fasolino oct fag icg
DESCRIPTION
http://www.tvrs.gr/TRANSCRIPT
G Fasolino MD
S Russo MD
QUESTION
WICH IS THE BEST WAY TO FOLLOW OUR PATIENT
JUST TO REFRESHhellip
Non-contrastrographic
StandardFO
Confocal SLO
Color image
Red free
Autofluorescence (new filters)
IR Infra-red
BR Blue reflectance
Autofluorescence
Contrastographic
StandardFO
Confocal SLO
FAG static
ICG static
FAG static and dynamic ICG static and dynamic
Simultaneous FAG and ICG
OCT
Autofluorescence
bull Fundus Autofluorescence in vivo is mainly derived from RPE lipofuscin
bull (Delorirsquos spectrophotometric examinations)
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
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SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
QUESTION
WICH IS THE BEST WAY TO FOLLOW OUR PATIENT
JUST TO REFRESHhellip
Non-contrastrographic
StandardFO
Confocal SLO
Color image
Red free
Autofluorescence (new filters)
IR Infra-red
BR Blue reflectance
Autofluorescence
Contrastographic
StandardFO
Confocal SLO
FAG static
ICG static
FAG static and dynamic ICG static and dynamic
Simultaneous FAG and ICG
OCT
Autofluorescence
bull Fundus Autofluorescence in vivo is mainly derived from RPE lipofuscin
bull (Delorirsquos spectrophotometric examinations)
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
JUST TO REFRESHhellip
Non-contrastrographic
StandardFO
Confocal SLO
Color image
Red free
Autofluorescence (new filters)
IR Infra-red
BR Blue reflectance
Autofluorescence
Contrastographic
StandardFO
Confocal SLO
FAG static
ICG static
FAG static and dynamic ICG static and dynamic
Simultaneous FAG and ICG
OCT
Autofluorescence
bull Fundus Autofluorescence in vivo is mainly derived from RPE lipofuscin
bull (Delorirsquos spectrophotometric examinations)
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Non-contrastrographic
StandardFO
Confocal SLO
Color image
Red free
Autofluorescence (new filters)
IR Infra-red
BR Blue reflectance
Autofluorescence
Contrastographic
StandardFO
Confocal SLO
FAG static
ICG static
FAG static and dynamic ICG static and dynamic
Simultaneous FAG and ICG
OCT
Autofluorescence
bull Fundus Autofluorescence in vivo is mainly derived from RPE lipofuscin
bull (Delorirsquos spectrophotometric examinations)
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Autofluorescence
bull Fundus Autofluorescence in vivo is mainly derived from RPE lipofuscin
bull (Delorirsquos spectrophotometric examinations)
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
AF in retinal imaging
bull With the advent of SLO it is now possible to image fundus autofluorescence and its spatial distribution over large retinal areas in vivo
indirect information concerning the metabolic activity of the RPE
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Lipofuscinbull Lipofuscin the prevalent fluorophore of
fundus is mainly derived from the chemically modified residues of incompletely digested photoreceptor outer segment disc
Impaired lysosomal Impaired lysosomal protein degradationprotein degradation
RPE APOPTOSIS
Photoreceptor damage
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Autofluorescence Image
dark
Macular pigment
Inner blood retinal barrier
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Blue reflectance
Infrared
Autofluorescence
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Blue reflectance Infrared
Autofluorescence
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
AMD DRY
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OCT
bull Optical Coherence Tomography provides high-resolution cross sectional images of the eye
bull Its proving to be an accurate tool for the early diagnosis analysis and monitoring of rethinopaty
bull It has higt repeatability and resolution
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
HISTOLOGY
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
TIME DOMAIN vs SPECTRAL DOMAIN
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OCT specification comparisonSpectral Domain OCT
Time Domain
Stratus OCT
Benefit of Spectral Domain
Light Source 840 nmBroader bandwidth
820 nm Provides higher resolution
Detector Spectrometer Single detector
Fewer moving parts ndash faster scan acquisition
Axial Resolution 5-7m 10mBetter visualization of retinal layers and pathologyTransverse Resolution 10 - 20m 20m
Maximum A-scans
per B-scan
4000 - 8000 512 Better visualization of tissuepathology
Scan Depth 2mm 2mm Slightly better penetration of light
Scanning Speed
A scans per second
18000 ndash 40000 400 Better registration 3D scanning and analysis
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Invasive procedurebull SFO
ndash static FAndash static ICG
bull Confocal SLOndash Static amp High-speed dynamic FAndash Static amp High-speed dynamic ICGndash Simultaneous FA amp ICG
