principle of oct reading between the lines: oct interpretation · reflectance for results...
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Reading Between the Lines: OCT Interpretation
Mohammad Rafieetary, OD, [email protected]
• Mohammad Rafieetary, OD, FAAO– Disclosures
• Alcon/Novartis: Clinical Investigator• Genentech: Clinical Investigator, Advisory Board
Consultant• Heidelberg Engineering: Clinical Investigator, Advisory
Board Consultant • Regeneron: Clinical Investigator • RegenXBio: Clinical Investigator •
Initial ConceptTalia 1990s
Principle of OCT
• Introduction– Optical Biopsy– Morphologic Evaluation
of Live Tissue – Measurements
• Axial• Thickness and Depth
Advantage: High Resolution Cross Section Images
Allowing you to make appropriate clinical decisions when the suitable scan is obtained!
Disadvantage: Limited Scanned Area
OCT-A
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Interpretation of Data/Images• Thickness Maps• Actual Cross Sectional
Images– In Plane view– 3D Modes– Resolution Mode
• Color Scheme
Interpretation of DataPros and Cons of Thickness Map
– (+)Ability to measure change over time– (+)Overall assessment of an area in one glance– (+)Use in Clinical Trials– (-)Inability to make specific diagnosis– (-)If not compared to actual tissue lead to
judgment errors– (-)Relies on automated algorithms and tissue
reflectance for results
Topography/Thickness Maps
BM
Thickness Map vs. Anatomy
A. Juxtapapillary CNV B. One month s/p IVI (anti-VEGF)
CNVM
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Right superior quadrantanopiaSent For Neuroimaging
Scanning Strategies And adequacy for follow up scan
Scanning
Scanning Mode to Avoid Missed Pathology
12 Radial
13 Volume or Raster
1) Vitreo-Retinal Interface
2) Inner
3) Outer 4)PR 5) RPE, BM
6) Choroid
Tomography………..Morphologic Evaluation
Pathologic Dysmorphic Changes
Early diabetic changes that may be clinically undetectable
Advanced diabetic disease, ischemic/atrophic retina
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Vitreous and Vitreoretinal Interface
VMAVMTEMMLMHFTMH
Neurosensory Retinal Anatomy
NFLGCL
IPLINLOPL
ONLELM
RPE Ellipsoid
Retinal Anatomy: S
Neurons: GCL, INL, ONL
Synaptic Layers:IPL, OPL
Examples of RelatedDisease: RP, POAG
RPE
One of the most biologically active tissues of the body.
Normal
DegenerativeAMD
Inflammatory/AutoimmuneAMPPE
Vascular Anatomy
Inner retinal changes due to vascular disease such as DR, RVO, RAO
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Effect of Disease on Vasculature Compare the ratio in H vs V
A
V
A V
Atherosclerotic changes
Vascular Anatomy
Haller’s Sattler’s Choriocapillaris
Variation of choroidal thickness in certain conditions (AMD, Myopic D, CSR).Alteration of choroid by certain conditions (Choroidal Sclerosis).Alteration of the retina by choroidal disease (Posterior Uveitis, Ischemic disease)
SPCA
OCT-Peripheral Retina Montage
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Wide Field OCT
30⁰
55
ONH
OCT Dissection and Deduction E-mail consult form colleague discussing 78 Y/O patient with AMD Colleague concern and question: How do we know this is not a melanoma?
Courtesy of: Nick Belill, OD Clio, MI
Melanoma?
Answering what isn’t vs what is!
Email Consult: What is this on retinal surface?
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Colleagues Opinion: “OCT Shows thickening of NFL and RPE”. Is this accurate?
