ARMD - Investigations

ARMDInvestigations & ManagementDr Gyanendra LamichhaneLumbini Eye InstituteBhairahawa,Nepal : 

ARMDInvestigations & ManagementDr Gyanendra LamichhaneLumbini Eye InstituteBhairahawa,Nepal References: Retina & Vitreous – AAO, section 12, 2003-4 OPHTHALMOLOGY- Myron Yanoff Principles and Practice of Ophthalmology, Albert & Jakobiec, Vol.2 RETINA - Stephan J Ryan, Vol.2 Clinical Ophthalmology – Kanski Internet

Fundus Fluorescein Angiography : 

Fundus Fluorescein Angiography Signs & symptoms FFA Stereoscopic angiography Late-phase photographs (2, 5 & 10 min) Appropriate management

I. Drusen : 

I. Drusen Hard drusen: fluorescing brightly in early phase and fading soon after the background choroidal fluorescence. Soft drusen: fill more slowly & are not brightly as hard drusen but remain fluorescent for a longer period.

II. Geographic Atrophy : 

II. Geographic Atrophy Early hyperfluorescence of atrophic area- late staining Focal hyperpigmentation: pigment clumps micro-reticular pattern.

III. Serous RPE detachment : 

III. Serous RPE detachment Early phase: uniform bright hyperfluorescence Venous phase: increase in intensity Late phase: same size

IV. Choroidal Neovascularization : 

IV. Choroidal Neovascularization Types based on FFA : Well defined / Classic CNV (10-15%) Poorly defined / Occult CNV Fibrovascular PEDs Late leakage of undetermined source

Classic CNV : 

Classic CNV Early phase: well-demarcated boundaries of hyperfuorescence Progressive dye leakage pooling in the overlying subretinal space (1-2min) lacy network of vessels: lacy pattern

Occult CNV : 

Occult CNV Fibrovascular PEDs: Irregular elevation of the RPE which detected on stereoscopic FA. Not discrete or bright as areas of classic CNV during the transit. By 1-2 min after injection, area of stippled hyperfluorescence becomes apparent By 10 min, there is persistence of fluorescein staining or leakage within a sensory retinal detachment overlying this area.

Occult CNV : 

Occult CNV Late leakage of undetermined source Areas of late choroidal fluorescein leakage Appearing as speckled hyperfluorescence Pooling of dye in the overlying subsensory retinal space in which there is no discernible, discrete, well-demarcated area of hyperfluorescence that might be considered the source of leakage from earlier photography.

Angiographic features that obscure the boundaries of CNV : 

Angiographic features that obscure the boundaries of CNV Blood Hyperplastic pigment or fibrous tissue Serous detachment of the RPE

Other angiographic features of CNV : 

Other angiographic features of CNV Fading CNV Recognized in the early-or middle-transit with fading in the late phase Not required treatment in this area (MPS in 1991)

Other… : 

Other… Feeder vessels: Choroidal vessels apparent during the transit phase

Other… : 

Other… Loculated fluid: this fluid consists of a well-demarcated area of hyperfluorescence extends beyond CNV borders Early-transit phase Late-transit phase

Other… : 

Other… Tears or rips of the RPE Seen on early-transit phase extremely sharp, well-demarcated hyperfluorescence. Blocked fluorescence corresponds to folded, torn pigment epithelium.

Classification on FFAAccording to location : 

Classification on FFAAccording to location Extrafoveal – extends no closer than 200 μm from centre of FAZ. Juxtafoveal – edge of CNV extends within 1-199 μm from the centre of FAZ Subfoveal – involving the centre of FAZ (very poor visual prognosis)

Indocyanine Green Angiography : 

Indocyanine Green Angiography Infrared based digital imaging technique Advantages over FFA : Highly protein bound dye , leaks slowly from choriocapillaries. Greater degree of penetration through RPE, blood Uses – detection of occult CNV detection of recurrent CNV following Laser

Appearance of CNV : 

Appearance of CNV Focal/Hot spots : <1DD in size , well delineated Placoid hyperfluorescence : occult CNV >1DD may/may not well defined and not obscured by h’age Combination

Serous RPE detachment- : 

FFA ICG angiography Serous RPE detachment-

Serous RPE detachment- : 

FFA ICG angiography Serous RPE detachment-

Confocal scanning Laser fundus fluorescein with ICG : : 

Confocal scanning Laser fundus fluorescein with ICG : Method – 5oo mg of Fluorescein + 25 mg ICG (mixed together ) Heidelberg Retina Angiograph. Argon laser beam (488 nm) + diode laser beam (795 nm) delivered by single mode fibers . emission – 500 –700 nm and above 800nm. digital image

Confocal scanning… : 

Advantages : High contrast image during all phases Accurate correlation of findings Low retinal irradiance Less time consuming Confocal scanning…

MANAGEMENT : 

MANAGEMENT

DRY ARMD : 

DRY ARMD Micronutrient supplements: (AREDS) Antioxidants: vit.C 500mg, vit.E 400IU and beta carotene 15mg Minerals: zinc oxide 80mg and cupric oxide 2mg Sunglasses Photocoagulation: under study Education & F/U Low-vision aids

