why is imaging critical in my uveitis practice? · 1 developed in collaboration why is imaging...
TRANSCRIPT
1
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.
2
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.
3
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
4
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.
5
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.
6
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
7
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]
8
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.
9
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.
10
© 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