Mixed Disease
Review of Structural Changes inDisease
Macular Degeneration and Degenerative Condition
Early AMD (Drusen)
AMD
Small Drusen
Intermediate (63-125 um)
Large (>125 um)
Drusen-Dynamic Evolution
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Intermediate AMD
EMM
Large-Placoid-Soft Drusen
BM
Large-Placoid-Soft Drusen Progression
Large Drusen (coalesced, placoid) RPE Abnormalities
Large Drusen Fellow Eye
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RPE Abnormalities-GA
BMGA
Sinking Retina
GA
GA Progression
Choroidal sclerosis Hyperreflectance of choroid
EMM
GA-Choroidal Sclerosis
Advance AMD (Neovascular) 6 years follow-up
Challenges due to patient’s compliance
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SRF SRH
PED
1 MO S/P IVI
4 Mo from onset
CNV
SRF
CNV
IRH
R/O Wet AMD
Outer Retina
Inner Retina
OCT Guided Dx-Dissection OS
Choroidal Thickness BM
Drusen
Thin Choroid
Intact BM
Altered RPE and Drusen
No Contiguity
Dissection
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SRF SRH
PED
1 MO S/P IVI
4 Mo from onset
CNV
SRF
CNV
IRH
R/O Wet AMD
Outer Retina
Inner Retina
OCT Guided Dx-Dissection OS
Choroidal Thickness BM
Drusen
Thin Choroid
Intact BM
Altered RPE and Drusen
No Contiguity
Dissection
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Cone Dystrophy
MacTel
MacTel
MacTel CNV
Juvenile X-linked retinoschisis
Acquired Macular Schisis
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Myopic Degeneration and CNV
3 months later
Lacquer cracks
PPA
Angiod Streaks
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OHS
B
A
B
C
D
C
A
A D
OHS (Late) Punched out lesion!
CNV
SRF
CSR
6 weeks later
Choroid RPE
Simultaneous FA/OCT
Multifocal CSR
1 Mo later 2 mo later
Pigmented Lesion and Tumors
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CHRPE
Choroidal Nevus
Elevated Nevus
Localizing Lesions (Choroidal Nevus)
Choroidal Tumor
Choroidal Hemangioma
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Retinal Hemangioblastoma
Retinal Vascular Disease
• DR• RVO• RAO
Diabetic Retinopathy
Inner Retina-Retinal Vascular Disease
MA-NPDR 6 months
Diabetic Retinopathy
Shorter Scan Line Better Resolution
2 months later
JUN 2014
DEC 2014
APR 2016
SEP 2016
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NPDR (MA constriction resolution of ME)
S/P Focal
Exudates
Exudates
Cotton Wool Spots
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DME
Post-TX
q
P
PDR-NV
Retinal Vessels
Posterior Vitreous Cortex
Vessel Walls
Possible vessel wall in vitreous space
Invasion of retinal vessel to retinal surface
PDR-VH
Shadow
PDR-TRD
PDR-TRD
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1 Mo
One year MultipleTxs
RVO
RVO
RVO
In BRVO there is uneven distribution of pathology
Exudates Outer Migration
RVO –Proliferative Retinopathy
RAO
Fellow Eye
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RAO
2 Mo
BRAO OCT
Vitreous and Vitreoretinal Interface
Fibrils New Onset Floaters
Do Not Use EDI for Surface Disease
Patient Referred R/O AMD
Retractile areas on fundus exam
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PVD
VMA
VMT-Spectrum
Spontaneously Improved
Other Examples
9/24
10/30
12/15
1/18
2/15
5/6
Tractional Striae
VR Tufts (Traction)
Epimacular MembraneSingle layer vs overall assessment
EMM-Postop
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Prognostic Markers
MH (Partial- Full-thickness)
LMH Spectrum and Repair
MH-S/P Repair
Infectious/Inflammatory/Autoimmune Disorders
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Toxoplasmosis
Toxoplasmosis
Vit. Cells
20/40
Conditions of Inner-Retina
Recurrence
White Dot Syndrome 19 Y/O WM
23 AfAm F
Unilateral Recent Onset Vision Loss
43 WF
Acute Posterior Multifocal Placoid Pigment Epitheliopathy
1 week
1 month
6 month
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Multiple Evanescent White-Dot Syndrome
Vit Cells
Punctate Inner Choroidopathy
2 weeks S/P Ozurdex Implant
Acute Zonal Occult Outer Retinopathy
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Peripheral Retinal Disease
RRD vs. Retinoschisis
Lattice (Snail Track) Degeneration
Peripheral Vitreo-retina Interface and Lattice
Pocket of liquefied vitreousAbnormal attachment of formed vit
Peripheral Microcystoid
OCT-Lattice/RT/Subclinical RD
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Absence of choroidal features
Paving Stone Degeneration
Optic Nerve
RNFL
PPA
Termination of BM
BMO
Posterior Ciliary Artery
BM
RPE
Peripapillary Atrophy
1
2
3
4
1. PPA (OR atrophy)2. Choroidal sclerosis3. Pigment clumping4. Pigmented old CNV
RNFL
BMOScleral Canal
Tilted Disc (GL dilemma)
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Bergmeister’sPapilla
Optic Pit
ONH Drusen
Papilledema
Young Obese Female Pseudotumor Cerebri
Thank you