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Sarah Moyer, CRA, OCT-CDirector of Ophthalmic Imaging
Kenneth L. Cohen, MDProfessor of Ophthalmology
Kittner Eye CenterDepartment of OphthalmologyUniversity of North Carolina at Chapel HillSchool of Medicine
Clinical Applications of Anterior Segment OCT
No financial interest
What Does Anterior Segment OCT Do?
• 2-dimensional cross section image of the anterior segment– Conjunctiva– Cornea– Anterior chamber– Iris/Angle– Lens– Sclera
Understanding Anterior Segment OCT
• Vendors• How does AS-OCT work?• Technical aspects• What does AS-OCT measure?• How is AS-OCT used clinically?
Image Anterior Segment
• Low magnification image
Image Anterior Segment
• High magnification image
Anterior Segment OCT Vendors
Bioptigen Handheld OCTHeidelberg Spectralis- AAO 2011?Opko Spectral OCT SLOOptovue RT-Vue with CAM
iVueTopcon AAO 2011?Zeiss Visante and Cirrus
Bioptigen
Courtesy of John CarpentierCourtesy of Sunita Sayeram and Joseph Vance
Heidelberg Spectralis
Courtesy of Tim Steffens
Opko Spectral OCT SLO
Courtesy of Opko
Optovue RT-Vue with CAM
Courtesy of Optovue
Courtesy of Bruno Bertoni, CRA, OCT-C and Tamera Davis, CRA
Zeiss Cirrus
4mm scan lengthInternal optics
Software upgrade needed
Zeiss Stratus
This is not FDA approved!
Zeiss Stratus
Courtesy of Alexis Smith, OCT-C, CRA
Zeiss Visante
Courtesy of Zeiss
1 Week After Phaco and 1-Piece Posterior Chamber IOL
Dislocated IOLIOL in the Capsular Bag Tecnis One-Piece Causes of the Dislocted IOL
• IOL not in capsular bag but in ciliarysulcus
• Ruptured zonules• Hole in posterior capsule• Broken haptic• Crimped haptic
Relationship Between the IOL and the Capsular Bag?
• How can I obtain a 2-dimensionsal cross-sectional image of the anterior segment of the eye?
Anterior segment OCT Immersion B-scan ultrasound
Relationship Between the IOL and the Capsular Bag?
4 o’clockIOL haptic truncated
Ultrasound Biomicroscopy (UBM)
• 2-dimensional cross-sectional image of anterior segment
• Multiple meridians
Dislocated IOL UBM
4:004:00
IOL haptic truncated
OCT Versus UBM• 2-dimensional cross-sectional images
of anterior segment• Multiple meridians• OCT provides more fine detail and
magnified image• OCT non-contact versus UBM contact
(water bath)• OCT more useful to the anterior
segment surgeon because easy to use
OCT Versus UBM• MD or photographer performs UBM• Photographer performs OCT• OCT and UBM require communication
between MD and photographerAnatomic structure(s)LocationMagnificationImaging protocol
What Are the Technical Aspects of Anterior Segment OCT?
OCT Specifications ComparisonSpecifications Stratus Cirrus Visante RT-VueDomain Time Spectral Time Spectral
SLD Wavelength 820 840 1310 840
Scan SpeedA-Scans/sec
400 27,000 2,000 26,000
Axial Resolution ≤ 10 μm 5 μm 18 μm 5.0µm
Transverse Res 20 μm 15 μm 60 μm 15µm
Scan Depth 2mm 2mm 6mm 2-2.3mm
Optical Power 750 μW < 725 μW < 6500 µW 750µW
Visante is designed specifically for Anterior Segment OCT.
Time and Spectral Domain OCT
Anterior Segment Specifications
Specifications Visante RT-VueSLD Wavelength 1310 840
Optical Power < 6500 µW 750µW
The longer wavelength of light and stronger optical power allow TD technology to penetrate deeper into the angle.
The shorter wavelength of light and lower optical power make it possible for the SD technology to also image the retina
Anterior Segment SpecificationsSpecifications Visante RT-VueSLD Wavelength 1310 840
Scan Depth 3mm,6mm 2-2.3mm
Scan Length 10mm, 16mm
1-2,1-6
Higher Wavelength allows for deeper scan depth and longer scan length
More scan depth is able to image cornea to lens
Longer scan length can image limbusto limbus.
