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All you need to know aboutAMD and the OCT – but wereafraid to ask!
Talk summary• The pathophysiology of AMD• OCT principles• Quiz and prize• Talk available on line
Attention span graph
A bit of confusing anatomy
Anatomy made simple• Neuro-retina• Potential sub-retinal space• Retinal Pigment epithelium• Choroid
Neuro-retina• Nerve fibre layer1.1 million fibres per eye• Ganglion cells• Bipolar cells• Rods and Cones (photoreceptors)C...
Retinal pigment epithelium• Recycles material from rods and cones– Recycling needed to maintain efficient function• Contai...
Choroid• Supply oxygen and glucose to photoreceptorsand RPE• Highest blood flow per unit area of any tissuein the body• Lo...
Important terminology• Outer retinaRPE and photoreceptorsSupplied by choroid• Inner retinaNerve fibre layerGanglion cellsB...
RPE and photoreceptors mustnot part company – they actas a single unit
Is light bad for the eyes ?• Form of electromagnetic radiation• Look what happens with excess sunlight onthe skin• Eye is ...
What harm does light do to theretina?• Reacts with fat in cell membranes• Produces reactive oxygen (free radicals)• Damage...
How does retina protect itselffrom light?• Luteal pigment at macular protects againsthigh energy blue light• Rods and cone...
How does macular degenerationstart?• Chronic damage to cells from high energy light– Damage to DNA (and cannot repair)• Re...
Wet AMD• Abnormal blood vessels grow upwards fromChoroid into Retina (Choroidal neovascularmembrane)• May remain under the...
Visual loss with wet AMD• No treatment (natural history)– Loss of 5 lines of Snellen acuity in 2 years• Most of the loss o...
Fundus fluorescein angiography• Dye injected into vein in arm• Abnormal blood vessels leak the dye• Choroidal neovascular ...
retinaRPEchoroidOccult CNV
Classic CNVChoroidRetinaRPE
Classic CNV – “ring of fire”
Damage to vision• Classic– Disrupts RPE / photoreceptor partnership– More aggressive process– Significant and rapid visual...
What is RAP?• Choroidal neovascular membrane (CNV) areabnormal blood vessels growing upwardsfrom Choroid into Retina (Occu...
RAP• Multiple intraretinalhaemorrhages at macular• Can look like macular branchretinal vein occlusion but doesnot stop at ...
CNV haemorrhage is predominantlysubretinal or sub RPE
Judah Folkman MD• Prof of Paediatric Surgery at Harvard• 17 Honorary degrees• His lab discovered vascular endothelial grow...
Landmark Marina and Anchorstudies• Lucentis injected every month for 2 years• Average improvement of vision 10 letters• Ma...
Source: HORIZON data. Genentech.Treated-Initial (n=388) Untreated (n=33)ETDRSLetters-20-15-10-50510153 6 9 12 15 18 21 24H...
Average number of injections andcosts• 8 injections in the first year• 6 injections in the second year• Each injection cos...
INJECTING
First nurse-delivered injectionsservice in UK, 2008• West of England Eye Unit, Exeter• NP’s Brian Kingett, Nicola Mann• 7,...
Problems with injections• Does not address fundamental cause of wetAMD• Multiple injections for elderly patients• VEGF may...
How to reduce frequency ofinjections?• Radiation damages proliferating cellsEndothelial cells, inflammatory cells, fibrobl...
MERLOT study• Finished recruiting, results awaited• Vitrectomy + beta irradiation from strontiumsource
INTREPID study• Similar to MERLOT but external beamirradiation• X rays delivered via contact lens• IRay system from Oraya ...
Dry AMD• Build up of waste products due to poorrecycling (Drusen)• Changes in melanin pigment in the RPE• Geographic atrophy
What about dry AMD?• Main treatment remains low visual aids• Stem cell treatment• Neuro-protection• Intraocular telescopes...
