OCT-A what you need to know with this technology … · 01/10/2020 · Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 1 OCT-Angiography What You Need to Know with this

OCT-Angiography What You Need to with this New Technology

February 15, 20/20

Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 1

OCT-AngiographyWhat You Need to Know with this New

Technology

Disclosure Statement(next slide)

Greg A. Caldwell, OD, FAAOMid-Winter Getaway 20/20

3rd AnnualFebruary 15, 20/20

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Disclosures- Greg Caldwell, OD, FAAO

$ Will mention many products, instruments and companies during our discussion

¬ I don’t have any financial interest in any of these products, instruments or companies

$ Pennsylvania Optometric Association –President 2010

2 POA Board of Directors 2006-2011

$ American Optometric Association, Trustee 2013-2016

$ I never used or will use my volunteer positions to further my lecturing career

$ Lectured for: Aerie, Alcon, Allergan, BioTissue, Maculogix, OptoVue

$ Advisory Board: Allergan, Maculogix, Sight Sciences, Sun, Takeda

$ Envolve: PA Medical Director, Credential Committee

$ Optometric Education Consultants- Scottsdale, St. Paul, Quebec City, Nashville, and Orlando/Disney OCT Users meeting; Owner

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Financial Obligations

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Book Resources

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How Many People Here Have an OCT?

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February 15, 20/20


$ OCT is an optical signal acquisition and processing method

$ Time domain OCT

¬ 15-16 microns of resolution¬ Stratus (Zeiss)

$ Spectral domain (SD-OCT) or Fourier domain OCT

¬ Spatially encoded frequency domain OCT (SEFD-OCT)¬ 5-6 microns of resolution

2 Able to see photoreceptor morphology (inner/outer segments)¬ 50 times faster than time domain

$ Swept source OCT¬ Time encoded frequency domain OCT

¬ 1 micron of resolution

$ Future of OCT- intraoperative imaging, blood flow and oxygenation measurements

$ May have the possibility to assess retinal pathology like a pathologist

Optical Coherence Tomography

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OCT Angiography A New Approach to Protecting Vision

} Non-invasive visualization of individual layers of retinal vasculature} Pathology not obscured by fluorescein staining or pooling} Image acquisition requires less time than a dye-based procedure} Reduced patient burden allows more frequent imaging to better follow disease

progression and treatment response

OCTA of CNVFA of CNV

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Enface OCT-A SlabsBased on Retinal Anatomy

Deep Plexus (INL – OPL)

Superficial Plexus (ILM – IPL) Outer Retinal Zone (ONL – BM)

Choroid Capillaris

En Face Visualization of Layers Based on Retinal Anatomy

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February 15, 20/20


Normal Retinal Vasculature

Superficial Capillary Plexus

3µm Below ILM → 15 µm Below IPL

Deep Capillary Plexus

15µm Below ILM → 70 µm Below IPL

Outer Retina

70µm Below IPL → 30 µm Below RPE Reference

Choriocapillaris

30 µm Below RPE Reference → 60 µm Below RPE Reference

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Type 1 “Occult” CNV

} New vessels develop in the choroid

} New vessels located below RPE and above Bruch’s membrane

Choroid

Bruch’s Membrane

RPE

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Type 2 “Classic” CNV

$ New vessels develop in choroid$ New vessels located above the RPE and above Bruch’s membrane

Choroid

Bruch’s Membrane

RPE

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Diabetic Retinopathy

} Retinal capillary non-perfusion – seen as blackened area without blood flow outside FAZ} Microaneurysms} Enlarged FAZ

Superficial Capillary Plexus Deep Capillary Plexus Choriocapillaris

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Diabetes

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Wet AMD

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February 15, 20/20


Glad to Have it in the OfficeDisappointing without Quantitative Measurements

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AngioAnalytics

$AngioAnalytics is the world’s first OCTA metrics$The package includes the following tools:

¬ Foveal Avascular Zone (FAZ) measurements2 FAZ area, perimeter, A-circularity index and foveal vessel density

¬ Flow and Non-Flow Area measurements2 Measure the area of abnormal flow by outlining a region for vessel detection. The

extracted Flow Area measurement is based on the Outer Retina slab (OPL ~ BRM)

¬ Vessel Density mapping2 Measures the vessel density of the superficial and deep plexi of the retina as well as the

radial peripapillary capillary layer of the optic disc

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Clinical Applications of AngioAnalytics

$ Identify early vascular changes in diabetic eyes

$Assess disease progression$Compare structure and vasculature in glaucoma$Assess rate of change in optic disc vessel density

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AngioAnalyticsVessel Density Mapping

Vessel Density Superficial Plexus

Vessel Density Deep Plexus

Vessel Density Radial Peripapillary Capillaries

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AngioAnalyticsFAZ, Flow & Non-Flow Area Measurements

