3/6/2014. Hoda MH Mostafa MD Associate Professor of Ophthalmology Cairo University. The author has no proprietary interest. Today s Objectives

Transcription

1 Hoda MH Mostafa MD Associate Professor of Ophthalmology Cairo University The author has no proprietary interest Today s Objectives Identify the CLINICAL SCENARIOS IN MACULAR EDEMA where OCT plays a MAJOR role in decision making IDENTIFY our audience Demonstrate how OCT helps guide this decision making process Examples of cases 1

2 Clinical spectrum Vascular occlusion DR ME Other pathology VM traction OCT and Logical Decision Making Use coherent data Qualitative 2-D and 3-D images Quantitative analytical tests Retinal thickness Retinal mapping Progression analysis (MPA) Synthesis of ALL data to reach a diagnosis 2

3 OCT and Logical Decision Making Coherent data Qualitative findings Quantitative findings Medical and surgical history Additional retinal imaging ( FFA/AF) 2-D 3-D 3

4 DECISION MAKING Process Qualitative info Quantitative info Morphology Reflectivity Conformity with known patterns Retinal thickness and MPA Morphological alterations Anomalous structures Increased decreased Topographical variations MPA Clinical challenges Clinical picture Angiographic data What does SDOCT add to the equation? Clinical picture FFA/AF OCT Clinical decision 4

5 WHY CLASSIFICATION MATTERS LOCATION AMOUNT ME VR INTERFACE HARD EXUDATE KNOW WHAT YOU RE LOOKING FOR LOCATION AMOUNT VR INTERFACE HARD EXUDATES IS CENTRAL SF INVOLVED VOLUME AP YES/NO INNER AND/OR OUTER SUBFIELD MEAN THICKNESS TANGENTIAL LOCATION 5

6 OCT=objective Dx and follow-up of ME I Edema of the inner retinal layers II Cystoid spaces in the retina and/or Overall involvement III. Sub-retinal fluid accumulation IV. Tractional retina edema V. Combination of patterns I,II,III,IV Breakdown of inner/outer BRB Breakdown of inner/outer BRB Breakdown of outer BRB Breakdown of inner BRB PATHOPHYSIOLOGICAL CLASSIFICATION C. Lobo et al 2011 Know what to look for 6

7 MACULAR EDEMA The Normal Retina 7

8 Clinical challenge 1: Diabetic Macular edema Know what you are looking for Tractional element Associated CME and inner retinal thinning with risk of lamellar hole formation Other factors that may influence treatment decision Outer retinal layer integrity 8

9 Clinical challenge 1: Diabetic Macular edema Identify the pathology diffuse retinal thickening cystoid macular edema sub-retinal fluid with serous retinal detachment Interface traction T: posterior hyaloid/ilm traction AP: tractional macular detachment Co-existing pathology: ischemia These 5 morphological types have different prognostic significance Clearly demarcated by SD OCT The best visual acuity in patients with diffuse DME The worst in patients with posterior hyaloid traction and tractional macular detachment, PIL affection. 9

10 Clinical challenge 1: Diabetic Macular edema Identify the pathology diffuse retinal thickening Clinical challenge 1: Diabetic Macular edema Identify the pathology cystoid macular edema 10

11 Clinical challenge 1: Diabetic Macular edema Identify the pathology sub-retinal fluid with serous retinal detachment The PIL=IS/OS junction 11

12 Clinical challenge 1: Diabetic Macular edema Identify the pathology Posterior hyaloid traction Tractional macular detachment No traction Clinical challenge 1: Diabetic Macular edema Synthesis and correlation with other data Ischemia, Microaneurysm turnover rate and progression, intrastromal foveal exudates, PIL disrupted??? 12

13 MACULAR EDEMA Clinical challenge 2: ME + Vitreoretinal interface disorders 13

14 Clinical challenge 2a: Vitreoretinal interface disorders ERM Identify the pathology Clinical challenge 2a: Vitreoretinal interface disorders ERM with VR traction and retinal thickening 14

15 Clinical challenge 2b: Vitreoretinal interface disorders Clinical challenge 2b: Vitreoretinal interface disorders 15

16 Clinical challenge 2 PDR with A-P traction and tangential traction/emm macular edema Clinical challenge 2: Vitreo-retinal interface disorders Correlate with other data Vision FFA Associated posterior segment pathology 16

17 Clinical challenge 2: Vitreo-retinal interface disorders Management plan based on Morphological changes Quantitative and qualitative changes Often guarded visual prognosis Should be an informed decision MACULAR EDEMA 17

18 CME CME 18

19 Diffuse ME Tangential traction Diffuse ME 19

20 Macular edema Para-foveal traction Macular detachment Macular edema 20

21 Focal A-P traction EMM; tangential traction Macular edema 21

22 Focal AP traction Cystoid ME/Impending hole Diffuse macular edema N-S detachment 22

23 Diffuse ME Outer retinal layer edema Wrap-up: SD OCT is an invaluable tool in decision making process Coherent Data Synthesis of Q and Q Logical Decision SD OCT offers an opportunity to Re-define classification Detect prognostic indicators Plan for treatment strategies. 23

24 Credits Diagnostic Ophthalmology Unit : Dar El Oyoun Hospitals Guide to Interpreting SD OCT- Bruno Lumbroso and Marco Rispoli Photo Gallery- Carl Zeiss. Photo Gallery-Heidelberg Spectralis Monitoring Retinal Change in AMD Patients using Cirrus HD-OCT Images retrieved on OCT=objective follow-up of ME Patterns of macular edema: I. Edema of the inner retinal layers Breakdown of inner/outer BRB II. Cystoid spaces in the retina. Overall involvement Breakdown of inner/outer BRB III. Subretinal fluid accumulation Breakdown of outer BRB IV. Tractional retina edema Breakdown of inner BRB V. Combination of patterns I,II,III,IV C. Lobo et al