OCT Interpretation. Financial Disclosure. Jay M. Haynie, OD, FAAO. OCT Image Layers 7/21/2014

Transcription

1 OCT Interpretation Jay M. Haynie, OD, FAAO Financial Disclosure I have received honoraria or am on the advisory board for the following companies: Olympia Tacoma Renton Kennewick - Washington Carl Zeiss Meditec Reichert Technologies Arctic DX Macula Risk Notal Vision Thrombogenics Scans/ Resolution Single line scan second (microns) OCT A-scans x 500 points OCT A-scans x 500 points OCT3 Stratus OCT 512 A-scans 2002 x1024 points Cirrus HD-OCT A-scans x 1024 points 27,000 5 OCT Image Layers Nerve Fiber Layer, inner and outer plexiform layers *Ganglion cell nucleii, inner nuclear layer Henle s fiber layer h Photoreceptor nuclei External limiting membrane Inner Segment ellipsoid (old IS-OS junction) Outer Segment interface and Retinal Pigment Epithelium Choriocapillaris/Choroid C Duke Reading Center/CA Toth 1

2 OCT Evolution: Thickness algorithms differ by system OCT Evolution: Thickness algorithms differ by system Stratus: includes SRF stops at CNV and RPE Cirrus and Topcon: Includes SRF and CNV Stops at RPE Spectralis: Include SRF, CNV, PED Stops at Bruch s membrane Duke Reading Center/CA Toth Outer Retinal Complex Bright Bands 1.External Limiting Membrane = ELM 2. Inner segment ellipsoid = old ISOS 3. Photoreceptor Integrity Line = PIL 4. Retinal Pigment Epithelium = RPE Beautiful images, but Eye moving during image acquisition 2

3 Look for Signal Strength Opacities lower it! Dry Eye Cloudy Cornea/Lens Vitreous Densities OCT Artifacts OCT Artifacts Superficial Structures & Shadowing Vitreous debris (hyalosis, snowballs, operculata, hemorrhage) Macular edema Blood Vessels Images are only as good as the technician taking them Images depend on good fixation Let s start with the vitreous If something doesn t look right, dilate the patient and take a look clinically Liquefaction Hyaloid intact PVD 3

4 Initial PVD VA 20/40 Photoreceptor disruption PVD Diabetic patient presents for annual fundus examination Denies floaters 4 months later VA 20/25 E. Reichel, MD, Tufts new England Asteroid hyalosis Asteroid hyalosis Vitreomacular traction (VMT) Now we move from the vitreous to the vitreous-retinal interface 4

5 Vitreomacular traction (VMT) Vitreomacular traction (VMT) 78 year old man presented for a follow-up of diabetes VMT with impending macular hole Vision? 20/70 Had been treated for PDR OU Patient undergoes vitrectomy and membrane peel. Gas bubble placed in eye. 1 week post op 5

6 2 months post op VitreoMacular Traction VitreoMacular Traction VitreoMacular Traction Macular hole 1 day post op MH closed 6

7 Not a macular hole, but a peripheral retinal hole Different case What we have covered ERM Vitreous Vitreous retina interface Now, the retinal surface 7

8 ERM with lamellar macular hole Epiretinal membrane 2 weeks post op Epiretinal Membrane s/p Vitrectomy Pre - Op Post - Op Next, we move into the retina 73 year old man with a new scotoma OS BRAO Poorly controlled diabetes, HTN PDR OD s/p PRP 8

9 Macroaneurysm Sudden loss of central vision Macroaneurysm BRVO BRVO with CME BRVO Initially 20/40 BRAO 3 weeks after avastin and kenalog combo 20/20 9

10 CRVO with CME / SRF Diabetic Macular Edema Is this Diabetic Macular Edema? Lets look at the Fluorescein Angiogram 68 yr old diabetic man referred for retinal evaluation prior to cataract surgery Patient with 20/30 vision OD and 20/40 OS Late phase FA shows no diabetic retinopathy as we would expect What caused the macular edema? 2 Months later.. Medication review reveals that he had been using Niacin for management of cholesterol at a dose of 1500mg per day. Niacin can induce macular edema when taken at high doses. He was advised to discontinue his Niacin and return in 2 months.. Sometimes no medicine is the best medicine! 10

