Presentation is loading. Please wait.

Presentation is loading. Please wait.

Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 th February 2012 Anil Arora.

Similar presentations


Presentation on theme: "Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 th February 2012 Anil Arora."— Presentation transcript:

1 Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 th February 2012 Anil Arora

2 What you might rather be doing

3 What you might feel like right now

4 100 Things To Do Before You Die (www.bucketquiz.com) Give your mother a dozen red roses and tell her you love her. Give your mother a dozen red roses and tell her you love her. Shower in a waterfall. Shower in a waterfall. Sleep under the stars. Sleep under the stars. Fart in a crowded space Fart 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 is your greatest strength. Reflect on your greatest weakness, and realize how it is your greatest strength. Attend a Sunday morning ophthalmology conference in Terrigal -especially any lectures on retinal conditions and OCT Attend a Sunday morning ophthalmology conference in Terrigal -especially any lectures on retinal conditions and OCT

5 Shows accumulation of fluid within the retina and below the retina Shows accumulation of fluid within the retina and below the retina Changes in the neurosensory retina Changes in the neurosensory retina Cystic changes Cystic changes Alteration of contour or thickness Alteration of contour or thickness Vitreous – retinal interface abnormalities Vitreous – retinal interface abnormalities Irregularity or elevation of the RPE Irregularity or elevation of the RPE Quantification of the abnormalities and measurement of treatment response Quantification of the abnormalities and measurement of treatment response OPTICAL COHERENCE TOMOGRAPHY IN RETINAL DISEASES

6 Optical coherence tomography

7 Normal macula Foveal depression Foveal depression Symmetrical contour Symmetrical contour Normal thickness of fovea and perifoveal tissues Normal thickness of fovea and perifoveal tissues Flat and regular RPE Flat and regular RPE

8 Important Retinal Conditions Age-related macular degeneration Age-related macular degeneration Diabetic retinopathy Diabetic retinopathy Retinal detachment and predisposing diseases Retinal detachment and predisposing diseases Central and branch retinal vein occlusion Central and branch retinal vein occlusion Macular hole Macular hole Epiretinal membrane Epiretinal membrane Vitreomacular traction syndrome Vitreomacular traction syndrome Central serous retinopathy Central serous retinopathy

9 Age-Related Macular Degeneration Leading cause of blindness in the elderly Leading cause of blindness in the elderly Prevalence rate rises sharply with each decade Prevalence rate rises sharply with each decade In Australia there are about 5 million people 50+ In Australia there are about 5 million people 50+ ~ 15% of these will have ~ 15% of these will have age-related macular changes 1- 2% or ,000 of these 1- 2% or ,000 of these will have significant vision loss from geographic atrophy or from exudative changes

10 Exudative Macular Degeneration EXAMINATION EXAMINATION Visual acuity Visual acuity Variable – depends on size and location of haemorrhage/exudation Variable – depends on size and location of haemorrhage/exudation Amsler grid testing Amsler grid testing Fundus examination Fundus examination Haemorrhage Haemorrhage Elevation by subretinal fluid/blood Elevation by subretinal fluid/blood Drusen Drusen Pigment changes/atrophy/scarring Pigment changes/atrophy/scarring

11 Drusen Accumulation of debris between the RPE and Bruch’s membrane Accumulation of debris between the RPE and Bruch’s membrane

12 SRF and RPE detachment RPE thinned and irregular RPE SRF Exudative changes –SRF and sub-RPE fluid Fovea

13 PED – serous and fibrovascular b Serous PED dépression fovéale DEP DSR Occult Fovea PED RD Fibro vascular PED

14 Role of OCT in ARMD Evaluation of exudative changes Evaluation of exudative changes Quantification of retinal thickness Quantification of retinal thickness Response to treatment with anti-VEGF agents Response to treatment with anti-VEGF agents

