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Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 PowerPoint Presentation
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Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 th February 2012. Anil Arora. What you might rather be doing. What you might feel like right now. 100 Things To Do Before You Die (www.bucketquiz.com).

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slide1

Overview Of Retinal ConditionsClinical and OCT FindingsCentral Coast Day HospitalInaugural Optometrist Conference26th February 2012

Anil Arora

100 things to do before you die www bucketquiz com
100 Things To Do Before You Die (www.bucketquiz.com)
  • Give your mother a dozen red roses and tell her you love her.
  • Shower in a waterfall.
  • Sleep under the stars.
  • Fart in a crowded space
  • Give to a charity.
  • Run a marathon.
  • Reflect on your greatest weakness, and realize how it is your greatest strength.
  • Attend a Sunday morning ophthalmology conference in Terrigal -especially any lectures on retinal conditions and OCT
slide5
Shows accumulation of fluid within the retina and below the retina

Changes in the neurosensory retina

Cystic changes

Alteration of contour or thickness

Vitreous – retinal interface abnormalities

Irregularity or elevation of the RPE

Quantification of the abnormalities and measurement of treatment response

OPTICAL COHERENCE TOMOGRAPHY IN RETINAL DISEASES

normal macula
Normal macula
  • Foveal depression
  • Symmetrical contour
  • Normal thickness of fovea and perifoveal tissues
  • Flat and regular RPE
important retinal conditions
Important Retinal Conditions
  • Age-related macular degeneration
  • Diabetic retinopathy
  • Retinal detachment and predisposing diseases
  • Central and branch retinal vein occlusion
  • Macular hole
  • Epiretinal membrane
  • Vitreomacular traction syndrome
  • Central serous retinopathy
age related macular degeneration
Age-Related Macular Degeneration
  • Leading cause of blindness in the elderly
  • Prevalence rate rises sharply with each decade
  • In Australia there are about 5 million people 50+
    • ~ 15% of these will have

age-related macular changes

    • 1- 2% or 50-100,000 of these

will have significant vision loss from

geographic atrophy or from

exudative changes

exudative macular degeneration
Exudative Macular Degeneration
  • EXAMINATION
  • Visual acuity
    • Variable – depends on size and location of haemorrhage/exudation
  • Amsler grid testing
  • Fundus examination
    • Haemorrhage
    • Elevation by subretinal fluid/blood
    • Drusen
    • Pigment changes/atrophy/scarring
drusen
Drusen
  • Accumulation of debris between the RPE and Bruch’s membrane
slide12

Exudative changes –SRF and sub-RPE fluid

Fovea

SRF

RPE

SRF and RPE detachment

RPE thinned and irregular

slide13

Serous PED

b

PED – serous and fibrovascular

dépression fovéale

Fovea

RD

DSR

DEP

PED

Occult

Fibro vascular PED

role of oct in armd
Role of OCT in ARMD
  • Evaluation of exudative changes
  • Quantification of retinal thickness
  • Response to treatment with anti-VEGF agents
diabetic retinopathy
Diabetic Retinopathy
  • Presence of diabetic microvascular lesions
  • Most frequent ocular complication of DM
  • 1/3rd rule – About 1/3rd of all diabetics have some degree of retinopathy and in about 1/3rd of these have sight-threatening disease
  • After 15 years about 70% of people with diabetes will have some retinopathy
risk factors for retinopathy
Risk Factors For Retinopathy
  • Development of diabetic retinopathy related to:
    • Duration of diabetes
    • Glycaemic control
    • Hypertension management
    • Serum lipids and cholesterol
    • Other factors eg. pregnancy, nephropathy
diabetic retinopathy1
Diabetic Retinopathy
  • Two types of retinopathy
  • Nonproliferative retinopathy (NPDR)
    • Early stage diabetic retinopathy
  • Proliferative retinopathy (PDR)
    • Later stage diabetic retinopathy
nonproliferative diabetic retinopathy npdr
Nonproliferative Diabetic Retinopathy (NPDR)
  • Also called background diabetic retinopathy.
  • Earliest stage of diabetic retinopathy.
  • Damaged blood vessels in the retina leak fluid and blood into the eye.
  • Cholesterol or other fat deposits from blood, called hard exudates, may leak into retina.