WET ARMDTreatment Modalities : 

WET ARMDTreatment Modalities Photocoagulation Photodynamic therapy Transpupillary thermotherapy Radiation Submacular surgery Macular translocation Intravitreal clots lysis and pneumatic relocation of hge Rheotherapy Pharmacologic therapy

Photocoagulation : 

Photocoagulation Goal: To decrease risk of additional severe VA loss Different Wavelength (red/green)  no effect on tt benefit. Indication: Classic CNV with well-defined borders. Classic & occult CNV components with well-demarcated boundaries. Note: Extrafoveal & juxtafoveal lesions  photocoagulation Subfoveal lesions  photodynamic therapy

Preparation of patient : : 

Preparation of patient : Informed consents: Not a cure – persistent or recurrent CNV Regarding side effect - permanent scotoma,  distortion,  VA Periodic F/U Perform < 24hrs after FFA

Extrafoveal lesion : 

Extrafoveal lesion Lesion location : foveal edge of CNV 200-2500 μm from FAZ centre. Laser pattern : cover CNV, contiguous blockage , and 100 μm beyond. Recurrence : 54% at 5yrs

Juxtafoveal lesion : 

Juxtafoveal lesion Lesion location : foveal edge of CNV 1-199 μm from FAZ centre foveal edge of classic CNV >199 μm from FAZ centre with blockage by pigment or blood < 200 μm from FAZ centre Laser pattern : nonfoveal side: cover CNV, contiguous blockage , and 100 μm beyond. foveal side: cover CNV; If CNV >100 μm from FAZ centre & blood is present, cover contiguous blood up to 100 μm beyond. By 5 yrs: PER: 32% - REC: 47%

Subfoveal lesion : 

Subfoveal lesion Lesion location: CNV under fovea Laser pattern: cover CNV, blockage and 100 μm beyond By 4 yrs: PER: 7% - REC: 37%

Recurrence : 

Recurrence Risk of recurrence is greatest: When fellow eye has evidence of active CNV or scarring. When treatment fails to cover the neovascular lesion in its entirety. When photocoagulation is not as intense as a moderately white treatment intensity standard

Recurrence : : 

Recurrence : Signs : decreased VA. persistence / increased SRF. new areas of hypopigmentation at tt scar edge. new late hyperfluorescence at tt scar edge. adjacent stippling of RPE on FFA. contiguous RPE detachment. new flecks of sub-retinal blood /lipid.

Photodynamic therapy (PDT) : 

Photodynamic therapy (PDT) Rx of classic sub-foveal CNV. photosensitizing drug: Verteporfin, tin ethyl etiopurpurin, and lutetium attaches to lipoproteins present in actively proliferating capillaries of CNV Laser causes photoactivation Verteporfin converts oxygen into highly energized oxygen singlet that damages endothelial cells of CNV Verteporfin (6mg/m2 of body surface)

PDT… : 

PDT… 15 min later a diode laser at 689 nm in slit lamp delivered 50 J/cm by continuous application of laser at 600 mw/cm2 for 83seconds. Treatment spot size was1000 μm larger than greatest linear dimension (5400 μm or less) Avoidance of direct sunlight for 48 hrs Verteporfin therapy reduces the risk of moderate to severe vision loss

Surgery in tt for subfoveal CNV : 

Surgery in tt for subfoveal CNV Full macular translocation with 3600 retinotomy (AJO 2002 Oct;134(4):560-5) Improve vision  reading & driving Consider effective approach Autologous peripheral RPE translocation (BJO2004;88:110-3) High PVR rate No measurable positive effect on functional outcome

Radiotherapy : 

Radiotherapy BJO 2004;88:114-9 Radiotherapy for recurrent CNV Methods: 7 fractions of 2Gy (total dose 14Gy) 5 fractions of 3Gy (total dose 15Gy) Results: palliative benefit with higher fractions sizes and doses Further investigation for 4Gy or higher

AJO 2003 Jan; 135(1): 109-112 : 

AJO 2003 Jan; 135(1): 109-112 Limited macular translocation for the mangement of subfoveal CNV after photodynamic therapy  viable option in pts who have previously undergone photodynamic therapy.

Klin Monatsbl Augenheilkd 2002 Jul;219(7): 512-8 (Germany) : 

Klin Monatsbl Augenheilkd 2002 Jul;219(7): 512-8 (Germany) Rx: minor submacular hemorrhage Intravitreal injection Fibrinolytic agents: rt-PA ( recombinant tissue plasminogen activator) 50 μg Gas SF6 0.5ml  Improved and accelerated visual recovery and low complication rate

Rheopheresis : 

Rheopheresis Ther Apher 2002 Aug;6(4): 271-81 (Germany) Elimination of high mol. wt. proteins from plasma (fibrinogen, cholesterol…)  risk factors for AMD RBC , platelet aggregation Reducing blood and plasma viscosity Improvement of microcirculation Recovery of retinal function.

Rehabilitation : : 

Rehabilitation : Patient education – importance of routine central vision testing Amsler grid – not sensitive and specific. Sunglasses. Low vision aids hand held magnifiers large print reading material bright illumination CCTV Family education.

Thank You ! : 

Thank You !