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NEW INSTRUMENTS/CASE DISCUSSION

NEW INSTRUMENTS/CASE DISCUSSION. Speaker M Jayasree Moderators J Manju Anju. Contents. Optical Coherence Tomography Microperimetry Multifocal Electroretinogram Glaucoma Diagnostics GDx HRT GLAUCOMA OCT HVF.

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NEW INSTRUMENTS/CASE DISCUSSION

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  1. NEW INSTRUMENTS/CASE DISCUSSION Speaker M Jayasree Moderators J Manju Anju

  2. Contents • Optical Coherence Tomography • Microperimetry • Multifocal Electroretinogram • Glaucoma Diagnostics • GDx • HRT • GLAUCOMA OCT • HVF

  3. OCULAR COHERENCE TOMOGRAPHY PRINCIPLE • Optical involves light and optics Used for Optical biopsy of retina. • Coherence– two light beams of same wave length in phase. Uses principle of low coherence interferometry. • Tomography Tome/Tomo – Greek for section /cutting

  4. SDOCT Resolution – 6 microns Wavelength – 840 nm 3-D imaging No movement artifacts 25,000 A-scans/second Determining and visualizing structure that absorb and scatter light Noncontact Noninvasive

  5. Indications • Retinal- macula and Optic nerve. • Inconclusive FFAs- done together. • Quantify extent of lesions ex-CNVM, thickness of macula. • Quantify RNFL thickness around Optic nerve head.

  6. Hypo reflectivity Hyper reflectivity Above the NFL Posterior Hyaloid ,Epiretinal Membrane,Blood In the NFL Inflammation, Cotton Wool Spots, Blood Vessels, Flame Shaped Hemorrhages In the nuclear and plexiform layers Hard Exudates, Dot Blot Hemorrhages In the RPE CC layer Hyperpigmentation, CNV In the sub RPE layer Drusens, Blood, Fibrosis In the choroids Scar, Transmission Absence Edema Cystoid spaces Fluid – serous

  7. NORMAL VITREO RETINAL INTERFACE • NORMAL FOVEAL CONTOUR WITH FOVEAL DIP • INNER RETINAL RETINAL LAYERS ARE NORMAL • NORMAL RPE CC COMPLEX • FOVEAL THICKNESS

  8. NORMAL VITREO RETINAL INTERFACE • FOVEAL CONTOUR ALTERED • THICKENED HYPERREFLECTIVE INNER LAYERS • E/O SRF , SUGGESTIVE OF ACTIVE CNVM WITH CYSTIC SPACES IN THE INNER RETINAL LAYERS

  9. THICK ERM NOTED • ALTERED FOVEAL CONTOUR • LARGE CNVM, NO E/O SRF SUGGESTIVE OF SCARRED CNVM

  10. THIN ERM • ELEVATED FOVEAL CONTOUR • THICKENED AND HIGH REFLECTIVE MEMBRANE NOTED SUBFOVEALLY • NO E/O SRF,SUGGESTIVE OF SCARRED CNVM • SMALL DRUSENOID PED

  11. WRINKLED ILM • ALTERED FOVEAL CONTOUR • INNER RETINAL LAYERS ARE THICK AND CYSTIC SPACES • THICKENED AND HIGH REFLECTIVE RPE-CC COMPLEX WITH MULTIPLE PED

  12. NORMAL VITREO RETINAL INTERFACE • FOVEAL CONTOUR ELEVATED AND THINNED • HYPER REFLECTIVE INNER LAYES • CSR • SEROUS PED

  13. NORMAL VITREO RETINAL INTERFACE • FOVEAL CONTOUR ALTERED • HEMORRHAGIC PED

  14. WRINLED ILM • FOVEAL CONTOUR ALTERED • CYSTIC SPACES IN THE INNER RETINAL LAYERS • SEROUS AND FIBROUS PED

  15. INCOMPLETE POSTERIOR VITREOUS DETACHMENT • FOVEAL CONTOUR ALTERED • FIBROVASCULAR PED

  16. INCOMPLETE POSTERIOR VITREOUS DETACHMENT • FOVEAL CONTOUR ALTERED • DRUSENOID PED

  17. NORMAL VITREO RETINAL INTERFACE • FOVEAL CONTOUR ALTERED • HARD EXUDATES IN THE INNER RETINAL LAYERS • NORMAL RPE CC COMPLEX

  18. NORMAL VITREO RETINAL INTERFACE • FOVEAL CONTOUR ALTERED • DIFFUSE HARD EXUDATES IN THE INNER RETINAL LAYERS • NORMAL RPE CC COMPLEX

  19. NORMAL VITREO RETINAL INTERFACE • CSME CME FOVEOLAR DETACHMENT • THICKENED HYPER REFLECTIVE CYSTIC SPACED INNER LAYERS • NORMAL RPE-CC COMPLEX