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Retinal vesselsbull Main arterioles (100microm) are in the nerve fiber and
ganglion cell layers
bull Only capillaries are present deeply until the inner nuclear layer
bull Three laminar network of capillaries at the posterior pole just one at periphery
bull Foveal avasculare zone (FAZ) 400-500microm
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Retinal vesselsbull Capillaries diameter 5-6microm
perycitesendothelial cells ratio 11
tight junctions among endothelial cells
Inner blood retinal barrier
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Sattlerrsquos layer
Hallerrsquos layer
Choriocapillaris
Choroid
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Choroidbull Choroidal thickness is 01mm anteriorly and
022mm posteriorly
medium vessels( Sattlerrsquos layer)
large arteries of 40-90microm and large veins of 20-100 microm (Hallerrsquos layer)
choriocapillaris wide diameters 20-25 microm
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Damage to the choriocapillaris 3 months after
retinal photocoagulation withArgon laser
Choriocapillaris
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Choroidal and retinal circulationbull Choroid
800-1000 mlmin per 100g of tissue
Self-regulation
3
bull Retina
80 mlmin per 100g of tissue
Autonomic nervous system
40
Blood flow
Regulation
Oxygen extraction
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Sodium Fluorescein
bull The dye absorbs light in the blue range of the visible spectrum with absorption peaking at 480nm (blue)
bull It emits light at 525nm (yellow)
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Sodium Fluorescein
bull It is metabolized by the liver and excreted by the kidneys
bull Most dye is cleared with 24 hours and patients should be warned that their urine will appear orange during this time
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Fluorescein angiography
It provides three main information
bull the flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid
bull fine details of the pigment epithelium and retinal circulation that may not otherwise be visible
bull give a clear picture of the retinal vessels and assessment of their functional integrity
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Circulation of the fundussodium fluorescein
ndash Choroidal circulation - the fluorescein freely leaks out of the fenestrated choroidal capillaries and from there through Bruchs membrane however tight junctions between retinal pigment epithelium (RPE) cells prevents dye reaching the retina
ndash Retinal circulation - the retinal blood vessel endothelial cells are joined by tight junctions which prevent leakage of fluorescein into the retina This constitutes the blood retinal barrier
Any leakage from the retinal vessels is abnormal
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV classic (early phase)
FA ICG
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV classic (late phase)
FA FA high magnification
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ICG Dye
bull Absorbs and emits in the near-infrared range of the spectrum
bull The dye maximally absorbs infrared light at 805 nm and maximally fluoresces at 835 nm
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ICG Dyebull Administrated via the
intravenous route for ophthalmic angiography
bull Rapidly and almost completely (98) bound to plasma proteins following injection
bull It has been demonstrated that in human serum 80 is bound to globulins probably α-1 lipoproteins
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ICG vs Sodium-Fluoresceinbull Penetration through ocular pigment and media opacities is
much more efficient than compared to the short wave-lenghts of visible light used in fluorescein angiography
bull Influence of blood and hemoglobin on the measurement of dye concentration at the 805 wl is small allowing detection of dye concentration by use of a densitometer
bull It is possible to penetrate some hemorrages and exudates
bull Because most of the infrared wavelenghts are not perceived by the patients ICG angiography often is tolerated better than FA
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ICG vs Sodium-Fluorescein adverse reactions
bull 015bull 02bull 005bull 1 per 333333
bull 1-10bull 16bull 005bull 1 per 222000
mild
moderate
severe
deaths
ICG FAG
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Simultaneous ICG and Fluorescein angiography
Three principal advantages over sequential methods
time sequence correlation exact overlap of corresponding fluorescein and ICG images
efficiencyimmediate results are obtained with just one injection and one photographic session
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV occult
FA occult
ICG well-defined
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV occult
FA Occult ICG well-defined
