University Hospital Basel. Optical Coherence Tomography Emerging Role in the Assessment of MS PD Dr. Konstantin Gugleta

Transcription

1 University Hospital Basel Optical Coherence Tomography Emerging Role in the Assessment of MS PD Dr. Konstantin Gugleta 15th State of the Art SMSS, Lucerne January 2013

2 Retinal Nerve Fiber Layer fibers 82% Axons, 18% Glia, no Myelin Iester M et al. ONH and RNFL Analysis. EGS 2005

3

4

5 Non-(pre)-OCT nerve fiber layer evaluation

6 Optical Coherence Tomography - OCT

7 Time-domain Frequency (spectral)-domain

8 SD-OCT is superior to TD-OCT, not only due to higher resolution, but due to more delievered data

9 Ganglion cell complex, for example RTVue GCC jedoch nicht der RNFL Messung überlegen.

10 do not only read the number observe, look for patterns

11 Diagnostic difficulties and roles of OCT in MS static - transversal examinations & issues dynamic follow up examinations & issues * Patterns of OCT-RNFL loss & OCT - Artefacts * ON Relapse * ON atrophy (post-on & ON-independent) * Varia (Macula etc.)

12 Patterns of RNFL loss, measurement artefacts, diagnostic difficulties

13 Diagnostic difficulties: patterns

14 Artefacts: decentration

15 other difficulties in new generation devices

16 Artefacts & diagnostic difficulties: age = normal RNFL loss varies between 0.15 und 0.5 micrometers per year. Ophthalmology, 2009

17 Normative database

18 Artefacts & diagnostic difficulties: signal strength and quality Material: Dr. P. Hasler, 2012

19 Artefacts & diagnostic difficulties: bulbus axial length (myopia effect) = no known and widely accepted correction still, do not forget... Ophthalmology, 2009

20 Artefacts & diagnostic difficulties: optic disc size = no known and widely accepted correction still, do not forget Ophthalmology, 2009

21 Case example: female patient, age 49 No therapy. Varying VF in course of time. Opthalmological findings, including the IOP, within the normal limits, except the VF and OCT. Concentric VF-defect = functional? OCT artefacts?

22 = inflammatorydemyelinating CNS disease OCT RNFL pattern loss not typical (sup./inf., instead of temporal perhaps an additional form of optic atrophy, NTG?); Plaques in visual pathway explain homonymity of the VF defects (BMW sign, bilateral posterior / occip./ lesions).

23 RBN (relapse), yes or no, to treat or not to treat, that is (are) the question(s)

24 Case example: female patient, age 41 MS diagnois since 2.5 years, DMT (Avonex). Visual disturbance in the left eye since couple of days, slightly blurred vision, diplopia (not constant). VA 1.0 OD, 0.7 OS. No RAPD. RBN (relapse) LA?

25 No RAPD on the left side. No (OCT/fundus) sign of RNFL swelling in the left eye whatsoever, compared to the right eye. VF not exactly typical for RBN. known intermittent esophoria/esotropia (OS) decompensation with known amblyopia P.S. already had high dose i.v. steroids

26 Seven consecutive patients with multiple sclerosis (MS) were prospectively imaged from the onset of ON for 6 to 12 months. RNFL measured with FD-OCT initially increased in all eyes with diffuse optic disc edema. Inner macula thickness and polarimetric RNFLT decreased already in the acute phase, in all eyes.poor image quality with polarimetry occurred in 2 eyes in the acute phase of ON. Conclusions. Change of RNFLT and macular thickness during the course of acute ON in MS strongly depends on the method used for the measurement. Inner macula thickness, measured with FD- OCT,was especially useful for the follow-up, since it was not influenced by initial disc edema and had consistently high image quality.

27 Longitudinal OCT RNFL readings in MS, useful as a parameter of disease activity?

28 Test-Retest variability / reproducibility

29 MS Acute ON excluded; 92.6% of ptients were RRMS; EDSS 2.5 at baseline; 36% no treatment, the rest Betaferone Rebif, Copaxone (two had Mitoxantrone). Healthy controls

30

31 Study: Pattern of retinal thickness changes measured by ocular coherence tomography in patients with multiple sclerosis 3-6 mm 3 mm -Retinal ganglion cells are concentrated (50%) in an area between mm from the center. -Wallerian degeneration leads to 1:1 Axon-Soma loss, producing an above affect. Gugleta et al. 2006

32 Miscellaneous

33 Case example: male patient, age 47 MS since 23 years. Referral question: ophthalmologic contraindication for Gilenya-Th? BCVA (best corrected VA) OD 0.6, OS 0.7 No RAPD. Both optic discs cupped glaucoma-like. Still, IOP within normal range (well, borderline), no clear risk profile for NTG, and cave large discs = relatively large cupping. Superior/inferior OCT RNFL loss corresponds to VF defects (OD>OS). In a longstanding MS, such pattern not typical, but not impossible. Still, other etiologies (NTG?) not excluded Temporal pallor in both discs present speaks for St. p. RBN, positive history for RBN bilaterally, but OCT RNFL temporal thinned only OS.

34 Macula OD shows a lamellar defect / hole, due to (idiopathic?) epiretinal fibroplasia. It explains the thickenning of all the retinal layers OD, and hence masking of RNFL atrophy due to St. p. RBN OD. VA is affected by the ERF / lamellar hole due to Style- Crawford effect. Referral question: green light for fingolimod, as far as eyes are concerned. Close follow-up nevertheless necessary.

35 Universitätsspital Basel Take-home messages: OCT is a promising and precise technique of visualising and quantifying ocular tissues at a histology in vivo micrometer level. It can be used as an adjunct diagnostic method in unclear cases of optic neuropathies. In MS patients, it can be used for the precise objective diagnosis of RBN (provided previous scans are available), and for the follow-up of optic nerve atrophy in MS, with or without history of ON (in latter case, unclear whether reproducibility / measurement sensitivity is high enough for studies shorter than several years).

36 Thank you for your attention!