15 Role Of OCT In ARMD Response to treatment

16 Diabetic Retinopathy Presence of diabetic microvascular lesions Presence of diabetic microvascular lesions Most frequent ocular complication of DM Most frequent ocular complication of DM 1/3 rd rule – About 1/3 rd of all diabetics have some degree of retinopathy and in about 1/3 rd of these have sight- threatening disease 1/3 rd rule – About 1/3 rd of all diabetics have some degree of retinopathy and in about 1/3 rd of these have sight- threatening disease After 15 years about 70% of people with diabetes will have some retinopathy After 15 years about 70% of people with diabetes will have some retinopathy

17 Risk Factors For Retinopathy Development of diabetic retinopathy related to: Development of diabetic retinopathy related to: Duration of diabetes Duration of diabetes Glycaemic control Glycaemic control Hypertension management Hypertension management Serum lipids and cholesterol Serum lipids and cholesterol Other factors eg. pregnancy, nephropathy Other factors eg. pregnancy, nephropathy

18 Diabetic Retinopathy Two types of retinopathy Two types of retinopathy Nonproliferative retinopathy (NPDR) Nonproliferative retinopathy (NPDR) Early stage diabetic retinopathy Early stage diabetic retinopathy Proliferative retinopathy (PDR) Proliferative retinopathy (PDR) Later stage diabetic retinopathy Later stage diabetic retinopathy

19 Nonproliferative Diabetic Retinopathy (NPDR) Also called background diabetic retinopathy. Also called background diabetic retinopathy. Earliest stage of diabetic retinopathy. Earliest stage of diabetic retinopathy. Damaged blood vessels in the retina leak fluid and blood into the eye. Damaged blood vessels in the retina leak fluid and blood into the eye. Cholesterol or other fat deposits from blood, called hard exudates, may leak into retina. Cholesterol or other fat deposits from blood, called hard exudates, may leak into retina. Top: Healthy retina Bottom: NPDR with hard exudates

20 Proliferative Diabetic Retinopathy Characterised by the growth of new blood vessels in response to tissue hypoxia Characterised by the growth of new blood vessels in response to tissue hypoxia NVD – new vessels at or within 1 DD of the optic disc NVD – new vessels at or within 1 DD of the optic disc NVE – new vessels elsewhere in the retina NVE – new vessels elsewhere in the retina Can lead to: Can lead to: Vitreous haemorrhage Vitreous haemorrhage Tractional retinal detachment Tractional retinal detachment

21 Proliferative Diabetic Retinopathy

22 With PDR, vision is affected when any of the following occur: With PDR, vision is affected when any of the following occur: Vitreous haemorrhage Vitreous haemorrhage Traction retinal detachment Traction retinal detachment Neovascular glaucoma Neovascular glaucoma Vitreous haemorrhage

23 Diabetic Macular Oedema Most common cause of decreased vision and blindness in diabetic retinopathy Most common cause of decreased vision and blindness in diabetic retinopathy Indicated by findings of microaneurysms, haemorrhages or hard exudates within 2DD of the fovea Indicated by findings of microaneurysms, haemorrhages or hard exudates within 2DD of the fovea CSME (Clinically significant macular oedema) Complicated definition, but basically retinal thickening or hard exudates within 500 um of the fovea CSME (Clinically significant macular oedema) Complicated definition, but basically retinal thickening or hard exudates within 500 um of the fovea

24 Macular oedema OCT scan showing macular oedema

25 Diabetic macular oedema – focal, cystoid and diffuse

26 Role of OCT in Diabetic Retinopathy Confirm clinical suspicion of macular oedema Confirm clinical suspicion of macular oedema Quantification of extent of oedema Quantification of extent of oedema Diagnosis of macular traction and localised macular tractional retinal detachment in cases of proliferative retinopathy Diagnosis of macular traction and localised macular tractional retinal detachment in cases of proliferative retinopathy Evaluation of response to treatment – laser and /or intravitreal Avastin/Triamcinolone Evaluation of response to treatment – laser and /or intravitreal Avastin/Triamcinolone

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

28 Retinal Detachment Most commonly due to a posterior vitreous detachment with a retinal tear developing Most commonly due to a posterior vitreous detachment with a retinal tear developing About 10% of PVD develop a retinal tear About 10% of PVD develop a retinal tear Risk of tear much higher if blood or pigmented cells present in vitreous Risk of tear much higher if blood or pigmented cells present in vitreous

29 Retinal Detachment 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. 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.