What about diet and AMD ?• Eat fresh fruit, dark green leaved vegetables• Vitamins supplements only if severe
Vitamins and AMD• Antioxidant treatments to “mop up” freeradicals• AREDS (Age related eye disease study)– Vit C 500mg, E 4...
Principles of the OCT• Non invasive• Based on interferometry– Interference between incident and reflected light• Like doin...
Optical coherence tomographyNormal anatomy
• Normal thickness = 200 microns• Thick retina > 250 microns– Usually due to leakage• Thin retina < 150 microns– Atrophic ...
The photoreceptor integrity line• Junction between inner and outer segments• Barely visible in histological sections• High...
Assess retinal function• Normal thickness retina – how is it functioning?• Well demarcated IS/OS junction suggest goodphot...
Retina pathology often in layers• Inner retina (retinal circulation)– Diabetic retinopathy– Retinal vein occlusion• Outer ...
OCT pathology often in layers• Retinal surface (mechanical problems)– Vitreo-macular traction– Epiretinal membrane• Inner ...
Retinal pathology in more thanone layer• Full thickness macular hole– All layers involved• Lamellar hole– Usually surface ...
• Posterior vitreous pulling on macula• Wide range of severity• Treat with vitrectomy• Treat with Ocriplasmin injection (J...
Severe Vitreo-macular traction0.5 LogMAR“Pointed - being Pulled”
Mild Vitreo-macular tractionInner retinal cyst0.12 LogMAR
• Posterior vitreous usually detached• Sometimes associated with lamellar hole• Wide range of severity• If incidental OCT ...
Epiretinal membrane
Mild epiretinal membrane0.1 LogMARLoss of foveal pit
Lamellar macular hole with ERMNote ERM with “saw tooth sign”Lamellar macular holeNote healthy IS / OS junctionVisual acuit...
Lamellar macular hole with ERM0.1 LogMARAsymptomatic
Full thickness macular hole
Spontaneous improvement in afull thickness macular hole
OCT and dry AMDDrusen“Lumpy bumpy” RPE
OCT and dry AMDRPE atrophyHigh signal beneath RPEThin retina
OCT and leakage• Wet AMD• Diabetic maculopathy• Retinal vein occlusions• CSR• Uveitis• Retinitis pigmentosa
Intraretinal fluidWhat the vision?
Sub-retinal fluidWhat is the vision?
Sub-RPE fluid (PED)What is the vision?
OCT and wet AMD• Outer retina first involved (choroidalcirculation)• Fluid– Sub RPE– Sub Retinal– Intra retinal if moderat...
OCT and wet AMDSub RPE fluidSub retinal fluidIntra retinal fluidNote previous dry changes
“Burnt out” Wet AMDDisciform Scarring
OCT and exudative diabeticmaculopathy• Inner retina first involved (retinal circulation)• Fluid– Intra retinal (including ...
OCT and exudative diabeticmaculopathy
OCT and retinal vein occlusions• Inner retina first involved (retinal circulation)• Fluid– Intra retinal (including cystoi...
Ozurdex in macular oedema fromcentral vein occlusion0.5 LogMARPre injection0.3 LogMARPost injection
Where is pathology mostdisruptive to vision?1. Outer retina (choroidal circulation)“Classic” Wet AMD2. Inner retina (retin...
Ask yourself• Anything on the surface?• Is it mainly inner or outer retina or both?• How does the RPE look?• How well dema...
Small BRVO or wet AMD atmacula?• BRVO– Inner retina– RPE normal– IS / OS may be preserved– Haemorrhage does not pass acros...
What is this?
OCT and CSR• Leakage from choroid through RPE• Fluid– Sub Retinal• RPE– May be small PED– Remaining RPE looks healthy
OCT and CSR
Uveitis
Retinitis pigmentosaPre – Sub Tenon’s steroid“Bell shape – from Below”Post injectionNote thin retinaNo IS / OS junction
What is this?
Adult vitelliform dystrophy0.0 LogMAR ODIntact IS / OS junction
What is this and what is the vision?