Graphic modified from Zeiss graphic
6x16 3x10
2x6 2x1
OCT Image Comparison
Stratus 3mm
Visante 16mm
Cirrus 4mm
RT-Vue 8mmStratus 10mm
RT-Vue 1mmVisante 10mm
Longer scan length gives overviewShorter scan length gives more resolution
Why is Scan Length Important?
• DSEK– Limbus to Limbus Imaging is necessary to
ensure proper attachment of the donor tissue
• Scleral Contact Lens Fitting– Needed to view the entire lens in one image
• Glaucoma– Able to measure both angles from one image.
Slipped DSEK Comparison Longer vs Shorter Scan Length
Courtesy Team Doheny Eye
16mm 10mm
6mm6mm
Text
Scleral Contact Lens
Glaucoma Why Do I Image the Cornea?• Analysis of new corneal transplantation
techniques• Management of postop complications• Document healing of surgical incisions• Plan operations• Management of corneal ulcers• Evaluate extent of tumors of the ocular surface• Measurements of the anterior segment
Fuchs Corneal Dystrophy
• Fuchs dystrophyInherited disease of corneal endotheliumEndothelium dysfunctionalCorneal edemaVision decreases
• Guttae obscure endotheliumSpecular microscopy
Corneal EndotheliumFunction
• Pumps H2O out of the cornea into the anterior chamber
• Keeps corneal stroma at 78% H2O• Transparent at thickness 550 μ• Pachymetry is a measurement of corneal
thickness• Gauges health of cornea
Corneal Edema
Hazy cornea Corneal folds
Fuchs DystrophyTreatment
• Penetrating keratoplasy• Full thickness recipient cornea removed• Full thickness donor cornea sutured into place• 360° full thickness corneal wound• 1 year for visual rehabilitation• Irregular healing of wound results in
variable visual results due to astigmatism
Penetrating Keratoplasty
Epithelial defect
Penetrating Keratoplasty
Irregular healing of full thickness incision
DSEK: Descemet’s Stripping Endothelial Keratoplasty
• Diseased endothelium removed (30 μ)• Donor endothelium and stroma inserted
(~150 μ)• Small incision (5 mm)• Rapid healing and visual rehabilitation in
30 to 60 days
OCT to Monitor Health of DSEK
• Position• Attachment of graft to recipient• Quality of interface• Corneal thickness
DSEK
1 D
1 W
1 M
1038 μ
687 μ
618 μ
DSEK 4 Weeks Post-op
Ultrasound pachymetry 549 μ
Ultrasound Pachymetry Incorrect
• Normal thickness 550 μ• 30 μ endothelium and Descemet’s
membrane removed• 180 μ donor cornea implanted• Pachymetry after DSEK should be at least
700 μ
DSEK 4 Weeks Postop Visante Flap Tool
Corneal thickness 769 μ
Detached DSEK 1 Day Postop Anterior Segment OCT
• DESK attachment 360° would indicate primary donor failureRequire graft replacement
• DSEK detachmentReattach graft with air
DSEK Reattachment1 day postop 1 week postop
7 weeks postop 4.5 months postop
Malpositioned DSEK Malpositioned DSEK
180° meridian
90° meridian
Slipped inferiorly
Automated Global Pachymetry
770 μ
Available Measurements
• Corneal thickness• Anterior chamber depth• Anterior chamber angle• Incision • Tumor
Corneal Thickness
Corneal thickness 769 μ
Pachymetry Data PointsGlobal Pachymetry
– 16 line scans
– 2048 data points in one map
Pachmate Pachymetry1 data point
Anterior Chamber Depth
Post-Op
5.16 mm3.61 mm
Pre-Op
Measuring Angles Measuring Angles
• AOD: angle-opening distance• TIA: trabecular-iris angle• TISA: trabecular-iris space area
Clear Corneal Incision Clear Corneal Incision
Descemet’s detachment Endothelial misalignment Epithelial misalignment
Endothelial gape Epithelial gape Loss of coaptation
Tumors / Cysts
Unable to use measurement features in Raw Mode
Must understand what is real and what is artifact on the scan
Artifacts Artifacts
• Corneal Reflex• Inverted Image (in Spectral Domain)• Shadowing• Image Averaging• Algorithm Failure
– Pachymetry: Corneal surface lines – Pachymetry: Lids
Corneal Reflex
Inverted ImageSpectral Domain Shadowing? Shadowing
Image Averaging
Top: Non-averaged ScansBottom: Averaged Scans
Averaging
Enhanced High Res Cornea Mode
Measuring with Averaging
Enhanced High Res Cornea Mode
Dewarping
Enhanced Mode
Algorithm Failure Due to Lids
superior inferior
Algorithm Failure Due to Lids
Algorithm FailureDue to Corneal Surface Lines
Algorithm FailureDue to Corneal Surface Lines
Algorithm FailureDue to Corneal Surface Lines
How Else Does Anterior Segment OCT Help Me With Patients?
