The Case:
The patient was a 73-year-old woman who has received anti-VEGF treatments for a choroidal neovascular membrane in the left eye. Her past ophthalmic history was otherwise unremarkable, and she had been in good general health. The visual acuity was 20/20-1 OD and 20/40 OS. The IOPs were mostly in the low teens and never exceeded 20.
After reviewing the images, what work-up and/or treatment is needed?
Answer:
The recent fundus photograph of the right eye revealed a Weiss ring, cupping of the optic disc, and macular pigmentary changes. The left eye also had a Weiss ring and cupping of the optic disc, and there was a Drance hemorrhage over the inferotemporal disc margin. The left macula had deep fibrosis.
OCT of the right eye revealed a “double-layer sign” in which there was shallow, irregular elevation of the RPE over Bruch’s membrane. There was no subretinal fluid or edema. OCTA of the right eye revealed a large CNVM.
OCT of the left eye two years ago showed a pigment epithelial detachment, reflective subretinal material, and a bacillary layer detachment. A bacillary detachment results from a splitting at the level of the photo receptor inner segment myoid, which leads to accumulation of subretinal fluid. There was no macular edema. OCTA of the left eye two years ago revealed a large choroidal neovascular membrane (CNVM). A more recent OCT of the left eye showed that, after anti-VEGF treatment, there was an irregular pigment epithelial detachment with reflective material, indicating fibrosis. The subretinal fluid and the bacillary layer detachment had resolved.
The right eye had a nonexudative choroidal neovascular membrane. Many of these patients eventually have hemorrhage or serous or lipid exudate, which makes anti-VEGF therapy tempting. However, optimal treatment remains unclear. Presumably, choroidal neovascularization is, at least for some patients, an adaptive response to local tissue needs. Indeed, occasionally patients experience worse visual after anti-VEGF treatment of CNVMs, even when there is reduced swelling on OCT. We generally defer on treating non-exudative CNVMs unless the patient relates a recent change in vision.
The bilateral disc cupping and the Drance hemorrhage suggest glaucoma, despite the normal eye pressures recorded in our office. Further evaluation for possible glaucoma was recommended.
Answer:
The recent fundus photograph of the right eye revealed a Weiss ring, cupping of the optic disc, and macular pigmentary changes. The left eye also had a Weiss ring and cupping of the optic disc, and there was a Drance hemorrhage over the inferotemporal disc margin. The left macula had deep fibrosis.
OCT of the right eye revealed a “double-layer sign” in which there was shallow, irregular elevation of the RPE over Bruch’s membrane. There was no subretinal fluid or edema. OCTA of the right eye revealed a large CNVM.
OCT of the left eye two years ago showed a pigment epithelial detachment, reflective subretinal material, and a bacillary layer detachment. A bacillary detachment results from a splitting at the level of the photo receptor inner segment myoid, which leads to accumulation of subretinal fluid. There was no macular edema. OCTA of the left eye two years ago revealed a large choroidal neovascular membrane (CNVM). A more recent OCT of the left eye showed that, after anti-VEGF treatment, there was an irregular pigment epithelial detachment with reflective material, indicating fibrosis. The subretinal fluid and the bacillary layer detachment had resolved.
The right eye had a nonexudative choroidal neovascular membrane. Many of these patients eventually have hemorrhage or serous or lipid exudate, which makes anti-VEGF therapy tempting. However, optimal treatment remains unclear. Presumably, choroidal neovascularization is, at least for some patients, an adaptive response to local tissue needs. Indeed, occasionally patients experience worse visual after anti-VEGF treatment of CNVMs, even when there is reduced swelling on OCT. We generally defer on treating non-exudative CNVMs unless the patient relates a recent change in vision.
The bilateral disc cupping and the Drance hemorrhage suggest glaucoma, despite the normal eye pressures recorded in our office. Further evaluation for possible glaucoma was recommended.
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