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  1. #1

    Default Hemi crvo case approach

    Ameen Marashi:
    your approach BCVA is 20/80
    Hemi crvo case approach attachment.php?attachmentid=3141&d=1495201010
    Amanda M:
    Age of patient sir?

    Ameen Marashi:
    55

    Zena Obideen:
    BRVO? ..semi
    FFA...oct

    Ameen Marashi:
    ok

    Zena Obideen:
    For ischemia or macular edema
    mean look up for those

    Ameen Marashi:
    to early to decide

    Ahmed Moharam:
    Monitor iop
    Treat underlying disease ..

    Ameen Marashi:
    ok what else

    Zena Obideen:
    generally observation. ..I think

    Ahmed Moharam:
    Aspirin ?!

    Ameen Marashi:
    no
    This is the internist job

    Ahmed Moharam:
    Sectoral Prp for ischemic area

    Zena Obideen:
    No laser. If there is not newvascular...is not right d Ameen

    Ameen Marashi:
    noooooo what for
    👍

    Ahmed Moharam:
    Ok

    Zena Obideen:
    Anti VEGF?

    Ameen Marashi:
    of course

    Zena Obideen:
    Realy ..I see...mmm

    Amanda M:
    Hemi crvo..
    Oct for macular edema..
    Physician consult for systemic assessment..

    Ameen Marashi:
    great and

    Zena Obideen:
    is there somthing else doctor?

    Ameen Marashi:
    yes protocol

    Amanda M:
    Look for RAPD and IOP..

    Ameen Marashi:
    iop yes RAPD i dont think it is relevant

    Amanda M:
    Non ischemic hemi crvo with mac edema and hhges over fovea and vsn 20/80..
    Anti vegf / ozurdex

    Ameen Marashi:
    excelent when ozurdec when anti-VEGF

    Amanda M:
    If iop high/phakic i wud go for only anti vegf..if oct shows mac edema with smd, iop normal and pseudophakic i wud consider ozurdex too.

    Ameen Marashi:
    I respect that but in real world practice this guide wont be accurate

    Amanda M:
    Yes sir.

    Ameen Marashi:
    Always start with ANTIVEGF at least for three consecutive injections every 4 weeks if no better BCVA switch to aflibercept for more 3 if not better then switch to ozurdex but if you have better results continue using the same agent

    Amanda M:
    Sir, when do you get ffa done in this case? Would you wait for hhges to clear from foneal region or only at 3 months?

    Ameen Marashi:
    i would wait

    Amanda M:
    Yes sir..but how long should we wait sir?

    Ameen Marashi:
    3 months to 6

    Amanda M:
    Sir may I know the reason behind this order of preference?

    Ameen Marashi:
    didn't understand

    Amanda M:
    1st anti vegf then aflibercept and then ozurdex..

    Ameen Marashi:
    because in the early course of the vascular diseases VEGF is the main driver of pathogensis of increased vascular permeability and VEGF trap is more effective than AntiVEGF so you can always start with aflibercept but it is costly however the more disease progress the inflammatory cytokines have more prominent role so steroids are recommended at this stage

    Amanda M:
    Thank you sir for the very lucid explanation😊

    Faisal Iqbal:
    Very well described sir. Lets put this case a bit forward into two further scenarios.
    One. After resolution of hges. There is erm and vmt causing non resolving macular odema with bcva 6/60 . Hiw would you approach ?
    Secondly. When sucha a case presents to you abt 3 years later on with approx 50 % of macular area showing capillary dropout and neo vessels and few collatrels insode the ischemic area and junction of perfused and non perfused retina. What would be your recommendation ? Vegf only ? Vegf and laser ? Prp or micropulse laser therapy ?

    Ameen Marashi:
    PPV with ILM pealing
    any neovessels??
    now I read it fully
    Aflibercept with scatter laser

    Faisal Iqbal:
    Well. How much laser ? And do u lase the ischemic macular area specifically?

    Ameen Marashi:
    at least 500-1000 shots in the area if the PERIPHERAL nonperfused areas never on the macula but for ischemic maculopathy I would treat it with intravitreal aflibercept

    Amanda M:
    How will aflibercept help in ischemic maculopathy sir?

    Ameen Marashi:
    still not known but it works like magic on ischemic maculopathy due to RVO and limited effect on ischemic maculopathy on DME

    Amanda M:
    How does it work sir? As in how do we know it is working? What do we look for?

    Ameen Marashi:
    you know by VA improvement it will improve by 2 lines in ischemic rvo and by 1/2 line to one line over DME

    Amanda M:
    Any changes in oct or ffa sir?

    Ameen Marashi:
    in ischemic maculopathy you dont see any changes on OCT except hyper reflectivity of inner tissue with thinning no cystic or thickening so you wont see any changes on OCT pre or post injection
    while FFA I dont think you will notice changed but on fundus photograph you find that the retina has fewer signs of RVO

    Amanda M:
    Sir, aflibercept gives this result when injected in the acute stage or even when given later?

    Ameen Marashi:
    at any stage

    Amanda M:
    Ok sir.👍

    Mamdouh Mannaa:
    nice.. what about diabetic ischemic maculopathy.. does it work too?

    Ameen Marashi:
    It does but not like RVO







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