Overview Of Retinal Overview Of Retinal ConditionsConditions

Clinical and OCT FindingsClinical and OCT Findings

Central Coast Day HospitalCentral Coast Day HospitalInaugural Optometrist Inaugural Optometrist

ConferenceConference2626thth February 2012 February 2012

Anil AroraAnil Arora

What you might rather be What you might rather be doingdoing

What you might feel like right What you might feel like right nownow

100 Things To Do Before You 100 Things To Do Before You DieDie

(www.bucketquiz.com) (www.bucketquiz.com) Give your mother a dozen red roses and tell her you Give your mother a dozen red roses and tell her you

love her. love her. Shower in a waterfall. Shower in a waterfall. Sleep under the stars. Sleep under the stars. Fart in a crowded spaceFart in a crowded space Give to a charity. Give to a charity. Run a marathon. Run a marathon. Reflect on your greatest weakness, and realize how it Reflect on your greatest weakness, and realize how it

is your greatest strength.is your greatest strength. Attend a Sunday morning ophthalmology conference Attend a Sunday morning ophthalmology conference

in Terrigal -especially any lectures on retinal in Terrigal -especially any lectures on retinal conditions and OCTconditions and OCT

Shows accumulation of fluid within the retina and Shows accumulation of fluid within the retina and below the retina below the retina

Changes in the neurosensory retina Changes in the neurosensory retina Cystic changesCystic changes Alteration of contour or thicknessAlteration of contour or thickness

Vitreous – retinal interface abnormalitiesVitreous – retinal interface abnormalities Irregularity or elevation of the RPEIrregularity or elevation of the RPE Quantification of the abnormalities and Quantification of the abnormalities and

measurement of treatment responsemeasurement of treatment response

OPTICAL COHERENCE TOMOGRAPHY IN RETINAL DISEASES

Optical coherence Optical coherence tomographytomography

Normal maculaNormal macula

Foveal depressionFoveal depression Symmetrical Symmetrical

contourcontour Normal thickness Normal thickness

of fovea and of fovea and perifoveal tissuesperifoveal tissues

Flat and regular Flat and regular RPERPE

Important Retinal Important Retinal ConditionsConditions

Age-related macular degeneration Age-related macular degeneration Diabetic retinopathyDiabetic retinopathy Retinal detachment and predisposing Retinal detachment and predisposing

diseasesdiseases Central and branch retinal vein Central and branch retinal vein

occlusionocclusion Macular holeMacular hole Epiretinal membraneEpiretinal membrane Vitreomacular traction syndromeVitreomacular traction syndrome Central serous retinopathyCentral serous retinopathy

Age-Related Macular Age-Related Macular DegenerationDegeneration

Leading cause of blindness in the elderlyLeading cause of blindness in the elderly Prevalence rate rises sharply with each decadePrevalence rate rises sharply with each decade In Australia there are about 5 million people In Australia there are about 5 million people

50+50+ ~ 15% of these will have ~ 15% of these will have

age-related macular changesage-related macular changes 1- 2% or 50-100,000 of these1- 2% or 50-100,000 of these

will have significant vision loss fromwill have significant vision loss from

geographic atrophy or fromgeographic atrophy or from

exudative changesexudative changes

Exudative Macular Exudative Macular DegenerationDegeneration

EXAMINATIONEXAMINATION Visual acuityVisual acuity

Variable – depends on size and Variable – depends on size and location of location of haemorrhage/exudationhaemorrhage/exudation

Amsler grid testingAmsler grid testing Fundus examinationFundus examination

HaemorrhageHaemorrhage Elevation by subretinal Elevation by subretinal

fluid/bloodfluid/blood DrusenDrusen Pigment Pigment

changes/atrophy/scarringchanges/atrophy/scarring

DrusenDrusen Accumulation of Accumulation of

debris between debris between the RPE and the RPE and Bruch’s Bruch’s membranemembrane

SRF and RPE detachment

RPE thinned and irregular

RPE

SRF

Exudative changes –SRF and sub-RPE fluid

Fovea

PED – serous and fibrovascular

b

Serous PED

dépression fovéale

DEPDSR

Occult

Fovea

PED

RD

Fibro vascular PED

Role of OCT in ARMDRole of OCT in ARMD

Evaluation of Evaluation of exudative exudative changeschanges

Quantification of Quantification of retinal thicknessretinal thickness

Response to Response to treatment with treatment with anti-VEGF agentsanti-VEGF agents

