Good Hope Eye Clinic

OCT Atlas, optical coherence tomography

David Kinshuck

Types of scan

raster and radial oct scans

 

 

 

 

Layers

layers in a healthy OCT
  • BJO
  • scan may be
    • decentred,
    • wavy (due to movement)
    • out of register

 

Macular oedema ...Case PFT

parafoveal telangiectasiasee PFT page OCT scans...2 scans thought the same eye, showing oedema in the foveal area. HbA1c was 5.9%. There has been no change over a year. Good vision (6/9). Other eye not affected. Enlarge explanation

 

Subhyaloid haemorrhage

subhyaloid haemorrhage and hyaloidotomyafter Yag laser hyaloidotomy                                Subhyaloid haemorrhage explanation

 

Macular oedema 2

macula oedema

minimal oedema after laser

before laser lots of oedema Enlarge

 

Macula oedema from a macroaneurysm (superior retina). The oedema reduced over the 6 months after laser (then returned, not shown!). Enlarge

 

Macular oedema 3

macula oedemaMacula oedema: there is an intact RPE layer (differentiating the condition from ARMD) Enlarge   explanation

 

Macular oedema 4..diabetic retinopathy 

 

oct retinal vein occlusion

Macula oedema: part of diabetic retinopathy  Enlarge   explanation
age 39 male, 20y diabetes, Hba1c poorly controlled till 2012, went on dafne , now well controlled , hba1c 7, retinopathy now much worse, BP has just gone up also, PRP laser awaits anti-VEgf

Macular oedema and response to treatment

  • Intraretinal cysts are predictive at week 4, so examine after 1 injection to determine prognosis.
  • These are similar to the hyper-reflective spots in this paper Retina16 which predict a poorer response. If the spots reduce in number vision improves.
  • Disrupted retinal inner layers (DRIL areas) indicate a worse prognosis see
  • Observing retinal thickness after 3 injections: if there is no improvement there will be no benefit no benefit of continuing anti-VEGF.

 

Wet AMRD

  • moderate specificity only 95% Eye14

wet armd with neurosensory retinal detachmentWet armd with neurosensory retinal detachment and a shallow PED (1 month after right photo). More anti-VEGF needed.  Enlarge    explanation

 

Wet AMRD 2

wet armd

Left: wet age 65y, male 6/18 vision. Neurosensory detachment (NSD/SRF) visible. explantation    Enlarge 

Right: Now 6/12. Some intraretinal fluid remains (regular Lucentis). Subsequently vision returned to 6/18 again. 

 

 

 

 

RAP

armd rap

neurosensory detachment and intraretinal fluid,
as part of a rap enlarge and OCT

rrrrrr

 

OCT signs

types of ped

various oct signs

 

 

Foveal cyst

foveal cyst

Patient 86y, well controlled diabetes, 6/9 vision, other eye good. No change over 3 months, no treatment other than maintaining good glucose and blood pressure control.

 

Wet armd 3

Regular Lucentis 6/18  no treatment between these OCTs In retrospect The April (photo on the right) photos shows intraretinal fluid and Lucentis should have been given.

armd

One month later there is subretinal fluid (neurosensory detachment) and more PED fluid, so 2 injections were given one month apart.   Enlarge   explanation
This April photo shows intraretinal fluid and lucent is was not given. In retrospect it should have been given as the left photo, one month later, shows increased leakage.

 

 

 

Wet armd 4..intraretinal fluidwet armd intraretinal fluid

August: after further Lucentis, less fluid (August).
June: intraretinal fluid present. (June)  enlarge
Graph: Green..less fluid (August scan on extreme left) versus blue (June).

 

 

 

 

Outer retinal tubules

out retinal tubules

"Outer retinal tubules represent chronic degenerative changes, not active leakage (anti-VEGF treatment not needed)."

