Principle of OCT Reading Between the Lines: OCT Interpretation · 2017. 10. 5. · 10/3/2017 1 Reading Between the Lines: OCT Interpretation Mohammad Rafieetary, OD, FAAO...

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Reading Between the Lines: OCT Interpretation

Mohammad Rafieetary, OD, FAAOmrafieetary@charlesretina.com

• 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