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OCTApplicationsinOptometry

ChuckAldridge,O.D.,M.B.A.

FellowAmericanAcademyofOptometry

MemberofOptometricGlaucomaSociety

AldridgeEyeInstitute

Burnsville,NC

•  The content of this course was prepared independently by myself without commercial influence from members of the ophthalmic industry.

•  I am on the Speaker Bureau’s of Allergan, Alcon and Optovue. I am a clinical investigator for Bausch & Lomb and CIBA. I am on Clinical Advisory Board for TearLab. However, I have no direct financial or proprietary interest in any company, product or service mentioned in this presentation.

•  I have not received commercial support in any form (honorarium, etc.)

for this presentation. •  The content and format of this course will be presented without

commercial bias and will not claim superiority of any commercial product or service.

COMMERCIAL DISCLOSURE Mandatory Slide

OCTGettherightonefortherightreason! WhichOCT?

• TimeDomain

• Fourier(Spectral)Domain

TimeDomainvs.Spectral“CirrusOCThasbetterscanqualitythanStratusOCT,

especiallyinglaucomatouseyes.Incaseswithgood-

qualityscans,thesensitivityandspecificity,andAUCs

weresimilar.Thebestagreementwasintheglobal

averageRNFLclassification.Thewidthsoflimitsof

agreementsexceedthelimitsofresolutionoftheOCTs.”

JavierMoreno-Montañés,NataliaOlma,etal.CirrusHigh-DefinitionOpticalCoherenceTomographyComparedwithStratusOpticalCoherenceTomographyinGlaucomaDiagnosis.IOVS;Jan2010,Vol51,no.1,335-343

FOURIERDOMAINOCTADVANTAGE

•  FDOCThastwicethedepthresolutionasTDOCT(5microns

vs10microns)

•  Allowsimagingandsegmentationofganglioncelllayers

•  Fasterspeedalsoallowsforgreaterdensityofsampling

pointsandreducesartifactsfromeye-movements(FDOCT

has26,000Ascans/secvsStratusTDOCTwith400Ascans/

sec)

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EvaluationoftheCorneaandAnteriorChamber

PachymetryMapsKeratoconus Analysis Thickness Parameters

B-Scans

Thickness Map color coded

6 mm diameter average thickness values by region Central circle 0-2mm Middle circle 2-5 mm Outer circle 5-6 mm

Power Calculations

Keratoconus

IMAGINGANDMEASUREMENTOFTHECORNEA

AngleCalculationsMEASUREDOCCLUDABLEANGLE

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Pre-CataractNarrowAngle

Post-CataractOpenAngle

OCTandGlaucoma

HowDoTheyCompare?

FDT,SWAP,flickerperimetry,andOCTareall

usefulmethodsfordiscriminatingbetweenhealthy

eyesandeyeswithearlyglaucoma.Amongall10

OCTparameters,NFLThasthehighestsensitivity

fordetectingearlyglaucomatouschangesinGS

patients.Nomoto,Hiroki;Matsumoto,Chota;Takada,Sonoko;Hashimoto,Shigeki;Arimura,Eiko;Okuyama,Sachiko;

Shimomura,Yoshikaz.DetectabilityofGlaucomatousChangesUsingSAP,FDT,FlickerPerimetryandOCT.Journalof

Glaucoma.18(2):165-71,Feb2009.

OVERLAYOFTHERNFLANDGCC(OS)WITHFDOCT

pRNFL

GCC

DENDRITICSHRINKAGE

Normal Ganglion cells (Primate) Glaucoma model Ganglion cells (Primate)

•  The first structural change from glaucoma was a shrinkage of the ganglion cell dendritic fields

GANGLIONCELLLOSSINTHEMACULA

•  Histologicstudieshaveshownganglioncelllossinthe

macula

•  Desatniketal.(1996)foundmacularganglioncellsare

lostinearlyglaucoma

•  Yuceletal.(2003)showedlossofcellsinthe

parvocellularlayersoftheLGNimplicatingcentral

ganglioncellloss

Desatnik H, Quigley HA, Glovisnky Y. J Glaucoma 1996; 5: 46-53. Yucel YH, Zhang Q, Weinreb RN, Kaufman PL, Gupta N. Prog Retin Eye Res 2003; 22:465-481

