Download OCT Image Acquisition - Illinois College of Optometry

All About the OCT: Glaucoma
Fall 2014
Disclosure
All About the OCT: Glaucoma
• Michael Chaglasian, O.D. is a paid advisor, consultant or researcher for the following commercial/industry groups:
– Allergan, Alcon Labs, Carl Zeiss Meditec
Michael Chaglasian, O.D.
Associate Professor
Illinois College of Optometry
Illinois Eye Institute
[email protected]
OCT Image Acquisition
“Cube of Data”
• Similar to ultrasound but uses light instead of sound to image tissue
• Beam of light is directed into tissue and reflections coming from different layers of the tissue are received by a detector
Time Domain OCT artifacts
can be common
Time Domain OCT:
susceptible to eye movements
•768 pixels (A‐scans) captured in 1.92 seconds is slower than eye movements
•Stabilizing the retina reveals true scan path (white circles)1
1. Koozekanani, Boyer and Roberts. “Tracking the Optic Nervehead in OCT Video Using Dual Eigenspaces and an Adaptive Vascular Distribution Model”; IEEE Transactions on Medical Imaging, Vol. 22, No. 12, 2003
1.
2.
3.
M. Chaglasian, OD
Sadda, Wu, et al. Ophthalmology 2006;113:285‐293
Ray, Stinnett, Jaffe . Am J Ophth 2005; 139:18‐29
Bartsch, Gong, et al. Proc. of SPIE Vol. 5370; 2140‐2151
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All About the OCT: Glaucoma
Fall 2014
Spectral Domain OCT
Spectral Domain: Many Options
• Enhance sensitivity and specificity in disease detection and reduce uncertainty in glaucoma suspects. • Improved software is available to help detect disease progression.
Spectral Domain: Many Options
Spectral Domain: Why??
• Enhanced reproducibility and registration.
• Objective quantitative data that supports standardization of care at an expert level.
• Pinpoint correlations in ocular structure and function, matching areas of abnormal tissue with attendant vision problems.
Key Advantage: Progression Analysis
Spectral Domain OCT Time Domain OCT
SPECTRALIS
Stratus
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M. Chaglasian, OD
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All About the OCT: Glaucoma
How to “Read” a Printout
• FIRST!: Signal Strength
– A KEY indicator of image quality
– Should be 7/10 or higher on Cirrus
– DO NOT interpret poor quality scan as “red” disease
• Well centered image
• No evidence of movement artifact
• Review Plots and Displays
– Thickness Map and Deviation Map
– Quadrant and Sector Plots
– TSNIT and Optic Nerve B‐Scan
Zeiss: Cirrus OCT Printouts
Fall 2014
Printout
Signal Strength Here
RNFL THICKNESS MAP shows the patterns and thickness of the nerve fiber layer within the full 6mm x 6mm area RNFL thickness and comparison to normative data is shown in circle, quadrants and clock hour display
RNFL DEVIATION MAP, overlaid on the OCT fundus image, illustrates precisely where RNFL thickness deviates from the normal range. Data points that are not within normal limits are indicated in red and yellow.
Quadrant and Sector MAPs
in middle of page
Glaucoma – RNFL Thickness Analysis
 The RNFL thickness map shows the
patterns and thickness of the nerve
fiber layer within the 6mm x 6mm cube
 Yellow and Red = Good / Normal
• The RNFL deviation map is overlaid on the
OCT fundus image to illustrate precisely
where RNFL thickness deviates from a
normal range
• Yellow and Red = Bad / Abnormal
RNFL
Glaucoma –
RNFL Thickness Analysis: TSNIT
 RNFL thickness is
displayed in
graphic format and
compared to agematched normative
data
M. Chaglasian, OD
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All About the OCT: Glaucoma
Normative Data: Glaucoma
Fall 2014
Example Normative Data:
• Average RNFL Thickness Distribution of Normals:
•
•
•
•
•
•
RNFL Symmetry
Rim Area
Disc Area
Average C/D Ratio
Vertical C/D Ratio
Cup Volume
Color coded indication of normative data comparison for RNFL and ONH. • The thickest 5% fall in the white area. • 90% of measurements fall in the green area. • The thinnest 5% fall in the yellow area or below. • The thinnest 1% of fall in the red area. • Measurements in red are considered outside normal limits. • ONH values will be shown in gray when the disc area does not match with normative data. Example Normative Data:
NEW: Ganglion Cell Analysis
• Measures thickness for the sum of the ganglion cell layer and inner plexiform
layer (GCL + IPL layers) using data from the Macular 200 x 200 or 512 x 128 cube scan patterns.