30 Retinal Detachment

31

32 Surgical Management Surgical Management Scleral buckle/cryotherapy Scleral buckle/cryotherapy Vitrectomy Vitrectomy +/- buckle/cryotherapy +/- buckle/cryotherapy +/- endolaser +/- endolaser +/- intraocular gas +/- intraocular gas +/- silicone oil +/- silicone oil +/- perfluorocarbon liquid +/- perfluorocarbon liquid Pneumatic retinopexy Pneumatic retinopexy In-rooms procedure In-rooms procedure Gas injection and positioning Gas injection and positioning

33 Role of OCT in Retinal Detachment Very limited role as the diagnosis is clinical and treatment in most cases is surgical Very limited role as the diagnosis is clinical and treatment in most cases is surgical Useful in assessing reason for poor vision following retinal detachment repair with anatomical reattachment of the retina. Useful in assessing reason for poor vision following retinal detachment repair with anatomical reattachment of the retina. May show: May show: Persistent macular oedema/subretinal fluid Persistent macular oedema/subretinal fluid Damage to photoreceptors Damage to photoreceptors Thinned and atrophic retina Thinned and atrophic retina Epiretinal membrane Epiretinal membrane

34 Central Retinal Vein Occlusion Common cause of loss Common cause of visual loss Usually history of hypertension Usually history of hypertension Two main forms Two main forms Non-ischaemic Non-ischaemic Ischaemic Ischaemic 75-80% non-ischaemic at presentation 75-80% non-ischaemic at presentation 15% non-ischaemic may convert to ischaemic 15% non-ischaemic may convert to ischaemic 50% of ischaemic -->neovascular glaucoma 50% of ischaemic -->neovascular glaucoma

35 Central Retinal Vein Occlusion Cause Of Visual Loss In CRVO In non-ischaemic CRVO vision reduction due to macular oedema &/or haemorrhage In non-ischaemic CRVO vision reduction due to macular oedema &/or haemorrhage In ischaemic CRVO vision reduced from macular ischaemia or later by retinal neovascularization with vitreous haemorrhage or from neovascular glaucoma In ischaemic CRVO vision reduced from macular ischaemia or later by retinal neovascularization with vitreous haemorrhage or from neovascular glaucoma

36 Central Retinal Vein Occlusion Management Macular oedema Macular oedema Intravitreal Avastin Intravitreal Avastin Intravitreal triamcinolone / dexamethasone Intravitreal triamcinolone / dexamethasone Macular grid laser in younger patients (<60) Macular grid laser in younger patients (<60) Ischaemia and neovascular complications Ischaemia and neovascular complications Panretinal photocoagulation Panretinal photocoagulation Anti-VEGF drugs Anti-VEGF drugs Management of hypertension and other cardiovascular risk factors Management of hypertension and other cardiovascular risk factors

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

38 Branch Retinal Vein Occlusion Late Complications Retinal or optic disc neovascularization with vitreous haemorrhage Retinal or optic disc neovascularization with vitreous haemorrhage Epiretinal membrane Epiretinal membrane Chronic macular oedema with formation of a foveal cyst or lamellar hole Chronic macular oedema with formation of a foveal cyst or lamellar hole “Atrophic maculopathy” from prolonged macular oedema or ischaemia “Atrophic maculopathy” from prolonged macular oedema or ischaemia

39 Branch Retinal Vein Occlusion Management Management Intravitreal Avastin Intravitreal Avastin Intravitreal triamcinolone or dexamethasone Intravitreal triamcinolone or dexamethasone Retinal laser Retinal laser Manage hypertension and other risk factors Manage hypertension and other risk factors

40 Role of OCT in RVO Assessment of macular oedema Assessment of macular oedema Quantification of retinal thickness Quantification of retinal thickness Response of macular oedema to treatment with intravitreal agents and/or laser Response of macular oedema to treatment with intravitreal agents and/or laser Assessment of late complications – epiretinal membrane, lamellar hole Assessment of late complications – epiretinal membrane, lamellar hole

