A macular pathology and oct update for optometrists
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A macular pathology and oct update for optometrists

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Presentation of OCT scan findings in common macular pathology for optometrists.

Presentation of OCT scan findings in common macular pathology for optometrists.

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A macular pathology and oct update for optometrists A macular pathology and oct update for optometrists Presentation Transcript

  • An u p d ate on m acu larp ath ology
  • Talk summary• Clinical signs – Retinal haemorrhage and differential diagnosis – The cotton wool spot – Exudate vs Drusen• OCT signs – Basics of OCT interpretation – When to refer – Some rare cases
  • Retinal haemorrhage, what depth? • Vitreous • Pre retinal • Intraretinal (superficial and deep) • Sub retinal • Sub RPE • More than one level
  • Vitreous haemorrhage• Poor fundal view / poor red reflex• Pulling on blood vessel – Retinal tear with PVD or trauma – Proliferative diabetic retinopathy / BRVO• “Break through” bleeding – Severe wet AMD – Retinal macroaneurysm
  • Pre retinal haemorrhage (boat shaped)Haemorrhage limited by extent of vitreous separationMasks retinal blood vessels
  • Superficial intra retinal haemorrhage (flame shaped)Confined by nerve fibre layer, masks retinal blood vessels
  • Deep intra retinal haemorrhage (dot and blot)May be in front of or behind the retinal blood vessels
  • Sub retinal haemorrhage (round) retinal blood vessels visible Sub RPE haemorrhage similar but darker
  • The “cotton wool spot”Think – Hypertension, Diabetes, SmokerRarely – HIV retinopathy, SLE What is this?
  • Exudate vs drusenIf exudate is present there must be signs of leakage fromabnormal blood vessels (micro or macroaneurysms, CNV)
  • Life is not that simple What is this?
  • Principles of the OCT• Based on interferometry – Interference between incident and reflected light• Like doing a vertical biopsy of the retina – Use laser light rather than knife!• Resolution down to 10 microns• Nerve fibre layer and RPE well defined• Good at showing swelling due to leakage• FFA still needed for showing blockage
  • Confusing but important terms• Inner retina – Next to vitreous cavity – Nerve fibre layer – Interconnecting neurons• Outer retina – Next to choroid – Rods and cones – RPE
  • Retina pathology often in layers• Inner retina – Diabetic retinopathy – Retinal vein occlusion• Outer retina – AMD – CSR
  • OCT pathology often in layers• Retinal surface – Vitreo-macular traction – Epiretinal membrane• Inner retina – Diabetic retinopathy – Retinal vein occlusion• Outer retina – AMD – CSR
  • Retinal pathology in more than one layer• Macular hole – All layers involved (full thickness)• Lamellar hole – Usually surface and inner retina• Severe retinal disease – Wet AMD – Diabetic eye disease – Retinal vein occlusions
  • Central macular thickness• Can be difficult to assess function on thickness alone• Normal thickness = 200 microns• Thick retina > 250 microns – Usually due to leakage• Thin retina < 150 microns – Atrophic with poor function
  • The photoreceptor integrity line• Junction between inner and outer segments• Barely visible in histological sections• Highly prominent with OCT• Due to difference in index of refraction of the inner and outer segments
  • Assess retinal function• Thick retina = oedema• Thin retina = atrophic retina• Normal thickness retina – how is it functioning?• Well demarcated IS/OS junction suggest good photoreceptor function
  • Vitreo-macular traction• Posterior vitreous pulling on macula• Wide range of severity• If incidental OCT finding and patient asymptomatic – do not refer
  • Severe Vitreo-macular traction 0.5 LogMAR “Pointed - being Pulled”
  • Mild Vitreo-macular traction Inner retinal cyst 0.12 LogMAR
  • Epiretinal membrane• Posterior vitreous usually detached• Sometimes associated with lamellar hole• Wide range of severity• If incidental OCT finding and patient asymptomatic – do not refer
  • Lamellar macular hole with ERM Note ERM with “saw tooth sign” Lamellar macular hole Note healthy IS / OS junction Visual acuity is 0.12 No symptoms
  • Mild epiretinal membrane 0.1 LogMAR Loss of foveal pit
  • Lamellar macular hole with ERM 0.1 LogMAR Asymptomatic
  • ERM with lamellar holeNo symptoms-0.1 LogMARGood IS / OS junction
  • Basics of diabetic retinopathy• Retinal blood vessels involved• Inner retina first involved• Fluid – Intra retinal (including cystoid oedema) – Sub retinal if severe – No Sub RPE fluid• Hard exudates – Highly reflective intraretinal spots• RPE looks ok
  • Basics of diabetic retinopathy
  • Basics of retinal vein occlusions• Retinal blood vessels involved• Inner retina first involved• Fluid – Intra retinal (including cystoid oedema) – Sub retinal if severe – No Sub RPE fluid• Hard exudates – Less frequently seen than in diabetics• RPE looks ok
  • Basics of retinal vein occlusions
  • Basics of dry AMDDrusen“Lumpy bumpy” RPE
  • Basics of dry AMDRPE atrophyHigh signal beneath RPEThin retina
  • Basics of Wet AMD• Blood vessels from choroid• Outer retina first involved• Fluid – Sub RPE – Sub Retinal – Intra retinal (includes cystoid oedema)• Usually previous dry AMD – Look at RPE line as rarely “pristine”
  • Basics of Wet AMDSub RPE fluid Intra retinal fluidSub retinal fluid Note previous dry changes
  • “Burnt out” Wet AMD Scarring and chronic leakage
  • Basics of CSR• Leakage from choroid• Fluid – Sub Retinal• RPE – May be small PED associated – Remaining RPE looks healthy
  • Basics of CSR
  • Full thickness macular hole
  • Spontaneous improvement in a full thickness macular hole 0.0 LogMAR0.1 LogMAR
  • Post macular hole op 0.32 LogMAR
  • Ask yourself• Anything on the surface?• Is it mainly inner or outer retina or both?• How does the RPE look?• How well demarcated is the IS /OS line?
  • Small BRVO or wet AMD at macula?• BRVO – Inner retina (inner and outer if severe) – RPE normal – IS / OS may be preserved• Wet AMD – Outer retina (inner and outer if severe) – RPE abnormal – IS / OS disrupted
  • Pre and post Ozurdex in macular oedema from vein occlusion0.5 LogMAR 0.3 LogMAR
  • Pre and post Ozurdex in diabetic
  • Sept 2011 Feb 2012 April 2012 Ozurdex for CRVO
  • What is this?
  • Adult vitelliform dystrophy
  • Adult vitelliform dystrophy 0.22 LogMAR OS 0.0 LogMAR OD Intact IS / OS junction
  • What is this and what is the vision?
  • Macula schisis0.0 LogMAR 0.1 LogMARIntact IS / OS junction Intact IS / OS junction
  • What is this?
  • It was due to this !
  • What is this?
  • Optic disc pit maculopathy
  • Retinitis pigmentosaPre – Sub Tenon’s steroid Post injection“Bell shape – from Below” Note thin retina No IS / OS junction