Visualize Depth of Corneal Scar
DSEK with a scar
Visualize Depth of Corneal Scar
Excellent detail of cornea
Ocular Surface Tumors
• Does the tumor extend into the cornea, sclera, and anterior chamber angle?
• Plan operative procedure
Corneal and ConjunctivalIntraepithelial Neoplasia
Corneal and ConjunctivalIntaepithelial Neoplasia
Infectious Keratitis
• Hazy cornea• Difficult to see extent of corneal involvement• Monitor response to medical therapy
Fungal Corneal Ulcer Anterior Chamber Depth
• Important for IOL calculation• Theoretical prediction formula: Haigis• Required to predict the post-op
position of the IOL• Correct IOL power can be inserted• 0.05 mm ACD error = 0.03 diopter
IOL power error
Pre-op Phaco IOL CalculationAnterior Chamber DepthIOLMaster Visante
4.10 mm
ACD difference = 1.8 mm = 1.08 diopters
Irregular Pupil Gonioscopy
Peripheral anterior synechiae Holes in iris
PAS
PASNormal ciliary body
OCT
UBM
What Are the Issues for Billing Anterior Segment OCT?
CA
NV UT
AZ NM
OR
WA
ID
MT ND
SD
WY
NE
KS
OK
TX
CO
MNWI
IA
IL
AR
LA
MI
INOH
KY
TN
MS AL GA
FL
SC
NC
VAWV
PA
NY
MENH
VT
MA
RICTNJ
DE
MD
HI
AK
DC
MO
Coverage Status for Anterior Segment OCTAs of September 2009
Coverage and payment for 0187T (28 states)
Coverage based on medical necessity (4 states)
Coverage may be gained after MAC transition (8 states)
In progress of requesting coverage via KOLS (4 states)
Carrier declined to cover (6 states)
Billing• 0187-T: Temporary Code, Medicare
reimbursement varied according to Medicare regions
• 92132: AMA established CPT code, Medicare covers this code. Some states may have a Local Medical Review Policy (LMRP) where only specific diagnosis are covered.
• SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, BILATERAL
Medicare leads to….• Cigna Government Services: (TN, NC, ID)• Highmark Medicare Services: (PA, DC, MD, DE, NJ)• National Government Service, Inc.: (IN, KY, NY, CT)• First Coast Service Options, Inc.: (FL, Puerto Rico, US
Virgin Islands)NHIC, Corp.: (ME, MA, VT, NH, RI)
• Palmetto GBA: (HI, CA, NV)• Noridian Administrative Services (WA, OR, AK, AZ,
UT, WY, MT, ND, SD)• Cahaba (TN, MS, AL, GA)
Billing Codes• 190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA
RETINA AND CHOROID• 190.4 MALIGNANT NEOPLASM OF CORNEA• 224.0 BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA
RETINA AND CHOROID• 224.4 BENIGN NEOPLASM OF CORNEA• 364.51 ESSENTIAL OR PROGRESSIVE IRIS ATROPHY• 364.52 IRIDOSCHISIS• 364.53 PIGMENTARY IRIS DEGENERATION • 364.54 DEGENERATION OF PUPILLARY MARGIN
364.55 MIOTIC CYSTS OF PUPILLARY MARGIN• 364.56 DEGENERATIVE CHANGES OF CHAMBER ANGLE • 364.57 DEGENERATIVE CHANGES OF CILIARY BODY• 364.59 OTHER IRIS ATROPHY• 364.60 IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY• 364.61 IMPLANTATION CYSTS OF IRIS AND CILIARY BODY• 364.62 EXUDATIVE CYSTS OF IRIS OR ANTERIOR CHAMBER• 364.63 PRIMARY CYST OF PARS PLANA• 364.64 EXUDATIVE CYST OF PARS PLANA• 364.70 ADHESIONS OF IRIS UNSPECIFIED• 364.71 POSTERIOR SYNECHIAE OF IRIS
Billing Codes• 364.71 POSTERIOR SYNECHIAE OF IRIS• 364.72 ANTERIOR SYNECHIAE OF IRIS • 364.73 GONIOSYNECHIAE• 364.74 ADHESIONS AND DISRUPTIONS OF PUPILLARY MEMBRANES• 364.75 PUPILLARY ABNORMALITIES• 364.76 IRIDODIALYSIS• 364.77 RECESSION OF CHAMBER ANGLE OF EYE• 364.81 FLOPPY IRIS SYNDROME• 364.82 PLATEAU IRIS SYNDROME• 364.89 OTHER DISORDERS OF IRIS AND CILIARY BODY• 365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA • 365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA SPECIFIED • 365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA• 365.22 ACUTE ANGLE-CLOSURE GLAUCOMA• 365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA• 365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA• 365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE NOMALIES \• 365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS• 365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT
ANOMALIES• 365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES
Billing Codes• 365.51 PHACOLYTIC GLAUCOMA• 365.52 PSEUDOEXFOLIATION GLAUCOMA• 365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS• 365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER• 365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK• 365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS• 365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE
365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS• 365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA• 365.81 HYPERSECRETION GLAUCOMA• 365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE• 365.83 AQUEOUS MISDIRECTION• 365.89 OTHER SPECIFIED GLAUCOMA• 370.04 HYPOPYON ULCER• 370.05 MYCOTIC CORNEAL ULCER• 370.06 PERFORATED CORNEAL ULCER• 371.03 CENTRAL OPACITY OF CORNEA• 371.71 CORNEAL ECTASIA• 371.72 DESCEMETOCELE • 371.73 CORNEAL STAPHYLOMA• 379.31 APHAKIA
Billing Codes• 379.31 APHAKIA• 379.32 SUBLUXATION OF LENS• 379.33 ANTERIOR DISLOCATION OF LENS• 379.39 OTHER DISORDERS OF LENS• 996.51 MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL RAFT• 996.53 MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS
PROSTHESIS• 996.69 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER
INTERNAL PROSTHETIC DEVICE IMPLANT AND RAFT
Thanks for your help!UNC DoctorsBruce Baldwin, OD, Ph.DCraig Fowler, MDDavid Russell, MDGeorge Escaravage, MDGraham Lyles, MDIsaac Porter, MDJonathan Dutton, MDKenneth Cohen, MD
UNC PhotographersDebra Cantrell, COARona Lyn Esquejo-Leon,
CRA
PhotographersDoheny Eye Institute
Bruno Bertoni, CRA, OCT-CTamera Davis, CRA
Henry Ford Health Systems Alexis Smith, OCT-C, CRA
University of California- DavisEllen Redenbo, CRA, ROUBKarishma Chandra
University of Florida Eye Institute John Carpentier, CRA, OCT-C
Wills Eye InstituteSandor Ferenczy, CRASusan Proietta
BioptigenEric Buckland, Ph.DSunita Sayeram, MSJoseph Vance
HeidelbergTim Steffens
OptovueBill DillworthMark ThomasCarl Denis, CRA
ZeissGreg HoffmeyerRick TorneyTracy MooreGary Michalec, CRA, COACherri Ritter
Kenneth L. Cohen, MDProfessor of Ophthalmology
Sarah Moyer, CRA, OCT-CDirector of Ophthalmic Imaging
[email protected] Eye Center, University of North Carolina Chapel Hill, NC