Mark Dunbar: Disclosure

Transcription

1 Important Things to Understand About OCT Mark T. Dunbar, O.D., F.A.A.O. Bascom Palmer Eye Institute University of Miami, School of Medicine Mark Dunbar: Disclosure Optometry Advisory Board for: Allergan Carl Zeiss Meditec Regeneron Mark Dunbar does not own stock in any of the above companies

2 OCT I Stratus SD OCT SD OCT Commercially Available Carl Zeiss: Cirrus OptiVue: Avantis, RTVue, ivue Heidelberg: Spectralis Topcon Optos Made by OPKO SOCT Copernicus Now owned by Cannon SD-OCT Differences Hardware is relatively similar It s all about the software! Device should be easy to use and patient friendly Should be competitively priced 2

3 Advances in SD-OCT Improving software Faster virtual angiography Noise reduction/over sampling technology Wider and deeper scans Greater density in the scans Improvements in 3D imaging Enhanced depth imaging imaging choroid Progression analysis software 2015 OCT Angiography (OCTA) Over 90,000 A scans per second Compares repeat scans acquired at the same position in the retina to look for changes The OCT anatomy of the eye is static The only changes in scans are caused by blood flowing through vasculature Blood flow within the eye is captured using motion contrast. What makes a good scan Signal strength Glaucoma: minimum of 7, 6 can t rely on data Less important in retina Make sure there is no algorithm failure Need a good tear film Have patient blink before the scan Good patient Good OCT operator 3

4 3Types of OCT Scans Retina scan Glaucoma scan Anterior Segment scan The Printout: Retina Cirrus Retina: 2 Important Scans to Acquire Raster Scan Macular Cube 4

5 New HD Raster Scans More beautiful b scans right where you want them with Smart HD Scan workflow HD 1 Line 100x 100x averaged VIVID Image Enhancement Technology Improved vitreous assessment Publication quality image HD 21 Line 21 lines 4/8x averaged Ideal for anti VEGF therapy monitoring HD Radial 12 lines 8x averaged Fovea as common reference point Ideal for macular hole assessment & surgical planning HD Cross 5 horizontal 5 vertical 8x averaged The The Macular Cube Cube 5

6 The Power of the Cube Incredible Scan Density 3 D viewing Advanced segmentation Guided progression analysis Change analysis Drusen and geographic atrophy analysis Ganglion cell analysis ivue Heidelberg Spectralis 6

7 Zeiss Cirrus Heidelberg Spectralis OptoVue ivue Main Clinical Utilities of OCT High resolution evaluation of retinal anatomy Diagnosis of conditions difficult to establish with traditional fundus exam Quantitative assessment of retinal and vitreoretinal anatomic alterations Objective means for monitoring disease progression and/or therapeutic response Diagnose and determine progression of glaucoma The Anatomy 7

8 Understanding and Interpreting Recognizing Macular Edema Where is the Fluid? Where is the Fluid? 8

9 PED involving fovea RPE Detachment 9

10 Central Serous Chorioretinopathy (CSR) 44 y/o Female: Notes blur in the LE X 1 mo BCVA: 20/25 53 y/o Hispanic Male /20 VA 10

11 53 y/o Hispanic Male PED 53 y/o Hispanic Male 8/2012 2/2014 Choroidal Neovascularization (CNV) 11

12 Degenerative Myopia with CNV Early AMD 12

13 RPE Elevations: If the RPE is raised, a new proprietary algorithm for Cirrus maps and measures the area and volume of the elevations. Advanced RPE Analysis Gain new insights on your AMD patients RPE Elevations Sub-RPE Illumination Sub-RPE Illumination. If the RPE is absent or has lost integrity a new proprietary algorithm for Cirrus can map and measure the affected area. 13

14 Esther: Geographic Atrophy /28/2010 vs. 1/18/ /28/2010 1/18/

15 3/20/10 6/5/2012 3/20/10 6/5/

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17 Full Thickness Macular Hole 66 yo Female Blurred vision RE X 6 weeks Longstanding blurred vision LE X 2 yrs 17

18 64 y/o White Female Blurred VA X 10 days Seen 2 mo ago: normal exam VA: 20/40 Heidelberg Spectralis 18

19 When is a hole.a hole? 67 y/o Hispanic Male 20/25 19

20 67 y/o Hispanic Male Told that he had a retinal problem 20

21 Macular Edema 5/7/ /200 6/9/ /25 7/28/ /200 Conditions Affecting IS/OS Junction AKA: PIL, Ellipsoid Line 20/70 20/60 57 y/o Hispanic Male: 21

22 20/70 20/70 20/60 Solar Maculopathy 22

23 SDOCT in Glaucoma 23

24 Traditional Methods of Assessing Glaucoma IOP monitoring Major risk factor Subjective evaluation of the optic nerve Visual field testing The value of the OCT in glaucoma Picking up early change That is difficult to see on clinical exam Before it shows up on the visual field Showing progression Which one has glaucoma? 24

25 At 95% specificity, up to 35% of eyes had abnormal average RNFL thickness 4 years before development of visual field loss and 19% of eyes had abnormal results 8 years before field loss. Conclusions: Assessment of RNFL thickness with OCT was able to detect glaucomatous damage before the appearance of VF defects on SAP. In many subjects, significantly large lead times were seen when applying OCT as an ancillary diagnostic tool. 25

26 Glaucoma Analysis with the RTVue: Nerve Head Map Provides Cup Area Rim Area RNFL Map 16 sector analysis compares sector values to normative database and color codes result based on probability values (p values) TSNIT graph Color shaded regions represent normative database ranges based on p values 26

27 RNFL Quadrants and Clock Hours Inter visit Tolerance: Clock Hours: 5 7 microns Quadrant: microns You Need 2 Different Scans for Glaucoma Analysis RNFL Print out With ON data Macular Cube print out Ganglion Cell Analysis 27

28 Macular Cube Average RNFL Thickness 75 microns tipping point Floor Affect in Advanced Glaucoma microns Disc Area Small < 2 mm Medium > 2 mm Large > 3 mm 28

29 Clinical Pearls With Cirrus SDOCT in Glaucoma Do 3 RNFL scans at a time Ensures consistency/reliability On follow up 2 of the scans can be used as the baseline for guided progression analysis GPA 1 st Scan 1 2nd Scan 2 29

30 3rd Scan 3 51 y/o Hispanic Female Reports shadow peripherally in her LE TA: on 3 visits 30

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32 Berta: 65 y/o Hispanic Female Followed for OHTN : TA

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34 Monday 3/27/15 TA 25/29 December TA 22/22 Inter visit Tolerance: Clock Hours: 5 7μ Quadrant: 10 12μ 34

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36 Tania: 44 y/o Hispanic Female Has been seen several times over the yrs for routine eye care 1998: TA 20/22 09/05: TA 18/20 12/07: 19/20 Tania: 44 y/o Hispanic Female 12/08: TA: 25/21 Pach: 610/620 μ u OCT done 1/5/08 for review 4/20/09: TA 23/24 4/19/10: TA 23/25 10/11/2010: TA 22/ /5/08 36

37 4/20/09 4/20/

38 Tania Ocular HTN No treatment Is there a reason to justify treating her? What is her risk for developing glaucoma? 5 yrs vs. lifetime? Issues Relevant to Tania What is his risk of actually developing glaucoma? From OHTS: Depends mostly on corneal thickness? IOP of mmhg Ave Corneal thickness < 556 µ: 36% Risk Corneal thickness 565 to 588 µ: 13% 38