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HD OCT Update50470-GO

Michael Cymbor, OD, FAAO Nittany Eye Associates

State College, PA

Adjunct Professor

Pennsylvania College of Optometry

Disclosure Statement• Member of the Speakers Bureau for Alcon, Optovue, and Inspire

• Principal site investigator for Ciba, Vistakon, and Bausch & Lomb

• Has received educational grants from Heidelberg Engineering, Zeiss and EyeIC

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In the last 15 years…

• What instrument has changed eye care the most???????

OCT

• O = Optical

• C = Coherence• Coherence comes from a Latin word meaning “to stick together

• T = Tomography• a technique used to obtain an image of a selected plane section of the

human body or some other solid object

How does it work?

• OCT utilizes near-infrared light waves to measure distances of anatomical structures. A beam of light is directed onto the structure and the echo time delay of light is then recorded.

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OCT Evolution

OCT

1995

OCT2

2000

OCT3

Stratus OCT

2002

Optovue

HD-OCT

2007

100 A-scans x

500 points

100 A-scans x

500 points

512 A-scans

x1024 points

4096 A-scans x

1024 points

100

100

500

26,000

20

20

10

5

Single line scanScans/

second

Resolution

(microns)

And now…

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In vivo sub-cellular resolution OCT (A) in a developmental biology animal model (African tadpole).

Resolution down to 1 micron!!!!

Retina Glaucoma/Optic Nerve Cornea/Anterior Segment

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OCT Trends

• The odds of undergoing testing using the newer ocular imaging devices increased by by 147% from 2001 to 2009.

Joshua D. Stein, M.D., M.S.

Trends in use of ancillary glaucoma tests for patients with open-angle glaucoma from 2001 to 2009. Ophthalmology, 2012.

And now……..

Vitreous

Vitreous

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Case

• 57 Y/O WF

• Cc: started seeing flashes out of left eye last night, thinks it might be related to congestion

• Va sc 20/20 OD and OS

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Practice Management

• 92134

• Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina

OCT Setup Pearl

• 2 options in our practice• Upload into practice management software

• Networked

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Why OCT for Anterior Chamber?

Cornea

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Case

• 45 Y/O White Female

• OcHx: Repeated HSK OD with stromal involvement

• SHx: Stage 4 GI cancer with liver involvement 2000, 6 months of chemo, clear until 2005 with lymph node involvement, 6 months chemo, clear since.

• On acyclovir 400mg bid upon flare –ups

• BCVA OD 20/70 OS 20/25

Ptk vs PK?

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Case

• 45 Y/O WM

• Hx of worsening keratoconus OU with occasional hydrops OD

• Attempted to send for corneal crosslinking, pt declines

• OD contact lens uncomfortable with inconsistent vision

Case Presentation

19 y/o white male

Entered office as a problem visit

Pt was at work using a nail gun without safety glasses

Reports that he got too close to gun, shot himself in the

eye

Trouble opening OS due to pain

Upon instillation of Proparacaine…

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Anterior Segment Photo

Anterior Segment Photo

Anterior Segment OCT

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Anterior Segment OCT

Diagnosis/Treatment

Dx: open globe injury due to penetrating

intraocular foreign body

A driver was found and the patient was sent to

tertiary care for immediate surgical repair

Case

• 60 Y/O WM

• Bilateral Keratoconus

• Cc: Sudden vision loss OD

• BCVA 20/80 OD, 20/40 OS

• Wearing large diameter SoClear Scleral lens

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• Corneal Power

The Present

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Case

• 78 Y/O WF

• Ocular History: Bilateral Phaco’s with IOL several years ago

• Initial post-op BCVA 20/25 OD and OS

• Cc: decreased VA

• Current BCVA 20/40 OD and OS

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Should we be using OCT for determining CCT?

Cornea Rapid Fire

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FIGURE 1 This is a cross-sectional OCT image of a scleral lens. Notice that the vault can be directly measured using a caliper tool, in this case, 0.37 mm (or 370 μm).

