NEWS & EVENTS
Retinal Review, Issue 60
Authored by Burton Wisotsky, M.D.
An 80 year old man was evaluated for persistent maculopathy. He has extensive ocular history including advanced glaucoma OU, cataract surgery OU, and previous exudative AMD OU. He has undergone retinal laser in the right eye for a CNVM temporal to the macula. He has also undergone previous antiVEGF injections in both eyes. He also has had CME in the past which was attributed to pseudophakia and possibly Xalatan use. He discontinued the Xalatan. Visual acuity has been reduced for years in both eyes, OD > OS. Past medical history is significant for hypertension. On examination VA was OD: 20/400 and OS: 20/50. IOP’s were 8 OU (successful trabeculectomy). The SLE examination was significant for bilateral filtering blebs and PCIOL’s. The right cornea was mildly edematous with mild bullous keratopathy. The left cornea was clear. DFE of the right eye showed a large cup with a temporal laser scar and chronic macular thickening. In the left eye there was a large cup, diffuse drusen, and chronic macular wrinkling and mild edema. OCT demonstrated vitreomacular traction OD > OS with macular edema and thickening. Fluorescein angiography confirmed extensive macular ooze in both eyes likely due to chronic CME and occult CNVM (see photos and OCT’s below):
This is clearly a complicated patient. He has longstanding maculopathy which appears to be a combination of CME as well as exudative AMD. He also has advanced glaucoma OU and corneal decompensation OD. His vision has been reduced for a number of years with only gradual worsening. We discussed treatment options ranging from injections to observation to surgery. We agreed on a trial of monthly antiVEGF injections. The patient underwent a series of antiVEGF injections in both eyes in the hope that the macular exudation would improve and the edema would resolve. Unfortunately after several injections there was no improvement in the OCT configuration or the visual acuity (see sequential OCT’s of the right eye below).
In some patients with exudative AMD, there is a tractional component. Our patient had a clear tractional component due to insertion of the posterior hyaloid on the macula as well as traction from an ERM OD > OS. In these patients, release of the traction alone can improve vision and macular architecture. It can also reduce the need for antiVEGF injections. We elected to proceed with vitrectomy and membrane peeling in the left eye. We chose to work on the left eye first because we thought the prognosis was better. The OCT results were startling (see first OCT below). The macula assumed a completely normal configuration with resolution of the edema as well as the macular traction. The vision improved slightly to 20/40. We then discussed the status of the right eye and elected to perform a similar procedure. The patient had equally stunning OCT post op results. The OCT returned to normal (see second OCT below). Visual acuity however remained at 20/400.
Unfortunately, over the ensuing months, the vision worsened in both eyes. Cystic changes occurred which were noted clinically and on the OCT. Vision worsened to OD: 20/400 and OS: 20/50. There were cystic changes noted on the photos and diffuse macular leakage on the fluorescein angiogram. The OCT was much worse OU (see below). At this stage, the best treatment is probably some sort of steroid injection such as Ozurdex implant or intravitreal kenalog. Unfortunately, due to the advanced glaucoma, steroid injections are contraindicated due to the common IOP spikes. We discussed additional antiVEGF injections. We elected to observe both eyes for a while. Vision has remained stable and the OCT’s have not worsened. We will continue to watch carefully and will consider additional antiVEGF injections if the status worsens. Exudative macular degeneration is usually an ongoing battle.