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Grand Rounds

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Grand Rounds Shivani V. Reddy, M.D. 7/18/14 University of Louisville Department of Ophthalmology and Visual Sciences – PowerPoint PPT presentation

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Title: Grand Rounds


1
Grand Rounds
Shivani V. Reddy, M.D. 7/18/14 University of
Louisville Department of Ophthalmology and Visual
Sciences
2
Patient Presentation
  • CC Blurry Vision OD
  • HPI 80 y/o AAF presents for yearly Plaquenil
    check She states that her vision had been stable
    until 1 month ago when she noticed some
    blurriness and dimming of vision OD. She denies
    experiencing metamorphopsia, flashes, floaters or
    scotomas.

3
History
  • POHx refractive error
  • PMHx Rheumatoid Arthritis, Hypertension,
    Hypothyroidism
  • FAMHx uknown
  • ROS joint pain
  • MEDS Plaquenil ( 3.04 mg/kg/day (65.7kg weight),
    200mg daily x 5 years)
  • Toprol, MTV, triamterone, synthroid
  • ALLERGIES NKDA

4
Exam
VA
TP P
no RAPD
EOM full OU CVF full OU

5
Exam
OD
OS LIDS/LASHES
WNL
WNL CONJ WNL
WNL CORNEA
WNL
WNL IRIS
WNL WNL LENS
2NS, 1CC 2NS, 1CC
6
Fundus Photos
OD
OS
OD photo demonstrates orangish-red faintly
circumscribed lesions in the peripapillary region
7
FAF Photos
OD
OS
8
1.OD
2.OD
3.OS
  1. Nasal pigment epithelial detachment with
    associated neurosensory detachement with
    sub-neurosensory fluid accumulation, some loss of
    foveal contour
  2. Nasal pigment epithelial detachment with
    overlying heme and fluid

9
FA/ICG
Early AV Phase
001945
Superonasal hypofluorescence, network of dilated
peripapillary vasculature with terminal bulb
Peripapillary staining, supero-nasal
hypofluorescence of dye
10
FA/ICG
AV Phase
002945
Increasing peripapillary hyperfluorescence
circular of hyperfluorescence at end of vascular
network
11
FA/ICG
Recirculation Phase
12145
Hyperfluorescence of polypoid lesion and
demonstration of surrounding vascular network
continual demonstration of peripapillary dye
leakage, increasing over area of polyp
12
FA/ICG
Late Phase
20045
Decreased hyperfluorescence of polyp with
surrounding area of hypofluorescence
Persistent peripapillary dye pooling representing
leakage
13
Summary
80 y/o AAF presents for routine plaquenil check
with 1 month history of blurriness and dimming of
vision OD. BCVA OD is 20/50-2. ICG angiography
demonstrates choroidal polyps with surrounding
vascular network and corresponding leakage on FA.
OCT demonstrates PEDs OD with overlying
neurosensory retinal detachment
  • DDx
  • Polypoidal Choroidal Vasculopathy
  • Other entities causing subretinal
    neovascularization
  • AMD
  • CSCR (central serous chorioretinopathy)
  • Pathologic myopia
  • Choroidal tumors or Mets
  • Infection

14
Treatment
First Visit 20/50-2
1 month post Avastin 1 VA 20/50
1 month post Avastin 2 VA 20/40-2
15
Polypoidal Choroidal Vasculopathy
  • Also known as posterior uveal bleeding syndrome
  • First described by Dr.Yannuzzi in 1982
  • Characterized by sub-retinal vascular lesions
    associated with serous and hemorrhagic
    detachments of the RPE
  • Named for its network of branching, choroidal
    vessels with terminal polyp-like aneurysmal
    dilations

16
Polypoidal Choroidal Vasculopathy
  • First described in middle -aged African American
    woman
  • Most commonly seen in 50-65 age group
  • Occurs 23-55 in Asian patients presenting with
    neovascular AMD
  • 4 to 9.8 prevalence reports in Caucasian
    patients with presumed AMD

