1. Retinal Imaging Conference Shivani V. Reddy, MD University of Louisville Department of Ophthalmology and Visual Sciences 6/5/2014

2. Patient Presentation CC: Blurry vision OS x 1month HPI: 52 y/o AAF presenting to the eye clinic for her first diabetic exam c/o occasional blurry vision OS x 1 month. Denies flashes, floaters, scotomas or episodes of vision loss.

3. Medical History POHx:none PMH: DMII (diagnosed 3 months prior, A1c: 8.9%) HTN with HTN urgency episode in 2012 HTN with HTN urgency episode in 2012 secondary to cocaine abuse secondary to cocaine abuse Meds: metformin, lantus insulin, norvasc, gabapentin Allergies: NKDA

4. Exam BCVA P T TP BCVA P T TP EOM: Full OU CVF: Full OU CVF: Full OU Anterior Segment: mild NS cataracts OU, otherwise WNL 20/20 -1 (sc) 3 ->2mm 14 17 (-) RAPD 20/60-2 (-1.00+1.00x180)

5. OCT Photos

6. OCT OD OS OS: retinal thickening with cystic spaces temporal to fovea, subfoveal disruption of ELM and ellipsoid region lines

7. Autofluorescence OS OD: Area of central hyperautofluorescence, hypoautofluorescense concentrated superiorly

9. FA Photo OS 00:19:53 Arterial phase : normal arterial filling

10. FA Photo OS 00:23:28 Mid AV phase : delayed superotemporal venous arcade filling, scattered areas of hypofluorescence, pinpoint hyperfluorescent areas

11. FA Photo OS 00:30:33 Late AV phase: persistent filling defect in superior temporal arcade, prominent macular collateral vessel, hypofluoresent ares scattered throughout the sup-temp segment

12. FA Photo OS 00:38:65 Venous Phase: Late filling of superotemporal venous arcade, increasing hyperfluorescence surrounding original pinpoint areas with persistent intervening hypofluorescent regions, hyperfluorescence temporal to the fovea, appearance of venous collaterals

13. FA Photo OS Recirculation phase: increasing hyperfluoresnce around pinpoint leakages, decreasing fluorescence of collateral vessels. Increasing hyperfluorescence temporal and superior to the fovea 01:44:39

14. FA Photo OS 02:24:1302:39:10

15. Assessment and Plan A: 52 yo AAF with CME OS secondary to old branch retinal vein occlusion. A: 52 yo AAF with CME OS secondary to old branch retinal vein occlusion. P: Avastin OS, follow-up pending P: Avastin OS, follow-up pending

16. Branch Retinal Vein Occlusion Vein occlusion that occurs most commonly at an AV crossing Mean age of presentation: 7 th decade Risk factors HTN Cardiovascular disease Glaucoma history Increased BMI at age 20 Most commonly effected area: supero-temporal quadrant

17. Acute Phase Acute Phase Segmental intraretinal hemorrhage with apex near obstructed vein Segmental intraretinal hemorrhage with apex near obstructed vein Subretinal hemorrhages less common Subretinal hemorrhages less common Cotton wool spots scattered throughout the occluded segment Cotton wool spots scattered throughout the occluded segment CME with layering intraretinal heme within the cysts CME with layering intraretinal heme within the cysts If CME present, round yellow spot can occur centrally that later disappears If CME present, round yellow spot can occur centrally that later disappears Branch Retinal Vein Occlusion

18. Chronic Phase Chronic Phase Resolution of subretinal heme at 9-12 months Resolution of subretinal heme at 9-12 months Underlying retinal vascular abnormalities seen on FA Underlying retinal vascular abnormalities seen on FA Collateral vessel formation around blockage site Collateral vessel formation around blockage site Capillary telangiectasia Capillary telangiectasia Capillary non-perfusion areas within involved segment Capillary non-perfusion areas within involved segment Branch Retinal Vein Occlusion

19. Branch Vein Occlusion Study (BVOS) Branch Vein Occlusion Study (BVOS) Questions asked: Questions asked: Can scatter laser prevent neovascularization? Can scatter laser prevent neovascularization? Can peripheral scatter laser prevent vitreous hemorrhage?. Can peripheral scatter laser prevent vitreous hemorrhage?. Can grid laser improve visual acuity in eyes with macular edema with vision <20/40? Can grid laser improve visual acuity in eyes with macular edema with vision <20/40? Conclusions: Conclusions: Grid laser is beneficial for macular edema with vision <20/40 for 3 months Grid laser is beneficial for macular edema with vision <20/40 for 3 months Scatter laser is beneficial for prevention of vitreous hemorrhage Scatter laser is beneficial for prevention of vitreous hemorrhage The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282. 2001;21:416-434.

20. Branch Retinal Vein Occlusion SCORE (BRVO) Study Question asked: Question asked: Is triamcinolone beneficial in the treatment of macular edema when compared to standard of care? Is triamcinolone beneficial in the treatment of macular edema when compared to standard of care? Patients were divided into 3 groups: grid laser, 4mg, 1mg group. Visual acuity changes were compared at 1 year Patients were divided into 3 groups: grid laser, 4mg, 1mg group. Visual acuity changes were compared at 1 year Conclusions: Conclusions: 3 groups with similar VA improvement BUT more complications in the steroid group. Therefore, Grid laser was the benchmark against which future treatments should be compared 3 groups with similar VA improvement BUT more complications in the steroid group. Therefore, Grid laser was the benchmark against which future treatments should be compared Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128.