  20. NORMAL VITREO RETNAL INTERFACE • FOVEAL CONTOUR ELEVATED/THINNING • NEURO SENSORY DETACHMENT • SRF, SUGGESTIVE OF CSR • NORMAL RPE COMPLEX

  21. ERM WITH ILM FOLDS • FOVEAL CONTOUR ALTERED • INNER RETINAL THICKENED • NORMAL RPE CC COMPLEX

  22. ERM WITH WRINKLING ILM • LAMELLAR MACULAR HOLE • THIN INNER RETINAL LAYERS • NORMAL RPE COMPLEX

  23. FULL THICKNESS MACULAR HOLE WITH OPERCULUM

  24. COMPLETE POSTERIOR VITREOUS DETACHMENT • VITREOUS TRACTION RELEASED

  25. NORMAL VITREO RETINAL INTERFACE • FOVEAL SCHISIS • THINNED CYTIC SPACES INNER LAYERS • RPE ALTERED

  26. FOVEAL CONTOUR ALTERED • OPTIC DISC PIT

  27. OPTIC DISC PIT MACULOPATHY

  28. VITREO MACULAR TRACTION

  29. Case 1 PRE TREATMENT • DATE OF VISIT 22/08/08 • BCVA OS 6/36, N36 • SL OS WNL • FUNDUS OS CNVM, SUB RETINAL HEAMORRHAGE • OCT OS E/O SRF , SUGGESTIVE OF ACTIVE CNVM WITH CYSTIC SPACES IN THE INNER RETINAL LAYERS OS INJ AVASTIN GIVEN THRICE POST TREATMENT • DATE OF VISIT 22/11/08 • BCVA OS 6/12, N8 • SL OS WNL • FUNDUS OS SCARREDCNVM, • OCT OS NO E/O SRF , SUGGESTIVE OF SCARRED CNVM WITH CYSTIC SPACES IN THE INNER RETINAL LAYERS

  30. PROGNOSIS HOLE FORM FACTOR • HFF > 0.9 - 100 % PRIMARY CLOSURE • HFF = 0.5 - 67 % PRIMARY CLOSURE • HFF < 0.5 - Poor closure rates • HIGHER HFF - BETTER POST OP VA

  31. CASE 2 PRE TREATMENT • DATE OF VISIT (25/09/08) • BCVA OS 6/48(ECC VIEW), N24 • S/L OS NO ABNORMALITY • FUNDUS OS FTMH • OCT OS FULL THICKNESS MACULAR HOLE WITH COMPLETE PVD POST TREATMENT S/P VIT+C3F8 UNDER GA • DATE OF VISIT (6/12/08) • BCVA OS 6/12+, N8 • S/L OS WNL • FUNDUS OS • OCT OS

  32. Multifocal Electroretinogram (mfERG) in Retinal Disorders

  33. Multifocal electroretinogram • Simultaneous recording of focal retinal responses • Offers direct, objective and topographical mapping of central 36-40º of retinal function • Cone driven responses • Fovea, Para fovea and near peripheral photopic retina function can be evaluated.

  34. mfERG Stimulus • Display contains array of hexagons- • Commonly used 103 hexagonal array • Scaling basis - Photoreceptor density • Produce local retinal responses of equal amplitude • Flickers according to pseudorandom binary m-sequence

  35. 1.6° 1.6°- 6° 6°-11.4° 11.4°-18.2° 18.2°-26.2° • 26.2°-35° • Waveforms grouping according to different retinal eccentricities • Subtends 35° horizontally and 31° vertically – viewing distance 53cm • The responses obtained from six zones

  36. First order kernel responses- Interpretation Multiplot Trace Array

  37. mfERG Components Parameters • N1 – First negative trough • P1- First positive Peak • Origins • Cone Photoreceptors • Dominated by on and off bipolar cells P1-IT P1- AMP N1- IT N1-AMP

  38. Interpretation • Degenerative photoreceptor disease • Larger delay in implicit times • Local lesions damaging INL • Larger reduction in amplitudes • Damage to NFL or GCL • No reduction or delay

  39. Clinical applications • To distinguish retinal diseases from optic nerve disease • Details extent of lesion • Sensitive indicator for retinal drug toxicity • Post-operative management following V-R surgery • Assess sub-clinical retinal changes in DR

  40. Case 1 Stargardt’s disease Few yellowish flecks at the macula

  41. FullfieldERG

  42. Multifocal ERG – Trace array

  43. Multiplot Crater like defect - MfERG delineates the macular pathology

  44. Case 2 Cone Dystrophy

  45. FullfieldERG

  46. Multifocal ERG – Trace array

  47. Multiplot

  48. Case 3

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