Top: Healthy retina

Bottom: NPDR with hard exudates

proliferative diabetic retinopathy
Proliferative Diabetic Retinopathy
  • Characterised by the growth of new blood vessels in response to tissue hypoxia
  • NVD – new vessels at or within 1 DD of the optic disc
  • NVE – new vessels elsewhere in the retina
  • Can lead to:
    • Vitreous haemorrhage
    • Tractional retinal detachment
proliferative diabetic retinopathy2
Proliferative Diabetic Retinopathy

With PDR, vision is affected when any of the following occur:

  • Vitreous haemorrhage
  • Traction retinal detachment
  • Neovascular glaucoma

Vitreous haemorrhage

diabetic macular oedema
Diabetic Macular Oedema
  • Most common cause of decreased vision and blindness in diabetic retinopathy
  • Indicated by findings of microaneurysms, haemorrhages or hard exudates within 2DD of the fovea
  • CSME (Clinically significant macular oedema) Complicated definition, but basically retinal thickening or hard exudates within 500 um of the fovea
slide24

Macular oedema

OCT scan showing macular oedema

role of oct in diabetic retinopathy
Role of OCT in Diabetic Retinopathy
  • Confirm clinical suspicion of macular oedema
  • Quantification of extent of oedema
  • Diagnosis of macular traction and localised macular tractional retinal detachment in cases of proliferative retinopathy
  • Evaluation of response to treatment – laser and /or intravitreal Avastin/Triamcinolone
retinal detachment
Retinal Detachment
  • Often preceded by a vitreous detachment with patient seeing flashes and floaters
  • Usually starts as a blurring or loss of peripheral vision in one area that progresses centrally
  • More likely in those with a history of
    • Myopia
    • Ocular trauma or surgery
retinal detachment1
Retinal Detachment
  • Most commonly due to a posterior vitreous detachment with a retinal tear developing
  • About 10% of PVD develop a retinal tear
  • Risk of tear much higher if blood or pigmented cells present in vitreous
retinal detachment2
Retinal Detachment
  • If a retinal tear is found before the retina detaches, it can often be treated with laser photocoagulation or cryotherapy or a combination of these.
retinal detachment5
Retinal Detachment
  • Surgical Management
  • Scleral buckle/cryotherapy
  • Vitrectomy
    • +/- buckle/cryotherapy
    • +/- endolaser
    • +/- intraocular gas
    • +/- silicone oil
    • +/- perfluorocarbon liquid
  • Pneumatic retinopexy
    • In-rooms procedure
    • Gas injection and positioning
role of oct in retinal detachment
Role of OCT in Retinal Detachment
  • Very limited role as the diagnosis is clinical and treatment in most cases is surgical
  • Useful in assessing reason for poor vision following retinal detachment repair with anatomical reattachment of the retina.
  • May show:
    • Persistent macular oedema/subretinal fluid
    • Damage to photoreceptors
    • Thinned and atrophic retina
    • Epiretinal membrane
central retinal vein occlusion
Central Retinal Vein Occlusion
  • Common cause of visual loss
  • Usually history of hypertension
  • Two main forms
    • Non-ischaemic
    • Ischaemic
  • 75-80% non-ischaemic at presentation
  • 15% non-ischaemic may convert to ischaemic
  • 50% of ischaemic -->neovascular glaucoma
central retinal vein occlusion1
Central Retinal Vein Occlusion

Cause Of Visual Loss In CRVO

  • In non-ischaemic CRVO vision reduction due to macular oedema &/or haemorrhage
  • In ischaemic CRVO vision reduced from macular ischaemia or later by retinal neovascularization with vitreous haemorrhage or from neovascular glaucoma
central retinal vein occlusion2
Central Retinal Vein Occlusion

Management

  • Macular oedema
    • Intravitreal Avastin
    • Intravitreal triamcinolone / dexamethasone
    • Macular grid laser in younger patients (<60)
  • Ischaemia and neovascular complications
    • Panretinal photocoagulation
    • Anti-VEGF drugs
  • Management of hypertension and other cardiovascular risk factors
branch retinal vein occlusion
Branch Retinal Vein Occlusion
  • Usually occurs in patients 50 – 70 yo
  • Hypertension is the main risk factor (70%)
  • Occurs at an A-V crossing where vein and artery have a common adventitial sheath
  • Visual loss from macular

oedema, haemorrhage or

ischaemia

branch retinal vein occlusion1
Branch Retinal Vein Occlusion

Late Complications

  • Retinal or optic disc neovascularization with vitreous haemorrhage
  • Epiretinal membrane
  • Chronic macular oedema with formation of a foveal cyst or lamellar hole
  • “Atrophic maculopathy” from prolonged macular oedema or ischaemia
branch retinal vein occlusion2
Branch Retinal Vein Occlusion
  • Management
  • Intravitreal Avastin
  • Intravitreal triamcinolone or dexamethasone
  • Retinal laser
  • Manage hypertension and other risk factors
role of oct in rvo
Role of OCT in RVO
  • Assessment of macular oedema
  • Quantification of retinal thickness
  • Response of macular oedema to treatment with intravitreal agents and/or laser
  • Assessment of late complications – epiretinal membrane, lamellar hole
macular hole
Macular Hole
  • Central visual loss in elderly
  • VA usually 6/36 – 6/60
  • 5 – 10% bilateral
  • Treatment consists of vitrectomy, peeling of the cortical vitreous +/- internal limiting membrane peeling and intravitreal gas injection with one to two weeks of face-down positioning
slide43

