OCT And OCT Angiography In Retina Disease

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OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Disclosures- Greg Caldwell, OD, FAAOThe content of this activity was prepared independently by me - Dr. CaldwellLectured for: Alcon, Allergan, Aerie, BioTissue, Kala, Maculogix, OptovueAdvisory Board: Allergan, Sun, Alcon, Maculogix, Dompe Envolve: PA Medical Director, Credential Committee OCT and OCT Angiographyin Retinal Disease Healthcare Registries – Chairman of Advisory CouncilI have no direct financial or proprietary interest in any companies, products or servicesmentioned in this presentation – Optovue The content and format of this course is presented without commercial bias and does not claimsuperiority of any commercial product or service Optometric Education Consultants - Scottsdale, Minneapolis, Florida (Ponte Verda Beach),Mackinac Island, MI, Nashville, and Quebec City - Owner Greg Caldwell, OD, FAAOSunday June 27, 202167Financial Obligations8Resource: OCT Community for OCT and OCT-A9Optical Coherence TomographyBook Resources10Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cellCourse Design111

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Optical Coherence Tomography O CT is an optical signal acquisition and processing m ethodOCT and OCT Angiography Tim e dom ain O CT 15-16 microns of resolution Stratus (Zeiss) Spectral dom ain (SD-O CT) or Fourier dom ain O CT Spatially encoded frequency domain OCT (SEFD-OCT) 5-6 microns of resolution2 Able to see photoreceptor morphology (inner/outer segments) 50 times faster than time domainBoth are Becoming Equally Important inDiagnosis, Management, and Treatment Sw ept source O CT Time encoded frequency domain OCT 1 micron of resolution Future of O CT- intraoperative im aging, blood flow and oxygenation m easurem ents M ay have the possibility to assess retinal pathology like a pathologist1213OCT Angiography: the Next Chapter in Posterior Imaging4 Basic Categories: Diseases of the . Images retinal microvasculature without dye injection Displays structure and function from a single imaging systemVitreousNeuro-Sensory RetinaRPE2014: OCTAChoroid2006: Spectral DomainOCT2002: Time Domain OCT14151617Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell2

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Normal Retinal VasculatureSuperficial Capillary PlexusDeep Capillary PlexusOuter RetinaChoriocapillaris3µm Below ILM 15 µmBelow IPL15µm Below ILM 70 µmBelow IPL70µm Below IPL 30 µmBelow RPE Reference30 µm Below RPE Reference 60 µmBelow RPE Reference18Review of Normal25 year old man19Review of Normal60 year old man2060 Year Old Montage OU21OCT of VitreoretinalInterface DisordersLearn to predict visual acuities22Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell233

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Poll 1 My office has:B.OCTOCT and OCT AngiographyC.No OCT instrument at this timeA.OCT of Vitreoretinal Interface Disorders Epiretinal membrane Pseudohole Vitreomacular adhesion Complete VMA at birth OCT reveals specific stage ofvitreous separation Lamellar hole Full Thickness Macular Hole Vitreomacular traction2425Epiretinal MembraneEpiretinal Membrame (ERM)Other names: premacular fibroplasia, preretinal glosis, macular pucker, surface wrinklingretinopathy Believed to be the result of proliferation of retinal glial cells on the internal limitingmembrane that escaped through breaks in the internal limiting membrane May create macular edema Amsler grid may elicit metamorphosia from surface wrinkling or macular edema Treatment: Monitor until severe then retinal consult, possible vitrectomy with membranepeeling Traction2627Epiretinal Membrane (ERM)Epiretinal Membrane (ERM)En Face O CT of ILMRetina M apRaster Scan28Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell294

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021VMA versus VMTFocal or Broad Attachment3031Vitreomacular Adhesion (VMA)32Focal versus Broad in VMA and VMT33Poll 2: Which eye has the better visual prognosis?Vitreomacular TractionFocalAB34Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell355

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Vitreo-Macular Traction (VMT)Focal3637Focal Vitreomacular Traction3839Stage 1-4 Macular HolesFull Thickness Macular Hole40Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell416