21. Branch Retinal Vein Occlusion BRAVO Study Purpose: to determine the safety and efficacy of Lucentis in treating macular edema Purpose: to determine the safety and efficacy of Lucentis in treating macular edema Design: Design: 3 groups – 0.3mg, 0.5mg ranibizumab and sham 3 groups – 0.3mg, 0.5mg ranibizumab and sham Patients received monthly injections Patients received monthly injections Number of patients with >15 letters gained at 6 months: Number of patients with >15 letters gained at 6 months: 0.5mg group: 61.1%, 0.3mg group: 55.2%, sham group: 28.8% 0.5mg group: 61.1%, 0.3mg group: 55.2%, sham group: 28.8% Conclusion: Intravitreal ranibizumab is effective for treatment of macular edema following BRVO Conclusion: Intravitreal ranibizumab is effective for treatment of macular edema following BRVO Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six- month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112.

22. Branch Retinal Vein Occlusion GENEVA Study GENEVA Study Purpose: to evaluate the efficacy and safety of Ozurdex for visual loss secondary to macular edema associated with BRVO Purpose: to evaluate the efficacy and safety of Ozurdex for visual loss secondary to macular edema associated with BRVO Design: patient injected with intravitreal implant 0.7mg, 0.35mg or sham Design: patient injected with intravitreal implant 0.7mg, 0.35mg or sham Conclusion: Dexamethasone intravitreal implant can reduce the risk of vision loss and improve speed and incidence of visual improvement Conclusion: Dexamethasone intravitreal implant can reduce the risk of vision loss and improve speed and incidence of visual improvement Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24.

23. Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusion Francesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, Fondazione GB Bietti, Roma Maurizio Parodi Macula Society, 2014 Purpose: to evaluate the effects of dexamethsone implant for the treatment of macular edema secondary to ischemic retinal vein occlusions over a 12 month follow-up Methods: - prospective, open-label, interventional, case series. - each patient received a comprehensive exam, FA & OCT imaging followed by - each patient received a comprehensive exam, FA & OCT imaging followed by a dexamethasone implant a dexamethasone implant - retreatment based on presence of macular edema at month 4 - retreatment based on presence of macular edema at month 4 primary outcome measure: ETDRS letter score primary outcome measure: ETDRS letter score secondary outcome measure: CME, number of injections during followup secondary outcome measure: CME, number of injections during followup

24. Dexamethasone implant for macular edema secondary to ischemic retinal vein occlusion Francesco Bandello, University of Vita-Salute, Scientific Institute San Raffaele Pierluigi Iacono, Fondazione GB Bietti, Roma Maurizio Parodi Macula Society 2014 Results: 24 patients enrolled (11 CRVO, 13 BRVO) - mean ETDRS letter score changed: - mean ETDRS letter score changed: BRVO 75,3 to 95,6 BRVO 75,3 to 95,6 CRVO 44,3 to 60,8 CRVO 44,3 to 60,8 - CMT change - CMT change BRVO 544um to 321um BRVO 544um to 321um CRVO 776um to 444um CRVO 776um to 444um - mean #injections - mean #injections BRVO: 1.7 BRVO: 1.7 CRVO: 1.8 CRVO: 1.8 Conclusions: Dexamethasone implant reduces ME in eyes with ischemic RVO’s, leading to a slight visual acuity improvement

25. The OMAR study: Comparison of Ozurdex and Triamcinolone Acetonide for Refractory Cystoid Macular Edema in Retinal Vein Occlusion Ahmet Ozkok, M.D.,*Omar A Saleh, M.D.,* Douglas K. Sigford, M.D.James W Heroman, M.D. Shlomit Schaal, M.D., Ph.D. Purpose: To compare the risks and benefits of adding either intravitreal dexamethasone implant (DEX) or preservative free triamcinolone acetonide (TA) to bevacizumab monotherapy in refractory CME due to RVO Purpose: To compare the risks and benefits of adding either intravitreal dexamethasone implant (DEX) or preservative free triamcinolone acetonide (TA) to bevacizumab monotherapy in refractory CME due to RVO Design: interventional, comparative study of Design: interventional, comparative study of 74 patients received bevacizumab, then later DEX (35) and TA (39) 74 patients received bevacizumab, then later DEX (35) and TA (39) outcome measures: BCVA, CMT, frequency of injections outcome measures: BCVA, CMT, frequency of injections Results: no significant change in BCVA Results: no significant change in BCVA significant improvement in CMT significant improvement in CMT significant decrease in number of injections per month, more so in significant decrease in number of injections per month, more so in DEX group (from 0.66 to 0.26 inj/mo) DEX group (from 0.66 to 0.26 inj/mo)

26. References Retina-Vitreous Macula. Guyer, Yannuzzi, Chang, Shields, Green BCSC. Chapter 12 Retina and Vitreous. 2012-2013:Chapter 6:121-127. The Branch Vein Occlusion Study Group. Argon laser photocoagulation for macular edema in branch vein occlusion. Am J Ophthalmol. 1984;98(3):271-282. 2001;21:416-434. Scott IU, Ip MS, Van Veldhuisen PC, et al; SCORE Study Research Group. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6. Arch Ophthalmol. 2009;127(9):1115-1128. Haller JA, Bandello F, Belfort R Jr, et al; OZURDEX GENEVA Study Group. Randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with macular edema due to retinal vein occlusion. Ophthalmology. 2010;117(6):1134-1146.Epub 2010 Apr 24. Campochiaro PA, heier JS, Feiner L, et al; BRAVO Investigators. Ranibizumab for macular edema following branch retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology. 2010;117(6):1102-1112. The Eye Disease Case-control Study Group. Risk factors for branch retinal vein occlusion. Am J Ophthalmol 1993;116(3):286- 96.

27. Thank You