Professional Blair Lonsberry MS OD MEd FAAO Diplomate American Board of Optometry Clinic Director and Professor of Optometry Pacific University College of Optometry blonsberrypacificuedu ID: 704748
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Imaging Interpretation for the Comprehensive Eye Care Professional
Blair Lonsberry, MS, OD, MEd., FAAO
Diplomate, American Board of Optometry
Clinic Director and Professor of Optometry
Pacific University College of Optometry
blonsberry@pacificu.eduSlide2
Time
% Loss
Early
Moderate
Severe
Visual Field changes occur late in the disease
The Optic disc often changes before visual fields
The RNFL usually changes before both the visual fields and optic disc
VF
Disc
RNFL
Structural / Functional Relationship in Glaucoma as the Disease ProgressesSlide3
Clinical Exam of the Optic Nerve Head
Utility and Limitations
Disc exam at the first visit – normal or abnormal?
Disc exams are subjective, or at best semi-quantitative
The wide variety of disc appearances requires long experience and expert judgment to separate normal from abnormal
Disc diameter must be taken into account
Disc exam to assess changeUnless stereoscopic photographs are taken and compared over time, the ability of a clinician to judge change is very limited (chronology is important!)Slide4
OCT: The Basics
4Slide5
Retinal LayersSlide6
Cirrus RNFL Analysis
CALCULATION CIRCLE
AutoCenter
™ function automatically centers the 1.73mm radius
peripapillary calculation circle around the disc for precise placement and repeatable registration.
OPTIC DISC CUBE SCAN
The 6mm x 6mm cube is captured with 200 A-scans per B-scan, 200 B-scans. Slide7
RNFL/ONH Analysis
RNFL THICKNESS
along the calculation circle is displayed in graphic format and compared to age-matched normative data
RNFL DEVIATION MAP
, overlaid on the OCT fundus image, illustrates precisely where RNFL thickness deviates from the normal range. Data points that are not within normal limits are indicated in
red
and
yellow
.
RNFL THICKNESS MAP
shows the patterns and thickness of the nerve fiber layer within the full 6mm x 6mm area
RNFL THICKNESS AND COMPARISON TO NORMATIVE DATABASE
is shown in circle, quadrants and clock hour display
ONH Analysis
:
rim/disc area, average C/D ratio, vertical C/D ratio and cup volumeSlide8
Cirrus RNFL and ONH Analysis Elements
RNFL
Peripapillary
Thickness profile, OU
compared to normative data
Neuro
-retinal Rim Thickness profile, OU compared to normative data
Optic Nerve Head calculations are presented in a combined report with RNFL thickness data. Key parameters are compared to normative data and displayed in table formatSlide9
Cirrus HD-OCT GPA Analysis
Two baseline exams are required
Baseline
Third exam is compared to the two baseline exams
Sub pixel map demonstrates change from baseline:
Yellow pixels denote change from both baseline exams
Third
and
fourth exams are compared to both baselines:
yellow pixels denote change from both baselines
change identified in three of the four comparisons is indicated by red pixels
Image Progression Map
Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studiesSlide10
Guided Progression Analysis (GPA™)
10
Page 2Slide11
Guided Progression Analysis (GPA™)
11Slide12
Macular Cube ScanSlide13
Automatic Fovea Finder™
Fovea center = 255, 71
Scan center = 255, 64
Macula Thickness Analysis is aligned with fovea location (left)
Resulting analysis may differ from analysis aligned on scan center (right) Slide14
Macular Thickness Normative Data
Macular thickness is compared to an age-matched normative database as indicated by a stop-light color codeSlide15
Macular Change Analysis
Provides visual and quantitative comparison of two exams. Slide16
Ganglion Cell AnalysisMeasures thickness for the sum of the ganglion cell layer and inner plexiform
layer (GCL + IPL layers)
RNFL distribution in the macula depends on individual anatomy, while the GCL+IPL appears regular and elliptical for most
normals
Deviations from normal are more easily appreciated in the thickness map by the practitioner, and arcuate defects seen in the deviation map may be less likely to be due to anatomical variations.