Some may disappear with anti-VEGF treatment BJO 16

outer retinal tubules

 

Wet ARMD 5 ..very early

  • This patient presented with good vision (6/6) in January with a little distortion.
  • The condition was thought to be dry, and no treatment was offered (patient was asked to attend if sight became worse).
  • In November there was definite wet ARMD (not illustrated here)
  • In retrospect this patient probably had early wet ARMD in January as illustrated on this scan. Even if treatment was not offered, a repeat scan should have been arranged, 1-2 months later.
  • This  OCT has 2 cuts of the SAME scan.

very early wet armd

intraretinal fluid  Enlarge.
     .. a  tiny break in the RPE/bruchs membrane

 

 

Wet ARMD 6

  • female, age 58
  • 2 weeks poor sight left eye, smokes 25, partner smokes
  • at first examination of the OCT the macular looks dry, but fluid is clearly seen as the mouse is moved
  • looks a little like CSR, but with very recent history, FFA not available, thought to be CNV (intraretinal fluid indicates wet CNV not CSR)
  • Lucentis begun
iwet cnv...you must move the mouse..these are 2 cuts of the same eye from the same scan
fovea looks dry  Enlarge
but if you move the mouse up the fluid is clearly visible. PED, subretinal fluid (neurosensory detachment), and PED

 

 

Wet ARMD 7

  • female, age 92, Regular lucent is with ~6/36 vision
  • worse over last 2 months, today 6/120
  • pin addtion to the wet ARMD, patient has developed a retinal vein occlusion, CRVO
  • see new Central RVO
  • high ESR (69)....looking for myeloma etc
wet armd, now new CRVO
November: lots of new subretinal fluid with lots of retinal haemorrhages...a new retinal vision occlusion Enlarge
October: wet ARMD with no fluid at this visit (regular Lucentis each time fluid reaccumulates)

 

 

 

Wet ARMD 8: vascularised PED: (Occult CNV type 1)

a vascularised PED (a type of wet ARMD)

November, 7 months later, a PED has developed, with a retinal haemorrhage. Also, intraretinal and subretinal fluid. enlarge
Patient, age 86, April, reasonable vision 6/24
Photo and OCT shows drusen, hard and soft

 

 

Wet ARMD 9: occult, no PED

a vascularised PED (a type of wet ARMD)

Classic with occult, no PED, a lot of vascular changes. So much exudate is unusual; responds temporarily to Lucentis, fluid comes and goes. 6/18 when dry, 6/36 when wet. Change to Eylea.   explanation  enlarge   

 

Wet ARMD 10: with submacular haemorrhage

wet armd with submacular haemorrhage

2 week history of loss of central vision 6/36). Lucentis carried out, (intravitreal streptokinase would not help as haemorrhage is submacular...streptokinase would help if preretinal haemorrhage. enlarge   FFA (shows classic CCNV)

 

Wet ARMD 11: neurosensory detachment and pigment epithelial detachment

wet, probably occult

Probably occult, 6/36,   explanation, compare to other eye

 

Wet ARMD 12: with bilateral submacular haemorrhage

submacular haemorrhage

top right eye...recent submacular haemorrhage; on warfarin (cause of haemorrhage?, 6/120 vision)

bottom left eye.........longstanding haemorrhage with subretinal fibrosis  CF vision

enlarge

 

Wet ARMD 13, intraretinal fluid

intraretinal fluid

Patient is known to have definite wet ARMD, treated with Lucentis, being followed up with OCT. Right scan, previous month is definitely dry. The left scan his month has intraretinal fluid,  (we believe), Lucentis...2 injections arranged. Change to Eylea at first opportunity.  Explanation

 

Wet ARMD 14, PED, poor response

ped  not responding

PED did not respond to treatment, right September, left October; there is probably IRF (intraretinal fluid). These findings (unresponsive PED) are common if there is a RAP.

Explanation    

 

 

Wet ARMD 15

 

intraretinal  fluid...active wet

intraretinal fluid: active leak, needs anti-VEGF treatment   Explanation  

 

Wet ARMD 16, subretinalfluid (neurosensory detachment)

ped  not responding

Routine eye test, reported wavy lines on amsler grid. age 54. SRF/NSD    Explanation   

 

 

Wet ARMD 17, classic

 

wet ARMD classic

classic CNV    Explanation   

 

 

Wet ARMD 18, intraretinal fluid

 

wet intraretinal fluid

October... wet intraretinal fluid                                              September dry 

known Lucentis wet ARMD patient  Explanation   

 

