Ophthalmic Imager Role

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MASTER OCT Ophthalmic Photographers Society October 18, 2014 Chicago, IL James B Soque, CRA COA Pamela A Weber, MD Island Retina Shirley, New York Commack, New York Financial Disclosure Genentech

1 MASTER OCT Ophthalmic Photographers Society October 18, 2014 Chicago, IL James B Soque, CRA COA Pamela A Weber, MD Island Retina Shirley, New York Commack, New York Financial Disclosure Genentech Ophthotech SD OCT Devices Island Retina Zeiss Cirrus Topcon 3D 1000 Heidelberg Spectralis Acknowledges L Gibbins West Chester, PA A Cullen Henry Ford, MI L Affel - Baltimore, MD D Landry Portland, ME Purpose: Proper Patient Positioning Advanced SD OCT Imaging Techniques Scans Based on Pathology En Face OCT, Macular and Raster Scanning EDI OCT Surgical Significance Adjust table height Feet on Floor Chair Position Wheel Chair Precautions Forehead position Chinrest position Fixation Internal (Visible - Size) or External (20/80 or worse of the tested eye) 2 45 th Annual Program OPS Ophthalmic Imager Role Proper Patient Instruction Intercontinental Hotel, Chicago, IL October 18 th, 2014 Course SA 3 - B Provide the Highest Quality Image Instruct your patient properly to gain greatest compliance Perform in a Timely and Efficient manner Pre register patient Study the Chart/Patient prior to performing your scans. EMR software / OCT review software Possible Flash Photo in OCT, (Topcon) Instruct Patient which direction to follow: Optic Nerve Scans- OD Scan, target moves to the left OS Scan, target moves to the right Peripheral Scanning Follow The Target!!! 3

Proper Device Set Up Study Protocols Zeiss Cirrus Anterior Segment - Cornea Scan Proper External Image in Focus External Landmarks Inner Edge of Iris / Pupil Tufts of Iris Tissue Center the Scanning

Raster Scan, + EDI Macula and Optic Nerve 200 x 200 Optic Nerve Anterior Segment Cornea Anterior Segment 512 x 512 - Angle Anterior Segment 512 Analysis, 4 x 4 mm Cube Caliper Tool = Measurement in

Retina (Red Free - LSO Image) Retinal Vessels Optic Nerve Vessels or RNFL IMPORTANCE FUTURE/COMPARISON STUDIES Macular Scan 512 x 128 Macula Macular Cube 200 x 200 - Macula 5 Line Raster Scan -

Caliper Tool = Measurement in microns (u) Alignment Features OCT Study Protocols = T (acquisition) Anterior Segment Cornea Scan Automatic Real Time (ART) - Heidelberg the camera head pans around the

2 Proper Device Set Up Study Protocols Zeiss Cirrus Anterior Segment - Cornea Scan Proper External Image in Focus External Landmarks Inner Edge of Iris / Pupil Tufts of Iris Tissue Center the Scanning Beam Manually Move Center Cross Hairs onto the Macula Move Center Cross Hairs over the Pathology Macular Scan 512 x 128 Macula Macular Cube 200 x Macula 5 Line Raster Scan - Macula HD 5 Line Raster Scan, + EDI Macula and Optic Nerve 200 x 200 Optic Nerve Anterior Segment Cornea Anterior Segment 512 x Angle Anterior Segment 512 Analysis, 4 x 4 mm Cube Caliper Tool = Measurement in microns (u) Proper Device Set Up Office Protocols Zeiss Cirrus Anterior Segment - Cornea Scan Optimization Function (Cirrus Function) Enhances OCT Beam Centers Beam on OCT Capture Window Focus of the Retina (Red Free - LSO Image) Retinal Vessels Optic Nerve Vessels or RNFL IMPORTANCE FUTURE/COMPARISON STUDIES Macular Scan 512 x 128 Macula Macular Cube 200 x Macula 5 Line Raster Scan - Macula HD 5 Line Raster Scan, + EDI Macula and Optic Nerve 200 x 200 Optic Nerve Anterior Segment Cornea Anterior Segment 512 x Angle Heidelberg Anterior Segment, Raster function. Caliper Tool = Measurement in microns (u) Alignment Features OCT Study Protocols = T (acquisition) Anterior Segment Cornea Scan Automatic Real Time (ART) - Heidelberg the camera head pans around the retina (on/off), during capture, aligns vessels. Repeat Set Up Function - Cirrus Aligns Red Free (LSO Fundus) Image, before capture, aligns vessels. Align and Synchronize - Topcon Synchronizes and aligns vascular image after capture. Single Line Scan = T(a) = 0.3 sec 1.01 Thousand A 6 mm. 5 Line Raster Scan = T(a) = 1.1 sec Thousand A Scan / 5 6 mm. 512 x 128 Scan = T(a) = 2.68 sec 64 Thousand A Scans in 6 mm x 6 mm box. Note: (Cirrus values - varies between devices) 3 D Visualization