Copyright © 2013 Optometry & Vision Science. Published by Lippincott Williams & Wilkins. 55

Central Vault in Dry Eye Patients Successfully Wearing Scleral Lens

Sonsino, Jeffrey; Mathe, Dora Sztipanovits

Optometry & Vision Science. 90(9):e248-e251, September 2013.

doi: 10.1097/OPX.0000000000000013

Descemet Membrane Endothelial Keratoplasty (DMEK)

Copyright © 2013 Optometry & Vision Science. Published by Lippincott Williams & Wilkins. 56

Descemet Membrane Endothelial Keratoplasty in Eyes with Glaucoma Implants

Heindl, Ludwig M.; Koch, Konrad R.; Bucher, Franziska; Hos, Deniz; Steven, Philipp; Koch, Hans-Reinhard; Cursiefen, Claus

Optometry & Vision Science. 90(9):e241-e244, September 2013.

doi: 10.1097/OPX.0b013e31829d8e64

Ocular Surgery News U.S. Edition, July 10, 2013

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August 15th, 2013 Issue of Review of OptometryAaron Bronner, OD

Role of anterior segment optical coherence tomogram in Descemet's membrane detachmentSonia Kothari, Kulin Kothari, Rajul S ParikhBombay City Eye Institute and Research Centre, Mumbai, India

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What is one of the most common pathologies you will image by OCT in practice?

Case

• 23 year old, Caucasian female

• LEE: 1.5 years

• Cc: Reduced vision through contact lenses

• No previous ocular history

• BCVA: 20/20 OD, 20/20 OS

• FDT: Normal OU

• NCT: 12 mm Hg OD/OS

• DFE: 1.5 DD slate grey choroidal lesion

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What to do?

A. Monitor yourself

B. Send to retinal specialist

C. Send to ocular oncologist

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Ocular Oncology

•Patient referred to Will’s Eye (Drs. Carol and Jerry Shields)

• 1/3/2011

• 2.5 x 2.5 mm

• Thickness: 1.6 mm

• (-) Subretinal fluid, (-) Lipofuscin

• 7/12/2011

• 2.5 x 2.5 mm

• (+) Lipofuscin (auto fluorescence)

• (-) Subretinal fluid

• Return visit to Will’s Eye in one year

• 6/15/2012

• 3mm x 3mm

• Thickness 1.4mm

• Return visit to Wills in one year

November 2011 Follow-up

Management

• Lesions less than 2 DD• Photo document

• B-scan

• Follow-up annually

• Lesions 2-5 DD• Refer for angiography

• Follow-up at six month intervals

• Lesions greater than 5 DD• Malignant melanoma until proven otherwise

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Risk Factors

Treatment The Collaborative Ocular Melanoma Study - (COMS)

• Enucleation

• Brachytherapy

• Transpupillary thermotherapy • Lasers used at subphotocoagulation levels (45°C to 60°C) to obtain tumor cell

necrosis by hyperthermia

• External beam proton therapy

• Resection of the tumor• Trans-scleral partial choroidectomy

• Transretinal endoresection

• Combination

Glaucoma

Anterior Segment

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Visante

• Calculates degree of angle

Taken from 2007 Review of Ophthalmology

Case Presentation

• 61 year old white female

• CC: Decreased vision and red eyes

• BCVA: 20/40 OD and 20/20 OS at distance

• IOP’s: 14 OU

• Refractive Status:+1.00-0.50x27

-0.50-1.00x140

• Anterior Segment:

-Cataracts OD>OS

-Blepharitis OU

-Narrow Angles OU (Grade 2 VH, ATM 360 deg. OU by gonio)

• Posterior Segment: Mild RPE mottling OD

Optovue Angle OD

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Optovue Angles-OS

Why not just gonio?