Macula schisis0.1 LogMARIntact IS / OS junction0.0 LogMARIntact IS / OS junction
What is this?
What is this?
Ruptured retinal macroaneurysm
What is this?
It was due to this !
Quiz• Self marking• 8 questions• 1 tie break question if needed
Questions• What should never part company?• Classic CNV is where in the retina?• What can look like a macular BRVObut is w...
Questions• What can you look at to check retinalfunction on the OCT?• All AMD patients should have vitaminsupplements? Tru...
Questions• What should never part company?– The photoreceptors and RPE• Classic CNV is where in the retina?– In front of t...
Questions• What can you look at to check retinal function onthe OCT?– The IS/OS junction• All AMD patients should have vit...
Tie break question• How many syringes were completelyvisible on the “Keep Calm and CarryOn” slide?
INJECTING
All you need to know about amd and the oct  but were afraid to ask
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All you need to know about amd and the oct but were afraid to ask

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A summary of macular degeneration and how to assess macular problems with the OCT

Published in: Health & Medicine

All you need to know about amd and the oct but were afraid to ask

  1. 1. All you need to know aboutAMD and the OCT – but wereafraid to ask!
  2. 2. Talk summary• The pathophysiology of AMD• OCT principles• Quiz and prize• Talk available on line
  3. 3. Attention span graph
  4. 4. A bit of confusing anatomy
  5. 5. Anatomy made simple• Neuro-retina• Potential sub-retinal space• Retinal Pigment epithelium• Choroid
  6. 6. Neuro-retina• Nerve fibre layer1.1 million fibres per eye• Ganglion cells• Bipolar cells• Rods and Cones (photoreceptors)Convert light into electrical impulses to transmitto the brainMost energy dependent tissue in body
  7. 7. Retinal pigment epithelium• Recycles material from rods and cones– Recycling needed to maintain efficient function• Contains pigment to stop internal reflections– Prevents “glare” inside the eye– Melanin pigment• Pumps water out of the neuro-retina andpotential sub-retinal space to keep it “dry”
  8. 8. Choroid• Supply oxygen and glucose to photoreceptorsand RPE• Highest blood flow per unit area of any tissuein the body• Look what happens when you faint• Retina is always working very hard!
  9. 9. Important terminology• Outer retinaRPE and photoreceptorsSupplied by choroid• Inner retinaNerve fibre layerGanglion cellsBipolar cellsSupplied by central retinal artery
  10. 10. RPE and photoreceptors mustnot part company – they actas a single unit
  11. 11. Is light bad for the eyes ?• Form of electromagnetic radiation• Look what happens with excess sunlight onthe skin• Eye is an optical system that exposes retinato radiation all the time• Light focused on the macula
  12. 12. What harm does light do to theretina?• Reacts with fat in cell membranes• Produces reactive oxygen (free radicals)• Damages the DNA in the cells• Repair mechanisms– Skin – repairs DNA all the time, new cells form– Brain – cannot create new cells as has to storememory– Retina – part of brain so cannot create new cells
  13. 13. How does retina protect itselffrom light?• Luteal pigment at macular protects againsthigh energy blue light• Rods and cones have “outer segments”• Although a “non dividing system” these outersegment cell membranes are constantly shedthen recycled by the RPE to form new cellmembranes
  14. 14. How does macular degenerationstart?• Chronic damage to cells from high energy light– Damage to DNA (and cannot repair)• Recycling becomes less effective with age– Accumulation of “waste products” (Drusen)• Toxins– Smoking• Genetic make up– Complement factor H
