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“Young Female with Painless Blurry Vision”

“Young Female with Painless Blurry Vision”. Mohammad Ali Sadiq, MD – PGY2 March 01, 2019. Patient Presentation. CC “Blurry vision in right eye” HPI 25 year old white female presented with Sudden, painless, blurry vision OD for the past one week. History. Past Ocular Hx : None

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“Young Female with Painless Blurry Vision”

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  1. “Young Female with Painless Blurry Vision” Mohammad Ali Sadiq, MD – PGY2 March 01, 2019

  2. Patient Presentation CC “Blurry vision in right eye” HPI 25 year old white female presented with • Sudden, painless, blurry vision OD for the past one week.

  3. History Past Ocular Hx: None Past Medical Hx: • Sinus tachycardia Fam Hx: Mom had a history of a retinal illness when she was 55 years old. Meds: None

  4. History Allergies: Penicillin Social Hx: No smoking/alcohol ROS: Negative except as in the HPI

  5. External Exam

  6. Anterior Segment Exam

  7. Posterior Segment Exam

  8. Fundus Photographs

  9. OCT

  10. Assessment and Plan A 25 year old white female with who presented with sudden onset, painless decreased vision OD. Differential Diagnosis: • Impending CRVO • Papillophlebitis • Hyperviscosity retinopathy (waldenstrom, multiple myeloma or blood dyscrasias) • Ocular Ischemic syndrome Plan: • Ordered extensive coagulopathy/infectious work up. • Re-assess in 2 weeks.

  11. Labs • CBC • ANA • Protein-C • Factor V Leiden • Homocysteine • Antithrombin Activity • Anticardiolipin • RPR, Lyme • Quantiferon • Lipid panel

  12. Update • No further visual changes • VA 20/25 and 20/20 • Work up was negative • Mild macular edema in OD on OCT Plan: • Continue to observe • Follow up in 3 weeks

  13. OCT

  14. Central Retinal Vein Occlusion • Second most common vascular cause of visual loss after DR • Most commonly associated with advancing age and hypertension. • Vision loss is sudden and painless • Ranging along a spectrum from non-ischemic (mild) to ischemic (severe).

  15. Non-Ischemic CRVO • Also known as partial, perfused or venous stasis retinopathy. • Vision >20/200 • Mild or no RAPD • Minimal areas of non-perfusion on FA • Anterior segment neovascularization is rare

  16. Ischemic CRVO • Also known as complete, non-perfused or hemorrhagic retinopathy • Defined as having ≥10 DD of retinal capillary non-perfusion. • Usually associated with poor vision. • Associated with anterior segment neovascularization • Presence of RAPD • More extensive venous dilation/tortuosity and hemorrhages

  17. Anterior Segment Neovascularization • High rate in ischemic CRVO (up to 60%) • Occurs on average 3-5 months after onset of symptoms. • Poor VA is the risk factor most predictive of iris NV in these patients. • Other risk factors include area of non-perfusion and presence of intraretinal blood (CVOS study).

  18. Risk Factors • Most important risk factor is age (>90% are older than 50). • Hypertension • Open-angle glaucoma • Diabetes mellitus • Hyperlipidemia • Hypercoagulability

  19. Hypercoagulability • Hyperhomocystinemia • Protein S deficiency • Protein C deficiency • Factor V leiden mutation • SLE • Sarcoidosis

  20. Management

  21. Management • Multimodal imaging • Initial evaluation with monthly visits x 6 months • In the CVOS study 16% of initially non ischemic CRVOs converted to ischemic by 4 months. By 36 months, the percentage increased to 34%

  22. IMAGING

  23. Collateralization

  24. CRVO and Cilioretinal Artery Occlusion

  25. CRVO and Carotid Cavernous Fistula

  26. Fluorescein Angiography

  27. OCT-Angiography

  28. Management Laser: • Grid laser not recommended for CRVO with macular edema. • Prophylactic PRP did not result in significant reduction in incidence of iris NV. • PRP when iris neovascularization is observed.

  29. Pharmacological Management • Anti VEGF agents have been well-studied for CRVO. • CRUISE – Ranibizumab • COPERNICUS – Aflibercept • SCORE – Intravitreal Triamcinolone • SCORE 2 – Bevacizumab and Aflibercept • Systemic anticoagulation not recommended

  30. Other Surgical Approaches • Peripheral laser anastomosis between retinal vein and choroidal circulation • Radial relaxing incision of optic nerve scleral ring • Retinal vein cannulation with infusion of TPA.

  31. Conclusions • CRVO is a common vascular cause of visual loss. • Mostly seen in patients above the age of 50. • Important to rule out precipitating causes of CRVO in the younger population. • Need to differentiate between ischemic and non-ischemic CRVO. • Anti VEGF therapy plays a critical role • PRP if there is anterior segment neovascularization.

  32. “If you can’t find a cause for something…. blame it on a VIRUS !” – Charles Barr, MD

  33. Acknowledgements • Charles Barr, MD • Efrat Fleissig, MD

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