Role Of OCT In ARMDRole Of OCT In ARMDResponse to treatmentResponse to treatment

Diabetic RetinopathyDiabetic Retinopathy

Presence of diabetic microvascular lesionsPresence of diabetic microvascular lesions Most frequent ocular complication of DMMost frequent ocular complication of DM 1/31/3rdrd rule – About 1/3 rule – About 1/3rdrd of all diabetics have of all diabetics have

some degree of retinopathy and in about some degree of retinopathy and in about 1/31/3rdrd of these have sight-threatening disease of these have sight-threatening disease

After 15 years about 70% of people with After 15 years about 70% of people with diabetes will have some retinopathydiabetes will have some retinopathy

Risk Factors For Risk Factors For RetinopathyRetinopathy

Development of diabetic retinopathy Development of diabetic retinopathy related to:related to: Duration of diabetesDuration of diabetes Glycaemic controlGlycaemic control Hypertension managementHypertension management Serum lipids and cholesterolSerum lipids and cholesterol Other factors eg. pregnancy, Other factors eg. pregnancy,

nephropathynephropathy

Diabetic RetinopathyDiabetic Retinopathy

Two types of retinopathyTwo types of retinopathy

Nonproliferative retinopathy (NPDR)Nonproliferative retinopathy (NPDR) Early stage diabetic retinopathyEarly stage diabetic retinopathy

Proliferative retinopathy (PDR)Proliferative retinopathy (PDR) Later stage diabetic retinopathyLater stage diabetic retinopathy

Nonproliferative Diabetic Nonproliferative Diabetic Retinopathy (NPDR)Retinopathy (NPDR)

Also called background Also called background diabetic retinopathy.diabetic retinopathy.

Earliest stage of diabetic Earliest stage of diabetic retinopathy.retinopathy.

Damaged blood vessels in Damaged blood vessels in the retina leak fluid and the retina leak fluid and blood into the eye.blood into the eye.

Cholesterol or other fat Cholesterol or other fat deposits from blood, called deposits from blood, called hard exudates, may leak hard exudates, may leak into retina.into retina.

Top: Healthy retinaTop: Healthy retina

Bottom: NPDR with Bottom: NPDR with hard exudateshard exudates

Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy

Characterised by the growth of new blood Characterised by the growth of new blood vessels in response to tissue hypoxiavessels in response to tissue hypoxia

NVD – new vessels at or within 1 DD of NVD – new vessels at or within 1 DD of the optic discthe optic disc

NVE – new vessels elsewhere in the retinaNVE – new vessels elsewhere in the retina Can lead to:Can lead to:

Vitreous haemorrhageVitreous haemorrhage Tractional retinal detachmentTractional retinal detachment

Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy

Proliferative Diabetic Proliferative Diabetic Retinopathy Retinopathy

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

Vitreous haemorrhage Vitreous haemorrhage Traction retinal Traction retinal

detachment detachment Neovascular glaucoma Neovascular glaucoma

Vitreous Vitreous haemorrhagehaemorrhage

Diabetic Macular OedemaDiabetic Macular Oedema

Most common cause of decreased vision Most common cause of decreased vision and blindness in diabetic retinopathyand blindness in diabetic retinopathy

Indicated by findings of Indicated by findings of microaneurysms, haemorrhages or hard microaneurysms, haemorrhages or hard exudates within 2DD of the foveaexudates within 2DD of the fovea

CSME (Clinically significant macular CSME (Clinically significant macular oedema) Complicated definition, but oedema) Complicated definition, but basically retinal thickening or hard basically retinal thickening or hard exudates within 500 um of the foveaexudates within 500 um of the fovea

Macular oedema

OCT scan showing macular oedema

Diabetic macular oedema – focal, cystoid and diffuse

Role of OCT in Diabetic Role of OCT in Diabetic RetinopathyRetinopathy

Confirm clinical suspicion of macular oedemaConfirm clinical suspicion of macular oedema Quantification of extent of oedemaQuantification of extent of oedema Diagnosis of macular traction and localised Diagnosis of macular traction and localised

macular tractional retinal detachment in macular tractional retinal detachment in cases of proliferative retinopathy cases of proliferative retinopathy

Evaluation of response to treatment – laser Evaluation of response to treatment – laser and /or intravitreal Avastin/Triamcinoloneand /or intravitreal Avastin/Triamcinolone

Retinal DetachmentRetinal Detachment

Often preceded by a vitreous detachment Often preceded by a vitreous detachment with patient seeing flashes and floaterswith patient seeing flashes and floaters

