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Targeted photocoagulation of peripheral ischemia to treat rebound edema.

Singer MA, Tan CS, Surapaneni KR, Sadda SR - Clin Ophthalmol (2015)

Bottom Line: To target the treatment to peripheral ischemia areas, a Navilas Panretinal Laser was used.A 64-year-old male with a central retinal vein occlusion and a visual acuity 20/300, and central macular thickness 318 μm presented with rubeosis.Angiography revealed extensive peripheral nonperfusion.

View Article: PubMed Central - PubMed

Affiliation: Medical Center Ophthalmology Associates, San Antonio, TX, USA.

ABSTRACT

Introduction: Peripheral retinal ischemia not detectable by conventional fluorescein angiography has been proposed to be a driving force for rebound edema in retinal vein occlusions. In this report, we examine the treatment of peripheral retinal ischemia with targeted retinal photocoagulation (TRP) to manage a patient's rebound edema.

Methods: To assess the extent of peripheral nonperfusion, an Optos 200Tx device was used. To target the treatment to peripheral ischemia areas, a Navilas Panretinal Laser was used.

Results: A 64-year-old male with a central retinal vein occlusion and a visual acuity 20/300, and central macular thickness 318 μm presented with rubeosis. Angiography revealed extensive peripheral nonperfusion. Despite TRP to areas of irreversible ischemia, after 2 months, he continued show rubeosis and rebound edema. Additional TRP laser was repeatedly added more posteriorly to areas of reversible nonperfusion, resulting in eventual resolution of rubeosis and edema.

Conclusion: In this study, we demonstrate the use of widefield imaging with targeted photo-coagulation of peripheral ischemia to treat rebound edema, while preserving most peripheral vision. In order to treat rebound edema, extensive TRP, across reversible and nonreversible areas of ischemia, had to be performed - not just in areas of nonreversible peripheral ischemia. These areas need to be mapped during episodes of rebound edema, when ischemia is at its maximum. In this way, by doing the most TRP possible, the cycle of rebound edema can be broken.

No MeSH data available.


Related in: MedlinePlus

Widefield FA prior to treatment.Notes: Areas of nonperfusion are shaded blue, while areas of perfusion are orange. The ischemic index is 50.6%.Abbreviation: FA, fluorescein angiography.
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f1-opth-9-337: Widefield FA prior to treatment.Notes: Areas of nonperfusion are shaded blue, while areas of perfusion are orange. The ischemic index is 50.6%.Abbreviation: FA, fluorescein angiography.

Mentions: The patient was a 64-year-old male with a central RVO who presented with a visual acuity of 20/200, and central macular thickness of greater than 318 μm and volume of 14 mm3. He was also noted to have rubeosis but declined recommended TRP therapy for fear of further loss of peripheral vision. As a result, he elected to have anti-VEGF injections. Optos wide-field FA demonstrated a relationship between his optical coherence tomography (OCT) volume and ischemic index, which was 50.6% on initial presentation (Figure 1). When treated with anti-VEGF agents, his OCT volume decreased to less than 9 mm3, his perfusion improved, and his ischemic index decreased to below 50% after each treatment. When his anti-VEGF therapy wore off, the amount of ischemia increased, his OCT volume increased to over 9 mm3, and his ischemic index increased to over 50%. This phenomenon of a region of apparent reversible nonperfusion following anti-VEGF therapy was a consistent finding, and the cyclical process continued for approximately 1 year. After nine injections and monthly follow up, the patient expressed interest in exploring options to decrease the number of injections, while still preserving as much of his peripheral vision as possible. He elected to have navigated TRP 2 weeks after his anti-VEGF injection. The goal of this treatment strategy was to stop the recurring cycle of rebound edema, while preserving as much peripheral vision as possible. The rationale for this combination approach was that anti-VEGF therapy would reveal areas of reversible ischemia, which might represent areas of “saveable” retina that could potentially be spared laser therapy. Thus, by only applying laser to areas of nonreversible ischemia, the cycle of rebound edema would hopefully be stopped, with the least amount of peripheral visual field loss.