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
Anatomy:
Ganglion Cell Layer and IPL
Cirrus: Ganglion Cell Analysis
The analysis contains:
• Data for both eyes (OU)
• Thickness Map –
– shows thickness measurements of the
GCL + IPL in the 6mm by
6mm cube and contains an
elliptical annulus centered about the fovea.
• Deviation Maps –
– shows a comparison of GCL + IPL
– thickness to normative data.
• Thickness table –
– shows average and minimum thickness
within the elliptical annulus.
M. Chaglasian, OD
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All About the OCT: Glaucoma
Macular/Ganglion Cell Analysis for Glaucoma
• Is a “complement” to traditional RNFL scans
• Has a large number of false positives.
• Should NOT be used as the sole basis of a diagnosis for glaucoma.
Fall 2014
What are practitioners' most common misunderstandings of imaging technology?
“The thought that these devices can diagnose glaucoma in the absence of corroborating clinical evidence is, in my opinion, the most common (and potentially dangerous) misunderstanding. The limited normative databases against which scans are compared can never cover the remarkably varied appearance and structure of the optic nerve we encounter in normal individuals.”
James Brandt, MD
Red Disease!
Red Disease
Disc Photos
CASE EE
IOP 21‐24 mmHg
CCT 545
M. Chaglasian, OD
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All About the OCT: Glaucoma
Fall 2014
Visual Fields
Combined Report
Disc Photos
CASE MZ
IOP in high teens
CCT= 560 M. Chaglasian, OD
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All About the OCT: Glaucoma
Fall 2014
Visual Fields
CASE CM
38 yo
GAT= 22 OD 25 OS
Visual Fields
M. Chaglasian, OD
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All About the OCT: Glaucoma
Fall 2014
Two important questions every glaucoma practitioner has:
Combined Report
• Is my patient getting worse?
Newer Question:
• What is the rate of progression?
• Variability in perimetric testing
• Can we quantify this?
• Challenges of ONH serial assessment
– How can I tell for certain?
Different Rates of Progression
Caprioli J. AJO 2008
M. Chaglasian, OD
Variability in Progression Rates
Heijl A. Acta Ophthalmol. 2013: 91: 92–99
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All About the OCT: Glaucoma
Fall 2014
Progression in Glaucoma: EMGT
Progression in Glaucoma: EMGT
~ -0.08 dB/yr
3x Normal
Aging Rate
Rate of Progression Range
~ -4 dB/yr
90 x Normal Rate
~ -0.05 dB/yr
2x Normal
Aging Rate
Rate of Progression Range
~ -0.60 dB/yr
12x Normal
Aging Rate
~ -0.35 dB/yr
7x Normal
Aging Rate
~ -2.5 dB/yr
50x Normal
Aging Rate
Zeiss Humphrey
GPA Summary Printout
Glaucoma
Progression Index
CONCLUSIONS: Glaucoma progression
rates calculated using the GPI seem to be
considerably less affected by cataract and
cataract surgery than rates based on the
traditional MDI.
Am J Ophthalmol 2008;145:343–353
GPA Summary
Printout
 Baseline Exams
 Visual Field Index
Visual Field Index (VFI)
Central points weighted more heavily than those on periphery
Reduces cataract contribution to the measurement of VF loss
B
A
 Most Recent Test
VFI = 90%
VFI = 81%
“ B”has more damaged central points and lower VFI than“A”.
M. Chaglasian, OD
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All About the OCT: Glaucoma
Fall 2014
Measures of Progression:
Trend Analysis
HFA GPA
VFI Summary - Interpretation at a Glance
 Trend Analysis
Loss to date
Projected future loss
100%
• “Measures the rate of change”
• A regression line is drawn to determine rate of
change for all the data that has been collected
over time.
The VFI Bar
• historical and
projected VFI loss
• Using VFI measures a % rate of change
• Most valuable when multiple VF tests
have been completed
• Good for identifying fast progressors
Arch Ophthalmol. 2009;127(12):1610-1615
GPA
Summary
Report:
Baseline
Trend
Analysis
GPA
Summary
Report:
Trend
Analysis
Most Recent Exam
Zeiss: Cirrus OCT Printouts
Case Example:
Progression Left Eye?
