Ancillary Testing in Neuro-ophthalmology : OCT et al./media/Images/Swedish/CME1/SyllabusPDFs... · neuro-ophthalmology and neurology –Demyelinating disease –Optic nerve edema

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Ancillary Testing in Neuro-ophthalmology :

OCT et al.

Bonnie M. Keung, MD

Neuro-ophthalmology Clinic

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Objectives

• Review of retinal and optic nerve anatomy

• To understand the role of OCT technology in neuro-ophthalmology and neurology

– Demyelinating disease

– Optic nerve edema vs pseudopapilledema

– Compression of the optic nerve

• Basic interpretation of OCT RNFL and GCC

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OCT

• Ancillary test in neuro-ophthalmology clinic

• OCT is a quick, non-contact, non-contrast technique for imaging tissues at a 3D micron- level resolution

• O = Optical = Light (infrared light)

• C = Coherence = monochromatic light

• T = Tomography = slices

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Resolution of OCT

http://obel.ee.uwa.edu.au/research/fundamentals/introduction-oct/

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OCT

• There are four generations

– 3rd generation: Time domain

– 4th generation: Spectral domain

• Routinely used in ophthalmology

– Glaucoma

– Retinal pathology

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Kimbrel EA, Lanza R. Current status of pluripotent stem cells: moving the first therapies to the clinic. Nat Rev Drug Discov. 2015 Oct;14(10):681-92

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http://www.siumed.edu/~dking2/ssb/EE020b.htm

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Duker JS, et al. Handbook of Retinal OCT. 2014

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OCT: imaging the macula

Case

• 50 yo neurosurgeon presents with central vision loss OS x 2 weeks, metamorphopsia

• PMH: seasonal allergies

• Meds: intranasal steroid spray

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OCT: imaging the macula

Case

• Exam

– VA 20/20, 20/60

– No RAPD

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OCT: imaging the macula

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OCT: imaging the macula

Duker JS, et al. Handbook of Retinal OCT. 2014

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OCT: imaging the macula Central Serous Chorioretinopathy

(CSCR)

• Build up of sub-retinal fluid in macula

• Related to increased corticosteroid exposure, stress, type A personality

• Resolves spontaneously in a few months

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OCT: macula to nerve

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OCT: RNFL Retinal Nerve Fiber Layer

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OCT: RNFL Retinal Nerve Fiber Layer

Lamirel C,et al. Optical coherence tomography (OCT) in optic neuritis and multiple sclerosis. Rev Neurol (Paris). 2010 Dec;166(12):978-86.

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OCT: print out

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OCT: RNFL

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OCT: GCC Ganglion Cell Complex

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• 23 yo with right sided headache x 10 days, followed by 24 hours of progressive vision loss OD. Eye pain OD with movement.

• EXAM

– VA hand motion OD

– large RAPD OD

– Fundus exam: swelling of the optic nerve

CASE

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CASE Goldmann Visual Field OD

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Case Goldmann Visual Field OS

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OCT RNFL

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OCT GCC

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OCT Macula

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CASE

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CASE – Optic neuritis Anterior and retrobulbar

• Received IV solumedrol: 1 g daily x 5 days

• 1 month follow up

– No pain

– VA 20/20 OD and 20/20 OS

• Was OCT really necessary?

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OCT- Optic Neuritis with Disc swelling - Acute

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OCT- Optic Neuritis with Disc swelling 1 month later…

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OCT & Optic neuritis

• Loss of up to 20 microns per optic neuritis

• RNFL thinning occurs later

– 3-6 months

Costello F et al. Quantifying axonal loss after optic neuritis with optical coherence tomography. Ann Neurol 2006 59:963-969

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OCT & Optic Neuritis

• Optic neuritis

– RNFL 75 u = threshold value for visual recovery*

Costello F, et al. Tracking retinal nerve fiber layer loss after optic neuritis: a prospective study using optical coherence tomography. Mult Scler. 2008 Aug;14(7):893-905

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OCT & Optic Neuritis

• Case of using GCL, in optic neuritis MS

• Not affected by swelling of the nerve

• Earlier loss

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OCT and Multiple Sclerosis (MS) • OCT in non-ON eyes showed thinning in RNFL

compared to controls

• OCT predicts MS disability in patient without ON

– RNFL < 88 u

• 2x risk of disability worsening in 1-3 years

• 4x risk of disability worsening in 3-5 years

• OCT of GCC thinning reliably mirrors brain degeneration

– More strongly associated with progressive MS

Martinez-Lapiscina EH, et al. Retinal thickness measured with optical coherence tomography and risk of disability worsening in multiple sclerosis: a cohort study. Lancet Neurol. 2016 May;15(6):574-84. Saidha, S., et al (2015), Optical coherence tomography reflects brain atrophy in multiple sclerosis: A four-year study. Ann Neurol., 78: 801–813

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OCT and NMOSD

• Average RNFL loss after MS-ON= 20 u

• Average RNFL loss after NMO-ON = 55-83 u

• Fellow eye in NMO less affected

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OCT? Papilledema vs Pseudopapilledema

CASE

• 20 yo female with history of migraine with aura, 3 months of worsened headache.

