Imaging Interpretation for the Comprehensive Eye Care Professional

Blair Lonsberry, MS, OD, MEd., FAAODiplomate, American Board of OptometryClinic Director and Professor of Optometry

Pacific University College of Optometryblonsberry@pacificu.edu

Time

%

Loss

Early

Moderate

Severe

• Visual Field changes occur late in the disease

• The Optic disc often changes before visual fields

• The RNFL usually changes before both the visual fields and optic disc

VF

Disc

RNFL

Structural / Functional Relationship in Glaucoma as the Disease Progresses

Clinical Exam of the Optic Nerve HeadUtility and Limitations

• Disc exam at the first visit – normal or abnormal?– Disc exams are subjective, or at best semi-

quantitative– The wide variety of disc appearances requires

long experience and expert judgment to separate normal from abnormal

– Disc diameter must be taken into account

• Disc exam to assess change– Unless stereoscopic photographs are taken and

compared over time, the ability of a clinician to judge change is very limited (chronology is important!)

OCT: The Basics

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Retinal Layers

Cirrus RNFL Analysis

CALCULATION CIRCLEAutoCenter™ function automatically centers the 1.73mm radius peripapillary calculation circle around the disc for precise placement and repeatable registration.

OPTIC DISC CUBE SCANThe 6mm x 6mm cube is captured with 200 A-scans per B-scan, 200 B-scans.

RNFL/ONH Analysis

RNFL THICKNESS along the calculation circle is displayed in graphic format and compared to age-matched normative data

RNFL DEVIATION MAP, overlaid on the OCT fundus image, illustrates precisely where RNFL thickness deviates from the normal range. Data points that are not within normal limits are indicated in red and yellow.

RNFL THICKNESS MAP shows the patterns and thickness of the nerve fiber layer within the full 6mm x 6mm area

RNFL THICKNESS AND COMPARISON TO NORMATIVE DATABASE is shown in circle, quadrants and clock hour display

ONH Analysis: rim/disc area, average C/D ratio, vertical C/D ratio and cup volume

Cirrus RNFL and ONH Analysis Elements

• RNFL Peripapillary Thickness profile, OU• compared to normative data

Neuro-retinal Rim Thickness profile, OU- compared to normative data

Optic Nerve Head calculations are presented in a combined report with RNFL thickness data. Key parameters are compared to normative data and displayed in table format

Cirrus HD-OCT GPA Analysis

Two baseline exams are required

Baseline

Third exam is compared to the two baseline exams Sub pixel map demonstrates change from

baseline: Yellow pixels denote change from both

baseline exams

Third and fourth exams are compared to both baselines: yellow pixels denote change from both baselines change identified in three of the four comparisons is indicated by red pixels

Image Progression Map

Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies

Guided Progression

Analysis (GPA™)

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Guided Progression

Analysis (GPA™)

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Macular Cube Scan

Automatic Fovea Finder™Fovea center = 255, 71 Scan center = 255, 64

Macula Thickness Analysis is aligned with fovea location (left)

Resulting analysis may differ from analysis aligned on scan center (right)

Macular Thickness Normative Data

Macular thickness is compared to an age-matched normative database as indicated by a stop-light color code

Macular Change AnalysisProvides visual and quantitative comparison of two exams.

Ganglion Cell Analysis

• Measures thickness for the sum of the ganglion cell layer and inner plexiform layer (GCL + IPL layers)– RNFL distribution in the macula depends on

individual anatomy, while the GCL+IPL appears regular and elliptical for most normals

– Deviations from normal are more easily appreciated in the thickness map by the practitioner, and arcuate defects seen in the deviation map may be less likely to be due to anatomical variations.

Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012

Ganglion Cell Analysis

17Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012

CIRRUS HD-OCT and HFA Combined Report

Case 1

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Case History

• 60 yo WM– Type 2 DM: 4 years– Hypertension: 4 years– Bilateral PK’s secondary to keratoconus

(has running suture OD)– Has history of steroid injections for lower

back stenosis (with history of increased IOP up to 40 after injections)

– VA(RGP): 6/7.5 (20/25), 6/6 (20/20)– IOP: OD: range 20-24, OS: range 17-20

OD OS

ODOS

Consider the below PSD plots.

