oct-a what you need to know with this technology … · 01/10/2020 · greg a caldwell, od, faao...
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 1
OCT-AngiographyWhat You Need to Know with this New
Technology
Disclosure Statement(next slide)
Greg A. Caldwell, OD, FAAOMid-Winter Getaway 20/20
3rd AnnualFebruary 15, 20/20
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Disclosures- Greg Caldwell, OD, FAAO
$ Will mention many products, instruments and companies during our discussion
¬ I don’t have any financial interest in any of these products, instruments or companies
$ Pennsylvania Optometric Association –President 2010
2 POA Board of Directors 2006-2011
$ American Optometric Association, Trustee 2013-2016
$ I never used or will use my volunteer positions to further my lecturing career
$ Lectured for: Aerie, Alcon, Allergan, BioTissue, Maculogix, OptoVue
$ Advisory Board: Allergan, Maculogix, Sight Sciences, Sun, Takeda
$ Envolve: PA Medical Director, Credential Committee
$ Optometric Education Consultants- Scottsdale, St. Paul, Quebec City, Nashville, and Orlando/Disney OCT Users meeting; Owner
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Financial Obligations
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Book Resources
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How Many People Here Have an OCT?
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 2
$ OCT is an optical signal acquisition and processing method
$ Time domain OCT
¬ 15-16 microns of resolution¬ Stratus (Zeiss)
$ Spectral domain (SD-OCT) or Fourier domain OCT
¬ Spatially encoded frequency domain OCT (SEFD-OCT)¬ 5-6 microns of resolution
2 Able to see photoreceptor morphology (inner/outer segments)¬ 50 times faster than time domain
$ Swept source OCT¬ Time encoded frequency domain OCT
¬ 1 micron of resolution
$ Future of OCT- intraoperative imaging, blood flow and oxygenation measurements
$ May have the possibility to assess retinal pathology like a pathologist
Optical Coherence Tomography
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OCT Angiography A New Approach to Protecting Vision
} Non-invasive visualization of individual layers of retinal vasculature} Pathology not obscured by fluorescein staining or pooling} Image acquisition requires less time than a dye-based procedure} Reduced patient burden allows more frequent imaging to better follow disease
progression and treatment response
OCTA of CNVFA of CNV
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Enface OCT-A SlabsBased on Retinal Anatomy
Deep Plexus (INL – OPL)
Superficial Plexus (ILM – IPL) Outer Retinal Zone (ONL – BM)
Choroid Capillaris
En Face Visualization of Layers Based on Retinal Anatomy
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 3
Normal Retinal Vasculature
Superficial Capillary Plexus
3µm Below ILM → 15 µm Below IPL
Deep Capillary Plexus
15µm Below ILM → 70 µm Below IPL
Outer Retina
70µm Below IPL → 30 µm Below RPE Reference
Choriocapillaris
30 µm Below RPE Reference → 60 µm Below RPE Reference
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Type 1 “Occult” CNV
} New vessels develop in the choroid
} New vessels located below RPE and above Bruch’s membrane
Choroid
Bruch’s Membrane
RPE
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Type 2 “Classic” CNV
$ New vessels develop in choroid$ New vessels located above the RPE and above Bruch’s membrane
Choroid
Bruch’s Membrane
RPE
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Diabetic Retinopathy
} Retinal capillary non-perfusion – seen as blackened area without blood flow outside FAZ} Microaneurysms} Enlarged FAZ
Superficial Capillary Plexus Deep Capillary Plexus Choriocapillaris
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Diabetes
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Wet AMD
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 4
Glad to Have it in the OfficeDisappointing without Quantitative Measurements
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AngioAnalytics
$AngioAnalytics is the world’s first OCTA metrics$The package includes the following tools:
¬ Foveal Avascular Zone (FAZ) measurements2 FAZ area, perimeter, A-circularity index and foveal vessel density
¬ Flow and Non-Flow Area measurements2 Measure the area of abnormal flow by outlining a region for vessel detection. The
extracted Flow Area measurement is based on the Outer Retina slab (OPL ~ BRM)
¬ Vessel Density mapping2 Measures the vessel density of the superficial and deep plexi of the retina as well as the
radial peripapillary capillary layer of the optic disc
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Clinical Applications of AngioAnalytics
$ Identify early vascular changes in diabetic eyes
$Assess disease progression$Compare structure and vasculature in glaucoma$Assess rate of change in optic disc vessel density
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AngioAnalyticsVessel Density Mapping
Vessel Density Superficial Plexus
Vessel Density Deep Plexus
Vessel Density Radial Peripapillary Capillaries
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AngioAnalyticsFAZ, Flow & Non-Flow Area Measurements
Foveal Avascular Zone Metrics Flow Area Measurements Non-Flow Area Measurements
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 5
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Next Generation Glaucoma Analysis with OCT + OCTA
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Learn What Normal Looks Like
Retina:Superficial Vascular
Complex
Disc: Radial Peripapillary
Capillaries
OD OS
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What Does Glaucoma Look Like? Normal Moderate Glaucoma Advanced Glaucoma
Disc
Retina
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Glaucoma
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Review of Normal25 year old man
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 6
Review of Normal60 year old man
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60 Year Old Montage OD
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60 Year Old Montage OS
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60 Year Old Montage OU
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68 year old woman with glaucoma$Wants second opinion for glaucoma management
$Recently had cataract surgery OS with iStent¬ September 25, 2017¬ Dorzolamide 2% BID OS, Lumigan 0.01% QD OS
$Our practice recently performed cataract surgery and Kahook dual blade (KDB) MIGS¬ July 24, 2018
$ IOPGAT: 12 and 16 at 11:27 am
