week 5

Question 1

OCT vs FA what do they detect?

Answer 1

OCT: best way to detect changes in thickness

Fluorescein Angiography: only way to detect leakage

Question 2

list some structures that might appear highly reflective on OCT?

Answer 2

horizontal structures, ERM, CWS, hemes, hard exudates, RPE hyperplasia, drusen, RPE atrophy, CNVM, retinal scars, choroidal nevi
*RPE dropout- this appears bright because there is more light from the retina getting though even though it’s a loss of pigment

Question 3

what are some structures with low reflectivity?

Answer 3

vertical structures, fluid, cysts or cavities, shadowed areas, “ beneath a detachment ( RD or PED), vitreous

Question 4

what 3 layers of OCT are hyperreflective?

Answer 4

ILM/ NFL and RPE are hyper-reflective

Question 5

Band 1=

Answer 5

ELM- band slightly lighter in color than ONL

Question 6

Band 2=

Answer 6

IS/OS- inner segment/outer segment junction- light band

Question 7

Band 3=

Answer 7

outer segment tip= Verhoff’s membrane

Question 8

Band 4=

Answer 8

RPE, possibly including Bruch’s

Question 9

Vitreomacular traction puts you at risk for?

Answer 9

Macular hole

Question 10

RPE contains what 2 types of pigment?

Answer 10

Melanin: does not change much after birth
Lipofuscin: increases with age

Question 11

what is lipofuscin made of?

Answer 11

mainly derived from chemically modified residues of partially digested photoreceptor outer segments

Question 12

Only OCT that can do autoFL?

Answer 12

spectralis OCT

Lipofuscin excitation: 300-600 nm

Question 13

T/F: in the Macular Photocoagulation Study (MPS) study, those who got lasered, ended up with the same vision as the untreated group after 5 years ?

Answer 13

Yes, but it was better bw the 5 years

Question 14

What were some of the findigns for the Macular Photocoagulation Study (MPS) study in regards to what laser should be used depending on where the CNV was?

Answer 14

• Only use Argon on extrafoveal areas
• For Jutxtafoveal areas use krypton laser (for lesions closer to fovea)
• For subfoveal, IF you do choose to laser, use Krypton

Question 15

which laser uses less thermal energy, ARgon or krypton?

Answer 15

krypton

Question 16

What were 4 major risk factors (those who already have CNV in one eye- chance of happening in the fellow eye: ) associated with MPS study?

Answer 16

1) Five or more drusen
2) confluent drusen
3) retinal hyperpigmentation
4) systemic hypertension

Patients with all 4 risk factors =87% chance to develop wet AMD (CNV) in fellow eye within 5 years
-Eyes with none of the risk factors have less than 5% chance to develop in the other eye

Question 17

WHat steps are taken in photodynamic therapy?

Answer 17

Verteporforin administered as intravenous infusion (aka Visudyne)

• binds to low density lipoprotein (LDL)
• goes to choroid
• absorbed by CNVM
• then apply laser (10 mins after dye has been injected)
• non-thermal infrared laser= no destruction of viable tissue – for no longer than 83 secs
• oxygen free radicals are released
• endothelial damage and thrombus occur
• abnormal vessels occlude

Question 18

how often did photodynamic therapy have to be repeated

Answer 18

• 1st year: 3-4 treatments

* 2nd year: 2-1 treatments

Question 19

what are some of the side effects of PDT?

Answer 19

pain associated with infusion= common
Visual disturbances= hallucinations
Photosensitivity reaction: had to be completely covered head to toe after treatment otherwise pts would get very sun-burnt
**Newer findings: PDT found to create “expression” of VEGF reason why repeated treatments are needed

Question 20

what was the outcome of Complications of Age-related Macular degeneration prevention trial (CAPT)?