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV occult with PED
Fluorescein angiography
ICG angiography
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CNV hot spot
ICG early phase ICG late phase
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
High-speed ICG AngiographyGiven the extremely rapid movement of blood
through the choroid characteristics of an ideal system for acquiring angiograms include
-very short image acquisition time (5 msec or less)
-rapid image acquisition rate (12 imagessec)
-high image signal-to-noise ratio
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
The potential benefits of HS-ICG angiography relies indeed on identification of lesions not visible by FA nor with static ICG
Kinetic Angiography
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
bull The main clinical application of H-S angiography to date has been in identification of CNV feeder vessels which relies upon the ability to determine direction of blood flow to discriminate between afferent and efferent vessels
Feeder vessel
Kinetic Angiography
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
The identification of FVs is based on their injection preceding that of the retinal vessels during the early phases of dynamic FA and ICG and on their relationship with choroidal circulation and the CNV during the early phase of the angiograms
Kinetic Angiography
Feeder vessel
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
RAP
Kinetic Angiography
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
The FA shows to clear locations of a sub-foveal CNV with extensive leakage in the late stages and the formation of CME In the early stages of the FA the two vessels dipping towards the CNV can be clearly seen although the ICGA images and especially the high magnification frames provide much more detail
RAP
Kinetic Angiography
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
NEW APPROACHSNEW APPROACHS
OPTOS SYSTEMOPTOS SYSTEM Panoramic 200 is non-mydriatic Panoramic 200 is non-mydriatic
non-contact scanning laser-based non-contact scanning laser-based
retinal imaging system designed to retinal imaging system designed to
produce a panoramic image of the produce a panoramic image of the
fundus covering about 200degfundus covering about 200deg
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OPTOSOPTOS PERIFERAL LESION PERIFERAL LESION
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OPTOSOPTOS MACULAR LESIONS MACULAR LESIONS
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGESULTRA-WIDE ANGLE ANGIOGRAPHIC IMAGES
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
NEW APPROACHSNEW APPROACHS
iVUE iVUE INTRAOPERATIVE INTRAOPERATIVE
OCT OCT
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
iVue intraoperative OCT
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
well evidence of the retina traction and macular thickness
well evidence of the complete well evidence of the complete absence of epiretinal membraneabsence of epiretinal membrane
measure of retina thickness soon measure of retina thickness soon after peelingafter peeling
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Per visualizzare questimmagine sono necessari QuickTimetrade e undecompressore Photo - JPEG
diabetic tractional macular diabetic tractional macular edemaedema
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
iVue intraoperative OCT
bull macula evaluation during surgery
bull anterior segment evaluation in particular surgical cases
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
bull intraoperative OCT is helpfull to the surgeon to evaluate the state of the retina at the end of the surgical procedure
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
NEW APPROACHSNEW APPROACHS
OCT EN FACEOCT EN FACE
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
EN FACE
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
EN FACE
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
EN FACE
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
EN FACE
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PUCKER MACULARE 3PREOPERATORIO
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PUCKER MACULARE 3POSTOPERATORIO 15 GG
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PUCKER MACULARE 4POSTOPERATORIO
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PEELING MACULARE 7POSTOPERATORIO
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
EN FACE
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
NEW APPROACHSNEW APPROACHS
OCT HEIDELBERGOCT HEIDELBERG
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Full Depth Imaging (FDI)
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
What is FDI
How to acquire FDI images
Examples
Outline
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Full Depth Imaging is where you get an equal contrast in the vitreous as you do in the choroid