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Full Thickness Macular HoleLarge and Without VMTFull Thickness Macular Hole4243What About the Other Eye?Small Full Thickness Macular Hole without VMT Oneeye has a full thickness macular hole0 macular hole Stage VMA Impendingmacular hole VMT Despite the name2 Can spontaneously resolve4446Macula Hole?47Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell487

OCT & OCT Angiography in RetinalDisease49June 27, 202150Pseudohole5152Let’s See How We Are Doing53Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell548

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Diagnosis?Poll 4FTMH with ?555630-year-old woman - Diagnosis?March 17, 20208 Weeks Later - Diagnosis?5758A Closer Look – Oh no!59Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cellPhew – Lucky! June 16, 2020609

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021February 15, 2020Next Case61628-24-2020Widefield Imaging638-24-2020 Phew!64Diagnosis?Poll 5 OCT Retinal AngiographyA.B.65Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cellRequires an injection of dyeDoes not require dye or an injection6610

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Enface OCT-A SlabsBased on Retinal AnatomyOCT AngiographyA New Approach to Protecting Vision} Non-invasivevisualization of individual layers of retinal vasculaturenot obscured by fluorescein staining or poolingacquisition requires less time than a dye-based procedure} Reduced patient burden allows more frequent imaging to better follow diseaseprogression and treatment response} PathologySuperficial Plexus (ILM – IPL)Outer Retinal Zone (ONL – BM)Deep Plexus (INL – OPL)Choroid Capillaris} ImageEn Face Visualization of LayersBased on Retinal AnatomyFA of CNVOCTA of CNV6768Type 1 “Occult” CNVNormal Retinal VasculatureRPEBruch’sMembraneChoroidSuperficial Capillary PlexusDeep Capillary PlexusOuter RetinaChoriocapillaris3µm Below ILM 15 µmBelow IPL15µm Below ILM 70 µmBelow IPL70µm Below IPL 30 µmBelow RPE Reference30 µm Below RPE Reference 60 µmBelow RPE ReferencetnculcOoneativudxe-VCN} New vessels develop in the choroid} New vessels located below RPE and above Bruch’s m em brane6970CNV?Type 1 “Occult” CNV New vessels develop in the choroidNew vessels located BELOW RPE andABOVE Bruch’s membraneRPEBruch’sMembraneChoroid71Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell7211

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Multimodal imaging and OCTAVAGUE?VascularizedNon-vascularized7374And the not so obvious ones 6x63x37576Case example: 70 y/o WM, AMDDiabetesBelow the RPE77Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell7812

OCT & OCT Angiography in RetinalDisease79June 27, 202180AngioWellness ReportAngioWellness ReportPatient 1 with DiabetesComprehensive Eye Exam - Healthy8182AngioWellness ReportAngioWellness ReportPatient 3 with DiabetesPatient 2 with Diabetes83Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell8413

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021AngioWellness Report29 year old man with diabetesPatient 3 with Diabetes Yearly diabetic Type 1 DMexam, reports no changes to vision BS:190 this AM, last HbA1c 8.620/20 Anterior segment: normal Vision Posterior segment: Non-proliferative DR2 Hem es and exudates No CSME Billedfor: Exam- 99214 Optomap, OCT-Wellness, and OCT-A 812-19-1812-19-201889Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell9014

OCT & OCT Angiography in RetinalDiseaseJune 27, 202112-19-18 what do you see?9112-19-18 what do you Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell9615

OCT & OCT Angiography in RetinalDiseaseJune 27, 202112-19-20189712-19-20189858-year-old man with diabetesWidefield Imaging Newpatient to the practiceunsure, last HbA1c unsure DM meds: metformin, glyburide, Invokana Vision 20/20 Anterior segment: normal BS:99100101102Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell16

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021FAZ Damage – This is DR64-year-old man with diabetesTime to get to know your BS and HBA1c BS: 134 this AM, last HbA1c 8.0meds: Novolog and Amaryl DM Vision20/20segment: normal Anterior103104Widefield Imaging10564-year-old man with diabetes10664-year-old man with diabetes107Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell64-year-old man with diabetes10817