  15. 15. Wet AMD• Abnormal blood vessels grow upwards fromChoroid into Retina (Choroidal neovascularmembrane)• May remain under the RPE “Occult”• May grow through RPE into neuro-retina“Classic”• VEGF driven• Treatment with anti-VEGF agents (Lucentis,Avastin and Eylea)
  16. 16. Visual loss with wet AMD• No treatment (natural history)– Loss of 5 lines of Snellen acuity in 2 years• Most of the loss of vision will take place withinthe first 6 months• Like a cut on the skin– First there is inflammation with swellingand haemorrhage– Then a scar forms (disciform scar)
  17. 17. Fundus fluorescein angiography• Dye injected into vein in arm• Abnormal blood vessels leak the dye• Choroidal neovascular membrane (CNV)
  18. 18. retinaRPEchoroidOccult CNV
  19. 19. Classic CNVChoroidRetinaRPE
  20. 20. Classic CNV – “ring of fire”
  21. 21. Damage to vision• Classic– Disrupts RPE / photoreceptor partnership– More aggressive process– Significant and rapid visual loss• Occult– RPE / photoreceptor partnership remains intact– May maintain better vision “low grade occult”
  22. 22. What is RAP?• Choroidal neovascular membrane (CNV) areabnormal blood vessels growing upwardsfrom Choroid into Retina (Occult and Classic)• Retinal angiomatous proliferations (RAP) areabnormal blood vessels growing downwardsfrom Retina into Choroid• 15% of wet AMD is RAP and 100% bilateralwithin 3 years
  23. 23. RAP• Multiple intraretinalhaemorrhages at macular• Can look like macular branchretinal vein occlusion but doesnot stop at horizontal midline
  24. 24. CNV haemorrhage is predominantlysubretinal or sub RPE
  25. 25. Judah Folkman MD• Prof of Paediatric Surgery at Harvard• 17 Honorary degrees• His lab discovered vascular endothelial growthfactor (VEGF) that stimulate blood vesselformation to allow tumour growth• Anti-angiogenesis drugs inhibit tumour growth• Anti-VEGF treatment for AMD has developedfrom his studies
  26. 26. Landmark Marina and Anchorstudies• Lucentis injected every month for 2 years• Average improvement of vision 10 letters• Maintained vision in most patients• If frequency of injections less than everymonth reduced effect noted• Most UK practice is now 3 loading injectionover 3 months then as needed injections
  27. 27. Source: HORIZON data. Genentech.Treated-Initial (n=388) Untreated (n=33)ETDRSLetters-20-15-10-50510153 6 9 12 15 18 21 24HORIZON Study+5.1-6.7+2.0-6.924MonthInitial baselineMarina/Anchor Studies+10.2-3.2
  28. 28. Average number of injections andcosts• 8 injections in the first year• 6 injections in the second year• Each injection costs £1,750 to the NHS– £750 for Lucentis• The first 2 years cost the NHS £24,000• Average life expectancy from diagnosis– 10 years
  29. 29. INJECTING
  30. 30. First nurse-delivered injectionsservice in UK, 2008• West of England Eye Unit, Exeter• NP’s Brian Kingett, Nicola Mann• 7,000 injections to date• Recently supported by Royal College ofOphthalmologists and Macular Society
  31. 31. Problems with injections• Does not address fundamental cause of wetAMD• Multiple injections for elderly patients• VEGF may be needed to help improvecirculation– Avoid if high risk of or recent stroke or heartattack• Risk of injection itself– Infection of eye (endophthalmitis) 1 in 1,000
  32. 32. How to reduce frequency ofinjections?• Radiation damages proliferating cellsEndothelial cells, inflammatory cells, fibroblastsInternal beam (MERLOT study)External beam (INTREPID study)• Longer acting anti-VEGF agentAflibercept (Eylea)
  33. 33. MERLOT study• Finished recruiting, results awaited• Vitrectomy + beta irradiation from strontiumsource
  34. 34. INTREPID study• Similar to MERLOT but external beamirradiation• X rays delivered via contact lens• IRay system from Oraya therapeutics Inc• Reduced injection rate by one third in study• Await “real world” results