Macular hole

OCT showing a macular hole before and after surgery

epiretinal membrane
Epiretinal Membrane
  • Usually idiopathic, seen in patients over 60
  • Sometimes after vein occlusion, inflammation
  • Variable effect on vision - blurring, distortion
  • May have associated cystoid macular oedema
  • Pseudohole – may look like macular hole
  • Retinal vessels irregular and tortuous
  • Vitrectomy and peeling if VA 6/18 or worse or even with better vision but troublesome distortion
epiretinal membrane2
Epiretinal membrane

Without pseudohole

With pseudohole

role of oct in macular hole and epiretinal membrane
Role of OCT in Macular Hole and Epiretinal Membrane
  • Clearly shows hole morphology
  • Differentiates full-thichness hole from lamellar hole or pseudohole
  • Demonstrates associated conditions such as macular oedema, macular cyst and vitreoretinal traction
  • Shows response to treatment eg. closure of macular hole, successful peeling of ERM
vitreomacular traction syndrome1
Vitreomacular traction syndrome
  • Traction on the retina by taut or contracted vitreous gel
  • May be part of a spectrum – VMT may be the result of antero-posterior traction while macular hole may be from tangential traction
  • Shows up well on OCT, sometimes in an asymptomatic patient with a normal retina
oct in vmt
OCT in VMT

More questions than answers?

The more you know the less you understand – LAO TSE

The more I learn, the more I learn how little I know - SOCRATES

  • Possible precursor to lamellar hole or macular hole/cyst ?
  • Possible precursor to epiretinal membrane formation?
  • Spectrum of vitreretinal interface disorders – VMT, ERM, macular cyst, lamellar hole, full-thickness macular hole
slide53
VMT

Treatment

  • Usually vitrectomy with removal of as much cortical vitreous as possible
  • ERM peel if ERM present
  • Intraocular gas fill and face down positioning
  • OCT useful to demonstrate post-op macular structure and release of traction
central serous retinopathy
Central Serous Retinopathy
  • CSR
    • Usually middle-aged male
    • Central visual blur/distortion
    • Micropsia
    • Association with “stress”
    • Can be subtle and easily missed on clinical examination
    • Vast majority recover
oct in csr
OCT in CSR
  • Shows extent of SRF very well – able to show patient
  • Can monitor progress of disease with serial OCT
  • Does not show leakage site in RPE. Need fluorescein angiography
conclusion
Conclusion
  • Multitude of common and important retinal conditions
  • Clinical diagnosis and an understanding of the potential severity of the condition are vital to good outcomes
  • OCT adds to our ability to diagnose and manage retinal diseases and is increasing our understanding of these conditions
question 1
Question 1

OCT is useful in exudative (“wet”) ARMD for all the following reasons EXCEPT:

  • Confirming the presence of subretinal or sub-RPE fluid
  • Assessing and quantifying the amount of fluid present
  • Assessing the size and activity of the choroidal neovascular membrane
  • Assessing response of the exudative changes to treatment
question 2
Question 2

OCT is useful in diabetic retinopathy to:

  • Assess the size and number of diabetic microaneurysms
  • Assess hard exudates and cotton-wool spots
  • Assess retinal and/or optic disc new vessels
  • Assess diabetic macular oedema
question 3
Question 3

Retinal detachment:

  • Is most commonly due to a posterior vitreous detachment with a retinal tear
  • Is best managed by monitoring with regular OCT examinations
  • Is most common in those with a history of hypertension
  • Usually resolves without treatment over several months
question 4
Question 4

The following are true about epiretinal membranes EXCEPT:

  • Can result in blurring and distortion of central vision
  • If visually symptomatic they should be treated with laser photocoagulation
  • May be associated with cystoids macular oedema
  • May spontaneously separate from the retina
question 5
Question 5

Central serous retinopathy:

  • Results in loss of central vision if not treated
  • Is managed by using OCT to find the leakage site
  • Is usually due to a leak at the level of the RPE
  • Is typically a disease of elderly females