Imaging Interpretationfor the Comprehensive Eye CareProfessional
Blair Lonsberry, MS, OD, MEd., FAAODiplomate, American Board of OptometryClinic Director and Professor of OptometryPacific University College of [email protected]
Time
% Loss
Early
Moderate
Severe
Visual Field changes occur late in the diseaseThe Optic disc often changes before visual fieldsThe RNFL usually changes before both the visual fields and optic disc
VF
Disc
RNFL
Structural / Functional Relationship in Glaucoma as the Disease Progresses
Clinical Exam of the Optic Nerve HeadUtility and Limitations
Disc exam at the first visit – normal or abnormal?Disc exams are subjective, or at best semi-quantitativeThe wide variety of disc appearances requires long experience and expert judgment to separate normal from abnormalDisc diameter must be taken into accountDisc exam to assess changeUnless stereoscopic photographs are taken and compared over time, the ability of a clinician to judge change is very limited (chronology is important!)
OCT: The Basics
4
Retinal Layers
Cirrus RNFL Analysis
CALCULATION CIRCLEAutoCenter™ function automatically centers the 1.73mm radiusperipapillarycalculation circle around the disc for precise placement and repeatable registration.
OPTIC DISC CUBE SCANThe 6mmx6mm cube is captured with200 A-scans per B-scan, 200 B-scans.
RNFL/ONH Analysis
RNFL THICKNESSalong the calculation circle is displayed in graphic format and compared to age-matched normative data
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 inredandyellow.
RNFL THICKNESS MAPshows the patterns and thickness of the nerve fiber layer within the full 6mm x 6mm area
RNFL THICKNESS AND COMPARISON TO NORMATIVE DATABASEis shown in circle, quadrants and clock hour display
ONH Analysis:rim/disc area, average C/D ratio, vertical C/D ratio and cup volume
Cirrus RNFL and ONH Analysis Elements
RNFLPeripapillaryThickness profile, OUcompared to normative data
Neuro-retinal Rim Thickness profile, OUcompared to normative data
Optic Nerve Head calculations are presented in a combined report with RNFL thickness data. Key parameters are compared to normative data and displayed in table format
Cirrus HD-OCT GPA Analysis
Two baseline exams are required
Baseline
Third exam is compared to the two baseline examsSub pixel map demonstrates change from baseline:Yellow pixels denote change from both baseline exams
Thirdandfourth exams are compared to both baselines:yellow pixels denote change from both baselineschange identified in three of the four comparisons is indicated by red pixels
Image Progression Map
Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies
GuidedProgression Analysis (GPA™)
10
Page 2
GuidedProgression Analysis (GPA™)
11
Macular Cube Scan
Automatic Fovea Finder™
Fovea center = 255, 71
Scan center = 255, 64
Macula Thickness Analysis is aligned with fovea location (left)Resulting analysis may differ from analysis aligned on scan center (right)
Macular Thickness Normative Data
Macular thickness is compared to an age-matched normative database as indicated by a stop-light color code
Macular Change Analysis
Provides visual and quantitative comparison of two exams.
Ganglion Cell Analysis
Measures thickness for the sum of the ganglion cell layer and innerplexiformlayer (GCL + IPL layers)RNFL distribution in the macula depends on individual anatomy, while the GCL+IPL appears regular and elliptical for mostnormalsDeviations from normal are more easily appreciated in the thickness map by the practitioner, andarcuatedefects seen in the deviation map may be less likely to be due to anatomical variations.
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
Ganglion Cell Analysis
17
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
CIRRUS HD-OCT and HFA Combined Report
Case 1
19
Case History
60yoWMType 2 DM: 4 yearsHypertension: 4 yearsBilateral PK’s secondary tokeratoconus(has running suture OD)Has history of steroid injections for lower back stenosis (with history of increased IOP up to 40 after injections)VA(RGP):6/7.5 (20/25), 6/6 (20/20)IOP: OD: range 20-24, OS: range 17-20
OD
OS
OD
OS
Consider the below PSD plots.
OS
OD
Predict what TSNIT graphs you would obtain for this patient.
1
2
3
4
OS
OD
OD
OD
OD
OD
OS
OS
OS
OS
OD
OS
OD
OS
Case 2
Entrance Skills
60 YR WMComplaint of blurry visionCurrently wearing sister’s contacts as he lost his glassesPMHx: depression but not currently controlledPOHx: unremarkableBCVa: 6/6 (20/20) OD, OSAll other entrance skills unremarkable
28
Health Assessment
SLE:ArcusOD, OSAnterior chamber: deep and quietLens: trace NSIOP:26 and 23 OD, OS (first visit)24 and 20 OD, OS (second visit)DFE:C/D: 0.75/0.75 (with temporal sloping) OD and 0.6/0.6 OS
29
30
31
32
33
Case 3
34
Case: Gonzalez
33 HF presents with a painful, red right eyeStarted a couple of days ago, deep boring painHas tried Visine but hasn’t helped the rednessPMHx: patient reports she experiences joint pain and has been“diagnosed”with rheumatoid arthritis for 3 yearstakes Celebrex for the joint painpatient reports she occasionally gets a skin rash when she is outdoors in the sunPOHx: unremarkablePMHx: mother has rheumatoid arthritis
Case: Gonzalez
VA:6/9 (20/30)OD,6/6 (20/20)OSPupils: PERRL –APDVF: FTFC OHEOM’s: FROM OUBP: 130/85 mm Hg RASSLE: see picture2+ cells, mild flareIOP’s: 16, 16 mm HGDFE: see fundus photo
Etiologies of Cotton Wool Spots
Antimalarial Ocular Complications
usual dose is200-400 mg/d @night with onset of action after a period of 2-4 monthsHave affinity for pigmented structures such as iris, choroid and RPEToxic affect on the RPE and photoreceptors leading to rod and cone loss.Have slow excretion rate out of body with toxicity and functional loss continuing to occur despite drug discontinuation.