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012Slide17
Ganglion Cell Analysis
17
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012Slide18
CIRRUS HD-OCT and HFA Combined ReportSlide19
Case 1
19Slide20
Case History
60
yo
WM
Type 2 DM: 4 years
Hypertension: 4 yearsBilateral PK’s secondary to
keratoconus (has running suture OD)Has history of steroid injections for lower back stenosis (with history of increased IOP up to 40 after injections)
VA(RGP): 6/7.5 (20/25), 6/6 (20/20)
IOP: OD: range 20-24, OS: range 17-20Slide21
OD
OSSlide22
OD
OSSlide23
Consider the below PSD plots.
OS
OD
Predict what TSNIT graphs you would obtain for this patient
.Slide24
1
2
3
4
OS
OD
OD
OD
OD
OD
OS
OS
OS
OSSlide25
OD
OSSlide26
OD
OSSlide27
Case 2Slide28
Entrance Skills60 YR WMComplaint of blurry vision
Currently wearing sister’s contacts as he lost his glasses
PMHx
: depression but not currently controlled
POHx: unremarkableBCVa: 6/6 (20/20) OD, OSAll other entrance skills unremarkable
28Slide29
Health AssessmentSLE:Arcus
OD, OS
Anterior chamber: deep and quiet
Lens: trace NS
IOP: 26 and 23 OD, OS (first visit)24 and 20 OD, OS (second visit)DFE: C/D: 0.75/0.75 (with temporal sloping) OD and 0.6/0.6 OS
29Slide30
30Slide31
31Slide32
32Slide33
33Slide34
Case 3
34Slide35
Case: Gonzalez
33 HF presents with a painful, red right eye
Started a couple of days ago, deep boring pain
Has tried Visine but hasn
’
t helped the redness
PMHx: patient reports she experiences joint pain and has been “diagnosed
” with rheumatoid arthritis for 3 yearstakes Celebrex for the joint painpatient reports she occasionally gets a skin rash when she is outdoors in the sun
POHx: unremarkablePMHx: mother has rheumatoid arthritisSlide36
Case: Gonzalez
VA:
6/9 (20
/
30)
OD,
6/6 (20/
20) OSPupils: PERRL –APDVF: FTFC OH
EOM’s: FROM OUBP: 130/85 mm Hg RAS
SLE: see picture2+ cells, mild flareIOP’
s: 16, 16 mm HGDFE: see fundus photoSlide37
Etiologies of Cotton Wool Spots
Vascular Occlusive Disease
Hypertension
Ocular Ischemic Syndrome
Autoimmune Disease e.g. SLE
Hyperviscosity syndromes
Trauma
Pre-eclampsia
Radiation Retinopathy
Toxic e.g. interferon
Neoplastic e.g. leukemia
Anterior Ischemic Syndrome
Infectious e.g. HIVSlide38
Antimalarial Ocular Complications
usual dose is
200
-400 mg/d @night with onset of action after a period of 2-4 months
Have affinity for pigmented structures such as iris, choroid and RPE
Toxic affect on the RPE and photoreceptors leading to rod and cone loss.
Have slow excretion rate out of body with toxicity and functional loss continuing to occur despite drug discontinuation.Slide39
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
1
2
3
4Slide40
Question
Which of the following depicts a retina undergoing hydroxychloroquine toxicity?
ARMD
Macular Hole
OHS
Bull
’
s Eye MaculopathySlide41
Question
Which OCT goes with a patient undergoing hydroxychloroquine toxicity?
