why is imaging critical in my uveitis practice? · 1 developed in collaboration why is imaging...

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Developed in collaboration

Why Is Imaging Critical in My Uveitis Practice?

Dilraj S. Grewal, MD

Multimodal Imaging

FP

OCT

OCTA

FA (WF)ICGA

B-scan

FAF

Imaging Is the Backbone of Uveitis Workup and Monitoring Treatment Response

Abbreviations:

• FP = fundus photography

• OCT = optical coherence tomography

• OCTA = optical coherence tomography angiography

• FA (WF) = fluorescein angiography (wide field)

• ICGA = indocyanine green angiography

• B-scan = B-scan ultrasound

• FAF = fundus autofluorescence

Pichi F, et al. Prog Retin Eye Res. 2017;59:178-201; Denniston AK, et al. Invest Ophthalmol Vis Sci. 2017;58:BIO131-40; Gangaputra S, et al. Ocul Immunol Inflamm. 2017;25:160-8.

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Young Woman With Decreased Vision OU x 1 Week

Agarwal A, et al. Clin Exp Ophthalmol. 2018;46:62-74.

20/60 20/80Case 1

External Examination: Malar Butterfly Rash

Retinal vasculitis in macula is urgently vision threatening

FA Is Critical to Assess Severity of Retinal Vasculitis

Tolba DA, et al. Ocul Immunol Inflamm. 2017;25:884-90; Lee JH, et al. Clin Exp Rheumatol. 2013;31:871-6.

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Hyperreflective Foci

Subretinal Fluid

OCT• Possible OCT markers

as VA surrogates:

– External limiting membrane integrity

– Ellipsoid zone integrity

– Hyperreflective foci

– Subretinal fluid

– Pattern of cystoid macular edema (cystoid > diffuse)

– Disorganization of retinal inner layers

Grewal DS, et al. Am J Ophthalmol. 2017;177:116-25; Pelosini L, et al. Invest Ophthalmol Vis Sci. 2011;52:2741-8; Sugar EA, et al. Am J Ophthalmol. 2011;152:1044-52.e5.

After Treatment for 6 Months With Cyclophosphamide

20/20 OU Few residual HRFNo DRIL

Shulman S. Lupus. 2017;26:1420-5.

External exam: resolution of malar/periocular rash Micro NFL infarcts can cause NFL loss and VF defects

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OCT Biomarkers

Reduction in Choroidal Thickness

After Initiation of Therapy

Punctate Inner Choroiditis

EDI OCT: Monitoring Changes in Choroidal Thickness

Agrawal R, et al. Int Ophthalmol. 2018;38:993-1002.

20/100

20/30

20/20

Vogt-Koyanagi-Harada Disease: Monitor Choroidal Thickness on EDI OCT

Jap A, et al. Br J Ophthalmol. 2017;101:186-9; da Silva FT, et al. Br J Ophthalmol. 2013;97:70-4.

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Pediatric Patient With Floaters and Decreased Vision OD

20/200 20/20Case 2

Intermediate Uveitis With Perivascular Leakage

Improvement in disc and perivascular

leakage with treatment

Can obtain oral fluorescein in children

Patel M, et al. Curr Opin Ophthalmol. 2014;25:213-20; Tsui I, et al. Ophthalmic Surg Lasers Imaging Retina. 2013;44:59-67.

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OCT to Visualize Vitreous Cells

Keane PA, et al. Ophthalmology. 2014;121:1706-14.20/20

20/2020/40

Middle-Aged Man With Shadow in Vision OD x 3 Months

Case 3

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20/3020/40Case 3Treatment response with reduction of hyperautofluorescence

FAF TB-Associated Serpiginous-Like Choroiditis

6 months post-treatment with INH and rifampin and 6-week course of tapering steroids

Using ICGA

Immunosuppressed Man With

Cryptococcal Choroiditis

Case 4 Reprinted with permission. Vu DM, et al. RetinCases Brief Rep. 2018. doi: 10.1097/ICB.0000000000000703. Accessed October 29, 2018 [Epub ahead of print]

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Immunosuppressed Man With Cryptococcal Choroiditis• OCTA shows

choriocapillaris flow voids, which colocalize with areas of hypocyanescence on ICG

Reprinted with permission. Vu DM, et al. Retin Cases Brief Rep. 2018. doi: 10.1097/ICB.0000000000000703. Accessed October 29, 2018 [Epub ahead of print]

OCTA-ICG Overlay

OCTA-ICG Colocalization

OCT and OCTA to monitor response to anti-VEGF treatmentOCTA

RETCAM FA

High flow lesion

OCTA: Inflammatory CNV

Agarwal A, et al. J Ophthalmic Inflamm Infect. 2018;8:13.

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Photo FAF OCTA Choriocapillaris Slab

Flow voids

Serpiginous Choroiditis: OCTA Shows Nonperfusion in Choriocapillaris

Borrelli E, et al. Prog Retin Eye Res. 2018. [Epub ahead of print]; El Ameen A, et al. Retin Cases Brief Rep. 2018;12:279-85.

OCTA in Retinal VasculitisChurg-Strauss Syndrome

Spaide RF. Retina. 2017;37:1034-42.

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© 2018

Unless otherwise indicated, photographed subjects who appear within the content of this activity or on artwork associated with this activity are models;

they are not actual patients or doctors.

Imaging in Uveitis: Abbreviations and Acronyms B-scan = B-scan ultrasound CME = cystoid macular edema CNV = choroidal neovascularization DRIL = disorganization of retinal inner layers EDI = enhanced depth imaging FA = fluorescein angiography FAF = fundus autofluorescence FP = fundus photography HRF = hyperreflective foci ICGA = indocyanine green angiography INH = isoniazid NFL = nerve fiber layer OCT = optical coherence tomography OCTA = optical coherence tomography angiography OD = oculus dexter (right eye) OS = oculus sinister (left eye) OU = oculus uterque (both eyes) TB = tuberculosis VA = visual acuity VEGF = vascular endothelial growth factor VF = visual field WF = wide field