OS OD

Predict what TSNIT graphs you would obtain for this patient.

1 2

3 4

OS OD

OD OD

OD OD

OS OS

OS OS

OD

OS

ODOS

Case 2

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Entrance Skills

• 60 YR WM– Complaint of blurry vision– Currently wearing sister’s contacts as he lost his

glasses– PMHx: depression but not currently controlled– POHx: unremarkable– BCVa: 6/6 (20/20) OD, OS– All other entrance skills unremarkable

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Health Assessment

• SLE:– Arcus OD, OS– Anterior chamber: deep and quiet– Lens: trace NS

• IOP: – 26 and 23 OD, OS (first visit)– 24 and 20 OD, OS (second visit)

• DFE: – C/D: 0.75/0.75 (with temporal sloping) OD and 0.6/0.6

OS

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31

32

33

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Case 3

Case: Gonzalez

• 33 HF presents with a painful, red right eye• Started a couple of days ago, deep boring pain• Has tried Visine but hasn’t helped the redness

• PMHx: patient reports she experiences joint pain and has been “diagnosed” with rheumatoid arthritis for 3 years• takes Celebrex for the joint pain• patient reports she occasionally gets a skin

rash when she is outdoors in the sun• POHx: unremarkable• PMHx: mother has rheumatoid arthritis

Case: Gonzalez

• VA: – 6/9 (20/30) OD, – 6/6 (20/20) OS

• Pupils: PERRL –APD• VF: FTFC OH• EOM’s: FROM OU• BP: 130/85 mm Hg RAS• SLE: see picture

– 2+ cells, mild flare• IOP’s: 16, 16 mm HG• DFE: see fundus photo

Etiologies of Cotton Wool Spots

Vascular Occlusive Disease

Hypertension Ocular Ischemic Syndrome

Autoimmune Disease e.g. SLE

Hyperviscosity syndromes

Trauma

Pre-eclampsia Radiation Retinopathy

Toxic e.g. interferon

Neoplastic e.g. leukemia

Anterior Ischemic Syndrome

Infectious e.g. HIV

Antimalarial Ocular Complications

• usual dose is 200-400 mg/d @night with onset of action after a period of 2-4 months

• Have affinity for pigmented structures such as iris, choroid and RPE

• Toxic affect on the RPE and photoreceptors leading to rod and cone loss.

• Have slow excretion rate out of body with toxicity and functional loss continuing to occur despite drug discontinuation.

Question

Which of the following depicts a retina undergoing hydroxychloroquine toxicity?

1 2 3 4

Question

Which of the following depicts a retina undergoing hydroxychloroquine toxicity?

ARMD Macular HoleOHS

Bull’s Eye Maculopathy

QuestionWhich OCT goes with a patient undergoing hydroxychloroquine toxicity?

1 2

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Antimalarial Ocular Complications

• Toxicity can lead to whorl keratopathy, “bulls eye” maculopathy, retinal vessel attenuation, and optic disc pallor.

• Early stages of maculopathy are seen as mild stippling or mottling and reversible loss of foveal light reflex

• “Classic” maculopathy is in form of a “bulls eye” and is seen in later stages of toxicity– this is an irreversible damage to the retina

despite discontinuation of medication

Antimalarials

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Bulls Eye Maculopathy Whorl Keratopathy

Revised Recommendations on Screening for Retinopathy

• 2002 recommendations for screening were published by Ophthalmology

• Revised recommendations on screening published in Ophthalmology 2011;118:415-42– Significant changes in light of new data on

the prevalence of retinal toxicity and sensitivity of new diagnostic techniques

– Risk of toxicity after years of use is higher than previously believed• Risk of toxicity approaches 1% for

patients who exceed 5 years of exposure

Revised Recommendations on Screening for Retinopathy

• Amsler grid testing removed as an acceptable screening technique– NOT equivalent to threshold VF testing