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OCT for Pachymetry in Glaucoma
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 7
OCT GCC and NFL
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Visual Fields
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Angiography and AngioAnalytics of Disc
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En Face Radial Peripapillary Capillaries (RPC)
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Angiography and AngioAnalytics of Retina
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Montage OD
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 8
Montage OS
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Montage OU
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$POAG, OS > OD
$Lumigan 0.01% QD OU
$Combigan BID OU
74 year old man
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VF OD and OS 1-26-2018
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VF OD and OS GPA 1-26-2018
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OCT NFL and GCC 9-25-2018
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 9
Change Analysis NFL-GCC
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OCT-A 9-25-2018POAG OS > OD
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OCT-A 9-25-2018POAG OS > OD
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Montage OD
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Montage OS
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Montage OU
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 10
They do read their EHR communication
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$ Ocular Hypertension since 2014¬ No treatment
$ Pigment Dispersion
$ Baseline IOP or Tmax 26/26¬ 2014— March 2018
$ Today 30/32, new Tmax 9-25-18
49 year old man
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VF 24-2 Sita-Faster9-25-2018
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OCT NFL and GCC3-22-18
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OCT-A 9-25-2018
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OCT-A 9-25-2018
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 11
Montage OD
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Montage OS
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Montage OU
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$Shows early changes in the retina and optic disc
$Adds new information to the diagnosis
$Aids in progression detection
How Does OCTA Change the Way You See Glaucoma?
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Glaucoma versus Other Optic Neuropathy
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Next Generation Diabetes and RetinaAnalysis with OCT + OCTA
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 12
29 year old man with diabetes
$Yearly diabetic exam, reports no changes to vision¬ Type 1 DM
$BS: 190 this AM, last HbA1c 8.6 $Vision 20/20$Anterior segment: normal
$Posterior segment: ¬ Non-proliferative DR
2 Hemes and exudates
¬ No CSME
$Billed for:¬ Exam- 99214¬ Optomap, OCT-Wellness, and OCT-A (Angiography)
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10-31-2017
12-19-2018
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12-19-2018
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12-19-2018
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12-19-18
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12-19-18 what do you see?
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 13
12-19-18 what do you see?
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12-19-2018
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12-19-18
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12-19-2018
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12-19-2018
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12-19-2018
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 14
12-19-2018
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OCT and OCT-A
$Treatment? $Certainly useful, beneficial, essential, and important in following the patient
with diabetes$ Improved HbA1c
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63 year old man
$Complicated ERM surgery OD¬ Increased IOP¬ Vitreous hemorrhage
$ERM peel 8-16-2018¬ My visit 11-20-18
2 IOP 18/13
$Vision 20/20¬ But “can not see top part of vision in right eye”
$Patient returned to me because the surgeon said it will take time for vision to return
$OCT and OCT-A reveals the diagnosis and prognosis
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 15
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Superficial
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Deep
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Diagnosis?
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69 year old woman
$ In for 6 month diabetic check¬ History of idiopathic juxtafoveal telangiectasia
$BVA OD 20/80 OS 20/40 $Thoughts are the macula changes DM and IJT?$OCT and OCT-A
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OD OCT
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 16
OD OCT
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OS OCT
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OS OCT
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OS OCT
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OS OCT
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OS OCT
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 17
OD OCT-A
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OD OCT-A
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OS OCT-A
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OS OCT-A Superficial
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OS OCT-A Deep
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CNVM
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 18
CNVM
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CNVM
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CNVM
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Which is More Suspicious?
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BRVO
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BRVO
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OCT-Angiography What You Need to with this New Technology
February 15, 20/20
Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 19
Other UsesEndothelial Disease
AlzheimerDementia
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Thank-Youand
Hope You Enjoyed
Greg Caldwell, OD, [email protected]
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