Visual Field is Stable
M. Chaglasian, OD
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All About the OCT: Glaucoma
Fall 2014
Cirrus GPA Progression Report How to Evaluate Progression?
Cirrus OCT GPA Analysis
Cirrus RNFL “Event” Analysis
• Event Analysis:
– Progression is defined when the difference between baseline and follow up is greater than test‐retest
SS = 10
Baseline
Registration 
SS = 10
Baseline
Registration 
SS = 8
Registration 
SS = 9
• Trend Analysis:
– Progression is defined when there is a significant negative slope of a regression line, which is performed on a particular parameter
Patterns of Progression
• Two baseline exams are required
• Yellow Coded: Change greater
than test-retest variability.
• Red: Confirmed on follow up.
Appearance of Defect
• Initial Appearance of Defect
• Widening of Defect
• Deepening of Defect
Leung et al. Ophthalmol 2012
M. Chaglasian, OD
Leung et al. Ophthalmol 2012
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All About the OCT: Glaucoma
Fall 2014
Widening of Defect
Deepening of Defect
Leung et al. Ophthalmol 2012
Leung et al. Ophthalmol 2012
Cirrus RNFL/ONH Trend Analysis
Cirrus GPA Analysis
Four Parameters: Average, Superior, Inferior RNFL; Average C/D Ratio Trend Analysis: Statistical Program
 A Regression Line is drawn to determine rate of change for all the data that has been collected over time.
RNFLT (microns)
 Less variability with Structural/OCT testing as compared to Functional/ Visual Field testing.
250
TSNIT Progression Graph
200




150
100
50
TSNIT values from each exam are shown Significant difference is colorized yellow or red
Yellow denotes change from both baseline exams
Red denotes change from 3 of 4 comparisons
0
0
50
100
150
200
250
TSNIT
Cirrus GPA: Trend Analysis
Cirrus Guided Progression Analysis
Page 1
Page 2
• Average RNFL Thickness
values are plotted for each
exam.
• Yellow marker denotes
change from both baseline
exams.
• Red marker denotes change
sustained over consecutive
visits.
• Rate and significance of
change are shown in text
M. Chaglasian, OD
Ver 6.0
77
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All About the OCT: Glaucoma
Fall 2014
Page 2 Data
Cirrus GPA: TSNIT Analysis
•TSNIT values from baseline and current exams are plotted. •Areas of statistically significant change are color‐coded yellow when first noted and then red when the change is sustained over consecutive visits.
•Progression is less frequently noted on this plot. Leung, 2012
Cirrus GPA™ Analysis
RNFL Summary
• Legend summarizes GPA analyses and indicates with a check mark if there is
possible or likely loss of RNFL
• RNFL Thickness Map Progression (best for focal change)
• RNFL Thickness Profiles Progression (best for broader focal change)
• Average RNFL Thickness Progression (best for diffuse change)
M. Chaglasian, OD
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All About the OCT: Glaucoma
Limitations to OCT Progression
Fall 2014
Age Related Change:
• Age Related RNFL and Macular Thinning:
– Is not accounted for in the analysis
– ‐0.52 µm/year and ‐0.25 µm/year
• Leung et al Ophthalmology 2012, 2013
– thus, not all negative slope is disease related and may not be related to glaucoma progression
• Review all clinical findings, do not base management decisions on OCT alone
– Avoid “Red Disease”
Leung. Curr Opinion 2013
Disc Photos
CASE VM
48 yo
Several Year History of OHTN
CCT ~ 575µ
Negative Family History
Monitored q3‐4m without Treatment
Current and Initial OCT
M. Chaglasian, OD
Right OCT
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All About the OCT: Glaucoma
Fall 2014
Left OCT
GPA Visual Fields
Ganglion Cell Analysis
Case EG
•
•
•
•
•
•
•
67 yo, AA male, Retired school teacher
Good health, no medications
+ Family History of glaucoma
OHTN/Early Glaucoma
CCT= 565, 555
Pre‐ Tx IOP ~ 30 mmHg OD, OS With PGA:
– Always 20‐23 mmHg x 5+yrs
– Good Compliance
ONH Photos
M. Chaglasian, OD
Current and Initial
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All About the OCT: Glaucoma
Fall 2014
Progression?
