Imaging Interpretation for the
Comprehensive Eye Care Professional
Blair Lonsberry, MS, OD, MEd., FAAO
Diplomate, American Board of Optometry
Clinic Director and Professor of Optometry
Pacific University College of Optometry
blonsberry@pacificu.edu
Structural / Functional Relationship in Glaucoma as
the Disease Progresses
VF
•Visual Field changes
occur late in the disease
•The RNFL usually
changes before both the
visual fields and optic
disc
% Loss
•The Optic disc often
changes before visual
fields
Early
Moderate
Severe
Time
Clinical Exam of the Optic Nerve Head
Utility 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
4
Retinal Layers
Cirrus RNFL Analysis
OPTIC DISC CUBE SCAN
The 6mm x 6mm cube is captured
with
200 A-scans per B-scan, 200 Bscans.
CALCULATION CIRCLE
AutoCenter™ function automatically
centers the 1.73mm radius
peripapillary calculation circle around
the disc for precise placement and
repeatable registration.
RNFL/ONH Analysis
RNFL THICKNESS MAP shows the patterns
and thickness of the nerve fiber layer within
the full 6mm x 6mm area
ONH Analysis: rim/disc area,
average C/D ratio, vertical C/D ratio and
cup volume
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 AND COMPARISON
TO NORMATIVE DATABASE is shown in
circle, quadrants and clock hour display
RNFL THICKNESS along the calculation
circle is displayed in graphic format and
compared to age-matched normative data
Cirrus RNFL and ONH Analysis Elements
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
•
RNFL Peripapillary Thickness profile, OU
• compared to normative data
Neuro-retinal Rim Thickness profile, OU
- compared to normative data
Cirrus HD-OCT GPA Analysis
Image Progression Map
Baseline
Two baseline exams are required
 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
Change refers to statistically significant change, defined as change that exceeds
the known variability of a given pixel based on population studies
Page 2
Guided
Progression
Analysis
(GPA™)
10
Guided
Progression
Analysis
(GPA™)
11
Macular Cube Scan
Automatic Fovea Finder™
Fovea center = 255, 71
Macula Thickness Analysis
is aligned with fovea
location (left)
Resulting analysis may
differ from analysis
aligned on scan center
(right)
Scan center = 255, 64
Macular Thickness Normative Data
Macular thickness is compared to an
age-matched normative database as
indicated by a stop-light color code
Macular Change Analysis
Provides 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
17
Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012
CIRRUS HD-OCT and HFA Combined Report
Case 1
19
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
OS
OD
Consider the below PSD plots.
OS
OD
Predict what TSNIT graphs you
would obtain for this patient.
OS
OD
OD
1
OD
2
OS
OS
OD
3
OD
4
OS
OS
OD
OS
OS
OD
Case 2
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
28
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
29
30
31
Technician: Operator, Cirrus
Signal Strength: 8/10
6/10
Ganglion Cell OU Analysis: Macular Cube 512x128
OD
OD Thickness Map
OS Thickness Map
Fovea: 252, 64
Fovea: 266, 65
OD Sectors
OS
OS Sectors
OD Deviation Map
OS Deviation Map
OD Horizontal B-Scan
OS Horizontal B-Scan
32
Comments
Doctor's Signature
Technician: Operator, Cirrus
Signal Strength: 6/10
7/10
ONH and RNFL OU Analysis:Optic Disc Cube 200x200
RNFL Thickness Map
OD
OS
RNFL Thickness Map
RNFL Deviation Map
RNFL Deviation Map
Neuro-retinal Rim Thickness
Disc Center(-0.21,0.09)mm
Extracted Horizontal Tomogram
RNFL Thickness
Extracted Vertical Tomogram
Disc Center(0.12,-0.03)mm
Extracted Horizontal Tomogram
Extracted Vertical Tomogram
RNFL
Quadrants
RNFL Circular Tomogram
RNFL Circular Tomogram
RNFL
Clock
Hours
33
Case 3
34
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 Hole
OHS
Bull’s Eye
Maculopathy
Question
Which OCT goes with a patient undergoing hydroxychloroquine toxicity?
1
2
3
4
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
29
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
Normal Retina:
VF/OCT/ERG
TD-OCT
Outer Nuclear Layer
PIL
SD-OCT
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775780.
PIL=PR Integrity Line
Copyright restrictions may apply.
Mild Maculopathy
Normal
Foveal
Peak
Paracentral Scotomas
Thinned Outer
Nuclear Layer
PIL
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775780.
Copyright restrictions may apply.
Bull’s Eye Maculopathy
Flattened
Foveal
Peak
Dense Para/Central Defects
RPE Atrophy
Remnant of PIL
Rodriguez-Padilla, J. A. et al. Arch Ophthalmol 2007;125:775780.
Copyright restrictions may apply.
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 Scans
OD
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
What’s This???
2012
OD
OSCase Courtesy of Dr. Mark Dunbar
OD
OS
RE
2010
201
1
2012
Case Courtesy of Dr. Mark Dunbar
GPA Progression
Analysis OD
GPA Progression
Analysis OS
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 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
Case Courtesy of Dr. Mark Dunbar
OCT Retinal Images
Cirrus
Pigment Epithelial Detachment
Cystoid Macular Edema
Cirrus
Exudative AMD
Macular Hole
Cirrus
Vitreomacular Traction
Epiretinal Membrane
Cirrus
Central Serous Chorioretinopathy
Diabetic Macular Edema
Thank You!
69