  35. 35. Dry AMD• Build up of waste products due to poorrecycling (Drusen)• Changes in melanin pigment in the RPE• Geographic atrophy
  36. 36. What about dry AMD?• Main treatment remains low visual aids• Stem cell treatment• Neuro-protection• Intraocular telescopes– VIP IOL– Implantable miniature telescope– ARGUS II (digital camera in glassescommunicates with retinal chip)
  37. 37. What about diet and AMD ?• Eat fresh fruit, dark green leaved vegetables• Vitamins supplements only if severe
  38. 38. Vitamins and AMD• Antioxidant treatments to “mop up” freeradicals• AREDS (Age related eye disease study)– Vit C 500mg, E 400IU, beta carotene 15mg andzinc 80mg– Decreased risk of progression of AMD withsubgroup analysis• AREDS 2 study results 5th May 2013– Lutein and zeaxanthin can safely replace betacarotene (Lung cancer risk) and omega 3 fattyacids of no benefit
  39. 39. Principles of the OCT• Non invasive• Based on interferometry– Interference between incident and reflected light• Like doing a vertical biopsy of the retina– Use laser light rather than knife!• Good at showing swelling due to leakage• FFA still needed for showing blockage ofblood vessels
  40. 40. Optical coherence tomographyNormal anatomy
  41. 41. • Normal thickness = 200 microns• Thick retina > 250 microns– Usually due to leakage• Thin retina < 150 microns– Atrophic with poor function• Can be difficult to assess function onthickness aloneCentral macular thickness
  42. 42. 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 theinner and outer segments
  43. 43. Assess retinal function• Normal thickness retina – how is it functioning?• Well demarcated IS/OS junction suggest goodphotoreceptor function
  44. 44. Retina pathology often in layers• Inner retina (retinal circulation)– Diabetic retinopathy– Retinal vein occlusion• Outer retina (choroidal circulation)– AMD– CSR
  45. 45. OCT pathology often in layers• Retinal surface (mechanical problems)– Vitreo-macular traction– Epiretinal membrane• Inner retina (retinal circulation)– Diabetic retinopathy– Retinal vein occlusion• Outer retina (choroidal circulation)– AMD– CSR
  46. 46. Retinal pathology in more thanone layer• Full thickness macular hole– All layers involved• Lamellar hole– Usually surface and inner retina• Severe retinal disease– Wet AMD (starts in outer retina)– Diabetic eye disease (starts in inner retina)– Retinal vein occlusions (starts in inner retina)
  47. 47. • Posterior vitreous pulling on macula• Wide range of severity• Treat with vitrectomy• Treat with Ocriplasmin injection (Jetrea)• If incidental OCT finding and patientasymptomatic – do not referVitreo-macular traction
  48. 48. Severe Vitreo-macular traction0.5 LogMAR“Pointed - being Pulled”
  49. 49. Mild Vitreo-macular tractionInner retinal cyst0.12 LogMAR
  50. 50. • Posterior vitreous usually detached• Sometimes associated with lamellar hole• Wide range of severity• If incidental OCT finding and patientasymptomatic – do not referEpiretinal membrane
  51. 51. Epiretinal membrane
  52. 52. Mild epiretinal membrane0.1 LogMARLoss of foveal pit
  53. 53. Lamellar macular hole with ERMNote ERM with “saw tooth sign”Lamellar macular holeNote healthy IS / OS junctionVisual acuity is 0.12No symptoms
  54. 54. Lamellar macular hole with ERM0.1 LogMARAsymptomatic
  55. 55. Full thickness macular hole
  56. 56. Spontaneous improvement in afull thickness macular hole
  57. 57. OCT and dry AMDDrusen“Lumpy bumpy” RPE
  58. 58. OCT and dry AMDRPE atrophyHigh signal beneath RPEThin retina
  59. 59. OCT and leakage• Wet AMD• Diabetic maculopathy• Retinal vein occlusions• CSR• Uveitis• Retinitis pigmentosa
  60. 60. Intraretinal fluidWhat the vision?
  61. 61. Sub-retinal fluidWhat is the vision?
  62. 62. Sub-RPE fluid (PED)What is the vision?