Targeted photocoagulation of peripheral ischemia to treat rebound edema.

Singer MA, Tan CS, Surapaneni KR, Sadda SR - Clin Ophthalmol (2015)

Widefield FA prior to treatment.Notes: Areas of nonperfusion are shaded blue, while areas of perfusion are orange. The ischemic index is 50.6%.Abbreviation: FA, fluorescein angiography.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4335623&req=5

f1-opth-9-337: Widefield FA prior to treatment.Notes: Areas of nonperfusion are shaded blue, while areas of perfusion are orange. The ischemic index is 50.6%.Abbreviation: FA, fluorescein angiography.
Mentions: The patient was a 64-year-old male with a central RVO who presented with a visual acuity of 20/200, and central macular thickness of greater than 318 μm and volume of 14 mm3. He was also noted to have rubeosis but declined recommended TRP therapy for fear of further loss of peripheral vision. As a result, he elected to have anti-VEGF injections. Optos wide-field FA demonstrated a relationship between his optical coherence tomography (OCT) volume and ischemic index, which was 50.6% on initial presentation (Figure 1). When treated with anti-VEGF agents, his OCT volume decreased to less than 9 mm3, his perfusion improved, and his ischemic index decreased to below 50% after each treatment. When his anti-VEGF therapy wore off, the amount of ischemia increased, his OCT volume increased to over 9 mm3, and his ischemic index increased to over 50%. This phenomenon of a region of apparent reversible nonperfusion following anti-VEGF therapy was a consistent finding, and the cyclical process continued for approximately 1 year. After nine injections and monthly follow up, the patient expressed interest in exploring options to decrease the number of injections, while still preserving as much of his peripheral vision as possible. He elected to have navigated TRP 2 weeks after his anti-VEGF injection. The goal of this treatment strategy was to stop the recurring cycle of rebound edema, while preserving as much peripheral vision as possible. The rationale for this combination approach was that anti-VEGF therapy would reveal areas of reversible ischemia, which might represent areas of “saveable” retina that could potentially be spared laser therapy. Thus, by only applying laser to areas of nonreversible ischemia, the cycle of rebound edema would hopefully be stopped, with the least amount of peripheral visual field loss.

Bottom Line: To target the treatment to peripheral ischemia areas, a Navilas Panretinal Laser was used.A 64-year-old male with a central retinal vein occlusion and a visual acuity 20/300, and central macular thickness 318 μm presented with rubeosis.Angiography revealed extensive peripheral nonperfusion.

View Article: PubMed Central - PubMed

Affiliation: Medical Center Ophthalmology Associates, San Antonio, TX, USA.

ABSTRACT

Introduction: Peripheral retinal ischemia not detectable by conventional fluorescein angiography has been proposed to be a driving force for rebound edema in retinal vein occlusions. In this report, we examine the treatment of peripheral retinal ischemia with targeted retinal photocoagulation (TRP) to manage a patient's rebound edema.

Methods: To assess the extent of peripheral nonperfusion, an Optos 200Tx device was used. To target the treatment to peripheral ischemia areas, a Navilas Panretinal Laser was used.

Results: A 64-year-old male with a central retinal vein occlusion and a visual acuity 20/300, and central macular thickness 318 μm presented with rubeosis. Angiography revealed extensive peripheral nonperfusion. Despite TRP to areas of irreversible ischemia, after 2 months, he continued show rubeosis and rebound edema. Additional TRP laser was repeatedly added more posteriorly to areas of reversible nonperfusion, resulting in eventual resolution of rubeosis and edema.

Conclusion: In this study, we demonstrate the use of widefield imaging with targeted photo-coagulation of peripheral ischemia to treat rebound edema, while preserving most peripheral vision. In order to treat rebound edema, extensive TRP, across reversible and nonreversible areas of ischemia, had to be performed - not just in areas of nonreversible peripheral ischemia. These areas need to be mapped during episodes of rebound edema, when ischemia is at its maximum. In this way, by doing the most TRP possible, the cycle of rebound edema can be broken.

No MeSH data available.


Related in: MedlinePlus