What is FDI
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
What is FDI
How to acquire FDI images
Examples
Outline
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Select normal OCT mode
Place top of retina just below the four blue markers indicating the sweet spot
Activate ART Mean
Activate EDI mode afterthe desired ART numberis reached (eg ART 100)
Acquire an image whenchoroid amp vitreous appearwith equal contrast
How To Acquire FDI images
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
FDI Examples
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
FDI Examples
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
FDI Examples
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
FDI enables users to acquire imageswith good contrast in choroid and vitreous
The image quality is similar to thatof swept source OCT systems
Conclusion
9365
4-0
01 IN
TA
E13
copy H
eide
lber
g E
ngin
eerin
g G
mb
H
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
SPECTRALISreg with Nsite Axonal Analyticstrade
Measuring Axonal Loss and Neurodegeneration
in the Retina
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
The Eye ndash The window to the Brain
Retina is part of central nervous system
Retinal Nerve Fiber Layer (RNFL) contains unmylinated axons
Processes of neurodegeneration neuroprotection and potentially neurorestauration can be assessed in the eye
OCT allows quantification and classification of axonal damage in the RNFL which correlates with brain atrophy
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Eye Imaging in Neurodegeneration
Over 200 published studies show that retinal nerve fiber layer and macular measurement by Optical Coherence Tomography (OCT) correlate with clinical function in
Multiple Sclerosis Brain lesions and atrophy by MRI Physical disability (EDSS) Likely early detector of disease
Alzheimerrsquos disease Cognitive impairment
Parkinsonrsquos disease Physical disability
Epilepsy Vision loss in SABRILreg (vigabatrin) patients
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
RNFL Thickness Analysis
Fundus Image
OCT-Scan Location
OCT Image
Automatic RNFL Segmentation
RNFL Thickness Graph and ClassificationSector Analysis
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
SPECTRALISreg
Nsite Axonal AnalyticsTM
Software Module
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optimized Scan Pattern
Standard Glaucoma Software
TSNIT scan
Scan begins and ends temporal
Data quality limited in temporal sector by reduced overlap of individual scans
New Nsite Axonal AnalyticsTM
NITSN scan
Scan starts and ends nasally
Best data quality in temporal sector allows to analyse the PMB
RNFL damage in MS patients typically occurs in temporal sector
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
NITSN Graph ndash RNFL Classification
Classification of RNFL
EdemaAxonal Loss
thickening
thinning
Sector Analysis of the RNFL
Pappilo-Macular-Bundle(PMB) analysis
Nasal to Temporal Ratio
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Nsite Axonal Analyticstrade
Standard Glaucoma-Analytics
Dedicated Neurology Software
No abnormalities in the temporal sector Examination result
No abnormalities in the temporal sector Dedicated Nsite Axonal Analyticstrade
classification of the papillo-macula sector Examination result
CONCLUSION Selective analysis of the papillo-macula bundle (PMB) within the temporal sector enables an earlier detection of significant changes
Within Normal Limits
Below Normal Limits
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Advantages of SPECTRALIS Solution
3D imaging of ONH
Classification of acute edema and axonal loss
Analysis of RNFL thickness changes with smallest measurable change of 1microm
Patient friendly exam
Exams can be performed in neurology office or clinic by trained technicians
Cost effective technology
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
THE NEW AND THE FUTURE
Central Serous Chorioretinopathy
OCT and Outer Retina Layer
The futurehellip
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CENTRAL SEROUS CHORIORETINOPATHY
bull Idiopathic disorder
bull Involving focal or multifocal leak at the level of RPE usually in conjuction with a serous detachment
bull Presence of thickened choroid
bull Usually occurs unilaterally in males beteween the ages of 30 and 50
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PATHOGENESIS
bull CHOROIDAL VASCULAR HYPERPERMEABILITY
bull INCREASED HYDROSTATIC PREASSURE
bull DAMAGE TO THE RPE
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
DIAGNOSTIC IMAGING
bull FA AND ICG
bull OCT
FUNDUS AUTOFLUORESCENCE
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
THERAPY
bull MEDICAL THERAPY
bull LASER TREATMENT
bull PHOTODYNAMIC THERAPY