• Seen by optometry, referred urgently for papilledema with VA 20/20 OD and OS. Mother requesting that MRI be done right now.

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OCT? Papilledema vs Pseudopapilledema

EXAM

VA: 20/20 OD and OS, no dyschromatopsia

Motility: full, orthophoric

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OCT? Papilledema vs Pseudopapilledema

+HVF testing = normal

+OCT =

+CT scan (old) =

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Optic Disc Drusen (ODD)

• Autosomally dominant inherited

• Intracellular and extracellular deposits that become calcified over time.

• Scalloped disc margins

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Optic Disc Drusen (ODD)

• 0.3%-2% of population

• Usually asymptomatic, or some visual field defects

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OCT? Papilledema vs Pseudopapilledema

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Papilledema vs Pseudopapilledema Drusen

• ? OCT

• Fundus EXAM!

• B scan

• CT scan

• Fluorescein angiogram (FANG)

• Fundus auto-fluorescence (FAF)

• Lumbar puncture

• Enhanced depth OCT (EDI-OCT)

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The Fundus EXAM

Papilledema

• Disc vessels are obscured

• Elevation goes beyond disc

• Hemorrhages, exudates

• Not familial

Pseudopapilledema

• Overt superficial drusen

• Disc vessels clear

• Elevation confined to disc

• Usually no hemorrhages

• Drusen- autosomal dominant

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The Fundus EXAM

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B-scan

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CT scan

https://radiologykey.com/the-orbit/

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Fluorescein Angiogram

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Fundus Autofluorescence (FAF)

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Enhanced depth OCT (EDI-OCT)

Silverman AL, Tatham AJ, Medeiros FA, Weinreb RN. Assessment of optic nerve head drusen using enhanced depth imaging and swept source optical coherence tomography. J Neuroophthalmol. 2014 Jun;34(2):198-205

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OCT: Papilledema

CASE

• 23 yo obese female

• 2 weeks of headache, shoulder pain, double vision

• Mason General – CT (-), MRV (-), LP = 49 cm H20

– Acetazolamide 1500 mg daily

• Optometrist calls – VA 20/80 OD, 20/70 OS

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OCT: Papilledema

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OCT: Papilledema

EXAM

• 250#

• Esotropia

• Stage 4 disc swelling

https://clinicalgate.com/use-of-the-hand-held-ophthalmoscope/

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Goldmann Visual Field OD

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Goldmann Visual Field OS

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OCT: Papilledema

DIAGNOSIS:

• IIH, visual dysfunction

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IIH: Idiopathic Intracranial Hypertension

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OCT: Papilledema

DIAGNOSIS:

• IIH, visual dysfunction

PLAN:

• Acetazolamide 3500 mg daily

• Weight loss

• Close follow up – Serial visual fields

– Serial OCTs

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OCT: Papilledema

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Follow-up Goldmann Visual Field

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OCT: Pseudopapilledema vs Papilledema

• OCT can be used to aid in the differentiation between pseudopapilledema and papilledema

– Still lean on fundus exam, HPI

– Buried Drusen

• B scan, CT scan, FANG, FAF

• In cases of IIH, OCT can objectively track RNFL elevation and help explain progress to patient

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OCT: Pituitary Adenoma

CASE • 56 y/o veteran with frontal and retro-orbital

headache, many weeks • First received anti-biotics for presumed sinusitis • Three days later, “blurred vision OS > OD”

• VA: 20/25 OD, 20/60 OS • Normal ophthalmologic examination

– Ophthalmology attending: “He did have a trace RAPD OS”

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Junctional Scotoma

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OCT: Pituitary Adenoma

• Significant improvement in visual field if baseline OCT

– RNFL was normal

– if > 75-80 microns

Danesh-Meyer HV, et al. In vivo retinal nerve fiber layer thickness measured by optical coherence tomography predicts visual recovery after surgery for parachiasmal tumors. Invest Ophthalmol Vis Sci. 2008 May;49(5):1879-85

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