ARMD - intraretinal fluid

[deepak_deepak]

Dear Doc,

My father, aged 77, has ARMD.  I give the details below:

He complained of regular diminution of vision in left eye post cataract surgery in 2004.   He had a spectacle corrected visual acuity of 6/6P in the right eye and counting finger 2 ½ mt. in the left eye.  Intraocular pressure was recorded 16.0 mmHG in the right eye and 13.0 mmHG in the left eye.  Examination of the anterior segment revealed posterior chamber intraocular lens with minimal posterior capsular opacification in right eye and posterior chamber intraocular lens with YAG opening in left eye.  Fundus examination of the right eye revealed soft drusen with fluid and the left eye showed disciform scar.  Fundus fluorescein angiography showed age related macular degeneration in both eyes with right eye ? peripapillary choroidal neovascular membrane and left eye disciform scar.

On subsequent observation his visual acuity was 6/18, N8 in right eye and counting finger 1 mt. in left eye.  Fundus fluorescein angiography showed an illdefined peripapillary choroidal neovascular membrane.  ICG was done on same day which showed a large choroidal neovascular plaque at macula.  Optical coherence tomography done showed illdefined subfoveal membrane extending supero-nasally and nasally with cystoid macular edema, neurosensory detachment.  Left eye scan showed scarred choroidal neovascular membrane with overlying cystoid macular edema.  Transpupillary thermotheraphy was done.  He complained further difficulty in reading.  He had a spectacle corrected vision of 6/20, N24 in both eyes.  Intraocular pressure was 14.0 mmHg in right eye and 13.0 mmHg in left eye.  Fundus revealed partially regressed choroidal neovascular membrane in right eye and disciform scar in left eye.  He was advised Fundus fluorescein angiography and Optical coherence tomography.  Optical coherence tomography showed partially scarred choroidal neovascular membrane with activity in temporal and supero-temporal part of choroidal neovascular membrane with cystoid macular edema and neurosensory detachment and pigment epithelial detachment infero-temporally in right eye.  Left eye showed scarred membrane with overlying cystoid macular edema.  He was advised Intravistreal Avastin in right eye.  He was reviewed again and his vision was found to be 5/60 in right eye and counting finger 3 mt. in left eye.  Fundus examination showed regressed choroidal neovasuclar membrane in right eye and scar in left eye.  He was advised Fundus fluorescein angiography and optical coherence tomography.  Optical cohdrence tomography showed flattened pigment epithelial detachment, resolution of neorosensory detachment, scarring in subfoveal choroidal neovascular with membrane appearing more compact and decreasein cystoid macular edema in right eye.  Fundus fluorescein angiography done later showed staining of scar with decrease in leakage.  He was advised repeat Avastin injection in right eye.

On review fundus picture was stable in both eyes.  He had a best corrected visual acuity of 6/60, N24 in right eye and counting finger 1 mt. in left eye.  Fundus showed scarred choroidal neovascular membrane in both eyes.  He was reassured and refracted under dilation.

All this happened in 2007.  Recently, we consulted a retina specialist who diagnosed that there is major inflammation in left eye because of intraretinal fluid and prescribed intravitreal shots of Avastin and Tricort my father got in the month of August.  A large cystic cavity was noted and there is a large macular scar.  There are small fluid filled cavities in inner retina.  Now on review after Optical Coherence Tomography and Fundus photography, he insists that another shot is required as inflammation is less than it was before.  He has prescribed some eyedrops and vitamins and antioxidants.

My question is simply if another shot is really required?  Would the existing inflammation cause further deterioration in vision?  Because in private practice in India, you never know if these recommended costly procedures are really necessary, I would greatly appreciate your invaluable advice, whether we should go ahead with the treatment.

Thanks and regards.

Deepak, India

[deepak_deepak]

Thanks Dr Oyakawa,

But I would like to add here that we just went for a preventive.  His vision has not deteriorated from what it was before.  If you read the complete case history, you could advise whether another shot is required even if visual acuity is same as it was before.  Regards.

[Ray T Oyakawa, MD]

Yes,  unfortunately, some patients require monthly shots.

Dr. O.