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Similar a A macular pathology and oct update for optometrists
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A macular pathology and oct update for optometrists
- 1. An u p d ate on m acu lar p ath ology
- 2. Talk summary • Clinical signs – Retinal haemorrhage and differential diagnosis – The cotton wool spot – Exudate vs Drusen • OCT signs – Basics of OCT interpretation – When to refer – Some rare cases
- 3. Retinal haemorrhage, what depth? • Vitreous • Pre retinal • Intraretinal (superficial and deep) • Sub retinal • Sub RPE • More than one level
- 4. Vitreous haemorrhage • Poor fundal view / poor red reflex • Pulling on blood vessel – Retinal tear with PVD or trauma – Proliferative diabetic retinopathy / BRVO • “Break through” bleeding – Severe wet AMD – Retinal macroaneurysm
- 5. Pre retinal haemorrhage (boat shaped) Haemorrhage limited by extent of vitreous separation Masks retinal blood vessels
- 6. Superficial intra retinal haemorrhage (flame shaped) Confined by nerve fibre layer, masks retinal blood vessels
- 7. Deep intra retinal haemorrhage (dot and blot) May be in front of or behind the retinal blood vessels
- 8. Sub retinal haemorrhage (round) retinal blood vessels visible Sub RPE haemorrhage similar but darker
- 9. The “cotton wool spot” Think – Hypertension, Diabetes, Smoker Rarely – HIV retinopathy, SLE What is this?
- 10. Exudate vs drusen If exudate is present there must be signs of leakage from abnormal blood vessels (micro or macroaneurysms, CNV)
- 11. Life is not that simple What is this?
- 12. Principles of the OCT • Based on interferometry – Interference between incident and reflected light • Like doing a vertical biopsy of the retina – Use laser light rather than knife! • Resolution down to 10 microns • Nerve fibre layer and RPE well defined • Good at showing swelling due to leakage • FFA still needed for showing blockage
- 13. Confusing but important terms • Inner retina – Next to vitreous cavity – Nerve fibre layer – Interconnecting neurons • Outer retina – Next to choroid – Rods and cones – RPE
- 14. Retina pathology often in layers • Inner retina – Diabetic retinopathy – Retinal vein occlusion • Outer retina – AMD – CSR
- 15. OCT pathology often in layers • Retinal surface – Vitreo-macular traction – Epiretinal membrane • Inner retina – Diabetic retinopathy – Retinal vein occlusion • Outer retina – AMD – CSR
- 16. Retinal pathology in more than one layer • Macular hole – All layers involved (full thickness) • Lamellar hole – Usually surface and inner retina • Severe retinal disease – Wet AMD – Diabetic eye disease – Retinal vein occlusions
- 17. Central macular thickness • Can be difficult to assess function on thickness alone • Normal thickness = 200 microns • Thick retina > 250 microns – Usually due to leakage • Thin retina < 150 microns – Atrophic with poor function
- 18. The photoreceptor integrity line • Junction between inner and outer segments • Barely visible in histological sections • Highly prominent with OCT • Due to difference in index of refraction of the inner and outer segments
- 19. Assess retinal function • Thick retina = oedema • Thin retina = atrophic retina • Normal thickness retina – how is it functioning? • Well demarcated IS/OS junction suggest good photoreceptor function
- 20. Vitreo-macular traction • Posterior vitreous pulling on macula • Wide range of severity • If incidental OCT finding and patient asymptomatic – do not refer
- 21. Severe Vitreo-macular traction 0.5 LogMAR “Pointed - being Pulled”
- 22. Mild Vitreo-macular traction Inner retinal cyst 0.12 LogMAR
- 23. Epiretinal membrane • Posterior vitreous usually detached • Sometimes associated with lamellar hole • Wide range of severity • If incidental OCT finding and patient asymptomatic – do not refer
- 24. Lamellar macular hole with ERM Note ERM with “saw tooth sign” Lamellar macular hole Note healthy IS / OS junction Visual acuity is 0.12 No symptoms
- 25. Mild epiretinal membrane 0.1 LogMAR Loss of foveal pit
- 26. Lamellar macular hole with ERM 0.1 LogMAR Asymptomatic
- 27. ERM with lamellar hole No symptoms -0.1 LogMAR Good IS / OS junction
- 28. Basics of diabetic retinopathy • Retinal blood vessels involved • Inner retina first involved • Fluid – Intra retinal (including cystoid oedema) – Sub retinal if severe – No Sub RPE fluid • Hard exudates – Highly reflective intraretinal spots • RPE looks ok
- 29. Basics of diabetic retinopathy
- 30. Basics of retinal vein occlusions • Retinal blood vessels involved • Inner retina first involved • Fluid – Intra retinal (including cystoid oedema) – Sub retinal if severe – No Sub RPE fluid • Hard exudates – Less frequently seen than in diabetics • RPE looks ok
- 31. Basics of retinal vein occlusions
- 32. Basics of dry AMD Drusen “Lumpy bumpy” RPE
- 33. Basics of dry AMD RPE atrophy High signal beneath RPE Thin retina
- 34. Basics of Wet AMD • Blood vessels from choroid • Outer retina first involved • Fluid – Sub RPE – Sub Retinal – Intra retinal (includes cystoid oedema) • Usually previous dry AMD – Look at RPE line as rarely “pristine”
- 35. Basics of Wet AMD Sub RPE fluid Intra retinal fluid Sub retinal fluid Note previous dry changes
- 36. “Burnt out” Wet AMD Scarring and chronic leakage
- 37. Basics of CSR • Leakage from choroid • Fluid – Sub Retinal • RPE – May be small PED associated – Remaining RPE looks healthy
- 38. Basics of CSR
- 39. Full thickness macular hole
- 40. Spontaneous improvement in a full thickness macular hole 0.0 LogMAR 0.1 LogMAR
- 41. Post macular hole op 0.32 LogMAR
- 42. Ask yourself • Anything on the surface? • Is it mainly inner or outer retina or both? • How does the RPE look? • How well demarcated is the IS /OS line?
- 43. Small BRVO or wet AMD at macula? • BRVO – Inner retina (inner and outer if severe) – RPE normal – IS / OS may be preserved • Wet AMD – Outer retina (inner and outer if severe) – RPE abnormal – IS / OS disrupted
- 44. Pre and post Ozurdex in macular oedema from vein occlusion 0.5 LogMAR 0.3 LogMAR
- 45. Pre and post Ozurdex in diabetic
- 46. Sept 2011 Feb 2012 April 2012 Ozurdex for CRVO
- 47. What is this?
- 49. Adult vitelliform dystrophy 0.22 LogMAR OS 0.0 LogMAR OD Intact IS / OS junction
- 50. What is this and what is the vision?
- 51. Macula schisis 0.0 LogMAR 0.1 LogMAR Intact IS / OS junction Intact IS / OS junction
- 52. What is this?
- 53. It was due to this !
- 54. What is this?
- 55. Optic disc pit maculopathy
- 56. Retinitis pigmentosa Pre – Sub Tenon’s steroid Post injection “Bell shape – from Below” Note thin retina No IS / OS junction