41 Macular Hole Central visual loss in elderly Central visual loss in elderly VA usually 6/36 – 6/60 VA usually 6/36 – 6/60 5 – 10% bilateral 5 – 10% bilateral 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 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

42 Macular Hole

43 Macular hole OCT showing a macular hole before and after surgery

44 Stages of a macular hole on OCT

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

46 Epiretinal Membrane

47 Epiretinal Membrane With Pseudohole

48 Epiretinal membrane Without pseudoholeWith pseudohole

49 Role of OCT in Macular Hole and Epiretinal Membrane Clearly shows hole morphology Clearly shows hole morphology Differentiates full-thichness hole from lamellar hole or pseudohole Differentiates full-thichness hole from lamellar hole or pseudohole Demonstrates associated conditions such as macular oedema, macular cyst and vitreoretinal traction Demonstrates associated conditions such as macular oedema, macular cyst and vitreoretinal traction Shows response to treatment eg. closure of macular hole, successful peeling of ERM Shows response to treatment eg. closure of macular hole, successful peeling of ERM

50 Vitreomacular traction syndrome

51 Traction on the retina by taut or contracted vitreous gel Traction on the retina by taut or contracted vitreous gel May be part of a spectrum – VMT may be the result of antero-posterior traction while macular hole may be from tangential traction May be part of a spectrum – VMT may be the result of antero-posterior traction while macular hole may be from tangential traction Shows up well on OCT, sometimes in an asymptomatic patient with a normal retina Shows up well on OCT, sometimes in an asymptomatic patient with a normal retina

52 OCT in VMT 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 Possible precursor to lamellar hole or macular hole/cyst ? Possible precursor to lamellar hole or macular hole/cyst ? Possible precursor to epiretinal membrane formation? Possible precursor to epiretinal membrane formation? Spectrum of vitreretinal interface disorders – VMT, ERM, macular cyst, lamellar hole, full-thickness macular hole Spectrum of vitreretinal interface disorders – VMT, ERM, macular cyst, lamellar hole, full-thickness macular hole

53 VMT Treatment Usually vitrectomy with removal of as much cortical vitreous as possible Usually vitrectomy with removal of as much cortical vitreous as possible ERM peel if ERM present ERM peel if ERM present Intraocular gas fill and face down positioning Intraocular gas fill and face down positioning OCT useful to demonstrate post-op macular structure and release of traction OCT useful to demonstrate post-op macular structure and release of traction

54 Central Serous Retinopathy CSR CSR Usually middle-aged male Usually middle-aged male Central visual blur/distortion Central visual blur/distortion Micropsia Micropsia Association with “stress” Association with “stress” Can be subtle and easily missed on clinical examination Can be subtle and easily missed on clinical examination Vast majority recover Vast majority recover

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

56 Conclusion Multitude of common and important retinal conditions Multitude of common and important retinal conditions Clinical diagnosis and an understanding of the potential severity of the condition are vital to good outcomes Clinical diagnosis and an understanding of the potential severity of the condition are vital to good outcomes OCT adds to our ability to diagnose and manage retinal diseases and is increasing our understanding of these conditions OCT adds to our ability to diagnose and manage retinal diseases and is increasing our understanding of these conditions

57 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

58 Question 2 OCT is useful in diabetic retinopathy to: A. Assess the size and number of diabetic microaneurysms B. Assess hard exudates and cotton-wool spots C. Assess retinal and/or optic disc new vessels D. Assess diabetic macular oedema

59 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 hypertension D. Usually resolves without treatment over several months

60 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 oedema D. May spontaneously separate from the retina

61 Question 5 Central serous retinopathy: A. Results in loss of central vision if not treated B. Is managed by using OCT to find the leakage site C. Is usually due to a leak at the level of the RPE D. Is typically a disease of elderly females


Download ppt "Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26 th February 2012 Anil Arora."

Similar presentations


Ads by Google