Cirrus GPA: Stable OD and OS
Page 2 Data
GPA Visual Fields
GCA
Case EW
• 73 yo, “Snowbird”
• Pseudophakic OU
• PreTx GAT:
– 34 mmHg and 24 mmHg
• Currently:
– 22 and 18 mmHg on a PGA
M. Chaglasian, OD
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All About the OCT: Glaucoma
Photos
Current and Initial OCTs
Cirrus GPA
Right Eye: Page 2 Data
GPA Visual Fields
M. Chaglasian, OD
Fall 2014
GCA
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All About the OCT: Glaucoma
Detection of Progression using both Structure and Function
• Structural tests not necessarily better than functional tests in early disease
• Both imaging and visual function tests should be used to monitor OHT and early glaucoma
• Earliest detection/progression will vary amongst patients
M. Chaglasian, OD
Fall 2014
Take Home Message:
• RNFL and ONH Progression Analysis on OCTs is now at a higher level.
– Macular/Ganglion Cell Scans may be included in the future
• Structural Progression Analysis will become a regular part of the best practice patterns for glaucoma.
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All About the OCT: Retina
Disclosure Statement
Retinal and OCT Grand
Rounds
Steven Ferrucci, OD, FAAO
Chief, Optometry Sepulveda VA
Professor, SCCO/MBKU
OCT Technology: Advantages
 Has ushered in a whole new era of retinal care
 Diagnosis
 Response to treatment
 New diagnoses once only speculated
 VMT
 Macular Schisis
 Information once only available through
histopathology or dissection
 Can replace FA in some cases
CME
S. Ferrucci, OD
Speakers bureau/Advisory Board
Alcon
Macula Risk
MacuLogix
Nicox
Autogenomics
Science Based Health
Thrombogenics
OCT Technology: Caveats
 DOES NOT take place of clinical exam!
 DOES NOT take place of careful history taking
 DOES NOT replace FA in some cases!
 DOES NOT REPLACE COMMON SENSE!
ONE MORE PIECE OF CLINICAL
PICTURE
 Not the end all be all!!
 Not to be taken in vacuum
FA
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All About the OCT: Retina
Plaquenil Toxicity: How Prevalent?
1: 10-2
2: ERG
3. SD-OCT
4. FAF
Reading the OCT associated with plaquenil
toxicity
Normal Patient
Where’s the damage?
Plaquenil Patient
Impact of the guidelines on today's practice!
AJO 8/2013

OCT:
Saucerazation & Sinkhole appearance


perifoveal outer retinal abnormalities
displacement of the inner retinal structures toward the RPE with increase retinal atrophy
n=183 pts came for f/u & 36 were evaluated for
baseline
Evaluated by 26 ophthalmologist & 3 ODs
Results
 40% increase on health care cost
 No additional pts discover with toxicity in accordance to new
guideline.
 Incidence of toxicity remains at 1%, as noted in f/u pts
 No pts was followed at recommended guidelines of 5-year
period after baseline (even if low-risk patient)
Chen et al. Clinical Ophthalmology 2010
S. Ferrucci, OD
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All About the OCT: Retina
Macular Thickness Normative Data
Cirrus HD-OCT Healthy Macula
NFL
ILM
GCL
IPL
INL
OPL
ONL
Macular thickness is compared to an agematched normative database as indicated
by a stop-light color code
ELM
NFL: Nerve Fiber Layer
ILM: Inner Limiting Membrane
GCL: Ganglion Cell Layer
IPL: Inner Plexiform Layer
INL: Inner Nuclear Layer
IS
IS/OS
OS
OPL: Outer Plexiform Layer
ONL: Outer Nuclear Layer
ELM: External limiting membrane
IS: Photoreceptor Inner Segment
RPE
Choroid
IS/OS: Junction of inner and outer
photoreceptor segments
OS: Photoreceptor Outer Segment
RPE: Retinal Pigment Epithelium
13 Retinal Layers !
EXAMPLES
Basic B-Scan Interp.
MH Case
MH Case
 65 yo Hispanic male
 CC: decreased VA OS for several years. Unsure
of exact diagnosis. Was curious if anything could
be done to improve vision. Laser? Injection?