Usually starts as a blurring or loss of Usually starts as a blurring or loss of peripheral vision in one area that peripheral vision in one area that progresses centrallyprogresses centrally

More likely in those with a history of More likely in those with a history of MyopiaMyopia Ocular trauma or surgery Ocular trauma or surgery

Retinal DetachmentRetinal Detachment

Most commonly due to a posterior Most commonly due to a posterior vitreous detachment with a retinal vitreous detachment with a retinal tear developingtear developing

About 10% of PVD About 10% of PVD develop a retinal teardevelop a retinal tear

Risk of tear much higher Risk of tear much higher if blood or pigmented if blood or pigmented cells present in vitreous cells present in vitreous

Retinal DetachmentRetinal Detachment If a retinal tear is If a retinal tear is

found before the found before the retina detaches, it retina detaches, it can often be treated can often be treated with laser with laser photocoagulation or photocoagulation or cryotherapy or a cryotherapy or a combination of combination of these.these.

Retinal DetachmentRetinal Detachment

Retinal DetachmentRetinal Detachment

Retinal DetachmentRetinal Detachment Surgical ManagementSurgical Management Scleral Scleral

buckle/cryotherapybuckle/cryotherapy VitrectomyVitrectomy

+/- buckle/cryotherapy+/- buckle/cryotherapy +/- endolaser+/- endolaser +/- intraocular gas+/- intraocular gas +/- silicone oil+/- silicone oil +/- perfluorocarbon liquid+/- perfluorocarbon liquid

Pneumatic retinopexyPneumatic retinopexy In-rooms procedureIn-rooms procedure Gas injection and Gas injection and

positioningpositioning

Role of OCT in Retinal Role of OCT in Retinal DetachmentDetachment

Very limited role as the diagnosis is clinical Very limited role as the diagnosis is clinical and treatment in most cases is surgicaland treatment in most cases is surgical

Useful in assessing reason for poor vision Useful in assessing reason for poor vision following retinal detachment repair with following retinal detachment repair with anatomical reattachment of the retina.anatomical reattachment of the retina.

May show:May show: Persistent macular oedema/subretinal fluidPersistent macular oedema/subretinal fluid Damage to photoreceptorsDamage to photoreceptors Thinned and atrophic retinaThinned and atrophic retina Epiretinal membraneEpiretinal membrane

Central Retinal Vein Central Retinal Vein OcclusionOcclusion

Common cause of Common cause of visual loss loss Usually history of hypertensionUsually history of hypertension Two main formsTwo main forms

Non-ischaemicNon-ischaemic IschaemicIschaemic

75-80% non-ischaemic at presentation75-80% non-ischaemic at presentation 15% non-ischaemic may convert to 15% non-ischaemic may convert to

ischaemicischaemic 50% of ischaemic -->neovascular glaucoma50% of ischaemic -->neovascular glaucoma

Central Retinal Vein Central Retinal Vein OcclusionOcclusion

Cause Of Visual Loss In CRVOCause Of Visual Loss In CRVO In non-ischaemic CRVO vision reduction In non-ischaemic CRVO vision reduction

due to macular oedema &/or due to macular oedema &/or haemorrhagehaemorrhage

In ischaemic CRVO vision reduced from In ischaemic CRVO vision reduced from macular ischaemia or later macular ischaemia or later by retinal neovascularization by retinal neovascularization with vitreous haemorrhage or with vitreous haemorrhage or from neovascular glaucoma from neovascular glaucoma

Central Retinal Vein Central Retinal Vein OcclusionOcclusion

ManagementManagement Macular oedemaMacular oedema

Intravitreal AvastinIntravitreal Avastin Intravitreal triamcinolone / Intravitreal triamcinolone /

dexamethasonedexamethasone Macular grid laser in younger patients Macular grid laser in younger patients

(<60)(<60) Ischaemia and neovascular complicationsIschaemia and neovascular complications

Panretinal photocoagulationPanretinal photocoagulation Anti-VEGF drugsAnti-VEGF drugs

Management of hypertension and other Management of hypertension and other cardiovascular risk factorscardiovascular risk factors

Branch Retinal Vein Branch Retinal Vein OcclusionOcclusion

Usually occurs in patients 50 – 70 yoUsually occurs in patients 50 – 70 yo Hypertension is the main risk factor Hypertension is the main risk factor

(70%)(70%) Occurs at an A-V crossing where vein Occurs at an A-V crossing where vein

and artery have a common and artery have a common adventitial sheathadventitial sheath

