The San Diego View

We regret to inform you that after 10 years this will be the final Retina Corner for the SDCOS Newsletter. We have thoroughly enjoyed the collaboration and hope that our articles have, in some way or another, benefitted you and your patients. Retina is an interesting field where we take a very deep dive into a very small intellectual space. As retina specialists we are extremely lucky to have witnessed remarkable advances over the past few decades, with even more exciting discoveries on the horizon that we can’t wait to share with you. To be able to pass these advances on to our patients and fight alongside them to preserve, enhance, and even restore vision is a huge honor. Given that this is our final article here, we thought it might be best to wrap things up in a rapid-fire format. Despite the potential intellectual complexities of our field, in the end we often describe ourselves as just “simple retina specialists” and often boil down pathology and patient care concepts to the bare minimum. So here we go:

Dry AMD: Very common to see mild changes in our patients over 60 or so. Most do not require treatment other than recommending a healthy (Mediterranean) diet, active lifestyle, avoiding smoking, and routine home and MD/OD monitoring. Patients with Intermediate AMD have a higher risk of progression to advanced AMD (GA and/or nAMD), and should take an AREDS2 supplement with tighter adherence to all recommendations.

Geographic Atrophy: One of the advanced forms of AMD where the RPE becomes dysfunctional and eventually dies. More common in our older patients, 80-90+, and more common that you may realize. Circular areas of macular atrophy develop and grow at an average of 2mmsq per year. Visual function is greatly affected in all stages, and visual acuity significantly declines with foveal involvement. GA is best monitored with fundus autofluorescence and OCT. We are on the brink of our first treatment option to slow the growth of GA, something many patients are desperate for. Please look out for GA and consider a referral to your retina doc.

Wet AMD: Previously devastating to vision, and now extremely treatable with anti-VEGF injections as long as it is caught early before bleeding and fibrosis develops. Patients tend to do well with treatment every 1-3 months on average. Injections are extremely safe and should be essentially painless with proper technique. We have very exciting treatment options on the horizon in clinical trials (currently enrolling, feel free to ask), including long-acting injections that should control the disease for 6 months or longer, as well as gene therapy, which transforms the eye into an anti-VEGF manufacturing plan, potentially a cure for some patients.

Intravitreal Injections: Speaking of nAMD and intravitreal injection technique, this has evolved over the past 15 years. Initially docs applied betadine to the eye and surrounding skin, and always used a lid speculum. This was very uncomfortable with lingering pain for hours. Now, at least at RCSD, we use aggressive topical and subconjunctival anesthesia, only minimal betadine, and have access to chlorhexidine for very sensitive patients. We also often do not use a lid speculum, and prescribe topical anti-inflammatory drops for patients post-injection discomfort. Patients do quite well, and often comment on our technique.

Vitreous Opacities: Lots of talk about symptomatic vitreous haze and floaters these days. There are few options for patients: observation, laser (yag) vitreolysis, vitrectomy, and recently a nutritional supplement. Of these most retina docs do not endorse laser or supplements due to cost and limited efficacy. Vitrectomy for select (preferably pseudophakic) patients is extremely safe and effective with very impressive results including improvement in contrast, color saturation, and clarity. These are our happiest patients, and the days of telling patients that they need to simply live with massive floaters are long gone.

Macular Hole: Another condition that once had no treatment options that is now repairable in 99% of cases. The key to diagnosis is OCT, looking for a full-thickness defect (all the way to the RPE). Not an emergency as repair is highly successful even months out, but I’d get them to your retina specialist soon to plan surgery. Vitrectomy is performed in most cases, with a gas bubble. Positioning after surgery is controversial, but there is convincing evidence that face down positioning is NOT necessary, and we at RCSD very seldom require it, much to the relief of our patients.

Epiretinal Membrane: An extremely common finding of a hyper-reflective layer on the inner macula on OCT and cellophane-like macular appearance on exam. Macular distortion and thickening correlates well with symptoms, and vitrectomy is indicated for symptomatic patients, particularly with a VA deficit. The surgery is not urgent, is again extremely safe and effective, and, to be honest, pretty fun to perform. Most patients do well after surgery, with a slow recovery in symptoms.

Diabetic Retinopathy: Over the course of many years, most patients with diabetes are bound to develop damage to the retinal vascular network, including pericyte loss, vascular leakage, microaneurysm formation, and, when these rupture, intraretinal hemorrhages. Some patients progress to closure of segments of the of vascular tree with secondary tissue ischemia. Consequences of this include macular edema and neovascularization. VEGF is a major driver of this process and fortunately anti-VEGF injections have a profound effect on regressing diabetic retinopathy and macular edema. This is also an exciting area of research, with long-acting medications and gene therapy being explored in clinical trials. Feel free to contact us for more information or possible candidates.

Retinal Tears and Detachment: Peripheral retinal pathology can be anxiety-provoking both for patients and eye doctors. Retinal tears typically develop secondary to vitreous separation in the far periphery. In older patients with a liquified vitreous these are fairly urgent situations with laser barricade indicated the same day in most cases, however many tears will not progress quickly and younger, asymptomatic patients can be treated on a less urgent basis. The risk of an untreated tear is progression to a retinal detachment, where liquid vitreous enters the subretinal space. RDs often require more than just laser, but we can nearly always repair them. Good options include in-office pneumatic retinopexy, as pioneered by our practice in the 1990s, vitrectomy, and scleral buckling. On the other hand, asymptomatic retinal holes in a patient without risk factors such as RD history in them or a family member, symptoms of traction, early subretinal fluid, or systemic disease associated with RD, can usually be observed.

Retinal Vein Occlusion: In many cases RVOs develop macular edema, which can nearly always be successfully treated with anti-VEGF injections. Unlike nAMD, patients eventually should be weaned off treatment.

Patient Communication: Retinal pathology can be extremely anxiety-provoking for patients, and it is very important that us retina docs to communicate clearly, kindly, and thoroughly with them. I love to use multimodal imaging on large monitors to review exactly what is going on with patients. I strongly believe that when they understand their pathology they can be a more active participant in the treatment plan. Patients and their caregivers appear to really appreciate these explanations as well. I think you guys probably do a better job of this than most OMDs, so keep up the good work and I’d encourage you to ask your patients if things are being communicated well to them by their retina docs – if not, please let us know!

With that, I wanted to thank you all for reading our little articles over the years. We will certainly miss contributing to the SDCOS, but definitely understand the decision. We are actually in the process of developing our own Retina newsletter with educational content, meeting summaries, and interesting cases. You may see an email from us regarding this soon, and feel free to let me know if you are interested in receiving it. We are also in the process of planning a Retina Update meeting for the late summer or fall. More details to come soon!

Thanks everyone – please all keep in touch and never hesitate to call or us at any time. My cell number is 415-341-5456 and Mike Ammar’s is 480-323-9196. We are always happy to help with any patient as best we can.

Best wishes,
Nik and Mike

Nikolas London, MD, FACS
Retina Consultants San Diego
415-341-5456 (cell)
london@rcsd.com
www.rcsd.com