oct guided decision making: applications in common...

3/6/2014

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Hoda MH Mostafa MD

Associate Professor of

Ophthalmology

Cairo University

The author has no

proprietary interest

Today’s Objectives

Identify the CLINICAL SCENARIOS IN

MACULAR EDEMA where OCT plays a

MAJOR role in decision making

IDENTIFY our audience

Demonstrate how OCT helps guide this

decision making process

Examples of cases

H Mostafa EGVRS 2014

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Clinical spectrum

ME

Vascular occlusion

Other pathology

VM traction

DR


OCT and Logical Decision Making

Use coherent data

Qualitative 2-D and 3-D images

Quantitative analytical tests

Retinal thickness

Retinal mapping

Progression analysis (MPA)

Synthesis of ALL data to reach a

diagnosis


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OCT and Logical Decision Making

Coherent data

Medical and surgical history

Additional retinal

imaging ( FFA/AF)

Qualitative findings

2-D

3-D

Quantitative findings

http://www.carlglittenberg.com/OCT-Gallery/index.html H Mostafa EGVRS 2014

http://issuu.com/carlzeiss/docs/guide_to_interpreting_spectral_domain_oct H Mostafa EGVRS 2014

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DECISION MAKING

Process

Qualitative info

Morphology

Morphological alterations

Anomalous structures

Reflectivity Conformity with known patterns

Quantitative info

Retinal thickness and MPA

Increased

decreased

Topographical variations

MPA


Clinical challenges

Clinical picture

Angiographic data

What does SDOCT add to the equation?

Clinical picture

FFA/AF OCT Clinical decision


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WHY CLASSIFICATION MATTERS

LOCATION AMOUNT

VR INTERFACE

HARD EXUDATE

ME


KNOW WHAT YOU’RE LOOKING

FOR

LOCATION

IS CENTRAL SF INVOLVED

INNER AND/OR OUTER

SUBFIELD

AMOUNT

VOLUME

MEAN THICKNESS

VR INTERFACE

AP

TANGENTIAL

HARD EXUDATES

YES/NO

LOCATION


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OCT=objective Dx and follow-up of

ME

PATHOPHYSIOLOGICAL

CLASSIFICATION

C. Lobo et al 2011

I –Edema of the inner retinal layers

II–Cystoid spaces in the retina and/or Overall involvement

III. –Sub-retinal fluid accumulation

IV. –Tractional retina edema

V. –Combination of patterns I,II,III,IV

Breakdown of inner/outer

BRB

Breakdown of inner/outer

BRB

Breakdown of outer BRB

Breakdown of inner BRB


Know

what to look for


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MACULAR EDEMA


The Normal

Retina


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Clinical challenge 1: Diabetic

Macular edema

Know what you are looking for

Tractional element

Associated CME and inner retinal thinning

with risk of lamellar hole formation

Other factors that may influence treatment

decision

Outer retinal layer integrity


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Macular edema

Identify the pathology

diffuse retinal thickening

cystoid macular edema

sub-retinal fluid with serous retinal

detachment

Interface traction

○ T: posterior hyaloid/ILM traction

○ AP: tractional macular detachment

Co-existing pathology: ischemia


These 5 morphological types have

different prognostic significance

Clearly demarcated by SD OCT

The best visual acuity in patients with

diffuse DME

The worst in patients with posterior

hyaloid traction and tractional macular

detachment, PIL affection.


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Macular edema


diffuse retinal thickening



Macular edema


cystoid macular edema


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Macular edema


sub-retinal fluid with serous retinal

detachment


The PIL=IS/OS junction


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Macular edema


Posterior hyaloid traction

No traction

Tractional macular

detachment



Macular edema

Synthesis and correlation with other data

Ischemia, Microaneurysm turnover rate

and progression, intrastromal foveal

exudates, PIL disrupted???


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MACULAR EDEMA


Clinical challenge 2: ME + Vitreo-

retinal interface disorders


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Clinical challenge 2a: Vitreo-

retinal interface disorders ERM



Clinical challenge 2a: Vitreo-


ERM with VR traction and retinal thickening


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Clinical challenge 2b: Vitreo-



Clinical challenge 2b: Vitreo-



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PDR with A-P traction and tangential traction/EMM

macular edema

Clinical

challenge 2


Clinical challenge 2: Vitreo-retinal

interface disorders

Correlate with other data

Vision

FFA

Associated posterior segment pathology


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Clinical challenge 2: Vitreo-retinal

interface disorders

Management plan based on

Morphological changes

Quantitative and qualitative changes

Often guarded visual prognosis

Should be an informed decision


MACULAR EDEMA


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CME


CME


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Diffuse ME

Tangential traction


Diffuse ME


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Macular edema

Para-foveal traction


Macular detachment

Macular edema


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Focal A-P traction


EMM; tangential traction

Macular edema


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Focal AP traction

Cystoid ME/Impending hole


Diffuse macular edema

N-S detachment


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Diffuse ME

Outer retinal layer edema


Wrap-up: SD OCT is an invaluable

tool in decision making process

Coherent Data

Synthesis of Q and

Q

Logical Decision

SD OCT offers an opportunity to

Re-define classification

Detect prognostic indicators

Plan for treatment strategies. H Mostafa EGVRS 2014

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Credits

Diagnostic Ophthalmology Unit : Dar El

Oyoun Hospitals

Guide to Interpreting SD OCT- Bruno

Lumbroso and Marco Rispoli

Photo Gallery- Carl Zeiss.

Photo Gallery-Heidelberg Spectralis

“Monitoring Retinal Change in AMD

Patients using Cirrus™ HD-OCT”

Images retrieved on 22-9-2010


OCT=objective follow-up of ME

Patterns of macular edema:

I. –Edema of the inner retinal layers

– Breakdown of inner/outer BRB II. –Cystoid spaces in the retina. Overall involvement

– Breakdown of inner/outer BRB

III. –Subretinal fluid accumulation

– Breakdown of outer BRB

IV. –Tractional retina edema

– Breakdown of inner BRB V. –Combination of patterns I,II,III,IV


C. Lobo et al 2011

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