A macular pathology and oct update for optometrists

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

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A macular pathology and oct update for optometrists

  1. 1. An u p d ate on m acu larp ath ology
  2. 2. 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
  3. 3. Retinal haemorrhage, what depth? • Vitreous • Pre retinal • Intraretinal (superficial and deep) • Sub retinal • Sub RPE • More than one level
  4. 4. 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
  5. 5. Pre retinal haemorrhage (boat shaped)Haemorrhage limited by extent of vitreous separationMasks retinal blood vessels
  6. 6. Superficial intra retinal haemorrhage (flame shaped)Confined by nerve fibre layer, masks retinal blood vessels
  7. 7. Deep intra retinal haemorrhage (dot and blot)May be in front of or behind the retinal blood vessels
  8. 8. Sub retinal haemorrhage (round) retinal blood vessels visible Sub RPE haemorrhage similar but darker
  9. 9. The “cotton wool spot”Think – Hypertension, Diabetes, SmokerRarely – HIV retinopathy, SLE What is this?
  10. 10. Exudate vs drusenIf exudate is present there must be signs of leakage fromabnormal blood vessels (micro or macroaneurysms, CNV)
  11. 11. Life is not that simple What is this?
  12. 12. 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
  13. 13. Confusing but important terms• Inner retina – Next to vitreous cavity – Nerve fibre layer – Interconnecting neurons• Outer retina – Next to choroid – Rods and cones – RPE
  14. 14. Retina pathology often in layers• Inner retina – Diabetic retinopathy – Retinal vein occlusion• Outer retina – AMD – CSR
  15. 15. OCT pathology often in layers• Retinal surface – Vitreo-macular traction – Epiretinal membrane• Inner retina – Diabetic retinopathy – Retinal vein occlusion• Outer retina – AMD – CSR
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Vitreo-macular traction• Posterior vitreous pulling on macula• Wide range of severity• If incidental OCT finding and patient asymptomatic – do not refer
  21. 21. Severe Vitreo-macular traction 0.5 LogMAR “Pointed - being Pulled”
  22. 22. Mild Vitreo-macular traction Inner retinal cyst 0.12 LogMAR
  23. 23. 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
  24. 24. 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
  25. 25. Mild epiretinal membrane 0.1 LogMAR Loss of foveal pit
  26. 26. Lamellar macular hole with ERM 0.1 LogMAR Asymptomatic
  27. 27. ERM with lamellar holeNo symptoms-0.1 LogMARGood IS / OS junction
  28. 28. 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
  29. 29. Basics of diabetic retinopathy
  30. 30. 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
  31. 31. Basics of retinal vein occlusions
  32. 32. Basics of dry AMDDrusen“Lumpy bumpy” RPE
  33. 33. Basics of dry AMDRPE atrophyHigh signal beneath RPEThin retina
  34. 34. 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”
  35. 35. Basics of Wet AMDSub RPE fluid Intra retinal fluidSub retinal fluid Note previous dry changes
  36. 36. “Burnt out” Wet AMD Scarring and chronic leakage
  37. 37. Basics of CSR• Leakage from choroid• Fluid – Sub Retinal• RPE – May be small PED associated – Remaining RPE looks healthy
  38. 38. Basics of CSR
  39. 39. Full thickness macular hole
  40. 40. Spontaneous improvement in a full thickness macular hole 0.0 LogMAR0.1 LogMAR
  41. 41. Post macular hole op 0.32 LogMAR
  42. 42. 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?
  43. 43. 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
  44. 44. Pre and post Ozurdex in macular oedema from vein occlusion0.5 LogMAR 0.3 LogMAR
  45. 45. Pre and post Ozurdex in diabetic
  46. 46. Sept 2011 Feb 2012 April 2012 Ozurdex for CRVO
  47. 47. What is this?
  48. 48. Adult vitelliform dystrophy
  49. 49. Adult vitelliform dystrophy 0.22 LogMAR OS 0.0 LogMAR OD Intact IS / OS junction
  50. 50. What is this and what is the vision?
  51. 51. Macula schisis0.0 LogMAR 0.1 LogMARIntact IS / OS junction Intact IS / OS junction
  52. 52. What is this?
  53. 53. It was due to this !
  54. 54. What is this?
  55. 55. Optic disc pit maculopathy
  56. 56. Retinitis pigmentosaPre – Sub Tenon’s steroid Post injection“Bell shape – from Below” Note thin retina No IS / OS junction

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