Technicians & Nurses Program

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Kathleen Cummings
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1 ASCRS ASOA Symposium & Congress Technicians & Nurses Program April 17-21, 2015 San Diego, California

2 Optical Coherence Tomography: Essentials in Anterior and Posterior Segment Imaging Michael Stewart, M.D. Disclosure Allergan: Advisory Board, Research Support Boehringer-Ingelheim: Consultant Regeneron: Advisory Board, Research Support I will refer to off-label use of approved medications OCT What is this? Optical Coherence Tomography Laser Cross section Angle-closure Glaucoma ( Structural Levels) Do you need an anterior segment OCT To adequately image the anterior segment? Pupillary Block Plateau Iris VISANTE OCT Phacomorphic Glaucoma Malignant Glaucoma SL-OCT Ritch R. Liebmann JM, Lowe RF The history of angle-closure glaucomas: Philadelphia, Pa: Lippincott-Raven; 1997:

3 CASIA OCT Irido-Trabecular Angle imaging Pre-LPI Schlemm's canal Schwalbe's line Post- 1 week Scleral spur Post- 1 month 8 Quantitative Analysis Capabilities - Anterior chamber diameter, volume and pupillary diameter Cirrus HD-OCT Schwalbe's line Schlemm's canal Sectoral scan AS-OCT New parameters - Trabecular-iris contact length (TICL) and trabecular-iris space area (TISA-500 and 750) were introduced to describe the angle appearance. Radhakrishnan et al. Arch Ophthalmol. 2005; 123: Collector Channels Anterior segment imaging with spectral-domain / swept source OCT CC TM * SC Episcleral plexus RTVUE CIRRUS HD-OCT CASIA OCT IVP CC SC Ciliary body TM TM=Trabecular Meshwork *SC=Schlemm s canal CC=Collector channel CB=Ciliary body Dvorak-Theobald G

Ocular Trauma: Choroidal Haemorrhage Iris, Ciliary Body Trauma 13 14 Choroidal

UBM image showing choroidal effusion with no ciliary body detachment at 6-o clock

SL-OCT image showing choroidal effusion with no ciliary body detachment at the

cyclodialysis cleft at the same position (arrow) C.

effusion; CB, ciliary body; S, sclera; AC, anterior chamber 15 16 Filtering Blebs

conjunctiva in the bleb wall Cystic spaces within the bleb wall Scleral flap

difficulty in visualizing the forniceal edge of the bleb hidden beneath the upper

Coherence Tomography. Ophthalmology. 2007 Jan; 114(1):47-53. Epub 2006 Oct 27.

4 Ocular Trauma: Choroidal Haemorrhage Iris, Ciliary Body Trauma Choroidal Effusion Cyclodialysis Cleft A. UBM image showing choroidal effusion with no ciliary body detachment at 6-o clock (arrow) B. SL-OCT image showing choroidal effusion with no ciliary body detachment at the same position (arrow) CE, choroidal effusion; CB, ciliary body; AC, anterior chamber A. UBM image showing the cyclodialysis cleft at 3-o clock (arrow) B. SL-OCT image showing the cyclodialysis cleft at the same position (arrow) C. Well defined cleft (arrow) using SL-OCT color image function CE, choroidal effusion; CB, ciliary body; S, sclera; AC, anterior chamber Filtering Blebs ASOCT-Trabeculectomy Blebs Structures visualized: Bleb height and thickness of the conjunctiva in the bleb wall Cystic spaces within the bleb wall Scleral flap apposition and underlying sclera Patency of internal ostiumoutflow channel Some difficulty in visualizing the forniceal edge of the bleb hidden beneath the upper lid Singh M et al, Imaging of Trabeculectomy Blebs Using Anterior Segment Optical Coherence Tomography. Ophthalmology Jan; 114(1): Epub 2006 Oct 27. Miura M et al, Three-dimensional anterior segment optical coherence tomography of filtering blebs after trabeculectomy. Glaucoma Apr-May;17(3): Vertical AS-OCT image showing bleb micro-cysts and a slightly thinner cornea underlying the bleb in superior periphery (black arrow) AC: Anterior chamber; I: Iris

