Choroid Retina avascular 5/13/2017 OCT Angiography The Next Frontier Pierce Kenworthy OD, FAAO June 9, 2017 OCT Angiography (OCTA) 2016 Non-invasive, motion contrast imaging Represents erythrocyte movement in retinal blood vessels OCTA does NOT replace FA Possible advantages of OCTA over FA: 1) No IV Injection (no risk of dye) 2) Higher Resolution 3) Multiple retinal layers visualized Normal Retina Central retinal artery Superficial capillary network Deep capillary network Internal limiting membrane Nerve fiber layer Ganglion cell layer IPL INL Middle limiting membrane OPL ONL External limiting membrane Photoreceptor layer Blood retinal barrier: Tight junctions (zonula occludens) in RPE and between endothelial cells RPE 6x6 vs 3x3 (Just released 8x8) 3x3 6x6 1
VRI Superficial Deep Avascular Superficial Deep Avascular Choriocapillaris 2
Choroid Case 1 Cornea vs Retina? Chief Complaint Conundrum 57 yo African American female May have scratched her OS while doing construction work Something got in OS 2 weeks ago Pt c/o blurry vision in OS nasally x 2 weeks Described her VA as cloudy 20/30 OS Worse in the morning, gets better throughout day (-) pain, (-) discomfort 20/30 Superficial OCT Angiography Artifact from blood Reduced blood flow Source of the BRVO Motion Artifact Macula 3
Source of occlusion? Superficial Angiography Artifact from Blood VRI VRI Case 2 What if BRVO was 10 years ago? 73 year old white female diabetic 20/30-2 Macular edema occurs in 90% of BRVO cases 4
EnFace shows reflection Collateral Reabsorbed Cyst B-scan confirms no flow Projection Artifact Case 3 Which eye is abnormal? (Or are they both abnormal?) OD Early lamellar hole? OS Cystic space? Disrupted layer? 2016 2013 2016 What do you think NOW? 20/25 20/30 20/25 5
Images from 2013 OD Retina OCT-Angiography 3 years after CRVO OS OS 20/20 20/30 Where will retina be thinnest? Where will retina be thinnest? Case 4 68 year old white male Old Superior BRVO Ghost vessels? (Non-perfused, sclerotic) 20/25 Exudates (lipoprotein and lipid filled macrophages) Develop at junction of normal and edematous retina (from chronic, localized retinal edema) 6
Case 5 72 year old white female Ischemic BRVO >5 DD of nonperfusion on FA 20/40 bottom half of letters missing Blind Spot.right?? Deep Structure Or that one? Who cares!? 20/80 One Month Later 20/80 Two months Later 7
Diabetic Retinopathy Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) 1994 2000 2013 No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% 86% of individuals with type 1 DM and 40% of those with type 2 DM have some form of clinically evident diabetic retinopathy Diabetes 1994 2000 2013 No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics 8
Case 6 35 year old AA female Newly diagnosed diabetic A1C 11.7%, BS 330 Early Diabetic Retinopathy Double fovea motion artifact AKA: Rookie mistake 20/25-2 20/25+1 Capillary Drop Out (moth eaten) Areas of reduced blood flow Case 7 OD OS Mild Diabetic 45 year old AA male, diabetic Retinopathy 9
Why do capillary walls break? Death and absence of pericytes leading to focal dilation of wall En Face Image Exudates and microaneurysms Hyperfluorescent dots in early phase of FA FAZ remodeling 10
Superficial Angiography 1 2 Capillary Loops and Drop Out Case 8 Which quadrant has a problem? Diabetic pt no changes in VA 20/25-2 3 4 Structure Deep Avascular Angiography IS/OS Ellipsoid EnFace Lesson in Refraction Initial Initial One month resolution 1.00 Diopter shift Glasses re-make 11
More advanced diabetic retinopathy ~¼ of retina non-perfused before PDR develops Case 9 Macular Degeneration 20/30-2 76 yo white 20/30+1 female, 3+ NSC Drusen OU 63 microns 125 microns Angiography Retina Drusen tip error B-scan Flow Motion Artifact OD OS Avascular 12
Drusen progression OD OS 2014 2016 Choroid Angiography Case 10 88 year old white male Geographic Atrophy Hx of Eylea/Avastin injections right eye Geographic Atrophy 20/250 OD > OS 20/30 Drusen-related Neovascularization related OD Retinal Angiography about the same? Structural differences OS OD Choriocapillaris Angiography OS 13
Case 11 79 year old white female Advanced dry ARMD with GA OD 20/200 20/150 Retina OCT Angiography At level of RPE OD Retina OCT Angiography At level of RPE 80 microns below RPE Retina OCT Angiography 80 microns below RPE 58 yo female with drusen and FHx of macular degeneration 20/40 20/25 14
Choroidal neovascularization Abnormal growth of blood vessel complex through Bruch membrane from the choriocapillaris Formation of disciform scar My Big Three with Angioplex Understanding Retinal Vascular Occlusions Discovering Diabetic Retinopathy earlier Conversion from Dry to Wet AMD Other considerations: Choroidal Nevus Plaquenil Glaucoma 15
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