Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference.ppt

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					 Overview Of Retinal Conditions
   Clinical and OCT Findings

   Central Coast Day Hospital
Inaugural Optometrist Conference
       26th February 2012

           Anil Arora
What you might rather be doing
What you might feel like right now
     100 Things To Do Before You Die
n   Give your mother a dozen red roses and tell her you love her.
n   Shower in a waterfall.
n   Sleep under the stars.
n   Fart in a crowded space
n   Give to a charity.
n   Run a marathon.
n   Reflect on your greatest weakness, and realize how it is your
    greatest strength.
n   Attend a Sunday morning ophthalmology conference in
    Terrigal -especially any lectures on retinal conditions and OCT
  n   Shows accumulation of fluid within the
      retina and below the retina
  n   Changes in the neurosensory retina
       n Cystic   changes
       n Alteration   of contour or thickness
  n   Vitreous – retinal interface abnormalities
  n   Irregularity or elevation of the RPE
  n   Quantification of the abnormalities and
      measurement of treatment response
Optical coherence tomography
Normal macula
       n   Foveal depression
       n   Symmetrical contour
       n   Normal thickness of
           fovea and perifoveal
       n   Flat and regular RPE
    Important Retinal Conditions
n   Age-related macular degeneration
n   Diabetic retinopathy
n   Retinal detachment and predisposing
n   Central and branch retinal vein occlusion
n   Macular hole
n   Epiretinal membrane
n   Vitreomacular traction syndrome
n   Central serous retinopathy
Age-Related Macular Degeneration
n   Leading cause of blindness in the elderly
n   Prevalence rate rises sharply with each decade
n   In Australia there are about 5 million people 50+
    n ~ 15% of these will have
    age-related macular changes
    n 1- 2% or 50-100,000 of these

    will have significant vision loss from
    geographic atrophy or from
    exudative changes
    Exudative Macular Degeneration
n   Visual acuity
    n   Variable – depends on size and
        location of
n   Amsler grid testing
n   Fundus examination
    n   Haemorrhage
    n   Elevation by subretinal
    n   Drusen
    n   Pigment
n   Accumulation of
    debris between the
    RPE and Bruch’s
Exudative changes –SRF and sub-RPE fluid



        SRF and RPE detachment
         RPE thinned and irregular
PED – serous and fibrovascular

               Serous PED

                        dépression fovéale




        Fibro vascular PED
         Role of OCT in ARMD

n   Evaluation of
    exudative changes
n   Quantification of
    retinal thickness
n   Response to
    treatment with anti
    -VEGF agents
Response to treatment
          Diabetic Retinopathy

n   Presence of diabetic microvascular lesions
n   Most frequent ocular complication of DM
n   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
n   After 15 years about 70% of people with
    diabetes will have some retinopathy
    Risk Factors For Retinopathy

n   Development of diabetic retinopathy
    related to:
    n Duration of diabetes
    n Glycaemic control

    n Hypertension management

    n Serum lipids and cholesterol

    n Other factors eg. pregnancy, nephropathy
            Diabetic Retinopathy

n   Two types of retinopathy

n   Nonproliferative retinopathy (NPDR)
    n   Early stage diabetic retinopathy

n   Proliferative retinopathy (PDR)
    n   Later stage diabetic retinopathy
         Nonproliferative Diabetic
           Retinopathy (NPDR)
n Also called background diabetic
n Earliest stage of diabetic
n Damaged blood vessels in the
  retina leak fluid and blood into
  the eye.
n 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

n   Characterised by the growth of new blood
    vessels in response to tissue hypoxia
n   NVD – new vessels at or within 1 DD of
    the optic disc
n   NVE – new vessels elsewhere in the retina
n   Can lead to:
    n Vitreous haemorrhage
    n Tractional retinal detachment
Proliferative Diabetic Retinopathy
 Proliferative Diabetic Retinopathy
  With PDR, vision is affected
  when any of the following
n Vitreous haemorrhage

n Traction retinal detachment

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

n   Confirm clinical suspicion of macular oedema
n   Quantification of extent of oedema
n   Diagnosis of macular traction and localised
    macular tractional retinal detachment in
    cases of proliferative retinopathy
n   Evaluation of response to treatment – laser
    and /or intravitreal Avastin/Triamcinolone
           Retinal Detachment

n   Often preceded by a vitreous detachment
    with patient seeing flashes and floaters
n   Usually starts as a blurring or loss of
    peripheral vision in one area that progresses
n   More likely in those with a history of
    n   Myopia
    n   Ocular trauma or surgery
          Retinal Detachment

n   Most commonly due to a posterior vitreous
    detachment with a retinal tear developing
n   About 10% of PVD
    develop a retinal tear
n   Risk of tear much higher
    if blood or pigmented
    cells present in vitreous
             Retinal Detachment
n   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 Detachment
Retinal Detachment
                Retinal Detachment
n   Surgical Management
n   Scleral buckle/cryotherapy
n   Vitrectomy
    n   +/- buckle/cryotherapy
    n   +/- endolaser
    n   +/- intraocular gas
    n   +/- silicone oil
    n   +/- perfluorocarbon liquid
n   Pneumatic retinopexy
    n   In-rooms procedure
    n   Gas injection and positioning
Role of OCT in Retinal Detachment
n   Very limited role as the diagnosis is clinical
    and treatment in most cases is surgical
n   Useful in assessing reason for poor vision
    following retinal detachment repair with
    anatomical reattachment of the retina.
n   May show:
    n Persistent macular oedema/subretinal fluid
    n Damage to photoreceptors