11 Peripheral Retinoschisis Peripheral Retinoschisis with outer wall retinal break Peripheral Retinoschisis evolves into an RD Common Entities on OCT: Myopia and its Sequelae OU Myopic Foveal Schisis & OS Full Thickness Macular Hole Myopic Foveal Schisis does not respond to pharmacotherapy E. Reichel, MD, Tufts new England Eye Ctr 11

12 Common Entities on OCT: Myopia and its Sequelae Staphyloma PVD w/vmt Hole Schisis w/erm Vitreous What we have covered Vitreous retina interface Epiretinal Membrane w/schisis after partial peel Staphyloma Retinal arterioles Retinal surface Retina Now we move further down: under the retina Patient referred for retinal detachment Localized serous retinal detachment Vision 20/200 12

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14 Central Serous Retinopathy - Treatment: Acetazolamide (Diamox) 250mg daily 1 week later on oral Diamox 250mg Vision 20/40 Must correlate OCT with clinical exam to make an accurate diagnosis! 14

15 55 yr old man with sudden onset of decreased vision Rhegmatogenous retinal detachment Rhegmatogenous retinal detachment Rhegmatogenous retinal detachment MAC ON Even further down: under the retinal pigment epithelium (RPE) and choroid Drusen Dry AMD Variants Drusenoid PED s Geographic Atrophy 15

16 Dry AMD AMD RPE detachment (PED) Atrophic AMD Dry AMD changes Fluid Wet AMD Variants PED Serous Hemorrhagic Fibrovascular Wet AMD Variants Common Entities on OCT: Wet ARMD Variants RPE Rip RPE loss No shadowing RPE RIP or Tear Rolled edge Shadowing 16

17 WET AMD Variants Wet AMD CNV Active Above RPE Below RPE Subretinal Fluid (SRF) Disciform Scarn Diagnosis? 82 year old man with AMD and progressive vision loss over the past 6 months Wet AMD Eylea treatment 17

18 Choroidal nevus Choroidal Melanoma Vitelliform lesion Vitelliform lesion vs. PED Enhanced-depth imaging 69 year old male with maculopathy Stratus Cirrus Central Serous Retinopathy Spectralis Spectralis Enhanced depth imaging 350 microns 450 microns 18

19 74 year old female with maculopathy 56 year old with signs of AMD? Vitelliform macular dystrophy Choroidal Ischemia Advanced RPE analysis with Cirrus OCT Tracking of drusen and disease of the RPE as well as atrophy July 2011 July 2012 Advanced RPE analysis of RPE atrophy Advanced RPE analysis of Drusen 19

20 68 year old with AMD and new vision loss OD Inner segment ellipsoid = old ISOS External Limiting Membrane= ELM 54 year old woman taking Plaquenil Final Case (MN) is a 36 year old with MS. She describes progressive vision loss of her left eye over 8 months. Her Neurologist said to wait and see if it clears. She saw an OD who referred to me for an evaluation. Vision 20/20 OD and 20/30 OS Examination unremarkable. No APD Final Case Final Case 20

21 Final Case The retinal ganglion cell and inner plexiform complex is more sensitive to the demyelination process of MS and can be a prognostic marker in the expected quality of life and visual outcomes of patients with all subtypes of MS Regular monitoring with SDOCT may become standard for MS patients What s Coming Latest OCT Devices = Fourier Domain Detection Spectral Domain SD OCT (2006) 70,000 A scans/sec Swept Source SS OCT (Research only) 250, ,000 A scans/sec Better Light Sources Enhanced Depth Imaging (EDI) What s Coming Better Light Sources Choroidal anatomy (Heidelberg example) EDI Off EDI On N. Waheed, MD, Tufts new England Eye Ctr What s Coming What s Coming 3D imaging: External and Internal Video OCT Cone Mosaic Measure retinal blood flow Better software Quantify GA, RPED, CNVM, CSR... JS Duker, MD New England Eye Ctr, Tufts Medical Ctr 21

22 What s Coming Summary OR scope OCT s Allows for membrane peeling Eases fellow training OCT helps us examine the various layers of the back of the eye: Vitreous Vitreous-retina interface Retinal surface Retina RPE/Choroid Summary s As good as the images can be, we must rely on clinical correlation! JayH@retina-macula.com 22