Questions Dr. Fogt Said M3

What should you do after you see a BRVO?

Physical examination with blood tests

Management of the eye will depend on whether there is macular edema and/or retinal neovascularization

What does management of the eye in a BRVO depend on?

Whether there is macular edema and/or retinal neovascularization

What should the treatment be for a BRVO systemically?

Physical examination with blood tests

What happens if you do not do anything about a BRVO?

Usually, a lot of patients are fine, 50-60% of patients have a final VA of 20/40 or better even without treatment

What is the result of BRVO patients that do not get treated?

50-60% of patients have a final VA of 20/40 or better

What was the question asked for the branch vein occlusion study (BVOS)?

Does grid laser help macular edema after BRVO?

What study researched whether grid laser helped macular edema after a BRVO?

Branch Vein Occlusion Study (BVOS)

What was the result of the BVOS study?

Grid laser helps macular edema after a BRVO very mildly

What are other BRVO studies that established the treatment plan?

BRAVO, HORIZON, RETAIN

What is the standard of care treatment for BRVO?

Intravitreal anti-VEGF injections

What is the first-line treatment for a BRVO?

Intravitreal anti-VEGF injections

Where does the primary proof of efficacy for the standard of care treatment for BRVO come from?

BRAVO study and follow-up studies HORIZON and RETAIN

BRAVO and follow-up studies of HORIZON and RETAIN showed what?

Efficacy of intravitreal anti-VEGF injections being the first line treatment for BRVO

What else (in addition to anti-VEGF injections) may be included in BRVO management?

Laser photocoagulation

What can be used to treat BRVOs overall?

Anti-VEGF and laser, sometimes both together

What is the systemic laboratory workup for a BRVO?

Blood pressure

Fasting blood sugar or HbA1C

Lipid profile

Platelet count, maybe prothrombin time/partial thromboplastin time

CBC with differential

ESR or C-reactive protein

Why is blood pressure part of the systemic laboratory workup for BRVO?

hypertension closely correlated

Why is fasting blood sugar or HbA1C part of the systemic laboratory workup for BRVO?

test for diabetes

Why is platelet count (and maybe prothrombin time/partial thromboplastin time) part of the systemic laboratory workup for BRVO?

Occasionally, platelet aggregation/clotting can form an embolus

Why is ESR or C-reactive protein part of the systemic laboratory workup for BRVO?

nonspecific tests for systemic inflammation

What is the minimum for laboratory tests that a patient with a BRVO should have?

Blood pressure, fasting blood sugar or HbA1C, lipid profile, platelet count (may add prothrombin time/partial thromboplastin time), CBC with differential, ESR or C-reactive protein

What is 90-day or 100-day glaucoma?

Side effect of a CRVO in which the eye can be totally lost due to neovascular glaucoma secondary to iris and angle neovascularization/NVI

What is the process that occurs in 90-day or 100-day glaucoma?

Complete blockage, hypoxia, neovascularization (not in the retina), grows new blood vessels in the iris, vessels grow into the AC angle, blocks the angle, causes a spike in pressure

What is neovascular glaucoma secondary to?

Iris and angle neovascularization

Why is it called 90-day or 100-day glaucoma after a CRVO?

That is the timeline that the increase in pressure appears, around 3-5 months after CRVO

What does an ischemic CRVO retina look like in a picture?

Blown up

What does an non-ischemic CRVO retina look like in a picture?

Not blown-up

What is the risk for retinal neovascularization after a CRVO?

9%

What is the risk for iris neovascularization after a CRVO?

8-9%

What is the risk for macular edema after a CRVO?

80-90%

What 2 tests may be performed early on in CRVO management?

Fluorescein angiogram and maybe an OCTA

What could the fluorescein angiogram and OCTA look like early on after a CRVO?

There may be a lot of blood and may not be able to tell if there is neovascularization

What are systemic diseases that are associated with a CRVO?