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
1
2
3
4
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
ARMD
Macular Hole
OHS
Bull’s Eye Maculopathy
Question
Which OCT goes with a patient undergoing hydroxychloroquine toxicity?
1
2
3
4
4
Antimalarial Ocular Complications
Toxicity can lead to whorl keratopathy,“bulls eye”maculopathy, retinal vessel attenuation, and optic disc pallor.Early stages of maculopathy are seen as mild stippling or mottling and reversible loss of foveal light reflex“Classic”maculopathy is in form of a“bulls eye”and is seen in later stages of toxicitythis is an irreversible damage to the retina despite discontinuation of medication
Antimalarials
29
Bulls Eye Maculopathy
Whorl Keratopathy
Revised Recommendations on Screening for Retinopathy
2002 recommendations for screening were published by OphthalmologyRevised recommendations on screening published in Ophthalmology 2011;118:415-42Significant changes in light of new data on the prevalence of retinal toxicity and sensitivity of new diagnostic techniquesRisk of toxicity after years of use is higher than previously believedRisk of toxicity approaches 1% for patients who exceed 5 years of exposure
Revised Recommendations on Screening for Retinopathy
Amsler grid testing removed as an acceptable screening techniqueNOT equivalent to threshold VF testingStrongly advised that 10-2 VF screening be supplemented with sensitive objective tests such as:Multifocal ERGSpectral domain OCTFundus autofluorescence
Revised Recommendations on Screening for Retinopathy
Parafoveal loss of visual sensitivity may appear before changes are seen on fundus evaluationMany instances where retinopathy was unrecognized for years as field changes were dismissed as“non-specific”until the damage was severe10-2 VF should always be repeated promptly when central or parafoveal changes are observed to determine if they are repeatableAdvanced toxicity shows well-developed paracentral scotoma
Paracentral Scotomas
Courtesy of Dr. Mark Dunbar
Revised Recommendations on Screening for Retinopathy
SD-OCT can show localized thinning of the parafoveal retinal layers confirming toxicitynot appreciable with time-domain OCTchanges maybe visible prior to VF defectsFundus autofluorescence may reveal subtle RPE defects with reduced autoFL or show areas of early photoreceptor damageMF-ERG can objectively document localized paracentral ERG depression in early retinopathy
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Normal Retina:VF/OCT/ERG
Outer Nuclear Layer
PIL
PIL=PR Integrity Line
TD-OCT
SD-OCT
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
MildMaculopathy
PIL
Thinned Outer Nuclear Layer
Paracentral Scotomas
Normal Foveal Peak
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Bull’s Eye Maculopathy
Remnant of PIL
RPE Atrophy
Flattened Foveal Peak
Dense Para/Central Defects
Revised Recommendations on Screening for Retinopathy
Revised Recommendations on Screening for Retinopathy
Older literature focused on daily dose/kg whereas newer literature emphasizes cumulative dose as the most critical factorInitial baseline then screening for toxicity should be initiated no later than 5 years after starting the medication
SD-OCT 5 Line Raster Scans
OD
OS
Case 4
Vesta: 61 y/o Hatian Female
GL suspect 2001 – suspicious ON’sNTGsince2006Meds:AlphaganP bid OU,latanoprostqhsOUMedicalHx: HTN, HIV (+) for > 15yrsVA: 6/6 (20/20)TA for the past 3 or 4yrs: 9-13 mmHg OULast 2 visits 9 mmHg – today 13Pachs: 450 microns
Case Courtesy of Dr. Mark Dunbar
2010
Case Courtesy of Dr. Mark Dunbar
OD
OS
2012
What’s This???
RE
OD
OS
2010
2011
2012
Case Courtesy of Dr. Mark Dunbar
GPA Progression Analysis OD
GPA Progression Analysis OS
Vesta: 61 y/o Hatian Female
NTG OU with thin corneasOS:Optic Nerveand HVF show trend towards progression….OCT shows no change
Case Courtesy Dr. Mark Dunbar
Vesta: 61 y/o Hatian Female
How do you manage this patient?Currently onlatanoprostandalphaganOUThis is what was done….StoppedAlphaganPSwitch toCombiganbid OUContinue withlatanoprostqhsOURTC 1mo
Case Courtesy of Dr. Mark Dunbar
OCT Retinal Images
Cirrus
Pigment Epithelial Detachment
Cystoid Macular Edema
Cirrus
Exudative AMD
Macular Hole
Cirrus
VitreomacularTraction
EpiretinalMembrane
Cirrus
Central SerousChorioretinopathy
Diabetic Macular Edema
Thank You!
69
0
Embed
Upload