5 Glaucoma implants Anterior Segment Tumors-Iris Tumors Long term follow-up images of tube insertion in the sulcus in different patients: (A) Slit-lamp picture showing tube tip in pupillary area, well positioned between iris and lens (B) Tube positioned parallel to iris and lens visualized by ultrasound biomicroscopy (C) SL-OCT image confirming location of the tube in posterior chamber sulcus Post DSAEK- Visante Enhanced Depth Imaging OCT TD-OCT SD-OCT (Cirrus) SD-OCT (Spectralis) EDI SD-OCT (Spectralis) Jhanji, Greenrod, Vajpayee. Donor dislocation after DSAEK. BJO 2009 * Spaide RF et al. Am J Ophthalmol. 2008;146:496. Lamina Cribrosa 4

6 Focal Laminar Defect Lamina Cribrosa Depth OD max IOP 28 OS max IOP 20 Posterior Laminar Surface Lamina Cribrosa Pore?????? Central Retinal Vessels Short Posterior Ciliary Artery Artery Short posterior ciliary artery Vein Artery & veins Cilioretinal artery 5

7 Parapapillary Choroid Subarachnoid Space Jonas JB, et al. IOVS 2003;44:5189. Optic Nerve Complex Examination of deep ONC structures - Lamina cribrosa - Vascular structures - Peripapillary choroid/sclera - Subarachnoid space - Lamina cribrosa - Vascular structures - Peripapillary choroid/sclera - Subarachnoid space 6

8 Examine angles What is this? Normal cornea Pre-op Visante Visante OCT Epithelium Bowman s layer Stroma Descemet s membrane 300 μm SD UHR OCT Eye with an anterior corneal scar 7

9 Pre-op UHR OCT Visante POD #11 Graft: 221 um Residual scar: 107 um Central Corneal thickness: 590 um ( um) 43 Visante POD #11 OCT Imaging = Optical Biopsy Normal Macular Anatomy Graft: 221 um Residual scar: 107 um Central Corneal thickness: 590 um ( um) OCT B-Scan Normal Macular Anatomy Pre-operative macular hole NFL GCL IPL OPL ONL ELM IS/OS RPE Choroid Post-operative Modified from: Retina 5 th Ed, Chapter 3, Optical Coherence Tomography 8

Previous vitrectomy with silicone oil 20 minutes

assessment of retinal anatomy: SDOCT Imaging of

for quantitative assessments: ILM segmentation RPE

Retinal thickness SDOCT Imaging of Wet AMD

thickness maps: Retinal thickness VA: 20/100 SDOCT

thickness map ILM segmentation RPE segmentation

10 Previous vitrectomy with silicone oil 20 minutes later Aqueous SDOCT Imaging of Macula Qualitative assessment of retinal anatomy: SDOCT Imaging of Macula Segmentation of retinal layers necessary for quantitative assessments: ILM segmentation RPE segmentation Subretinal Fluid PED Subretinal Fluid Retinal thickness SDOCT Imaging of Wet AMD Segmentation algorithms result in reliable retinal thickness maps: Retinal thickness VA: 20/100 SDOCT Imaging of Wet AMD: Anti-VEGF Therapy Retinal thickness map ILM segmentation RPE segmentation VA: 20/40 Anti-VEGF Therapy: 1 month post-injection RPE segmentation 9

11 SDOCT Imaging of Dry AMD Segmentation algorithms result in reliable RPE elevation (drusen) maps (Cirrus, software 6.0): SDOCT Imaging of Wet AMD Segmentation algorithms result in reliable RPE elevation (PED) maps (Cirrus, software 6.0): RPE RPE floor RPE RPE floor Vol: 0.58mm 3 RPE segmentation RPE Elevation map Gregori G, Wang F, Rosenfeld PJ, et al. Spectral domain optical coherence tomography imaging of drusen in nonexudative age-related macular degeneration. Ophthalmology. 2011;118(7): RPE segmentation Retinal thickness RPE Elevation map Macular edema RPED SDOCT Imaging of Wet AMD Vitreomacular interface abnormalities Epiretinal membrane 10