Foveal Avascular Zone Metrics Flow Area Measurements Non-Flow Area Measurements

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Next Generation Glaucoma Analysis with OCT + OCTA

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Learn What Normal Looks Like

Retina:Superficial Vascular

Complex

Disc: Radial Peripapillary

Capillaries

OD OS

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What Does Glaucoma Look Like? Normal Moderate Glaucoma Advanced Glaucoma

Disc

Retina

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Glaucoma

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Review of Normal25 year old man

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Review of Normal60 year old man

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60 Year Old Montage OD

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60 Year Old Montage OS

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60 Year Old Montage OU

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68 year old woman with glaucoma$Wants second opinion for glaucoma management

$Recently had cataract surgery OS with iStent¬ September 25, 2017¬ Dorzolamide 2% BID OS, Lumigan 0.01% QD OS

$Our practice recently performed cataract surgery and Kahook dual blade (KDB) MIGS¬ July 24, 2018

$ IOPGAT: 12 and 16 at 11:27 am

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OCT for Pachymetry in Glaucoma

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OCT GCC and NFL

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Visual Fields

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Angiography and AngioAnalytics of Disc

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En Face Radial Peripapillary Capillaries (RPC)

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Angiography and AngioAnalytics of Retina

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Montage OD

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Montage OS

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Montage OU

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$POAG, OS > OD

$Lumigan 0.01% QD OU

$Combigan BID OU

74 year old man

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VF OD and OS 1-26-2018

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VF OD and OS GPA 1-26-2018

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OCT NFL and GCC 9-25-2018

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Change Analysis NFL-GCC

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OCT-A 9-25-2018POAG OS > OD

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OCT-A 9-25-2018POAG OS > OD

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Montage OD

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Montage OS

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Montage OU

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February 15, 20/20


They do read their EHR communication

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$ Ocular Hypertension since 2014¬ No treatment

$ Pigment Dispersion

$ Baseline IOP or Tmax 26/26¬ 2014— March 2018

$ Today 30/32, new Tmax 9-25-18

49 year old man

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VF 24-2 Sita-Faster9-25-2018

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OCT NFL and GCC3-22-18

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OCT-A 9-25-2018

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OCT-A 9-25-2018

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February 15, 20/20


Montage OD

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Montage OS

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Montage OU

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$Shows early changes in the retina and optic disc

$Adds new information to the diagnosis

$Aids in progression detection

How Does OCTA Change the Way You See Glaucoma?

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Glaucoma versus Other Optic Neuropathy

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Next Generation Diabetes and RetinaAnalysis with OCT + OCTA

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February 15, 20/20


29 year old man with diabetes

$Yearly diabetic exam, reports no changes to vision¬ Type 1 DM

$BS: 190 this AM, last HbA1c 8.6 $Vision 20/20$Anterior segment: normal

$Posterior segment: ¬ Non-proliferative DR

2 Hemes and exudates

¬ No CSME

$Billed for:¬ Exam- 99214¬ Optomap, OCT-Wellness, and OCT-A (Angiography)

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10-31-2017

12-19-2018

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12-19-2018

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12-19-2018

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12-19-18

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12-19-18 what do you see?

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February 15, 20/20


12-19-18 what do you see?

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12-19-2018

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12-19-18

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12-19-2018

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12-19-2018

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12-19-2018

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12-19-2018

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OCT and OCT-A

$Treatment? $Certainly useful, beneficial, essential, and important in following the patient

with diabetes$ Improved HbA1c

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63 year old man

$Complicated ERM surgery OD¬ Increased IOP¬ Vitreous hemorrhage

$ERM peel 8-16-2018¬ My visit 11-20-18

2 IOP 18/13

$Vision 20/20¬ But “can not see top part of vision in right eye”

$Patient returned to me because the surgeon said it will take time for vision to return

$OCT and OCT-A reveals the diagnosis and prognosis

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Superficial

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Deep

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Diagnosis?

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69 year old woman

$ In for 6 month diabetic check¬ History of idiopathic juxtafoveal telangiectasia

$BVA OD 20/80 OS 20/40 $Thoughts are the macula changes DM and IJT?$OCT and OCT-A

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OD OCT

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OD OCT

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OS OCT

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OS OCT

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OS OCT

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OS OCT

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OS OCT

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OD OCT-A

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OD OCT-A

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OS OCT-A

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OS OCT-A Superficial

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OS OCT-A Deep

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CNVM

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CNVM

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CNVM

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CNVM

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Which is More Suspicious?

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BRVO

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BRVO

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February 15, 20/20


Other UsesEndothelial Disease

AlzheimerDementia

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Thank-Youand

Hope You Enjoyed

Greg Caldwell, OD, [email protected]

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OCT-A what you need to know with this technology … · 01/10/2020 · Greg A Caldwell, OD, FAAO [email protected] 814-931-2030 cell 1 OCT-Angiography What You Need to Know with this

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