• Strongly advised that 10-2 VF screening be supplemented with sensitive objective tests such as:– Multifocal ERG– Spectral domain OCT– Fundus autofluorescence

Revised Recommendations on Screening for Retinopathy

• Parafoveal loss of visual sensitivity may appear before changes are seen on fundus evaluation

• Many instances where retinopathy was unrecognized for years as field changes were dismissed as “non-specific” until the damage was severe

• 10-2 VF should always be repeated promptly when central or parafoveal changes are observed to determine if they are repeatable

• Advanced toxicity shows well-developed paracentral scotoma

Paracentral Scotomas

Courtesy of Dr. Mark Dunbar

Revised Recommendations on Screening for Retinopathy

• SD-OCT can show localized thinning of the parafoveal retinal layers confirming toxicity– not appreciable with time-domain OCT– changes maybe visible prior to VF defects

• Fundus autofluorescence may reveal subtle RPE defects with reduced autoFL or show areas of early photoreceptor damage

• MF-ERG can objectively document localized paracentral ERG depression in early retinopathy

Copyright restrictions may apply.

Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.

Normal Retina: VF/OCT/ERG

Outer Nuclear Layer

PIL

PIL=PR Integrity Line

TD-OCT

SD-OCT

Copyright restrictions may apply.

Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.

Mild Maculopathy

PILThinned Outer Nuclear Layer

Paracentral ScotomasNormal Foveal Peak

Copyright restrictions may apply.

Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775-780.

Bull’s Eye Maculopathy

Remnant of PILRPE Atrophy

Flattened Foveal Peak

Dense Para/Central Defects

Revised Recommendations on Screening for Retinopathy

Factors Increasing Risk of Retinopathy

Duration of use > 5 years

Cumulative Dose > 1000 g (total)

Daily Dose > 400 mg/day

Age Elderly

Systemic Disease Kidney or liver dysfunction

Ocular Disease Retinal disease or maculopathy

Revised Recommendations on Screening for Retinopathy

• Older literature focused on daily dose/kg whereas newer literature emphasizes cumulative dose as the most critical factor– Initial baseline then screening for

toxicity should be initiated no later than 5 years after starting the medication

SD-OCT 5 Line Raster ScansOD OS

Case 4

Vesta: 61 y/o Hatian Female

• GL suspect 2001 – suspicious ON’s• NTG since 2006• Meds: Alphagan P bid OU, latanoprost qhs OU• Medical Hx: HTN, HIV (+) for > 15 yrs• VA: 6/6 (20/20)• TA for the past 3 or 4 yrs: 9-13 mmHg OU

– Last 2 visits 9 mmHg – today 13– Pachs: 450 microns

Case Courtesy of Dr. Mark Dunbar

2010

Case Courtesy of Dr. Mark DunbarOD OS

2012

What’s This???

RE

OD OS

2010

2011

2012

Case Courtesy of Dr. Mark Dunbar

GPA Progression Analysis OD

GPA Progression Analysis OS

Case Courtesy Dr. Mark Dunbar

Vesta: 61 y/o Hatian Female

• NTG OU with thin corneas• OS:

– Optic Nerve and HVF show trend towards progression….

• OCT shows no change

Case Courtesy of Dr. Mark Dunbar

Vesta: 61 y/o Hatian Female

• How do you manage this patient?– Currently on latanoprost and alphagan OU

• This is what was done….– Stopped Alphagan P – Switch to Combigan bid OU– Continue with latanoprost qhs OU– RTC 1 mo

OCT Retinal Images

Cirrus

Pigment Epithelial Detachment Cystoid Macular Edema

CirrusExudative AMD Macular Hole

CirrusVitreomacular Traction Epiretinal Membrane

CirrusCentral Serous Chorioretinopathy Diabetic Macular Edema

Thank You!

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