12 11

13 12

14 Why this shadow? Why this shadow? Gas bubble 1945µ 2819µ 13

15 14

16 2 weeks later 15

17 OS 20/40 Stage 2 OD 20/25 Stage 1 Lamellar hole Cyst? Lamellar hole Epiretinal Membrane 16

18 20/40 20/30 Pre-Op Post-Op 17

19 18

20 9/29/ /31/ /30/2005 1/11/

21 Subretinal fluid RPED Case 71 yo man with wet AMD OS Multiple injections for the last 12 months Complains of worsening in VA after treatment Wet AMD Dry AMD Do anti-vegf injections cause geographic atrophy of the RPE? Case 74 y.o. man decreased vision OD (20/200) Case 20/200 Ranibizumab #1 After 1 month 20/80 Ranibizumab #2 20

woman with a vascularized, hemorrhagic PED

56 mm 3 Color photo Early FA Late FA Baseline

6 mm 3 66 year old woman 10 injections: Bev

Dosing Every 2 Weeks FA-early FA-late 8w post

6 mm 3 Modified from: Stewart MW, et al.

22 VA: 20/40 Ranibizumab #1 Case Monthly Injections 73 y.o. woman with neovascular AMD Case 3 65 y/o woman with a vascularized, hemorrhagic PED VA: 20/20 Ranibizumab #2 Vol: 0.73 mm 3 Vol: 0.63 mm 3 VA: 20/20 Ranibizumab #3 Vol: 0.56 mm 3 Color photo Early FA Late FA Baseline Anti-VEGF #1, Anti-VEGF #2 4w post Inj. #2 Observed 6w post Inj. #2 Observed Volume: 6.9 mm 3 Volume: 2.6 mm 3 66 year old woman 10 injections: Bev X6, Ran X4 (~q5wks) July /50 Case 4: Dosing Every 2 Weeks FA-early FA-late 8w post Inj. #2 Anti-VEGF #3 Volume: 3.2 mm 3 1 year later 20/200 4w post Inj. #3 Observed Volume: 3.9 mm 3 Volume: 1.6 mm 3 Modified from: Stewart MW, et al. Pharmacokinetic Rationale For Dosing Every 2 Weeks Versus 4 Weeks With Intravitreal Ranibizumab, Bevacizumab, And Aflibercept (Vascular Endothelial Growth Factor Trap-eye). Retina Dec 18. OCT Baseline 20/200 Ran Inj. #1 2 w post Inj. #1 20/40 Bev Inj. #2 2 w post Inj. #2 20/30 Ran Inj. #3 2 w post Inj.#3 20/30 Bev Inj. #4 21

23 OD BDR OS Diagnosis? IOP = 4 OD 1 month later OS Dense cataract Pre-op Baseline Phaco + IVT 1 day Post-op Following steroid injection 6 months VA: 20/20 22

24 c/o superior field defect Acute retinal artery occlusion Inner retina thickening Retinal thinning 23

25 Treatment options: 1. External beam irradiation 2. Systemic chemotherapy Treatment 1.Observation 2.Laser photocoagulation 24

26 NFL Lines in nasal periphery 65 y.o. s/p scleral buckle for RD Now with VA of 20/100 for 6 months. 2 nd opinion: 68 y.o s/p renal transplant with iritis and VA of 20/40 OU 25

27 Conclusions 1. OCT has revolutionized the management of chorioretinal vascular diseases. 2. OCT has added greatly to the management of glaucoma. 3. Improved techniques and scanners are advancing the imaging of anterior segment structures. 26

Optical Coherence Tomography: Pearls for the Anterior Segment Surgeon Basic Science Michael Stewart, M.D.

Optical Coherence Tomography: Pearls for the Anterior Segment Surgeon Basic Science Michael Stewart, M.D. Disclosure OCT Optical Coherence Tomography No relevant financial relationships I will refer to