Speakers discuss management of Retinal arterial occlusion, anterior ischemic optic neuropathy & ocular nerve palsies in hypertensive patients

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 Ophthalmology Session during PHL 22nd Annual Congress
Speakers discuss management of Retinal arterial
occlusion, anterior ischemic optic neuropathy &
ocular nerve palsies in hypertensive patients
Treatment for central retinal artery occlusion is prevention.
Once you have this disease, it is usually end of the vision

LAHORE: A number of interesting papers were presented in the session devoted to Ophthalmology during the 22nd Annual Congress of Pakistan Hypertension League held at Lahore from 21-24th February 2019. This session was chaired by Prof. Nadeem Riaz and Dr. Abdul Rauf. Prof. Nadeem Riaz discussed Anterior Ischemic Optic neuropathy with special reference to new hypertension retinopathy classification. Dr. Sohail Sarwar made a presentation on Quantification of optic swelling and showed some informative slides. Referring to the management of a patient he stated that with the use of Acetazolamide the patient’s values came down and the drug was stopped and stent was implanted.

Prof. Sidrah Riaz talked about Cataract and uncontrolled hypertension. She discussed in detail the complications associated with hypertension. She pointed out that there is no consensus on figures of systolic blood pressure and diastolic blood pressure and when to stop surgery. However, one can operate on a patient even with blood pressure of 160/90 for cataract surgery. If the blood pressure is more then there is a risk of stroke. Angina and pain is associated with increase in blood pressure. Diastolic blood pressure is more in undiagnosed patients. She then discussed the reasons for poor visual prognosis after surgery and showed a video. Do not operate with increased IOP which should be below 30. Before one starts surgery the IOP and systolic blood pressure should be controlled, she added.

Prof. Nadeem Riaz remarked that pre-operative evaluation for phacoemulsification is very important. Identify the patients which can have problems on the operating table. Let the anesthetist monitor the patient before the start of surgery. At time intravenous mannitol is needed. It was also pointed out that antiplatelet therapy is given to the patients on long term basis, hence do not stop it. In diabetic patients while undertaking any ocular surgery, have a liaison with the physician. It is better that the ophthalmologist and the physician work together to manage these patients. Thorough medical examination is essential before surgery. If hypertension is uncontrolled, one should be careful while doing any surgery on these patients. In patients with aortic valve cardiologist should be consulted. The type of anesthesia to be used in these patient is also important. IOP should be maintained under control. You might kill the patient if you stop warfarin. Selection of anesthesia is a very specialized field, he added.

In the next session Dr. Abdul Rauf discussed artery occlusion and presented some cases. It presents in early 60s and prevalence is reported to be 8.5/10,000 and is seen more in men as compared to women. Speaking about the clinical features he mentioned sudden loss of vision. Visual acuity signs were also discussed and the investigations mentioned included ECG, ESR and Lipid profile etc. For arterial occlusion, ocular massage is one form of treatment. Anticoagulants and steroids are also used. He emphasized the importance of treating these patients as early as possible. Cardiovascular diseases are the major cause of mortality, hence immediate referral to cardiologist is a must.

Dr. Haroon Tayyab was the next speaker whose presentation was on Central Retinal Artery Occlusion. He first described its basic anatomy and epidemiology. These patients may present with sudden, severe painless loss of vision. To begin with they may complain of very low visual acuity. Leading cause of death in these patients is cardiovascular disease followed by diabetes mellitus. Giant cell arteritis, he said, should be ruled out in emergency. It just takes fifteen to twenty minutes to result in irreversible damage to retina and after this the survival time is very limited. Ocular massage is important. Carlogen can be used. Paper bag breathing is also used to get vasodilation. Steroids and vasodilators can be used to manage these patients. Iris new vessel, retinal neo vessels are some of the complications. It is recommended to have three to four weeks follow up to see if there are any complications. The life expectancy of CARO patients is about five and a half years, he added.

Prof. Huma Kayani Saigol was the next speaker whose presentation was on Management of Rubeotic glaucoma with special reference to Vitreoretinal surgeon’s perspective. This condition, she stated, is also known as Neo vascular glaucoma. She then discussed normal and abnormal blood vessel, BRAVO and CRVO, pathogenesis of venous occlusion and Rubeosis. About 60% of patients with retinal ischemia will develop venous occlusion. Speaking about the consequences of venous occlusion, she pointed out that these vessels will bleed because they are different from other vessels.

Continuing she pointed out that central venous occlusion was first described in 1906. In this condition IOP is raised and it gradually progresses to blindness. Patients have painful eye, they are dependent, it also increases financial burden besides creating some psychosocial issues not only for the patient but also for the whole family. She laid emphasis on controlling IOP by medical and surgical means to minimize visual loss. Retinal examination is recommended after every two to three months. Early diagnosis is crucial to reduce visual loss. In the treatment anti VEGF is useful. Pars Plana is the route of administration. Pretreatment with VEGF leads to greater success rate. She also mentioned about the laser PRP treatment of retina, it reduces overall oxygen demand to retina. In surgical Pars Plana vitrectomy, new vessels can easily bleed due to vitreous hemorrhage. Hypertension is associated with venous occlusion. These patients require early ocular management and proper monitoring to prevent blindness.

Prof. Abdul Hye spoke about surgical management of Rubeotic glaucoma. The goal of treatment, he said, is to prevent further loss of vision and make the patient comfortable and these things must be kept in mind. He then discussed in detail Trabeculectomy, AHMED glaucoma valve and cyto ablation with diode laser. Enucleation may have to be performed if the patient requests for this, he added. Trabeculectomy can be performed to help the patient to decrease vision loss. During the procedure the patient should be awake and responding to surgeon’s commands. He then discussed the use of drainage implant, valves or tube implants. AHMED Glaucoma Valve is the one which is very commonly used. He then showed an interesting video to demonstrate how the valve works. Diode laser ablation is used only in those patients who are blind or have very little beneficial vision. With the use of Retro Bulbar Alcohol injection the IOP is not reduced but the pain is relieved, he added.

Dr. Sohail Sarwar’s presentation was on ocular nerve palsies. He discussed the OMNSP grading scale. Its prevalence, he said, is 4/100,000 per year. We see more nerve palsies. He also talked about pathophysiology of micro vascular ischemia, 61% of patients have pain. He then referred to third nerve and fourth nerve palsy, patching as initial treatment besides highlighting the controlled measured movement of the eye.

Summing up the session Dr. Abdul Hye and Prof. Nadeem Riaz said that treatment for central retinal artery occlusion is prevention. Once you have this disease, it is usually end of the vision.

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