! EYES w/o early Prophylactic Tx Responded BETTER TO PRP! * More likely to regress in untreated eyes than those treated prophylactically.

Question 36

CVOS Conclusions 1. Is there ANY ADVANTAGE to EARLY PROPHYLACTIC Tx w/PRP of ISCHEMIC CRVO? 2. PRP ONLY AFTER WHAT IS SEEN? 3. DID MACULAR LASER have a significant effect on VA? 4. Monthly EVAL for what? 5. WHAT 2 exams are done on EVERY VISIT ARE MANDATORY?! 6. Increased risk of INV/ANV with what? 7. Most significant risk factor for predicting INV/ANV? 8. Eyes w/20/40 or better: F/U when? 9. Eyes 20/200 or WORSE?

Answer 36

1. NO 2. after NEO is SEEN 3. NO. So it's NOT INDICATED! 4. for INV/ANV 5. SLE with GONIOSCOPY! 6. with decreased Vision 7. Amt of Non-perfused retina 8. every 1-2 months for 6 months 9. FU monthly for 6-8 months