Hypertension, Hyperlipidemia, Diabetes

What question did the CRVO Group M study ask?

Does grid laser help with macular edema with a CRVO?

Does grid laser help with macular edema with a CRVO?

Did not help at all (Group-M study answer)

What question did the CRVO Group N study ask?

If you do panretinal photocoagulation prophylactically, would this prevent iris neovascularization?

If you do panretinal photocoagulation prophylactically, would this prevent iris neovascularization?

No this does not help, there is no point (Group N study answer)

When should you do panretinal photocoagulation for a CRVO?

After iris neovascularization shows up, this will cause some of the iris neovascularization to go away (Group N CRVO study answer)

What was the question that the Group I CRVO study asked?

How likely are eyes with a lot of hemorrhages to be ischemic?

How likely are eyes with a lot of hemorrhages to be ischemic?

VERY likely (Group I study answer)

What did optometrists take away from the CRVO studies (M, N, I)?

Many optometrists monitored CRVOs until neovascularization shows up, monitored their patients very closely

What was the treatment indications from the CRVO studies (M, N, I)?

Monitor CRVO until neovascularization shows up, still refer to PCP, then refer once there is neovascularization

What is the current treatment for CRVO (different from the CRVO study treatment indications)?

Refer all the time, patients will get anti-VEGF

What studies changed the previous treatment indications from the CRVO studies (M, N, I)?

CRUISE, HORIZON, RETAIN

What is anti-VEGF effective against in CRVO treatment?

macular edema and neovascularization

What is the treatment for retinal neovascularization?

Anti-VEGF medications with possible PRP

What is the treatment for iris neovascularization?

PRP with possibly anti-VEGF medications

What is the difference between treatment for retinal neovascularization versus treatment for iris neovascularization?

Treatment for retinal neo starts with anti-VEGF while treatment for iris neo starts with PRP

What was the question that was investigated in the NIH SCORE study?

Would intreavitreal steroid medications help with macular edema compared to observation?

What was the result of the NIH SCORE study?

Corticosteroid treatment helped about 27% by improving acuity compared to observation (but increased SE with steroid)

How do you know if a retinal vein occlusion has been there for a long time?

Dot blot hemorrhages and can see the space in the retina between the bleeds

List the occlusions in the retina from most common to least common

BRVO, CRVO, arterial occlusions

What is the most common retinal occlusion?

BRVO

What is the second most common retinal occlusion?

CRVO (5x less common than a BRVO)

What is the least common retinal occlusion?

Arterial occlusion (way less common than CRVO and BRVO)

What does fluorescein look like with a CRAO?

Hyperreflectivity, adjacent to fovea (Paracentral acute middle maculopathy)

What causes the hyperreflectivity on fluorescein with a CRAO?

Axoplasmic leakage from hypoxic nerve fibers

What is the hyperreflectivity adjacent to the fovea in fluorescein of a CRAO?

Paracentral acute middle maculopathy (PAMM)

How much time do you have after a CRAO until damage is permanent?

4 hours

When do you want to do therapy after a CRAO?

Preferably 1-2 hours but definitely within 4 hours

If you are able to do therapy after a CRAO within 4 hours what is possible?

occlusion may be partially reversible

What in the initial management of a BRAO or CRAO in office?

Acetazolamide 500mg or two drops of timoptic 0.50% and get to the emergency room or a stroke center

What are the two medications options to give in office for retinal artery occlusions?

Acetazolamide 500mg or 2 drops of timoptic 0.50%

Why do you want to give Acetazolamide or timoptic during a retinal artery occlusion?

these are carbonic anhydrase inhibitors which will drop the IOP fast

What is the basic management of hypertension and hypertensive retinopathy?

Need to get blood pressure under control through diet (low saturated and low trans fat) and exercise, medications

Where do you start with treatment for vascular disease?

Diet and exercise!

What are the dietary considerations for hypertension?

Low saturated fat

Salt restriction for HTN

Alcohol only in moderation

Lack of potassium promotes HTN

What increases/decreases do you want to have for a hypertensive diet?