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
MEDICAL THERAPY
bull CARBONIC ANHYDRASE INHIBITORS
bull BETA BLOCKERS
bull ALDOSTERONE ANTAGONISTS
bull TOPICAL USE OF NON STEROIDAL ANTI-INFLAMMATORY DRUG
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
LASER TREATMENT Comparative study of patients with central serous
chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy ( Br j ophthalmology 2011 Apr)
bull Lim JW1 Kang SW Kim YT Chung SE Lee SW
bull Laser treatment of diffuse retinal pigment epitheliopathy ( Eur j ophthalmology 1992)
bull Yannuzzi LA1 Slakter JS Kaufman SR Gupta K
bull Laser photocoagulation treatment of central serous chorioretinopathy (Int ophthalmological clin)
bull Samy CN1 Gragoudas ES
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
LASER TREATMENT
bull LASER PHOTOCOAGULATION CAN BE APPLIED TO A PIGMENT EPITHELIAL LEAK UNDER THE GUIDANCE OF FLUORESCEIN ANGIOGRAPHY TO RESOLVE DETACHMENT IN CSC
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
bull PDT Collaborative retrospective macula society study of
photodynamic therapy for chronic central serous chorioretinopathy (Ophthalmology 2014 May)
bull Lim JI1 Glassman AR2 Aiello LP2 Chakravarthy U2 Flaxel CJ2 Spaide RF2 Macula Society CSC Collaborative Study Group Research and Education Committee and Website Committee
Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy one-year results of a randomized trial ( Ophthalmology 2014 Feb) Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY
5 Lee JY6 Song SJ7 Park TK8 Moon SW9 Chung H5bull Lack of positive effect of intravitreal bevacizumab
in central serous chorioretinopathy meta-analysis and review
bull Chung YR Seo EJ Lew HM Lee KH
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
bull PDTbull Half-dose photodynamic therapy targeting the
leakage point on the fluorescein angiography in acute central serous chorioretinopathy a pilot study
bull (Am j Ophthalmology 2014 Feb)bull Kim KS1 Lee WK2 Lee SB3
bull Half-fluence versus half-dose photodynamic therapy in chronic central serous chorioretinopathy ( Am j Ophthalmology 2014 May)
bull Nicoloacute M1 Eandi CM2 Alovisi C3 Grignolo FM3 Traverso CE4 Musetti D4 Cardillo Piccolino F5
Low-fluence photodynamic therapy versus
ranibizumab for chronic central serous
chorioretinopathy one-year results of a randomized
trial ( Ophthalmology 2014 Feb)bull Bae SH1 Heo J2 Kim C3 Kim TW4 Shin JY5 Lee JY6 Song SJ7 Park TK8 Moon SW
9 Chung H5
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Copyright restrictions may apply
Schmidt-Erfurth U et al Arch Ophthalmol 2002120835-844
Light microscopy of a choroidal section of eye 2 following photodynamic therapy
A The superficial portion of the choroid appears condensed with obliterated vascular lumina within the capillary layer (arrow) while large vessels remain patent B Choriocapillary vessels and deeper vessels of an untreated area are open (arrow) and contain red blood cells (original magnification x450)
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PDT
bull PHOTODINAMIC THERAPY (PDT) IS APPROPRIATE WHEN THE LEAK IS CLOSE TO THE CENTER OF THE MACULA OR IF THERE IS DIFFUSE INCONTINENCE TO THE PIGMENT EPITHELIUM
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PDT
bull HALF DOSE PDT IS CONCORDANTLY REGARDED AS BEING JUST AS EFFECTIVE AS FULL-DOSE PDT AND IS THEREFORE RECCOMENDED IN CASES OF RECURRENT OR CHRONIC CSC
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CONCLUSIONS
bull CSC IS AN IDIOPATHIC DISORDER
bull OBSERVATION AND REDUCTION OF STRESS ARE OFTEN SUFFICIENT TO OVERCOME VISUAL DETERIORATION
bull IN THE PERCENTAGE OF PATIENTS (40-50) SUFFER OF RECURRENT FORM THE ONLY EFFICACIES THERAPIES ARE LASER PHOTOCOAGULATION AND PDT
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
o Previous histologic studies of human retina have demonstrated PhOS length of 25 to 63 microm in the macula
o The PhOS was measured with ultra higt-speed OCT in the healthy subjects It was 406 microm in their fovea
Srinivans et Al Vis Sci 2008495103-10
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Internal Limiting MembraneNerve FiberGanglion CellInner PlexiformInner NuclearOuter PlexiformOuter NuclearExternal Limiting MembraneInnerOuter Segment JunctionRPE
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Is increased retinal thickness which equals macular edema
a good indicator of visual acuity loss
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed (1)
1) CYSTOID SPACES Small round hyporeflective lacunae with high signal elements
bridging the retinal layers
(1) OTANI ET AL 1999
2032
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
2) OUTHER RETINAL SWELLING characterized by an ill-defined widespread hyporeflective area of
thickening
OTANI ET AL 1999
2025
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
