Imaging Interpretation for the Comprehensive Eye Care Professional
Blair Lonsberry, MS, OD, MEd., FAAODiplomate, American Board of OptometryClinic Director and Professor of Optometry
Pacific University College of [email protected]
Time
%
Loss
Early
Moderate
Severe
• Visual Field changes occur late in the disease
• The Optic disc often changes before visual fields
• The RNFL usually changes before both the visual fields and optic disc
VF
Disc
RNFL
Structural / Functional Relationship in Glaucoma as the Disease Progresses
Clinical Exam of the Optic Nerve HeadUtility and Limitations
• Disc exam at the first visit – normal or abnormal?– Disc exams are subjective, or at best semi-
quantitative– The wide variety of disc appearances requires
long experience and expert judgment to separate normal from abnormal
– Disc diameter must be taken into account
• Disc exam to assess change– Unless stereoscopic photographs are taken and
compared over time, the ability of a clinician to judge change is very limited (chronology is important!)
OCT: The Basics
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Retinal Layers
Cirrus RNFL Analysis
CALCULATION CIRCLEAutoCenter™ function automatically centers the 1.73mm radius peripapillary calculation circle around the disc for precise placement and repeatable registration.
OPTIC DISC CUBE SCANThe 6mm x 6mm cube is captured with 200 A-scans per B-scan, 200 B-scans.
RNFL/ONH Analysis
RNFL THICKNESS along the calculation circle is displayed in graphic format and compared to age-matched normative data
RNFL DEVIATION MAP, overlaid on the OCT fundus image, illustrates precisely where RNFL thickness deviates from the normal range. Data points that are not within normal limits are indicated in red and yellow.
RNFL THICKNESS MAP shows the patterns and thickness of the nerve fiber layer within the full 6mm x 6mm area
RNFL THICKNESS AND COMPARISON TO NORMATIVE DATABASE is shown in circle, quadrants and clock hour display
ONH Analysis: rim/disc area, average C/D ratio, vertical C/D ratio and cup volume
Cirrus RNFL and ONH Analysis Elements
• RNFL Peripapillary Thickness profile, OU• compared to normative data
Neuro-retinal Rim Thickness profile, OU- compared to normative data
Optic Nerve Head calculations are presented in a combined report with RNFL thickness data. Key parameters are compared to normative data and displayed in table format
Cirrus HD-OCT GPA Analysis
Two baseline exams are required
Baseline
Third exam is compared to the two baseline exams Sub pixel map demonstrates change from
baseline: Yellow pixels denote change from both
baseline exams
Third and fourth exams are compared to both baselines: yellow pixels denote change from both baselines change identified in three of the four comparisons is indicated by red pixels
Image Progression Map
Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies
Guided Progression
Analysis (GPA™)
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Guided Progression
Analysis (GPA™)
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Macular Cube Scan
Automatic Fovea Finder™Fovea center = 255, 71 Scan center = 255, 64
Macula Thickness Analysis is aligned with fovea location (left)
Resulting analysis may differ from analysis aligned on scan center (right)
Macular Thickness Normative Data
Macular thickness is compared to an age-matched normative database as indicated by a stop-light color code
Macular Change AnalysisProvides visual and quantitative comparison of two exams.
Ganglion Cell Analysis
• Measures thickness for the sum of the ganglion cell layer and inner plexiform layer (GCL + IPL layers)– RNFL distribution in the macula depends on
individual anatomy, while the GCL+IPL appears regular and elliptical for most normals
– Deviations from normal are more easily appreciated in the thickness map by the practitioner, and arcuate defects seen in the deviation map may be less likely to be due to anatomical variations.
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
Ganglion Cell Analysis
17Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
CIRRUS HD-OCT and HFA Combined Report
Case 1
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Case History
• 60 yo WM– Type 2 DM: 4 years– Hypertension: 4 years– Bilateral PK’s secondary to keratoconus
(has running suture OD)– Has history of steroid injections for lower
back stenosis (with history of increased IOP up to 40 after injections)
– VA(RGP): 6/7.5 (20/25), 6/6 (20/20)– IOP: OD: range 20-24, OS: range 17-20
OD OS
ODOS
Consider the below PSD plots.
OS OD
Predict what TSNIT graphs you would obtain for this patient.
1 2
3 4
OS OD
OD OD
OD OD
OS OS
OS OS
OD
OS
ODOS
Case 2
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Entrance Skills
• 60 YR WM– Complaint of blurry vision– Currently wearing sister’s contacts as he lost his
glasses– PMHx: depression but not currently controlled– POHx: unremarkable– BCVa: 6/6 (20/20) OD, OS– All other entrance skills unremarkable
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Health Assessment
• SLE:– Arcus OD, OS– Anterior chamber: deep and quiet– Lens: trace NS
• IOP: – 26 and 23 OD, OS (first visit)– 24 and 20 OD, OS (second visit)
• DFE: – C/D: 0.75/0.75 (with temporal sloping) OD and 0.6/0.6
OS
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33
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Case 3
Case: Gonzalez
• 33 HF presents with a painful, red right eye• Started a couple of days ago, deep boring pain• Has tried Visine but hasn’t helped the redness
• PMHx: patient reports she experiences joint pain and has been “diagnosed” with rheumatoid arthritis for 3 years• takes Celebrex for the joint pain• patient reports she occasionally gets a skin
rash when she is outdoors in the sun• POHx: unremarkable• PMHx: mother has rheumatoid arthritis
Case: Gonzalez
• VA: – 6/9 (20/30) OD, – 6/6 (20/20) OS
• Pupils: PERRL –APD• VF: FTFC OH• EOM’s: FROM OU• BP: 130/85 mm Hg RAS• SLE: see picture
– 2+ cells, mild flare• IOP’s: 16, 16 mm HG• DFE: see fundus photo
Etiologies of Cotton Wool Spots
Vascular Occlusive Disease
Hypertension Ocular Ischemic Syndrome
Autoimmune Disease e.g. SLE
Hyperviscosity syndromes
Trauma
Pre-eclampsia Radiation Retinopathy
Toxic e.g. interferon
Neoplastic e.g. leukemia
Anterior Ischemic Syndrome
Infectious e.g. HIV
Antimalarial Ocular Complications
• usual dose is 200-400 mg/d @night with onset of action after a period of 2-4 months
• Have affinity for pigmented structures such as iris, choroid and RPE
• Toxic affect on the RPE and photoreceptors leading to rod and cone loss.