1
2
3
4
4Slide42
Antimalarial Ocular Complications
Toxicity can lead to whorl keratopathy,
“
bulls eye
”
maculopathy, retinal vessel attenuation, and optic disc pallor.Early stages of maculopathy are seen as mild stippling or mottling and reversible loss of foveal light reflex
“Classic
” maculopathy is in form of a “bulls eye”
and is seen in later stages of toxicitythis is an irreversible damage to the retina despite discontinuation of medicationSlide43
Antimalarials
29
Bulls Eye Maculopathy
Whorl KeratopathySlide44
Revised Recommendations on Screening for Retinopathy
2002 recommendations for screening were published by Ophthalmology
Revised recommendations on screening published in Ophthalmology 2011;118:415-42
Significant changes in light of new data on the prevalence of retinal toxicity and sensitivity of new diagnostic techniques
Risk of toxicity after years of use is higher than previously believed
Risk of toxicity approaches 1% for patients who exceed 5 years of exposureSlide45
Revised Recommendations on Screening for Retinopathy
Amsler grid testing removed as an acceptable screening technique
NOT equivalent to threshold VF testing
Strongly advised that 10-2 VF screening be supplemented with sensitive objective tests such as:
Multifocal ERG
Spectral domain OCT
Fundus autofluorescenceSlide46
Revised Recommendations on Screening for Retinopathy
Parafoveal loss of visual sensitivity may appear before changes are seen on fundus evaluation
Many instances where retinopathy was unrecognized for years as field changes were dismissed as
“
non-specific
”
until the damage was severe10-2 VF should always be repeated promptly when central or parafoveal changes are observed to determine if they are repeatable
Advanced toxicity shows well-developed paracentral scotomaSlide47
Paracentral Scotomas
Courtesy of Dr. Mark DunbarSlide48
Revised Recommendations on Screening for Retinopathy
SD-OCT can show localized thinning of the parafoveal retinal layers confirming toxicity
not appreciable with time-domain OCT
changes maybe visible prior to VF defects
Fundus autofluorescence may reveal subtle RPE defects with reduced autoFL or show areas of early photoreceptor damage
MF-ERG can objectively document localized paracentral ERG depression in early retinopathySlide49
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Normal Retina:
VF/OCT/ERG
Outer Nuclear Layer
PIL
PIL=PR Integrity Line
TD-OCT
SD-OCTSlide50
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Mild
Maculopathy
PIL
Thinned Outer Nuclear Layer
Paracentral Scotomas
Normal Foveal PeakSlide51
Copyright restrictions may apply.
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.
Bull
’
s Eye Maculopathy
Remnant of PIL
RPE Atrophy
Flattened Foveal Peak
Dense Para/Central DefectsSlide52
Revised Recommendations on Screening for Retinopathy
Factors Increasing Risk of Retinopathy
Duration of use
> 5 years
Cumulative Dose
> 1000 g (total)
Daily Dose
> 400 mg/day
Age
Elderly
Systemic Disease
Kidney or liver dysfunction
Ocular Disease
Retinal disease or maculopathySlide53
Revised Recommendations on Screening for Retinopathy
Older literature focused on daily dose/kg whereas newer literature emphasizes cumulative dose as the most critical factor
Initial baseline then screening for toxicity should be initiated no later than 5 years after starting the medicationSlide54
SD-OCT 5 Line Raster Scans
OD
OSSlide55
Case 4 Slide56
Vesta: 61 y/o Hatian Female
GL suspect 2001 – suspicious ON’s
NTG
since
2006Meds: Alphagan P bid OU, latanoprost qhs
OUMedical Hx: HTN, HIV (+) for > 15 yrsVA: 6/6 (20/20)
TA for the past 3 or 4 yrs: 9-13 mmHg OULast 2 visits 9 mmHg – today 13Pachs: 450 microns
Case Courtesy of Dr. Mark DunbarSlide57
2010
Case Courtesy of Dr. Mark Dunbar
OD
OS
2012
What’s This???Slide58
RE
OD
OS
2010
2011
2012
Case Courtesy of Dr. Mark DunbarSlide59Slide60
GPA Progression Analysis ODSlide61
GPA Progression Analysis OSSlide62
Vesta: 61 y/o Hatian Female
NTG OU with thin corneas
OS:
Optic Nerve
and HVF show trend towards progression….
OCT shows no change
Case Courtesy Dr. Mark DunbarSlide63
Vesta: 61 y/o Hatian Female
How do you manage this patient?
Currently on
latanoprost
and alphagan OUThis is what was done….Stopped
Alphagan P Switch to Combigan bid OUContinue with l
atanoprost qhs OURTC 1 mo
Case Courtesy of Dr. Mark DunbarSlide64
OCT Retinal Images Slide65
Cirrus
Pigment Epithelial Detachment
Cystoid Macular EdemaSlide66
Cirrus
Exudative AMD
Macular HoleSlide67
Cirrus
Vitreomacular
Traction
Epiretinal
MembraneSlide68
Cirrus
Central Serous
Chorioretinopathy
Diabetic Macular EdemaSlide69
Thank You!
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