1. Overview Of Retinal Conditions Clinical and OCT Findings Central Coast Day Hospital Inaugural Optometrist Conference 26th 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.
Shower in a waterfall.
Sleep under the stars.
Fart in a crowded space
Give to a charity.
Run a marathon.
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

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

6. Optical coherence tomography

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

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

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

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

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

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

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

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

15. Role Of OCT In ARMD Response to treatment

16. Diabetic Retinopathy Presence of diabetic microvascular lesions
Most frequent ocular complication of DM
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
After 15 years about 70% of people with diabetes will have some retinopathy

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

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

19. Nonproliferative Diabetic Retinopathy (NPDR)
Also called background diabetic retinopathy.
Earliest stage of diabetic retinopathy.
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.
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
NVD – new vessels at or within 1 DD of the optic disc
NVE – new vessels elsewhere in the retina
Can lead to:
Vitreous haemorrhage
Tractional retinal detachment

21. Proliferative Diabetic Retinopathy

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

23. Diabetic Macular Oedema
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
CSME (Clinically significant macular oedema) Complicated definition, but basically retinal thickening or hard exudates within 500 um of the fovea

24. 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
Quantification of extent of oedema
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

27. Retinal Detachment
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
More likely in those with a history of
Myopia
Ocular trauma or surgery

28. Retinal Detachment
Most commonly due to a posterior vitreous detachment with a retinal tear developing
About 10% of PVD develop a retinal tear
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.

30. Retinal Detachment

31. Retinal Detachment

32. Retinal Detachment Surgical Management Scleral buckle/cryotherapy
Vitrectomy
+/- buckle/cryotherapy
+/- endolaser
+/- intraocular gas
+/- silicone oil
+/- perfluorocarbon liquid
Pneumatic retinopexy
In-rooms procedure
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
Useful in assessing reason for poor vision following retinal detachment repair with anatomical reattachment of the retina.
May show:
Persistent macular oedema/subretinal fluid
Damage to photoreceptors
Thinned and atrophic retina
Epiretinal membrane

34. Central Retinal Vein Occlusion
Common cause of visual loss
Usually history of hypertension
Two main forms
Non-ischaemic
Ischaemic
75-80% non-ischaemic at presentation
15% non-ischaemic may convert to ischaemic
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 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
Intravitreal Avastin
Intravitreal triamcinolone / dexamethasone
Macular grid laser in younger patients (<60)
Ischaemia and neovascular complications
Panretinal photocoagulation
Anti-VEGF drugs
Management of hypertension and other cardiovascular risk factors

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

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

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

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

41. Macular Hole Central visual loss in elderly VA usually 6/36 – 6/60
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

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
Sometimes after vein occlusion, inflammation
Variable effect on vision - blurring, distortion
May have associated cystoid macular oedema
Pseudohole – may look like macular hole
Retinal vessels irregular and tortuous
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 pseudohole
With pseudohole

49. Role of OCT in Macular Hole and Epiretinal Membrane
Clearly shows hole morphology
Differentiates full-thichness hole from lamellar hole or pseudohole
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

50. Vitreomacular traction syndrome

51. Vitreomacular traction syndrome
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
Shows up well on OCT, sometimes in an asymptomatic patient with a normal retina

52. 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 epiretinal membrane formation?
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
ERM peel if ERM present
Intraocular gas fill and face down positioning
OCT useful to demonstrate post-op macular structure and release of traction

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

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

56. Conclusion Multitude of common and important retinal conditions
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

57. Question 1
OCT is useful in exudative (“wet”) ARMD for all the following reasons EXCEPT:
Confirming the presence of subretinal or sub-RPE fluid
Assessing and quantifying the amount of fluid present
Assessing the size and activity of the choroidal neovascular membrane
Assessing response of the exudative changes to treatment

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

59. Question 3 Retinal detachment:
Is most commonly due to a posterior vitreous detachment with a retinal tear
Is best managed by monitoring with regular OCT examinations
Is most common in those with a history of hypertension
Usually resolves without treatment over several months

60. Question 4 The following are true about epiretinal membranes EXCEPT:
Can result in blurring and distortion of central vision
If visually symptomatic they should be treated with laser photocoagulation
May be associated with cystoids macular oedema
May spontaneously separate from the retina

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