Visual loss from macular Visual loss from macular

oedema, haemorrhage or oedema, haemorrhage or

ischaemiaischaemia

Branch Retinal Vein Branch Retinal Vein OcclusionOcclusion

Late ComplicationsLate Complications Retinal or optic disc neovascularization Retinal or optic disc neovascularization

with vitreous haemorrhagewith vitreous haemorrhage Epiretinal membrane Epiretinal membrane Chronic macular oedema with formation Chronic macular oedema with formation

of a foveal cyst or lamellar hole of a foveal cyst or lamellar hole ““Atrophic maculopathy” from prolonged Atrophic maculopathy” from prolonged

macular oedema or ischaemiamacular oedema or ischaemia

Branch Retinal Vein Branch Retinal Vein OcclusionOcclusion

Management Management Intravitreal AvastinIntravitreal Avastin Intravitreal triamcinolone or Intravitreal triamcinolone or

dexamethasonedexamethasone Retinal laserRetinal laser Manage hypertension and other risk Manage hypertension and other risk

factorsfactors

Role of OCT in RVORole of OCT in RVO

Assessment of macular oedemaAssessment of macular oedema Quantification of retinal thicknessQuantification of retinal thickness Response of macular oedema to Response of macular oedema to

treatment with intravitreal agents treatment with intravitreal agents and/or laserand/or laser

Assessment of late complications – Assessment of late complications – epiretinal membrane, lamellar holeepiretinal membrane, lamellar hole

Macular HoleMacular Hole

Central visual loss in elderlyCentral visual loss in elderly VA usually 6/36 – 6/60VA usually 6/36 – 6/60 5 – 10% bilateral5 – 10% bilateral Treatment consists of vitrectomy, Treatment consists of vitrectomy,

peeling of the cortical vitreous +/- peeling of the cortical vitreous +/- internal limiting membrane peeling internal limiting membrane peeling and intravitreal gas injection with and intravitreal gas injection with one to two weeks of face-down positioningone to two weeks of face-down positioning

Macular HoleMacular Hole

Macular hole

OCT showing a macular hole before and after surgery

Stages of a macular hole on Stages of a macular hole on OCTOCT

Epiretinal MembraneEpiretinal Membrane

Usually idiopathic, seen in patients over 60Usually idiopathic, seen in patients over 60 Sometimes after vein occlusion, inflammationSometimes after vein occlusion, inflammation Variable effect on vision - blurring, distortionVariable effect on vision - blurring, distortion May have associated cystoid macular oedemaMay have associated cystoid macular oedema Pseudohole – may look like macular hole Pseudohole – may look like macular hole Retinal vessels irregular and tortuousRetinal vessels irregular and tortuous Vitrectomy and peeling if VA 6/18 or worse or Vitrectomy and peeling if VA 6/18 or worse or

even with better vision but troublesome even with better vision but troublesome distortiondistortion

Epiretinal MembraneEpiretinal Membrane

Epiretinal Membrane With Epiretinal Membrane With PseudoholePseudohole

Epiretinal membraneEpiretinal membrane

Without pseudohole

With pseudohole

Role of OCT in Macular Hole Role of OCT in Macular Hole and Epiretinal Membraneand Epiretinal Membrane

Clearly shows hole morphologyClearly shows hole morphology Differentiates full-thichness hole from Differentiates full-thichness hole from

lamellar hole or pseudoholelamellar hole or pseudohole Demonstrates associated conditions such Demonstrates associated conditions such

as macular oedema, macular cyst and as macular oedema, macular cyst and vitreoretinal tractionvitreoretinal traction

Shows response to treatment eg. closure Shows response to treatment eg. closure of macular hole, successful peeling of of macular hole, successful peeling of ERM ERM

Vitreomacular traction Vitreomacular traction syndromesyndrome

Vitreomacular traction Vitreomacular traction syndromesyndrome

Traction on the retina by taut or Traction on the retina by taut or contracted vitreous gelcontracted vitreous gel

May be part of a spectrum – VMT may be May be part of a spectrum – VMT may be the result of antero-posterior traction the result of antero-posterior traction while macular hole may be from while macular hole may be from tangential tractiontangential traction

Shows up well on OCT, sometimes in an Shows up well on OCT, sometimes in an asymptomatic patient with a normal asymptomatic patient with a normal retina retina

OCT in VMTOCT in VMTMore questions than answers? More questions than answers?

The more you know the less you The more you know the less you understand – LAO TSEunderstand – LAO TSE

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

Possible precursor to lamellar Possible precursor to lamellar hole or macular hole/cyst ?hole or macular hole/cyst ?