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TDOCTSTUDYLIMITATIONS

•  MajordisadvantageinthesestudiesisthatTD

OCTtypicallymeasuresfullretinalthickness

only(doesnotisolateganglioncells)

•  TDOCTdoesnothaveenoughdepth

resolutiontoimageandsegmenttheganglion

cellsaccuratelyandreliably

RETINALGANGLIONCELLSEXTENDTHROUGHTHREERETINALLAYERS

RNFL

Ganglion cell bodies

Ganglion cell axons

Ganglion cell layer

Inner plexiform layer

Inner nuclear layer

Outer plexiform layer

Outer nuclear layer

IS / OS Junction

RPE Layer

Ganglion cell dendrites

Ganglion cell complex (GCC)

GCC is: •  Nerve Fiber Layer – Ganglion cell axons •  Ganglion cell layer – Cell bodies •  Inner-Plexiform Layer - Dendrites

IMAGINGTHEGCCWITHTHEFDOCT

ILMNFLGCLIPLINLOPLONLPRIS/OSRPEChoriocapillarisandchoroid

BloodvesselGCC Full Retina Thickness

GCC is inner retinal layers •  Nerve Fiber Layer – Ganglion cell axons •  Ganglion cell layer – Cell bodies •  Inner-Plexiform Layer - Dendrites

DIAGNOSTICACCURACY:GCCVSTDOCTFULLRETINATHICKNESSINMACULA

•  Tanetal.(2009)foundtheGCC(FDOCT)was

significantlymoreaccuratefordetectingglaucoma

comparedtofoveathickness(fullmaculathickness)

withStratusTDOCT

•  Morietal.(2010)alsoshowedGCCwassignificantly

moreaccuratethanfullmaculathicknesswithTDOCT

Tan O, Chopra V, Lu AT et al. Ophthalmology 2009; 116:2305-2314. Mori S, Hangai M, et al. 2010; J Glaucoma, in press.

DIAGNOSTICACCURACY:GCCVSMACULAVFSENSITIVITYINMACULA

•  GCCTdeterminedbySD-OCT(RTVue-100)

showedastatisticallysignificantstructure-

functionassociationwithmacularVF,andthe

strengthoftheassociationwasgreaterthanthat

ofthempRNFLwithmacularVFinthesuperior

centralVFarea.

JungHwaNa,MichaelKook,etal.Structure-FunctionRelationshipoftheMacularVisualFieldSensitivityandthe

GanglionCellComplexThicknessinGlaucoma.IOVS.June14,2012.11-9401

DIAGNOSTICACCURACY:GCCVSFDOCTRNFL

•  Raoetal.(2010)foundGCChadsimilaraccuracylevels

asRTVueFDRNFL

•  Seongetal.(2010)foundsimilarresults

•  Kimetal.(2010)foundAROCvalueswerehigherfor

RNFLvsGCCinagroupofadvancedglaucoma

patients,butGCCvalueswerehigherthanRNFLina

groupofearlyglaucomapatients

RaoHL,ZangwillLM,WeinrebRNetal.Ophthalmology2010;inpress.SeongM,SungKR,ChoiEH,etal.InvestOphthalmolVisSci2010;51:1446-1452.KimNR,LeeES,SungGJ,etal.InvestOphthalmolVisSci2010;inpress

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FDOCT:GCCVSDISCVSRNFL

•  Huangetal.(2010)comparedthediagnosticaccuracyfor

GCC,opticdisc,andRNFLfromtheRTVue

•  AROCforRNFLwashighest(AROC=0.92),withGCCsecond

(AROC=0.86),andverticalC/Dratioaclosethird(AROC=

0.854)

•  Theyfoundtheaccuracyimprovedwhenthey

combinedallthreestructuresinanLDF(AROC=0.97)

Huang JY, Pekmezci M, Mesiwala N, Kao A, Lin S. J of Glaucoma 2010 Epub ahead of print

GCCSUMMARY•  GCCthicknesscorrelateswellwithvisualfields

•  Highlyreproducible

•  Morereproducibleandmoreaccuratefor

detectingglaucomathanmaculathickness

withTDOCT

•  SimilaraccuracyfordetectingglaucomaasFD

OCTRNFLthickness

GCC:Arriveatthesceneofthecrimebeforethecrime

InadditiontoppRNFL

thickness,themGCC

thicknesscouldbea

structuralparameterfor

detectingpreperimetric

glaucoma

Takagi,SeijiT.MD*,†;Kita,YoshiyukiMD,PhD*,†;Yagi,FumihikoMD,PhD*,†;Tomita,Goji

MD,PhD*,†MacularRetinalGanglionCellComplexDamageintheApparentlyNormal

VisualFieldofGlaucomatousEyesWithHemifieldDefects

Takagi.JournalofGlaucoma.June/July2012.Vol21.Issue5.p318.325.