3) SEROUS RETINAL DETACHMENT Is a different pattern characterized by absence of the hightly reflective
anterior boundary
the presence of serous retinal detachement isnrsquot correlated with poorer visual acuity
OTANI ET AL 1999
2040
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
4) DIFFUSE MACULAR EDEMA combined with CENTRAL CYSTS
OTANI ET AL 1999
2050
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Optical Coherence Tomography
Distint features of DME can be observed
5) TRACTIVE DIABETIC MACULAR EDEMA The posterior hyaloid appears thickened and hyperreflective
OTANI ET AL 1999
20100
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ARMD
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
II caseDMLE pre
AV 20300
RT 650 micron
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
AV 20300
RT 650 micron
II caseDMLE post
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
giugno2008
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Sett2008
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Ottobre 2008
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Dicembre 2008
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Gennaio 2009
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
o Macular thickness is only one of the factors related to the visual outcomes in eyes
with Macular Edema
Conclusions
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
In the retinal area involved in ME
other factors should be correlated
between RT and Visual Acuity
o finding of the large ldquocysticrdquo spaces
o duration of edema
o status of the retinal photoreceptors (PhOS)
Conclusions
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PARTICULAR CASE
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ANGIOID STREAKS
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
BEST DISEASE
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CONE DISTROPHY
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
POLIPOIDAL
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
STARGARDT DISEASE
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
THE FUTUREhelliphellip
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Split-Spectrum Amplitude Decorrelation (SSADA)
Algorithm Performance features
bull100000 axial scanssec
bull1050 nm tunable laser (deep penetration)
bull53 μm axial resolution in tissue
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Split-Spectrum Amplitude Decorrelation (SSADA) Algorithm bull Splitting the full OCT spectrum in to several
narrower bands reducing axial resolution and consequently axial motion noise
bull These changes improved detection of the flow signal which in the ocular fundus is predominantly in the transverse dimension
bull The contrast between the decorrelation of blood flow and static tissue can be used to extract flow signal
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
SSADA improves signal to noise ratio of flow detection
Full Spectrum
Split Spectrum
Less background noise
Clear vessell
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
Signal Information En Face Cross Section
Reflectance Anatomy
Doppler shift(between consecutive A-scans)
Total retina blood flow
Decorrelation between consecutive B scan
Angiography local circulation
Structural OCT
Functional OCT
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
SSADA NORMAL RETINA
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OVBCR
FAG
OCT FA
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
PERIPAPILLARY NEOVASCULARIZATION
FAG
OCT FA
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
MNV
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
3D OCT angiography of optic nerve head
SSADA algorithm used
3x3x3 mm OCT 3D angiography acquired in a 3-second scan
Reflectance (Structure Decorrelation (Flow)
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
OCT Angiography (SSADA) v FluoresceinICG Angiography
bull OCT Advantages OCT Disadvantages
bull3 dimensional Small field (3mm)
ndashEasily separates disc retinal and choroidal circulations No visualization of leakage bull and stain but can visualize
ndashSections amp projections along any plane fluid space and thickening
bullQuantitative
ndashFlow index
bullNo injection
ndashNo vomiting or anaphylactic reaction
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
ADAPTIVE OPTICS SCANNING LASER OPHTHALMOSCOPE
bull Visualizing individual photoreceptors and the movement of white blood cells
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
CONCLUSIONS
bull We have multiple choice device to follow our patient
bull Is possible to identify the damage in the retina single layer
bull Is possible to verify the modification of the tissue before after and during the different therapies ( surgery injection laser and)
bull But to follow the best way never forgethellip
THANK YOU
THANK YOU