Anterior Segment Angle Scan Posterior Segment Review

Anterior Segment - 512 Raster Change position of

of Target Eye follows Target, Beam remains

Eye Steering Relocate Scanning Beam / Eye Mapping

Landry of OCT Layers Save or Repeat Heidelberg,

Interruption NSC, PSC, Lens Vacuoles, Blood.

higher) Topcon Q Factor (35 or higher) Spectralis

necessary adjustments to your scan in accordance

3 Anterior Segment Angle Scan Posterior Segment Review of OCT Retinal Layers Techniques to Master Cirrus, Anterior Segment Raster Change position of Scanning Beam Eye remains Stationary Change position of Target Eye follows Target, Beam remains Stationary Change position of Both Relocate Target / Eye Steering Relocate Scanning Beam / Eye Mapping Courtesy: D. Landry Anterior Segment Angle Scan Posterior Segment Review of OCT Layers Save or Repeat Heidelberg, Anterior Segment Repeat Scan due to Beam Interruption NSC, PSC, Lens Vacuoles, Blood. Quality Levels Acceptable Ranges Cirrus (6 or higher) Topcon Q Factor (35 or higher) Spectralis (26 30) Study Protocols Save or Repeat Make necessary adjustments to your scan in accordance with the location of pathology, and its severity Scan interruption - Blood Relocation Sensitivity Angle

Save or Repeat Sensitivity Comparison Studies

contrast = increase sensitivity Save or Repeat

Master Angle Image too high, or low Change

Change Angle of Beam - Raster Scans, (Zero) 0

Display Thickness (u = microns) Conventional 5

Noise Decrease Contrast = Increase Sensitivity

Small Increments, 37-35 Improves Vitreous

4 Save or Repeat Sensitivity Comparison Studies Incomplete Image Breaks in Scan Decrease contrast = increase sensitivity Save or Repeat Display Thickness (u = microns) Techniques to Master Angle Image too high, or low Change Location of Beam Change Location of Target Change Angle of Beam - Raster Scans, (Zero) Degrees 6 mm Scan > 9 mm Scan Sensitivity Display Thickness (u = microns) Conventional 5 Line Raster Increase Sensitivity = Increase Noise Decrease Contrast = Increase Sensitivity Contrast Default (Cirrus) N = Change in Small Increments, Improves Vitreous Adhesions, Edema in DME and AMD Lesions, VMT Adhesions, and Epi Retinal Membranes

5 Conventional Optic Nerve Peripheral Scanning - BRVO FC FA Peripheral Scanning Circle Scan (Topcon)/ Raster Scan (Zeiss) 5 Line Raster Cirrus, OD, Nasal, 45 deg Offset Adjusting Gaze, and Location of a 5 Line Raster Scan Peripheral Scanning High Myope Angle = 0 degrees Relocated Superior, 5 Line Raster, Cirrus, Zero Offset 5 Line Raster, Macula Adjusting Gaze, Location, and Angle of a 5 Line Raster Scan Peripheral Scanning High Myope Angle = 325 degrees 5 Line Raster Cirrus, OS, Supero Nasal, 315 deg Offset 5 Line Raster, ON, 90 deg vertical offset

6 High Myope Stage 1 PVD Stage 3 PVD, Nasal Cut 5 line Raster, ON, Horizontal, Zero offset Relocated Gaze Nasaly, 5 Line, Cut 3 High Myope Stage 2 PVD Stage 3 PVD, Temporal Cut 5 Line, ON, 90 deg vertical offset Relocated Gaze Temporally, 5 Line, OS Vitreoretinal Interface Stage 3 PVD Stage 3 PVD 9 mm Posterior Vitreous Detachments (PVD) Epiretinal Membranes (ERM) Vitreo Macular Traction/Adhesion (VMT/VMA) Macular Hole 5 Line, OCT, Cirrus 5 Line Raster - 9 mm Scan Length, Mac / ON Critical Interfaces for the Vitreo Retinal Surgeon

7 Stage 3 PVD 9 mm Peripheral Scanning ERM Topography + OCT 5 Line Raster - 9 mm Scan length, Temporal DME, Dec VA OD, 512 Mac Scan. Tomogram 6 x 6 mm, OCT, Cirrus PVD, Nasal To Disk Peripheral Scanning ERM Line Scan- Relocate Gaze Nasal External Fixation (Topcon) 5 line Raster, Nasal gaze, ON, Dx: AION. Stage 2 PVD Epiretinal Membrane (ERM) ERM, Stage 3 PVD Stargardts Retinopathy, H.E. Spectralis [Courtesy: L. Affel] 12 mm Scan Length Study the images during Acquisition Mode Scan for Edema Scan for ALL Visible Boarders Scan for any Adhesions