“ProofinthePudding”CaseStudies

CaseHistory(2005)•  57YOM

•  Struggleswithdiabeticcontrol

•  Hashadsomelasertxinprior2-3years

•  CDalwayslarger;butsome?change

•  Matrixscreeningfieldhasnewfinding

•  IOPalwaysbeeninupperteens(17-19)

•  InitiateglaucomaevaluationforNTG

•  Sidenote:Approximately2009patientstartedCPAP

OpticNerveEvaluation(alsosomebackgrounddiabeticretinopathy)

Someexudates

ModerateCupping

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MatrixScreeningFieldMarch2005

MatrixComprehensiveFieldMarch2005

Inferiordefects(superiorOCT?) Superiordefects(inferiorOCT?)

OS OD(ODworsethanOS)

OCTScanApril2005

OD–Inferiordamage(ConsistentwithSuperiorFieldDefect)

OS-SuperiorDamage(ConsistentwithInferiorFieldDefect)

ODworsethanOS(consistentw/VF)

RNFLProgressionEvaluation(OD)02/09-04/12

Stable

RNFLProgressionEvaluation(OS)02/09-04/12

Stable

GCCProgressionEvaluation(OD)02/09–04/12

Startingtodrop?(RepeatOCTsooner)

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GCCProgressionEvaluation(OS)02/09-04/12

FairlyStable

7YearsLater(SDTOCT)April2012

Caveat

•  RNFLchangesoccurearlierthanfieldchanges

•  GCCchangesoccurearlierthanRNFL

•  EarlyprogressivechangeinGCCisEARLY!

•  RepeatOCTsoonertoverify

OCTandRetinalStuff

Patient Data •  74 yo wf

•  C/O vision stress

•  Non contributory history

•  Baby aspirin + vitamins

•  VA With Contact Lenses OD 20/30 OS 20/40

•  CCT 510/516 IOP 14/15

•  Long standing VM traction OS and ERM OU with a Hx of

refusing intervention

FundusPhotoswithMoreAtrophyODThanOS

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StratusTimeDomainImages

NotBad….BUT

PVDERM

VMTraction

LOOKATSPECTRALDOMAIN!

Andtheproblemis….

•  Examination12.14.11(29YOF)

– BCVA:OD:PL-0.50x082 20/20

OS:-0.25-1.00x097 20/20

-  IOP:13,13

-  EOM’s,CF,PupilsWNLOU

-  C/D:OD.3/.3ROS.3/.3R

-  PosteriorSegmentWNLOU

Andtheproblemis….

•  29y/ocaucasianfemale(6monthslater)

•  Reports“blackspotincenterofvisioninbotheyesforoneweek”

•  POH:unremarkable

•  PMH:unremarkable

•  SocialHistory:Cigarettes1pack/dayx10years

Andtheproblemis…•  Examination6.12.2012

–  BCVA:ODBCVA:OD:PL-0.50x082 20/40*

OS:-0.25-1.00x097 20/40*

*(VAw/eccentricviewing)

-  IOP:15,15

-  EOM’s,CFWNL.PupilsRoundReactive,OD>OSwithOD

reactionmoresluggishthanOS

-  C/D:OD.3/.3ROS.3/.3R

-  PosteriorSegment:

12.14.2011

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6.12.2012

What’sGoingonHere? It’sHereToo!

DIAGNOSIS?

•  SOLARMACULOPATHY

•  PATIENTWATCHEDTHEECLIPSEFOR

ABOUT30MINUTES!

“RoutineExam”

•  BVA20/20ODand20/25-OS(69YOF)

•  PosteriorIOLOUwithclearcapsules

•  BVA20/20OU1yrearprior

•  PERRLA•  Hypertensive,BP118/79

•  Fundus–unremarkable

•  Brotherhadamaculahole

•  UnexplainedacuitydecreaseOS????