Possible precursor to epiretinal Possible precursor to epiretinal membrane formation?membrane formation?

Spectrum of vitreretinal Spectrum of vitreretinal interface disorders – VMT, ERM, interface disorders – VMT, ERM, macular cyst, lamellar hole, macular cyst, lamellar hole, full-thickness macular holefull-thickness macular hole

VMT VMT

TreatmentTreatment Usually vitrectomy with Usually vitrectomy with

removal of as much removal of as much cortical vitreous as cortical vitreous as possiblepossible

ERM peel if ERM presentERM peel if ERM present Intraocular gas fill and Intraocular gas fill and

face down positioningface down positioning OCT useful to OCT useful to

demonstrate post-op demonstrate post-op macular structure and macular structure and release of tractionrelease of traction

Central Serous RetinopathyCentral Serous Retinopathy CSRCSR

Usually middle-aged Usually middle-aged malemale

Central visual Central visual blur/distortionblur/distortion

MicropsiaMicropsia Association with “stress”Association with “stress” Can be subtle and easily Can be subtle and easily

missed on clinical missed on clinical examinationexamination

Vast majority recoverVast majority recover

OCT in CSROCT in CSR

Shows extent of SRF Shows extent of SRF very well – able to show very well – able to show patientpatient

Can monitor progress of Can monitor progress of disease with serial OCT disease with serial OCT

Does not show leakage Does not show leakage site in RPE. Need site in RPE. Need fluorescein angiographyfluorescein angiography

ConclusionConclusion

Multitude of common and important Multitude of common and important retinal conditionsretinal conditions

Clinical diagnosis and an understanding Clinical diagnosis and an understanding of the potential severity of the condition of the potential severity of the condition are vital to good outcomesare vital to good outcomes

OCT adds to our ability to diagnose and OCT adds to our ability to diagnose and manage retinal diseases and is manage retinal diseases and is increasing our understanding of these increasing our understanding of these conditionsconditions

Question 1Question 1OCT is useful in exudative (“wet”) ARMD for all OCT is useful in exudative (“wet”) ARMD for all the following reasons the following reasons EXCEPTEXCEPT::

A.A.Confirming the presence of subretinal or sub-RPE Confirming the presence of subretinal or sub-RPE fluidfluid

B.B.Assessing and quantifying the amount of fluid Assessing and quantifying the amount of fluid presentpresent

C.C.Assessing the size and activity of the choroidal Assessing the size and activity of the choroidal neovascular membraneneovascular membrane

D.D.Assessing response of the exudative changes to Assessing response of the exudative changes to treatmenttreatment

Question 2Question 2

OCT is useful in diabetic retinopathy to:OCT is useful in diabetic retinopathy to:

A.A. Assess the size and number of diabetic Assess the size and number of diabetic microaneurysmsmicroaneurysms

B.B. Assess hard exudates and cotton-wool Assess hard exudates and cotton-wool spotsspots

C.C. Assess retinal and/or optic disc new Assess retinal and/or optic disc new vesselsvessels

D.D. Assess diabetic macular oedemaAssess diabetic macular oedema

Question 3Question 3

Retinal detachment:Retinal detachment:

A.A. Is most commonly due to a posterior Is most commonly due to a posterior vitreous detachment with a retinal tearvitreous detachment with a retinal tear

B.B. Is best managed by monitoring with Is best managed by monitoring with regular OCT examinationsregular OCT examinations

C.C. Is most common in those with a history of Is most common in those with a history of hypertensionhypertension

D.D. Usually resolves without treatment over Usually resolves without treatment over several monthsseveral months

Question 4Question 4The following are true about epiretinal The following are true about epiretinal membranes membranes EXCEPTEXCEPT::

A.A.Can result in blurring and distortion of central Can result in blurring and distortion of central visionvision

B.B.If visually symptomatic they should be If visually symptomatic they should be treated with laser photocoagulationtreated with laser photocoagulation

C.C.May be associated with cystoids macular May be associated with cystoids macular oedemaoedema

D.D.May spontaneously separate from the retinaMay spontaneously separate from the retina

Question 5Question 5

Central serous retinopathy:Central serous retinopathy:

A.A. Results in loss of central vision if not Results in loss of central vision if not treatedtreated

B.B. Is managed by using OCT to find the Is managed by using OCT to find the leakage siteleakage site

C.C. Is usually due to a leak at the level of Is usually due to a leak at the level of the RPEthe RPE

D.D. Is typically a disease of elderly femalesIs typically a disease of elderly females