8 ERM + Edema ERM Landscape of the Retina ERM Landscape of the Retina 512 Macular Scan, Temp Export View Macular 512 ERM + Vitreous Traction ERM Landscape of the Retina ERM Landscape of the Retina Macular OS, Relocated Scan, Relocate Gaze 5 line, Temp Scan, zero offset Macular 512, Relocated, Export View ERM Landscape of the Retina ERM Landscape of the Retina ERM 512 Macular Scan 5 line, Temp Gaze, 45 deg offset, Export View. Gaze Up, Slice Navigator, 5 Line, 90 deg, Export View.

9 ERM + VMT 3 D + OCT VMT / VMA VMT / VMA 5 line Raster, Relocated, 45 deg off set Bilateral Disease VMT VMT Macular Hole VMT, Stage 3 PVD, H.E. Spectralis [Courtesy L. Gibbins] MD requires Macular Hole Measurement Measurements performed Caliper Placement is CRITICAL VMT / VMA VMT Macular Hole 5 line HD VMT, Stage 3 PVD, H.E. Spectralis [Courtesy L. Gibbins] Cirrus, LSO, HD 5 Line Raster

10 Macular Hole Macular Scans En Face, Analysis ARMD Review Macular Analysis before dismissing patient from the OCT. Thickness Comparison between visits Volumetric Comparison between visits HD 5 line Raster OS, PVD, SRF, RPED. Changes in Apparent Fluid (u=microns) Dry and Wet AMD, CME, DME, RVO. Macular Hole Measurement ARMD Dry FC FA FV RPED ARMD Moorfields Eye Hospital and Whipps Cross Hospital, 30 eyes, (Lang, et al., 26, , 2012.) 5 Line HD, Cirrus Minimum Linear Dimension Measurement (Wakely L, et al., Br J Ophth, 2012) Proper macular hole measurement - diameter at the waist of the macular hole. Macular Hole Measurement ARMD Dry FV RPED ARMD 5 Line Raster

11 ARMD NV AMD DME DME Scan Both Eyes DME DME RVO 512 Mac Scan, Cirrus Vacuoles of Edema correlate with FA. FC, FA Superior BRVO DME DME RVO HD 5 Line, Cirrus Vacuoles of Edema correlate with FA. 512 Red Free, Horizontal, Cirrus

RVO S H R M Raster Scans with EDI 5 Line Raster, 90

Underneath RPE and Sclera Circulation, CNV, Tumors

Cullen CME S H E Subretinal Hyperreflective Exudation

Spectralis [ Courtesy: L Affel ] Diurnal thicker in

Hydration - affects al Volume Normal Thickest under

Key = measure in the same area Shah, Shah, et al:

Interest Macular Scans Study Centers, Wet ARMD (2013)

Material VRMC New York, S H E [Shah, et al.

12 RVO S H R M Raster Scans with EDI 5 Line Raster, 90 Deg Vertical, Cirrus EDI Enhanced Depth Imaging Underneath RPE and Sclera Circulation, CNV, Tumors Courtesy A. Cullen CME S H E Subretinal Hyperreflective Exudation Niacin Toxicity, Raster, H.E. Spectralis [ Courtesy: L Affel ] Diurnal thicker in the morning, retina is not diurnal. Hydration - affects al Volume Normal Thickest under the macula, T(m) = 287 u +/- 76 u. Key = measure in the same area Shah, Shah, et al: VRMC, NY, ASRS Toronto 2014:Abstract Courtesy A. Cullen New Interest Macular Scans Study Centers, Wet ARMD (2013) S H R M DUKE S H R M Sub-retinal Hyper Reflective Material VRMC New York, S H E [Shah, et al.] Sub Hyper reflective Exudation may represent CNV complex. AREDS Ancillary SD-OCT Study [Christenbury, JG, Ophthalmology 2013] Hyperreflective foci (HF) proliferation and migration. New biomarker for AMD progression. 5 Line HD Raster, Cirrus 5 Line Raster vs. EDI 5 Line HD, Cirrus

13 5 Line Raster vs. EDI 5 Line HD, Cirrus 5 Line EDI, Nasal Cut, OD EDI H.E. Spectralis, ART. [Courtesy L Affel] 5 Line EDI, Nasal Cut, OD, 45 deg Dr. Pamela A Weber al Mass, EDI H.E. Spectralis, ART [Courtesy L Affel] Full Report Presenting 4 Clinical Cases using Spectral Domain Optical Coherence Tomography.