 Oc hx: (+) POAG father and sister
 Med hx: hyperlipidemia
 VA cc 20/20 OD, 20/200 OS
 Ant seg: unremarkable
S. Ferrucci, OD
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All About the OCT: Retina
Macular Hole
Macular Hole
Full thickness macular hole OS
Consult with retinal specialist
Felt that due to duration of situation,
unlikely that any surgery would have
meaningful benefit on vision
RTC q 6 mos
Monocular precautions including
polycarbonate RX
Macular Hole
Present as a circular to oval depression of varying
degrees in the avascular area of the macula
 May have surrounding cuff of edema
Most common cause is idiopathic
 other causes include blunt trauma, severe myopia, solar
retinopathy, CME
Highest incidence in 7th decade of life
Women 2x as often as men
Macular Hole-OCT
Vision typically 20/80 to 20/200 with fullthickness hole
If pt has macular hole in one eye, 28-44%
chance of macular hole in other eye w/o a
PVD
If PVD already, very little chance
Watzke-Allen sign useful to differentiate true
hole from similar appearance
OCT very useful
FTMH
S. Ferrucci, OD
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All About the OCT: Retina
VMT CASE
VMT OCT
 80 yo male
 Decreased VA OS x 1 mos
 20/20 OD, 20/125 OS
 Med Hx: HTN, DM, CAD, s/p CVA
 Meds: acarbose, metformin, glipizide,
lisinopril, simvastatin
Post op OCT
VMT Case
 Dx: VMT with CME OS
 Pt underwent Avastin x 1 OS followed by PPV
and membrane peel OS
 POM #1 VA 20/200 OS!
Another presentation
Examination
 60 yo male presents for yearly diabetic
exam
 Cc: noted left eye had blurry spot in center
of vision, with lines compressed and
distorted vertically
 Med Hx: Type II DM x 3 years, HTN,
Hyperlipidemia
 Oc Hx: unremarkable
 BVA: OD 20/20, OS 20/50
 Amsler Grid:
 OD WNL
 OS central distortion, metamorphopsia
 Post pole:
S. Ferrucci, OD
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All About the OCT: Retina
OD 194um
VMT Case
OD 397um
Last VMT Case
63 yo white male
1 wk, noted straight lines were curved, both
horizontally and vertically left eye
Lines of text seemed “shrunken” as well, OS
Pt seen about 3 mos previous for routine
exam
Unremarkable, 20/20 OU
Mild HTN, ED
HCTZ, vardenafil
Last VMT Case
12/2011
 VA 20/30-1
CRT: 241
S. Ferrucci, OD
 A: VMT OS with impending macular hole
 Window defect on FA with no leakage
 P: repeat OCT in 1 month to see if hole
progresses or resolves
 Pt agrees with plan
 VA has since increased OS to 20/30+ with
decreased metamorphopsia
Last VMT case
9/2011: VA 20/20 OD, 20/40 OS
OCT: CRT 309

Pt elects to wait and see what happens
Last VMT Case
3/2012 VA 20/20
CRT: 3/2/2012 183
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All About the OCT: Retina
VMT: Vitreomacular Traction
 VMT syndrome is characterized by a partial
detachment of the posterior detachment with persistent
adherence to the macula
 Can lead to CME, ERM, and macular hole formation
 Once thought to be relatively rare, with advent of OCT
now being seen more and more
 In one study, 8% of pts were thought to have VMT by
clinical observation only, but 30% by OCT
VMT
VMT
VMT
 More commonly encountered in older
women
 Can occur in either sex, and age, no
apparent racial predilection
 Aphakia and pseudophakia are protective,
as these patient typically have a complete
PVD
 Pts may report decreased vision,
metamorphopsia and photopsia
VMT
 Natural progression of disease is rather
variable
 Slow progression possible with near
normal acuity
 Approx 10% will have spontaneous PVD
and resolution
 Therefore, close monitoring my be advised
for some patients
S. Ferrucci, OD
 Clinically, very hard to diagnose
 PVD with adherence to macular area
 Can present as macular surface wrinkling/striae
, similar to ERM, or loss of foveal reflex
 May also note a thickened posterior hyaloid
membrane
 Retinal blood vessel distortion straightening may
be present
 Retinal thickening /macular edema may be
associated
OCT IS THE KEY!!!!
