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EMB Case Discussion. R1 陳錫富 /VS 吳秀琛 June 20, 2011. Chief complaint. 2011/06/01 A 50 y/o man was referred to Dr. Wu’s clinic for poor control of IOP (OD) in recent three months. Past Medical Hx. 2001 2010/8 2011/1 2011/6. OU high myopia (about -8.0D)
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EMB Case Discussion R1 陳錫富 /VS 吳秀琛 June 20, 2011
Chief complaint • 2011/06/01 • A 50 y/o man was referred to Dr. Wu’s clinic for poor control of IOP (OD) in recent three months
Past Medical Hx • 2001 • 2010/8 • 2011/1 • 2011/6 OU high myopia (about -8.0D) • Hx of ocular trauma(-), glaucoma(-) Type 2 DM under regular OHA OD poor visual acuity noted accidentally • Cataract was told in LMD OD cataract surgery in Mackay M.H. • Postoperatively, OD ocular HTN and retinal detachment was noted • Diamox 1#TID and Alphagan BID Referred for poor control of IOP(OD)
Ext. photography (OD) • VAcPG OD:light perception(-), OS:0.9 • PT OD:26(23.9)mmHg, OS:15.3(14.5)mmHg • OS iris:rubeosis(-), lens:NS(1+), fundus: dot hemorrhage
Fundus (OD) • Funnel type retinal detachment
Question • Pre-op evaluation? cataract 送審? • Improvement in VA after cataract surgery?
Question • The timing of RD? Pre-op? post-op?
One week after IVI of Avastin • PT OD:39.7(38.5) OS:17.3(17.4)mmHg • OD rubeosis regressed keeps Alphagan BID
Introduction • NVG classically carries poor prognosis, typically ending up with severe loss of vision. • Early diagnosis and prompt treatment can prevent visual loss in patients with NVG • glaucomatous optic nerve damage • cataract formation • corneal decompensation • recurrent hyphema with corneal blood staining • phthisis bulbi
Manifestations of NVG • Prerubeosis stage • Normal IOP, rubeosis(-) • Best time to prevent NVG • Preglaucoma stage • Rubeosis starts to develop, IOP is still normal
Manifestations of NVG • Open-angle stage • More prominent NVI and NVA with elevated IOP • May be with Inflammation, hemorrhage, and glaucomatous optic neuropathy
Manifestations of NVG • Angle-closure stage • Conjunctival injection, edematous cornea, hyphema, can be mild pain or absent of pain • Peripheral anterior synechiae, ectropion uveae, pupillary dilation, IOP↑ or ↓→ if phthisis bulbi
Pathogenesis of NVG in this case • Three necessary elements • A hypoxic environment conducive to the production of angiogenic factors • A source of angiogenic factorsischemic retina due to retinal detachment, DM retinopathy and intraocular inflammation due to cataract surgery • A storehouse that allows for the accumulation of angiogenic factors synechial closed angle Seminars in Ophthalmology, 24, 113–121, 2009
Key management to NVG • Treatment of the underlying disease responsible for rubeosis • Retinal ischemic dx PRP: treatment of choice reduce global retinal oxygen demand and minimize angiogenic stimuli higher success rate for following glaucoma surgery, less rubeosis after cataract extraction • Panretinal cryotherapy, transscleral diode laser retinopexy, or TPPV+lensectomy+endolaser If media opacity • Pure inflammatory causes of NVG topical steroids Seminars in Ophthalmology, 24, 106–112, 2009
Key management to NVG • Treatment of the underlying disease responsible for rubeosis • Goniophotocoagulation on new vessels in the angle to prevent synechial closure of angle • Anti-VEGF therapy adjuvent therapy prior to glaucoma surgery regression of NV and prevents intraoperative bleeding and inflammation promote successful surgical outcomes Seminars in Ophthalmology, 24, 106–112, 2009
Key management to NVG • Treatment of the increased IOP • Pharmacologic agents limited effects if underlying diseases aren’t eliminated • Cyclodestructive procedures: poor visual prognosis treatment of choice: TSCP lower rate progreesed to phthisis than cryotherapy • Glaucoma filtration surgery or aqueous tube shunts high failure rate Seminars in Ophthalmology, 24, 106–112, 2009
Anti-VEGF therapy in NVG • Prospective multicenter studies are still lacking • In few case reports • IVI of Avastin effectively stabilized NVI activity and controlled IOP in NVG with open angle did not control IOP in those with closed angle Current Opinion in Ophthalmology 2010,21:112–117
Treatment of choice following IVI Avastin • Anti-glaucomatic agents limited effects • Trabeculectomy high failure rate • TSCP progression to phthisis bulbi cosmetic problems