14 SD OCT - Clinical Case No. 1 SD OCT OS 2/26/13 SD OCT 3/7/13 Infero Nasal MD, 44 year old male presented with decrease in vision OS x 2 weeks Medical Hx Unremarkable Profession: Graphic Designer BCVA OD- 20/20. OS- 20/200 FC RF 2/26/13 SD OCT OS 2/26/13 FC SD OCT OS 2/26/13 SD OCT 3/7/13 FA ICG

15 SD OCT 9/5/13 3 Weeks F/U, 9/27/13 OCT Pre and Post Laser BCVA OS 20/32 SD OCT 9/5/13 OCT Pre and Post Laser SD OCT - Clinical Case No. 2 JP, 16 year old female, C/O decreased vision OS, x 1 year BCVA OD- 20/20, OS- 20/160 Clinical Course OCT Pre and Post Laser Pre Op CSR - Remained active OS Micropulse Laser Performed OS 9/8/13 Diode Laser, 810 nm (5% duty cycle) 125 micron dia 800 mw 200 ms 10 Applications FC OS 1/21/10

16 Pre Op 25 g Pars Plana Vitrectomy Surgery with Membrane Peel SD OCT - Clinical Case No. 3 MS, 74 y/o WF. C/O seeing Bent Lines BCVA OD, 20/25. Pre Operative 1/21/10 - Optos Management OCT 25 Gauge vitrectomy surgery was performed on 2/5/10 The epiretinal membrane was successfully peeled Vision recovered to 20/20 9/24/10 Stage II PVD Pre Operative 1/21/10 Optos, Infero Nasal Angioma SD OCT Pre and Post Surgery OCT 3/23/11 OD 512 Mac Scan, Add l pull.

17 OCT Management Post Op 7/11/11 Stage 3 M Hole, decr VA 20/ Gauge PPV Surgery OD with ILM Peel 10/5/11 Air Fluid Exchange Air Gas Exchange, 15% C3F8 Post Op 12/22/11. OCT Post Op SD OCT - Clinical Case No. 4 9/12/11, OD progressing to full thickness Mac Hole. Post Op 10/19/11. AR, 72 y/o WM, C/O Dec VA OD BCVA OD 20/63 OCT Post Op OCT 9/12/11, HD 5 Line Raster Scan Post Op 11/14/11.

OCT Clinical Outcome Thank You Tomography, 512 Macular Scan 11 weeks post Jetrea James

com 1500 William Floyd Parkway, Ste 304 Shirley, New York (o) 631 924 4300 (e)

com OCT Clinical Outcome References Red Free and OCT, with Secondary Adhesion 11 weeks post

medicine/2013/713061 Christenbury JG, Folgar FA, O Connell RV, et al; Age-Related Eye

Progression of intermediate age-related macular degeneration with proliferation and inner

value in predicting anatomical and visual outcomes. Br J Ophth, 2012, 96:1003-7. Landa G.

, External limiting membrane and visual outcome in macular hole repair: spectral domain OCT

18 OCT Clinical Outcome Thank You Tomography, 512 Macular Scan 11 weeks post Jetrea James Soque, CRA, COA, OPS BOE Pamela Weber, MD Island Retina William Floyd Parkway, Ste 304 Shirley, New York (o) (e) (e) OCT Clinical Outcome References Red Free and OCT, with Secondary Adhesion 11 weeks post Jetrea Christenbury JG, Folgar FA, O Connell RV, et al; Age-Related Eye Disease Study 2 Ancillary Spectral Domain Optical Coherence Tomography Study Group. Progression of intermediate age-related macular degeneration with proliferation and inner retinal migration of hyperreflective foci. Ophthalmology. 2014;120(5): Lang et al., 2012, 26, Wakely L, et al., A comparison of macular hole measurement using optical coherence tomography, and their value in predicting anatomical and visual outcomes. Br J Ophth, 2012, 96: Landa G., et al., External limiting membrane and visual outcome in macular hole repair: spectral domain OCT analysis, EYE, 2012 (1):61-69 Clinical History Conclusion Jetrea OD, mg Intravitreal. Release occurs at 11 Weeks. Essential to understand the capabilities of your OCT Device Scans best performed after a review of the clinical history of the patient Significant disease can exist beyond the fovea, and, in many dimensions Mastering your OCT skills takes practice and perseverance.

Introduction to The Fluorescein Angiography Procedure James B Soque CRA COA. Island Retina Shirley, New York

Introduction to The Fluorescein Angiography Procedure James B Soque CRA COA Island Retina Shirley, New York 2 Purpose: Fluorescein Sodium Dye Blood Flow to The Eye Preparation of the FA Materials Sequence