VMT
 In patients with poor vision, or
symptomatic, a pars planar vitrectomy
(PPV) may be considered
 Duration, severity should also be
considered
 Literature repots up to a 75% success rate
and improvement of vision following PPV
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All About the OCT: Retina
Jetrea (Ocriplasmin)
 Intravitreal injection of thrombolytic agent that causes lysis of
vitreous
 Pharmacologic vitrectomy
 FDA approved October 2012 for treatment of symptomatic
vitreomacular adhesion
 Two phase 3 trails
 26.5% of pts had resolution of VMA vs. 10.1% with placebo
 Minimal adverse effects
 0.125 mg (0.1 ml) injection
 Available January 2013
 Cost?
ERM Case
 78 year old male
Notes mild decreased VA OS, and lines
appear “crooked when reading” OS. Older
brother has AMD so worried
Med hx: unremarkable NO MEDS!!!
Oc hx: unremarkable, older brother with “bad”
AMD
VA : OD 20/20-1, OS 20/40
ERM OS
ERM Case
OD: Normal
OS: ERM
ERM Case
ERM Case 2
Due to good VA, pt defers consult to retina
service for possible membrane peel/PPV
Pt relieved it is not AMD!!
RTC 6-12 mos
HAG
2011
63 yo male
Just wants new glasses
Feels OS is not as good as OD
20/20 OD, 20/40 OS
S. Ferrucci, OD
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All About the OCT: Retina
ERM case 2 -2011
20/25
20/40: mild ERM
ERM Case 2
Mild ERM OS
Overall satisfied with acuity “95% of the
time”
Not that interested in retinal consult
RTC 1 yr or PRN
ERM Case 2
Pt comes back in 2014, about 3.5 years
later
Feels Vision may be “a tad worse “ OS
ERM Case 2
ERM Case 2
ERM OS, progressed
VA from 20/40 to 20/150
Pt offered retinal consult
Pt ed that VA reduced and good time for
surgical evaluation
Decides not really bothered, so defers
Comes back a week later and states saw
outside retinal specialist (with his wife) who
recommended sx
Suddenly symptomatic!!!!
Refer to Retina clinic
PPV/MP OS scheduled in 1 mos
Happy with vision “90% of the time”
S. Ferrucci, OD
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All About the OCT: Retina
ERM case 3
ERM case 3
 67 yo male
 Notes gradual decreased VA OD x 1 yr
 20/70 OD
 20/20 OS
 1+ NSC OU
 Does not seem like 20/70 cataract
 Fundus appears normal
 Plan: get OCT
ERM case 3
ERM case 3
Epi-retinal Membrane
ERM case 3
ERM with traction OD on OCT
CRT 472 vs 296
No edema on FA
Refer to retina clinic for surgical eval ERM
peel
S. Ferrucci, OD
AKA macular pucker, cellophane maculopathy
Can be secondary to peripheral retinal
disease, such as detachment or tear; a retinal
vascular disease such as BRVO;
inflammation; trauma or idiopathic
Idiopathic tend to be more mild and nonprogressive vs. those after retinal tear
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All About the OCT: Retina
Epi-retinal Membrane
VA can range from 20/20 to 20/200 or worse
Studies show > 5% have worse than 20/200
Often metamorphopsia is only complaint with
idiopathic ERM
Fewer than 20% of cases are bilateral
Surgical removal is considered if severe vision
loss or distortion
Epi-retinal Membrane
Consider surgery if:
VA 20/40 or worse
Symptomatic
Visual need of patient
30 minute procedure
Face down compliance after surgery for up to
2 weeks
Make sure you have an experienced surgeon!!