Answer 20

Q: should they laser soft drusen? (Lasering drusen thins this aspect of Bruch’s causing increased permeability – goal is to restore normal transport between retina and choroid)
OUTCOME: No diff (nor harm but no benefit) in treating one eye vs untreated fellow eye for loss of 3 lines or more of acuity or progression to advanced AMD

Question 21

Macugen: cost, freq, why is it no longer first line?

Answer 21

Macugen (Pegaptanib)- breakthrough drug
1st anti-angiogenic drug approved for inhibiting VEGF with CNV formation ~2004
NOT FIRST LINE: Blocks VEGF of a particular isoform (doesn’t target all isoforms)
–Intravitreal injection every 6 weeks for 2 years  $$
–Approx. cost of $1,200 per injection

Question 22

Lucentis vs Avastin:

Answer 22

Lucentis done q3 months then q6 months/2 years (based on the PIER study) OR as needed basis (PRONTO study)
-Approx cost: $2000 per 0.3ml injection

Avastin:

• Larger molecule with a longer ½ life
• Approx cost: $50-150 for 0.3 ml injection
• Much less $$, used once a month

Question 23

how does elyea compare to lucentis/avastin?

Answer 23

possibly superior to others,

Approx cost: $1,850 per injection, every 2 months

Question 24

List several possible side effects of intravitreal injections:

Answer 24

endophthalmitis
catarcts-traumatic
RD-if injection goes too far
myocardial infarction
IOP spike 
uveitis

Question 25

If patient has a history of heart problems, choose which intravitreal injection?

Answer 25

If patient has a history of heart problems, choose Lucentis over Avastin; greater risk of MI with Avastin

Question 26

what was the outcome of “The comparison of treatment trial (CATT)”?

Answer 26

Comparison between Lucentis and Avastin ~2009

Results released in 2012: outcomes between the drugs are very similar, they work equally well

Question 27

what were the outcomes of the Pier trial? Pronto trial?

Answer 27

Q: How often should anti VEGF be used?
Inject 3x (1x a month), for 3 months, THEN:
–PIER trial: 1x every 6 months for 2 years OR
–PRONTO: as needed for the next 2 years (with regular f/u)

Question 28

In what populations do you expect to see Idiopathic Central Serious Choriodopathy

Answer 28

o Males > females; 10:1 or 9:1
o Age 21-30 in males, 31-40 in females
o Type A personalities, high achievers, people under high emotional stress
o May have history of migraine or headaches

Question 29

Describe the clinical presentation for central serous maculopathy: (VA, color VA, etc.)

Answer 29

o VA: sudden decrease in VA, no worse than 20/200 ; blurred , distortion or curved lines
o Color vision: colors look less saturated; perform red desaturation test
o Amsler grid: metamorphopsia present
o Refractive Correction: shift to plus

Question 30

Describe the appearance of central serous maculopathy:

Answer 30

• 1-4DD sized lesion

- elevated, round, or oval shaped, well defined

Question 31

Describe the recovery process for central serous maculopathy: (time, VA, end result etc)

Answer 31

• Several weeks to several months (up to 6) for full recovery
• Most will recover to 20/30 or better within 4-8 weeks
• End result: RPE mottling/ loss of foveal reflex; vision not perfect, colors stay less saturated

Question 32

How often does central serous recur?

Answer 32

1/3 to ½ of cases can relapse within the 1st year

• Each time they get it, the VA will be more affected
• *VA recovery has been noted to be worse in Mexican and Japanese populations

Question 33

epidemiology of epiretinal membrane?

Answer 33

common in those over the age of 65, mostly age related cases, occurs equally in men and women, no racial component

Question 34

pathophysiology of epiretinal membrane?

Answer 34

glial cells pile on top of ILM

Question 35

what surgical option can you consider for ERM?

Answer 35

Membrane peel- vitrectomy and remove the epiretinal membrane

Very invasive and extreme surgery for very severe cases

Question 36

what change in VA would you expect with VA for ERM

Answer 36

Decease in VA- mild to moderate decrease (from 20/20- to 20/80ish)