OCT & OCT Angiography in RetinalDiseaseJune 27, 202164-year-old man with diabetes10964-year-old man with diabetes11064-year-old man with diabetes11164-year-old man with diabetes112Central Serous RetinopathyOCT and OCT-A(Neurosensory Detachment ) Treatment? Certainlyuseful, beneficial, essential, and important in following the patientwith diabetes Improved HbA1c113Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell12318

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Central Serous Retinopathy46 year old man(Neurosensory Detachment ) Complains of a perfect yellow circle in the center of his OS The circle stays in the center of his vision even when he moves hiseye VA 20/20 OU Refraction OD Plano OS 1.00 D Prior visit Plano OU124125Photos126127RPE DetachmentRPE Detachment With Clear Fluid128Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell12919

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021Central Serous Chorioretinopathy130Central Serous Chorioretinopathy131Central Serous ChorioretinopathyPlaquenil ToxicityOh Boy!132133PLAQUENIL ZONERevised Recommendations on Screening for Chloroquine andHydroxychloroquine Retinopathy Last recom m endations w ere 2002by the Am erican Academ y ofO phthalm ology Im proved screening tools and newknowledge about prevalence oftoxicity have prom pt the change 1% after 5-7 years of use or a cumulativedose of 1000 grams (Plaquenil) There is no treatm ent for thiscondition Therefore must be caught early Screening for the earliest hints offunctional or anatom ic change Plaquenil toxicity is not w ellunderstood134Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell13520

OCT & OCT Angiography in RetinalDiseaseJune 27, 20211-1.5 MM PERIMACULAR GCCTHINNING THE FIRST SIGN OFPLAQUENIL TOXICITYSYMMETRICALANDNOTHINGOBVIOUS136WHY? THICKEST LAYEROF GANGLION CELLS ANDSMALLEST GANGLIONCELLS AT THAT LOCATION.VERY SENSITIVE TO TOXICITY137WHAT DO YOU SEE ON THE SCANS?A.B.C.D.THINNING OF THE GCC IN THE PLAQUENIL ZONEMACULAR EDEMACOMPROMISED PILNOTHING OF IMPORTDO YOU SEEANY PROBLEMIN THEPLAQUENILZONE?138139WHAT DO YOU SEE ON THE SCANS?A.B.C.D.THINNING OF THE GCC IN THE PLAQUENIL ZONEMACULAR EDEMACOMPROMISED PILNOTHING OF IMPORTDO YOU SEEANY PROBLEMIN THEPLAQUENILZONE?140Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell14121

OCT & OCT Angiography in RetinalDiseaseJune 27, 2021AUGUST 2014142AUGUST 2014143WHAT DO YOU SEE ON THE SCANS?A.B.C.D.WHAT DO YOU SEE ON THE SCANS?THE FLYING SAUCER SIGNMACULAR EDEMAINCREASED PERIMACULAR RETINAL THINNINGA AND CA.B.C.D.THE FLYING SAUCER SIGNMACULAR EDEMAINCREASED PERIMACULAR RETINAL THINNINGA AND CAC144AC145THE END GAME ONCE YOU DISCONTINUEPLAQUENIL IT STAYS AROUND A WHILE TOCREATE DAMAGE.LONG ½ LIFEWAY OUTTA THE BARNBILATERAL COM PROM ISE OF THE PIL (W HITE ARROW S)AFTER COLLAPSE OF PERIFOVEAL RETINA (RED DASHEDARROW S) W ITH FLYING SAUCER ATTACK (BLUE ARROW S)146Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell14722

OCT & OCT Angiography in RetinalDiseaseJune 27, 202171 yo woman With2016Lupus and hypertension Medications: Colazapam Plaquenil 200 mg BID, 15 years 81 mg ASA Prednisone Losartin VA20/25 OD/OS (mild cataracts)was told to see an ophthalmologist in 2013 Patient1481492016150151Questions?Thank you!OCT and OCT Angiographyin Retinal Disease152Greg Caldwell, OD, FAAOGrubod@gmail.com 814-931-2030 cell15623

OCT & OCT Angiography in Retinal Disease June 27, 2021 Greg Caldwell, OD, FAAO Grubod@gmail.com 814-931-2030 cell 4 Poll 1 My office has: A.OCT B.OCT and OCT Angiography C.

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