  63. 63. OCT and wet AMD• Outer retina first involved (choroidalcirculation)• Fluid– Sub RPE– Sub Retinal– Intra retinal if moderate or severe• Usually previous dry AMD– Look at RPE line as rarely “pristine”
  64. 64. OCT and wet AMDSub RPE fluidSub retinal fluidIntra retinal fluidNote previous dry changes
  65. 65. “Burnt out” Wet AMDDisciform Scarring
  66. 66. OCT and exudative diabeticmaculopathy• Inner retina first involved (retinal circulation)• Fluid– Intra retinal (including cystoid oedema)– Sub retinal if moderate or severe– No Sub RPE fluid• Hard exudates– Highly reflective intraretinal spots• RPE looks ok
  67. 67. OCT and exudative diabeticmaculopathy
  68. 68. OCT and retinal vein occlusions• Inner retina first involved (retinal circulation)• Fluid– Intra retinal (including cystoid oedema)– Sub retinal if moderate or severe– No Sub RPE fluid• Hard exudates– Less frequently seen than in diabetics• RPE looks ok
  69. 69. Ozurdex in macular oedema fromcentral vein occlusion0.5 LogMARPre injection0.3 LogMARPost injection
  70. 70. Where is pathology mostdisruptive to vision?1. Outer retina (choroidal circulation)“Classic” Wet AMD2. Inner retina (retinal circulation)Diabetic eye diseaseRetinal vein occlusions3. Sub-RPELow grade “Occult” Wet AMD / Chronic PED’s
  71. 71. 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?
  72. 72. Small BRVO or wet AMD atmacula?• BRVO– Inner retina– RPE normal– IS / OS may be preserved– Haemorrhage does not pass across the horizontalmidline• Wet AMD– Outer retina– RPE abnormal– IS / OS disrupted– Haemorrhage may be on either side of horizontalmidline
  73. 73. What is this?
  74. 74. OCT and CSR• Leakage from choroid through RPE• Fluid– Sub Retinal• RPE– May be small PED– Remaining RPE looks healthy
  75. 75. OCT and CSR
  76. 76. Uveitis
  77. 77. Retinitis pigmentosaPre – Sub Tenon’s steroid“Bell shape – from Below”Post injectionNote thin retinaNo IS / OS junction
  78. 78. What is this?
  79. 79. Adult vitelliform dystrophy0.0 LogMAR ODIntact IS / OS junction
  80. 80. What is this and what is the vision?
  81. 81. Macula schisis0.1 LogMARIntact IS / OS junction0.0 LogMARIntact IS / OS junction
  82. 82. What is this?
  83. 83. What is this?
  84. 84. Ruptured retinal macroaneurysm
  85. 85. What is this?
  86. 86. It was due to this !
  87. 87. Quiz• Self marking• 8 questions• 1 tie break question if needed
  88. 88. Questions• What should never part company?• Classic CNV is where in the retina?• What can look like a macular BRVObut is wet AMD?• What is the blood supply of the innerretina?
  89. 89. Questions• What can you look at to check retinalfunction on the OCT?• All AMD patients should have vitaminsupplements? True or False• Fluid under the RPE is usually fromvein occlusions? True or False• Drusen are in the inner retina?
  90. 90. Questions• What should never part company?– The photoreceptors and RPE• Classic CNV is where in the retina?– In front of the RPE• What can look like a macular BRVO but iswet AMD?– RAP lesions• What is the blood supply of the inner retina?– Central retinal artery
  91. 91. Questions• What can you look at to check retinal function onthe OCT?– The IS/OS junction• All AMD patients should have vitaminsupplements? True or False– False, only if high risk• Fluid under the RPE is usually from veinocclusions? True or False– False, fluid will be intraretinal or if severe subretinal• Drusen are in the inner retina? True or False– False, drusen are in the outer retina
  92. 92. Tie break question• How many syringes were completelyvisible on the “Keep Calm and CarryOn” slide?
  93. 93. INJECTING

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