Low saturated fat, lower salt, alcohol in moderation, increase potassium

Why does low saturated fat help in hypertension?

Promotes weight loss

Why does salt restriction help in hypertension?

Don't want sodium retention

Why does alcohol in moderation help in hypertension?

Ethanol can increase blood pressure

Why does increasing potassium help in hypertension?

a lack of potassium can be related to changes in sodium excretion, diminishes sodium excretion through changes in sodium re-absorption by kidney

What is the BP goal for a patient greater than 60 years old?

<150/90

What is the BP goal for a patient < 60 years old?

<140/90

Why is the BP goal for an older patient different than a younger patient?

Blood pressure is harder to control when you are older, more lenient restrictions/guidelines

What is the difference between the 3 and 4 scale for hypertensive retinopathy?

The 4 part scale divides the mild divison into 2 parts

What is considered mild in the hypertensive retinopathy scale?

Narrowing of arterial blood vessels

Widening of arterial light reflex (due to thickening of vessel walls)

Crossing changes (nicking and banking)

Silver-wiring due to calcium deposition

What is not included in the mild stage of hypertensive retinopathy?

No vascular leakage, cotton wool spots, microaneurysms

What is included in the moderate stage of hypertensive retinopathy?

Mild plus vascular leakage and/or vascular occlusion probably (like diabetic retinopathy)

microaneurysms, hemorrhages, hard exudates, cotton-wool spots, BRVO, CRVO, retinal macroaneurysm possible

How are mild/moderate/malignant stages of hypertensive retinopathy related?

Moderate has mild characteristics plus others

Malignant has moderate plus others

What is included in the malignant stage of hypertensive retinopathy?

Moderate stage of diabetic retinopathy plys optic nerve head swelling

Who created the hypertensive retinopathy grading scale?

Wong and Mitchell

What are the increased risks with hypertensive retinopathy?

Stroke, Coronary Heart Disease, and death

What are the systemic risks for mild retinopathy?

1-2x greater risk for stroke, coronary heart disease, and mortality

What are the systemic risks for moderate retinopathy?

2x or greater risk for stroke, coronary heart disease, cognitive decline, and cardiovascular mortality

What are the systemic risks for malignant retinopathy?

2x the greater risk for mortality

WHat can happen with the AV ratio in hypertensive retinopathy?

AV ratio can change due to arteriolar narrowing, related to the development of hypertension nad blood pressure over several years

What is the treatment for mild hypertensive retinopathy?

Check blood pressure in the office

Refer to primary care physician within 1-2 weeks

Remember the metabolic syndrome

Diet and exercise!

What do you need to remember about metabolic syndrome?

relationship between type 2 diabetes mellitus, hypertension, lipid abnormalities, and maybe gout

Can you get macular edema in hypertensive retinopathy?

YES

What do you do if there is macular edema present in moderate hypertensive retinopathy?

Refer to ophthalmology in 1-2 days

How to check if a patient with moderate hypertensive retinopathy has macular edema?

Rule macular edema in or out with OCT if possible

What are the common symptoms for diabetes mellitus and diabetes insipidus?

Excessive thirst (polydipsia) and excessive urination (polyuria)

What are the risk factors for diabetes?

Metabolic blood sugar control, positive family history, hypertension, hyperlipidemia, smoking, high body mass index, sleep apnea, and ethnicity and race (African American, Hispanic, and Native American)

What is the number 1 risk factor or diabetes?

Blood sugar control

What are the key factors in diabetic retinopathy development and progression?

Control and duration

What is the important question to ask regarding duration of diabetic retinopathy?

How long since your diagnosis of diabetes?

What is the important question to ask regarding control of diabetic retinopathy?

How are you controlling your blood sugar?

What are blood sugar control and duration important in for diabetic retinopathy?

Development and progression

What does damage to the blood vessel walls lead to?

Permeability, occlusion