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OSRetina MatrixScreeningVFVFatvisittoday VFdone1.5yearprior

Maculaintact?

WhatisThis?

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NormalMacula?

Thinning

AlookwithCirrus

OSwithCirrus

Thereitis

AndThinning!

FAofOS

•  FAshowsdelayedreturn

inferotemporal

•  Enoughtimethatany

edemaandhemresolved

onBIO

•  Nocentral“window

defect”relatedtomacula

hole

DIAGNOSIS?

•  OldBRVOinOS

•  OS-posteriorhyaloidfacepulledawayfrom

fovea.Demonstratesasmallremnantof

hyaloid.Mayhaveabitofretinashowingon

OCT(possiblywithsomeNFL),butNOhole

•  NeedtomonitorODnow

BlurryVisionCase

Lefttheirpreviousdoctorbecause“blurry

vision”notgettingbetter

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SawanotherODapp.1yr.ago•  “blurryatdistanceandnearabout6months”

•  39YOF

•  BVA20/20ODand20/30OS

•  Ta11/10@2:45pm

•  TraceguttataOU

•  Fundus-unremarkable

•  Gaveartificialtearandscheduledtore-refractwith

binoculartesting

Re-Refraction(1monthlater)

•  BVA20/20-ODand20/40OS

•  Plan:PrescribeRxwithBase-inprism

OneYearLater

•  “Gotrecallfrompriordoc,butvisionstillblurry

andwantedanotheropinion”

•  BVA20/20ODand20/50OS

•  CD.35/.35

•  PERRLA

•  AC-unremarkable

FundusEvaluationODOS

Alittlediscpallor?

MatrixFields

NAME: Mcdowell, Angela

ID: 118039

LEFT EYE

PUPIL DIAMETER: 8mm VISUAL ACUITY: AX: W/o rx

30

N-30-5 FDT Screening

TEST SPEED: NORMAL

BOTH

DOB: 08-07-1973 [38]

DATE: 02-14-2012 10:43 AM

RIGHT EYE

PUPIL DIAMETER: 8mm VISUAL ACUITY: RX: W/o rx

TOTAL DEVIATION

30 30

D P>=5° /0

P<5%

1:1P<2%

P<1%

TEST DURAT ION : 1 :32 FIXAT ION TARGET: Central

TEST DURAT ION : 0 :36 F I XAT ION TARGET : Central

F IXATION ER RS : 0/3 (0 %) F IXAT ION E RRS : 0/3 (0 %)

FALSE POS ER RS : 0/3 (0 %) FALSE POS ERRS : 0/3 (0 %)

NOTES : NOTES :

30

Aldridge Eye Inst.

419 East Main St.

Burnsville, NC

SW: M02.03.01[01 S06.00.03[0] P06.00.03[0] TID: 18768.20050310154 (R1)

Humphrey Matrix with Welch Allyn Frequency Doubling Technology

ODRNFLOSRNFL

RNFLdropout360ALittleThinHereToo?

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ODGCCOSGCC

Don’tLookGood

Whatdaheckisgoingon?

•  NeuroReferral:MRIdone

•  2.1x1.6cmplanumsphenoidalemeningiomaw/

meningealinvolvementofinferiororbitalgyrus,

deformationofolfactorynerves,encasementof

ant.cerebralartery,A1/A2segments,ontheleft,

right,invasionofleftcavernoussinus,and

stenosisofleftopticcanal

SurgeryPerformed

•  Compressionofleftopticnerveneeded

•  BVA20/40ODandNLPOS

GrowYourContactLensPracticewithOCT

Mini-Scleralbecome“mainstream”•  Scleraldesign–usefulfor“sickeyes”.Havealotofvault

(fluidlayer),reducedO2

•  Mini-scleral-

1.  SimilarsizeandcomforttosoftCL

2.  Minimalfluidlayer,greatO2

3.  Greatfordryeyepatients,toricandmultifocals

4.  UseofOCT“takestheartrightoutofit”withrespectto

fitting

MINI-SCLERALCONTACTS

Usethemeasuretooltoaccuratelydeterminevault288microns

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MINI-SCLERALCONTACTS

291microns

MINI-SCLERALCONTACTS

Edgeevaluation-  Howdoesitland?-  Clearlimbus?

MINI-SCLERALCONTACTS

THANKYOU!