Epi-retinal
Membrane
ERM
S. Ferrucci, OD
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All About the OCT: Retina
CSR Case
CSR Case
40 yo male. Works as used car salesman
Presents with blurry vision OS x 3 days
Med hx: HTN
Meds: HCTZ
VA 20/20 OD, 20/40 OS
CSR Case
CSR Case
CSR OS
Pt ed stress as risk factor as well as
steroids
RTC 1 mos
Pt calls clinic 3 mos later. Reports saw local
OD who said VA now 20/20 OS
CSR case #2
38 year old male
Small grey spot in central vision OS x 3
days
 Color distorted when looks through grey spot
 Peripheral vision normal
Oc Hx: unremarkable
Med Hx: h/o ulcerative colitis
Meds: prednisone 30 mg/day
S. Ferrucci, OD
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All About the OCT: Retina
CSR case 2
Consult to GI Clinic regarding systemic
steroids as risk factor
Pt eager to get off steroids
 Gained 30 lbs since started
Unable to verify with FA as pt has h/o
passing out when “sees a needle”
Pt Ed: RTC 6-8 weeks
EDI:
Enhanced
Depth Imaging
Normal EDI
CSR Case 3
56 yo white male
h/o decreased VA OS x 30 yrs
CSR case 3
20/20
20/20
 Unknown etiology
 Was told might resolve on own
 Probably related to stress
 Med HX: mild HTN, obesity, ED, hip replacment
S. Ferrucci, OD
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All About the OCT: Retina
EDI: Enhanced Depth Imaging
Central Serous Retinopathy
CSR Case 3
Inactive CSR in Macula
New area temporal to macula
Review with retinal specialist
 Agrees with findings
 PDT was discussed but not readily available
 Suggest grid laser OS since temporal due to
previous vision loss
Central Serous Retinopathy
Pt typically presents with fairly recent onset of
blurred VA in one eye with a scotoma, micropsia,
or metamorphopsia
 VA typically 20/30-20/70
Often correctable with low hyperopic RX
Unilateral in 70% of cases
S. Ferrucci, OD
Common disorder of unknown etiology
which typically affects men between age 20
and 45
Males to females 10:1
Serous detachment of neurosensory retina
due to leakage from small defect in RPE
Central Serous Retinopathy
Appears as a shallow round or oval elevation
of the sensory retina often outlined by a
glistening reflex
FA is helpful in providing definitive diagnosis
Classic Smoke stack appearance
(occasionally)
Ink-blot appearance
OCT shows marked elevation
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All About the OCT: Retina
Central Serous Retinopathy
Central Serous Retinopathy
Risk factors
Type A personality
Stress
Use of systemic cortico-steroids
Pregnancy
80-90% of pts will undergo spontaneous
resolution and return to normal (or near
normal) VA within 1-6 mos.
>60% resolve back to 20/20
Rare to have vision remain < 20/40
Approx 40% will get recurrence
CNVM is VERY rare occurrence, but possible
Central Serous Retinopathy
 No known medical therapy has been proven effective
 Topical steroids, NSAIDs etc
 Localized photocoagulation may be of some benefit,
but only if
 Duration at least 4 months
 VA in other eye is reduced from other attacks
 Recurrent CSR has already reduced VA in that eye
 Pt is intolerant of vision and willing to take risk
 PDT suggested in some cases
 Avastin?
 Behavior modification?
Solar Maculopathy
 65 yo male  No complaints
 Med hx: HTN, Obesity
 20/30 OU
 h/o sungazing in past ≈15 yrs ago when cocaine/LSD abuser
Solar Maculopathy
Solar Maculopathy
OCT characteristic for solar maculopathy
Pt ed, monitor
S. Ferrucci, OD
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All About the OCT: Retina
Solar Maculopathy
 Damage to the outer layers retina as shown on OCT
 Outer segment of photoreceptors and RPE
 Clinical exam, small yellowish lesion
 Acuity typically 20/40-20/60
 Little to no correlation with appearance and acuity
 Greater risk in younger individuals who are more
likely to start at sun or eclipse
High Myopia
 67 yo presents for annual exam. Wonders if
glasses need update
 States never had great vision OS
 OD: -9.25-2.75x080 20/30-2
 OS: -11.00-1.75x103 20/20-
 With clear lenses
 Also, schizophrenic pts, pts on LSD, etc.
Macular Schisis
 Relatively new entity, ≈1999 by Takano and Kishi
 Prior to this, misinterpreted as shallow RD or
even edema
 With OCT, thought to be not uncommon in highly
myopic individuals with posterior staphyloma
 Characterized by intraretinal splitting, in both inner
and outer retina, with cystoid spaces
Macular Schisis
OCT: Final Thoughts
 Fairly stable with time, with mild fluctuations in
vision
 Treatment (vitrectomy) generally only
recommended if vitreal traction, as may lead to
macula hole
 Consider OCT in high myopes with central vision
problems
Has ushered in a whole new understanding
of retinal disease
Fast becoming the standard of care
Many models /makes available
S. Ferrucci, OD
THANK YOU!!
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