17
Polypoidal Choroidal Vasculopathy
  • Diagnosis based on ICG angiography high
    definition OCT and fundus photography
  • FA not helpful as it demonstrates too much dye
    leakage
  • Classification based on imaging characteristics
  • Branching vascular network vs. feeder vessel
    supplying polyps
  • Cluster of polyps vs. single polyp
  • Juxtafoveal vs. extrafoveal polyps

18
Polypoidal Choroidal Vasculopathy
  • CNV or Not?
  • PCV is?
  • More likely to occur in pigmented races, although
    also demonstrated in Caucasians
  • lesions more likely to be peripapillary
  • ICG in late phases shows wash-out of polyp in
    contrast to late staining seen in occult CNV

19
Polypoidal Choroidal Vasculopathy
  • Treatment
  • Anti- VEGF treatment alone not helpful
  • EVEREST TRIAL
  • Compared PDT monotherapy and PDT ranibizumab to
    ranibizumab alone
  • Significantly higher proportion in the first 2
    groups showed regression at 6 months
  • Surgical intervention based on complications such
    as break-through vitreous hemorrhage

20
Polypoidal Choroidal Vasculopathy
  • Prognosis
  • Clinical outcomes in literature vary considerably
  • 35-68.2 of patient with reported poor outcomes
  • Larger polyps, juxtafoveal location of polyps and
    clustering of polyps are risk factors for massive
    subretinal and subsequent vitreous hemorrhages
  • In patients with large detachments, subretinal
    fibrosis can lead to eventual vision loss
  • PDT can lead to subretinal hemorrhage in upto 31
    of eyes, VH in 6-12.5 post treament, 8.9 of
    bleeding post anti-VEGF

21
  • Retrospective chart review
  • 17 patients with massive subretinal hemorrhages
    (SRH) secondary to PCV (16.7/- 7.1 DD) and
    associated vitreous hemorrhage (VH) enrolled
  • Patients underwent 20G Pars Plana Vitrectomy /-
    bevacizumab injection for new heme, PED or CME
  • Main outcome measure BCVA at end of follow-up
    period

22
  • Mean post-op follow up of 25.2 months
  • Mean duration from SRH to VH was 3.5 /- 1.2
    weeks
  • Time from VH to PPV 1.3 /- 0.7 months
  • BVCA (LogMar)
  • Pre VH 0.95 /- 0.60
  • Pre PPV 2.65 /- 0.57
  • 3 months post-op 1.62 /- 0.67
  • Final Visit 1.43 /- 0.82
  • VA gt 20/400 in 16.7 of juxtafoveal polyp
    patients, 87.5 of extraoveal polyp patients

23
THANK YOU
24
References
1.Retina and Vitreous, BSCS 2. Retina, Vitreous
and Macula , David R. Guyer MD, Lawrence A.
Yannuzzi MD, Stanley Chang MD and Jerry A.
Shields MD  3.Yannuzzi LA, Sorenson J, Spaide RF,
Lipson B. Idiopathic polypoidal choroidal
vasculopathy (IPCV). Retina 1990 10(1)
18. 4.Koh et al. EVEREST STUDY Efficacy and
Safety of Verteporfin Photodynamic Therapy in
combination with Ranibizumab or Alone Versus
Ranibizumab Monotherapy in Patients with
Symptomatic Macular Polypoidal Choroidal
Vasculopathy. Retina 2012 321453-1464. 5. Uyama
M, Wada M, Nagai Y, et al. Polypoidal choroidal
vasculopathy Natural history. Am J Ophthalmol.
2002 133(5)639-48. 6. Lim TH, Laude A, Tan CS.
Polypoidal choroidal vasculopathy An
Angiographic discussion. Eye (Lond) 2010
24483490 7.Kamaeda T, Tsujikawa A, Otani A, et
al. Polypoidal choroidal vasculopathy examined
with en face optical coherence tomography. Clin
Experiment Ophthalmol. 2007 35(7)596-601. 8.Sato
T, Kishi S, Watanabe G, et al. Tomographic
features of branching vascular networks in
polypoidal choroidal vasculopathy. Retina. 2007
27 589-594. 9.Park DH, Shin JP, Kim IT.
Association of plasma malondialdehyde with ARMS2
genetic variants and phenotypes in polypoidal
choroidal vasculopathy and age-related macular
degeneration. Retina 2013 0110.
25
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