Diagnosis

• Narrow anatomical angles OU

• Cataracts OD>OS

• Blepharitis OU

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Before and After: OD

2009

2010

OS

2009

2010

Case Report

3:45 PM 55 y/o white female presents with intense pain in the left eye (“This is the worst pain I've ever felt 11+ out of 10”)

Began with minor discomfort last night that has continually gotten worse.

Left eye has a history of coloboma of the optic nerve. VA has always been LP

Patient is on 20+ meds with multiple allergies

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Case

VA with correction 20/30 OD

LP OS

BP 132/79 p85

NCT 21 OD

ERROR OS

Pupil testing OS poorly reactive patient not cooperative for swing test

Case

Goldmann Tonometry OS 56 mmhg @4:00PM

Slit lamp findings Corneal edema

Cells in A/C

0 Vanherrick

Large dense cataract

Ran OCT of angle to confirm diagnosis of acute angle closure

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Case

OCT along with SLE findings provided confirmation of acute angle closure secondary to lens growth (phacomorphic)

Pt given one drop Iopidine @4:18 TA @ 4:38 by GAT: 52mmHG

One drop Cosopt @ 4:55PM with punctal occlusion BP 118/80 p80

Pt given 2, 250mg Diamox tabs at 5:08PM TA @ 5:19 by GAT: 50mmHG

Case

Patient pressure was monitored for 2 hours after Diamox was given TA @ 5:40pm 50mmhg

TA @ 5:55pm 49mmhg

TA @ 6:05pm 50mmhg

TA @ 6:20pm 47mmhg At this point a lengthy discussion about depression gonioscopy was

held. The decision was difficult for the patient due to the amount of distress she was in.

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Case

Depression gonioscopy performed at 7:11 PM We saw movement in the apposition on the iris and proceeded to indent for

roughly 1 ½ minutes.

TA immediately after depression 34mmHG At this point the pressure was low enough to instill pilocarpine 2% @

7:14pm???????? Pt was taken to OCT shortly after instillation.

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Case

Pt was given second dose of 2- 250mg Diamox tabs at 7:30pm. TA @ 7:52pm 21mmHg

Pt prescribed Pilocarpine 2% QID until morning and Diamox 500mg Q4H

Pt was scheduled with Oph first thing in the morning for LPI which was performed without complication

She is now scheduled for cataract extraction of the left eye.

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Case

• 77 YO/WF

• Advanced glaucoma

• Bilateral Trabeculectomies 2005, IOP 8-11 range

• Cataract Surgery OS 2 yrs ago, IOP 10-11 range

• Cataract Surgery OD 6 months ago, IOP 16-19 range

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Glaucoma Anterior Segment Rapid Fire

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Iris

What to do?

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• The annual incidence is approximately 1/million.

• The great majority of iris melanomas occur on the inferior half of the iris. Sun exposure?

• The overall rate of spread at 10 years is 3-5%.*

• Treatment options for iris melanomas include:

• Observation

• Excision

• Enucleation

• Plaque radiotherapy

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Iris Rapid Fire!

•

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Conjunctiva

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Anterior Segment Optical CoherenceTomography of Conjunctival NevusCarol L. Shields, MD, Irina Belinsky, MD, Massi Romanelli-Gobbi, BM, Juan Mica Guzman, MS,Douglas Mazzuca, Jr., BS, W. Ross Green, BS, Carlos Bianciotto, MD, Jerry A. Shields, MD Ophthalmology 2011;118:915–919

• This preliminary report shows evidence that AS-OCT may provide important data regarding the configuration of conjunctival lesions, tumor boundaries, and internalstructures. This information may contribute to establishing the clinical diagnosis of a benign conjunctival nevus and assist in defining the extent of the tumor. Further research into imaging of conjunctival lesions with AS-OCT may allow characterization of classic features to better aid in establishing a clinical diagnosis and detecting early malignant transformation

Thank You

mcymbor@nittanyeye.com www.nittanyeye.com