    n Thinned and atrophic retina

    n Epiretinal membrane
     Central Retinal Vein Occlusion
n   Common cause of visual loss
n   Usually history of hypertension
n   Two main forms
    n Non-ischaemic
    n Ischaemic

n   75-80% non-ischaemic at presentation
n   15% non-ischaemic may convert to ischaemic
n   50% of ischaemic -->neovascular glaucoma
 Central Retinal Vein Occlusion
Cause Of Visual Loss In CRVO
n In non-ischaemic CRVO vision reduction due
  to macular oedema &/or haemorrhage
n In ischaemic CRVO vision reduced from
  macular ischaemia or later
  by retinal neovascularization
  with vitreous haemorrhage or
  from neovascular glaucoma
   Central Retinal Vein Occlusion
n Macular oedema

   n Intravitreal Avastin

   n Intravitreal triamcinolone / dexamethasone

   n Macular grid laser in younger patients
n Ischaemia and neovascular complications

   n Panretinal photocoagulation

   n Anti-VEGF drugs

n Management of hypertension and other
  cardiovascular risk factors
    Branch Retinal Vein Occlusion
n   Usually occurs in patients 50 – 70 yo
n   Hypertension is the main risk factor (70%)
n   Occurs at an A-V crossing where vein and
    artery have a common adventitial sheath
n   Visual loss from macular
    oedema, haemorrhage or
 Branch Retinal Vein Occlusion

Late Complications
  n Retinal or optic disc neovascularization
    with vitreous haemorrhage
  n Epiretinal membrane

  n Chronic macular oedema with formation
    of a foveal cyst or lamellar hole
  n “Atrophic maculopathy” from prolonged
    macular oedema or ischaemia
    Branch Retinal Vein Occlusion
n   Management
n   Intravitreal Avastin
n   Intravitreal triamcinolone or dexamethasone
n   Retinal laser
n   Manage hypertension and other risk factors
          Role of OCT in RVO

n   Assessment of macular oedema
n   Quantification of retinal thickness
n   Response of macular oedema to treatment
    with intravitreal agents and/or laser
n   Assessment of late complications –
    epiretinal membrane, lamellar hole
               Macular Hole
n   Central visual loss in elderly
n   VA usually 6/36 – 6/60
n   5 – 10% bilateral
n   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
Macular Hole
             Macular hole

OCT showing a
macular hole before
and after surgery
Stages of a macular hole on OCT
           Epiretinal Membrane

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

Without pseudohole   With pseudohole
Role of OCT in Macular Hole and
      Epiretinal Membrane
n   Clearly shows hole morphology
n   Differentiates full-thichness hole from
    lamellar hole or pseudohole
n   Demonstrates associated conditions such
    as macular oedema, macular cyst and
    vitreoretinal traction
n   Shows response to treatment eg. closure
    of macular hole, successful peeling of ERM
Vitreomacular traction syndrome
    Vitreomacular traction syndrome

n   Traction on the retina by taut or contracted
    vitreous gel
n   May be part of a spectrum – VMT may be
    the result of antero-posterior traction while
    macular hole may be from tangential
n   Shows up well on OCT, sometimes in an
    asymptomatic patient with a normal retina
      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
n   Possible precursor to lamellar
    hole or macular hole/cyst ?
n   Possible precursor to epiretinal
    membrane formation?
n   Spectrum of vitreretinal interface
    disorders – VMT, ERM, macular
    cyst, lamellar hole, full-thickness
    macular hole
n Usually vitrectomy with
  removal of as much
  cortical vitreous as
n ERM peel if ERM present

n Intraocular gas fill and
  face down positioning
n OCT useful to demonstrate
  post-op macular structure
  and release of traction
         Central Serous Retinopathy
n   CSR
    n   Usually middle-aged male
    n   Central visual
    n   Micropsia
    n   Association with “stress”
    n   Can be subtle and easily
        missed on clinical
    n   Vast majority recover
                 OCT in CSR

n   Shows extent of SRF
    very well – able to show
n   Can monitor progress of
    disease with serial OCT
n   Does not show leakage
    site in RPE. Need
    fluorescein angiography

n   Multitude of common and important
    retinal conditions
n   Clinical diagnosis and an understanding of
    the potential severity of the condition are
    vital to good outcomes
n   OCT adds to our ability to diagnose and
    manage retinal diseases and is increasing
    our understanding of these conditions
              Question 1
OCT is useful in exudative (“wet”) ARMD for
all the following reasons EXCEPT:
A.Confirming the presence of subretinal or
sub-RPE fluid
B.Assessing and quantifying the amount of
fluid present
C.Assessing the size and activity of the
choroidal neovascular membrane
D.Assessing response of the exudative
changes to treatment
               Question 2

OCT is useful in diabetic retinopathy to:
A. Assess the size and number of diabetic
B. Assess hard exudates and cotton-wool
C. Assess retinal and/or optic disc new
D. Assess diabetic macular oedema
              Question 3

Retinal detachment:
A. Is most commonly due to a posterior
   vitreous detachment with a retinal tear
B. Is best managed by monitoring with
   regular OCT examinations
C. Is most common in those with a history of
D. Usually resolves without treatment over
   several months
               Question 4
The following are true about epiretinal
 membranes EXCEPT:
A.Can result in blurring and distortion of
 central vision
B.If visually symptomatic they should be
 treated with laser photocoagulation
C.May be associated with cystoids macular
D.May spontaneously separate from the
                Question 5

Central serous retinopathy:
A. Results in loss of central vision if not
B. Is managed by using OCT to find the
   leakage site
C. Is usually due to a leak at the level of the
D. Is typically a disease of elderly females

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