Ameen Marashi:
your approach BCVA is 20/80
Hemi crvo case approach attachment.php?s=d73344ab9cc7c0c0163bc7d37ecf6442&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:
ofcourse


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:
didnt 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