Wet ARMD 19, macular haemorrhage

 

wet with macular haemorrhage

No obvious SRF, IRF, or PED, but there is a haemorhage so must be wet  Explanation   

 

Wet ARMD 20, dry this visit

lucentis for wet ARMD

Previously wet treated with Lucentis, dry this visit, so no Lucentis needed. Explanation   

 

Wet ARMD 21, probably wet

known wet ARMD with probable intraretinal fluid

Known wet ARMD with probable intraretinal fluid. Explanation   

 

Polypoidal

polypoidalcnv

Drusenoid PED and epiretinal membrane left eye............

drusoind PED and ERM

Drusenoid PED and ERM. The drusenoid PED may progress to produce and area of atrophy; the ERM is stable >66% patients. 6/24 (6/18 right)    Explanation

 

 

...............right eye, drusenoid PED, same patient

drusoind PED and ERM

Drusenoid PED Enlarge  6/18 right

 

 

Early epiretinal membrane,

drusoind PED and ERM

Right eye healthy.                       Early ERM left eye   Explanation

 

 

Macular holes, bilateral

vmt case 28

top...left eye, macular hole, 2 years (declined surgery), 6/60 vision

bottom...right eye, macular hole and VMT referred for vitrectomy, reduced sight 2 months, 6/36 vision  explanation

 

 

Tiny macula hole

tiny macula hole

a tiny hole, would orciplasmin help?

 

 

Branch retinal vein occlusion

branch retinal vein occlusion

explanation

 

Choroidal OCT

  • thick choroid is related to disease activity, VKH etc
  • granulomas
  • toxo
  • if thick don't reduce steroids

 

 

Drusen

drusen

drusen    enlarge

 

 

Drusen, early

early drusen

drusen    explanation

 

 

Minor distortion, no diagnosis made

early drusen

disturbance of photoreceptors, Bruchs membrane, cause?  explanation

 

 

Rip 1

rip with cnva sharp near vertical edge to the CNV membrane the visit before

 

 

Rip 2

rip

a rip  explanation

 

 

Choroid

  • Choroidal view..push camera close to eye and evert image
  • choroidal thickness is related to ..age, refraction, site in eye, time of day
  • Choroidal thickness decreases...vascular problems
  • increases inflammation
  • Age related choroidal atrophy
  • Pachychoroidopathy and retinitis pigmentosa: choriocapillaris is thin
  • thick with central serous chorioretinopathy and polypoidal choroidal vasculopathy
  • thin with gyrate atrophy
  • sacrs: Helpp sydrome..high bp and pregnant, leaves scars
  • atrophy with ocular ischaemic syndrome 

 

OCT optometry support ideas

  • Funded at ~£45 by ccg?
  • Need IT support setting up
  • Example cases: patients who do not need or want to see ophthalmologist
  • Csr, erm, dry amd with visual changes or anxiety or high risk,
  • NO patient obviously wet requiring, wanting treatment
  • macula hole patient just want confirmation but no treatment
  • NO macula hole patient requiring, wanting treatment
  • HCA = health care assistant

Pathway

  • Contact by email...all correspondence electronic. Form...attached
  • Referral placed electronically on hospital note system.
  • Hca to carry out visual acuity and oct and smoking counselling and blood pressure
  • medisoft for data
  • OCT ...technician to complete medisoft and Email photo and report to referrer and dk
  • Medisoft letter with the photo
  • Dk to assist with audit

Form for referral

  • Box...patient agrees to referral and electronic correspondence
  • Box...patient angle wide enough to safely dilate
  • Box..patient informed not to drive and will need dilation
  • text space
    • past medial history
    • drugs
    • Reason for referral
    • If intervention may be needed do you want this to be initiated by hospital; if not, please state why.

Duration of prediabetes and diabetes

  • retina thins with the duration of prediabetes and diabetes (until retinopathy develops)

Hyperreflective Foci

Not described here

  • Foveal hyplasia can be graded

Lymphoma

  • think of lymphoma in chronic uveitis OI14
  • Undulating rpe when no AMD... Barry
  • Hyper-reflective sub rpe infiltration
  • Hyper-reflective pre rpe infiltration
  • Hyper-reflective choroidal lesions