• Have slow excretion rate out of body with toxicity and functional loss continuing to occur despite drug discontinuation.
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
1 2 3 4
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
ARMD Macular HoleOHS
Bull’s Eye Maculopathy
QuestionWhich OCT goes with a patient undergoing hydroxychloroquine toxicity?
1 2
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Antimalarial Ocular Complications
• Toxicity can lead to whorl keratopathy, “bulls eye” maculopathy, retinal vessel attenuation, and optic disc pallor.
• Early stages of maculopathy are seen as mild stippling or mottling and reversible loss of foveal light reflex
• “Classic” maculopathy is in form of a “bulls eye” and is seen in later stages of toxicity– this is an irreversible damage to the retina
despite discontinuation of medication
Antimalarials
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Bulls Eye Maculopathy Whorl Keratopathy
Revised Recommendations on Screening for Retinopathy
• 2002 recommendations for screening were published by Ophthalmology
• Revised recommendations on screening published in Ophthalmology 2011;118:415-42– Significant changes in light of new data on
the prevalence of retinal toxicity and sensitivity of new diagnostic techniques
– Risk of toxicity after years of use is higher than previously believed• Risk of toxicity approaches 1% for
patients who exceed 5 years of exposure
Revised Recommendations on Screening for Retinopathy
• Amsler grid testing removed as an acceptable screening technique– NOT equivalent to threshold VF testing
• Strongly advised that 10-2 VF screening be supplemented with sensitive objective tests such as:– Multifocal ERG– Spectral domain OCT– Fundus autofluorescence
Revised Recommendations on Screening for Retinopathy
• Parafoveal loss of visual sensitivity may appear before changes are seen on fundus evaluation
• Many instances where retinopathy was unrecognized for years as field changes were dismissed as “non-specific” until the damage was severe
• 10-2 VF should always be repeated promptly when central or parafoveal changes are observed to determine if they are repeatable
• Advanced toxicity shows well-developed paracentral scotoma
Paracentral Scotomas
Courtesy of Dr. Mark Dunbar
Revised Recommendations on Screening for Retinopathy
• SD-OCT can show localized thinning of the parafoveal retinal layers confirming toxicity– not appreciable with time-domain OCT– changes maybe visible prior to VF defects
• Fundus autofluorescence may reveal subtle RPE defects with reduced autoFL or show areas of early photoreceptor damage
• MF-ERG can objectively document localized paracentral ERG depression in early retinopathy
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Normal Retina: VF/OCT/ERG
Outer Nuclear Layer
PIL
PIL=PR Integrity Line
TD-OCT
SD-OCT
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Mild Maculopathy
PILThinned Outer Nuclear Layer
Paracentral ScotomasNormal Foveal Peak
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Bull’s Eye Maculopathy
Remnant of PILRPE Atrophy
Flattened Foveal Peak
Dense Para/Central Defects
Revised Recommendations on Screening for Retinopathy
Factors Increasing Risk of Retinopathy
Duration of use > 5 years
Cumulative Dose > 1000 g (total)
Daily Dose > 400 mg/day
Age Elderly
Systemic Disease Kidney or liver dysfunction
Ocular Disease Retinal disease or maculopathy
Revised Recommendations on Screening for Retinopathy
• Older literature focused on daily dose/kg whereas newer literature emphasizes cumulative dose as the most critical factor– Initial baseline then screening for
toxicity should be initiated no later than 5 years after starting the medication
SD-OCT 5 Line Raster ScansOD OS
Case 4
Vesta: 61 y/o Hatian Female
• GL suspect 2001 – suspicious ON’s• NTG since 2006• Meds: Alphagan P bid OU, latanoprost qhs OU• Medical Hx: HTN, HIV (+) for > 15 yrs• VA: 6/6 (20/20)• TA for the past 3 or 4 yrs: 9-13 mmHg OU
– Last 2 visits 9 mmHg – today 13– Pachs: 450 microns
Case Courtesy of Dr. Mark Dunbar
2010
Case Courtesy of Dr. Mark DunbarOD OS
2012
What’s This???
RE
OD OS
2010
2011
2012
Case Courtesy of Dr. Mark Dunbar
GPA Progression Analysis OD
GPA Progression Analysis OS
Case Courtesy Dr. Mark Dunbar
Vesta: 61 y/o Hatian Female
• NTG OU with thin corneas• OS:
– Optic Nerve and HVF show trend towards progression….
• OCT shows no change
Case Courtesy of Dr. Mark Dunbar
Vesta: 61 y/o Hatian Female
• How do you manage this patient?– Currently on latanoprost and alphagan OU
• This is what was done….– Stopped Alphagan P – Switch to Combigan bid OU– Continue with latanoprost qhs OU– RTC 1 mo
OCT Retinal Images
Cirrus
Pigment Epithelial Detachment Cystoid Macular Edema
CirrusExudative AMD Macular Hole
CirrusVitreomacular Traction Epiretinal Membrane
CirrusCentral Serous Chorioretinopathy Diabetic Macular Edema
Thank You!
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