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Cover

Cover

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ATLAS Optical Coherence Tomography of Macular Diseases

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ATLAS Optical Coherence Tomography of Macular Diseases

Assistant Vishali Gupta Professor MD Postgraduate Institute Department Chandigarh, of Medical of Ophthalmology India Education and Research

Professor Amod Gupta and Head MD Postgraduate Institute Department Chandigarh, of Medical of Ophthalmology India Education and Research

Mangat Additional R Dogra Professor MD Postgraduate Institute Department Chandigarh, of Medical of Ophthalmology India Education and Research

Department Chandigarh, of Medical of Ophthalmology India Education and Research LONDON AND NEW YORK A MARTIN

LONDON AND NEW YORK A MARTIN DUNITZ BOOK

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© 2004 Vishali Gupta, Amod Gupta, Mangat R Dogra First published in India in 2004 by

Gupta, Mangat R Dogra First published in India in 2004 by EMCA Jaypee House, Brothers 23/23B

EMCA Jaypee House, Brothers 23/23B Medical Ansari Road, Publishers Daryaganj, (P) Ltd, New New Delhi Delhi, 110 India. 002, India e­mail: Phones: jpmedpub@del2.vsnl.net.in, 23272143, 23272703, 23282021, Visit 23245672 our website: m\, www.jaypeebrothers.com Fax: +91–011–23276490 First distributed published worldwide in the United (excluding Kingdom the by Indian Taylor Subcontinent) Tel.: & Francis, +44 (0) a by 20 member Martin 7583 9855 of Dunitz, the Taylor a member & Francis of the Group Taylor in & 2004. Francis Exclusively Group. Fax.: E­mail: +44 info@dunitz.co.uk (0) 20 7842 2298 This edition published Website: in http://www.dunitz.co.uk the Taylor & Francis e­Library, 2005. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk. All accordance any rights means, reserved. with electronic, the No provisions part mechanical, of this of publication the photocopying, Copyright, may Designs be recording, reproduced, and or Patents otherwise, stored Act in without a 1988 retrieval or the under system, prior the permission terms or transmitted, of any of the licence in publisher any permitting form or or in by Although every effort has been limited made to copying ensure issued that all by owners the Copyright of copyright Licensing material Agency, have been 90 Tottenham acknowledged Court in Road, this publication, London W1P we 0LP. would be glad to acknowledge in Although prescribing every physician. effort has Neither been made the publishers to ensure that nor subsequent the drug authors doses reprints can and be other or held editions information responsible any omissions are for presented errors brought or accurately for any to our consequences attention. in this publication, arising from the ultimate the use responsibility of information rests contained with the herein. For detailed prescribing information or instructions instructional on the use material of any product issued by or the procedure manufacturer. discussed herein, please consult the prescribing information or A CIP record for this book is available from the British Library. ISBN Master e­book ISBN

ISBN 1 84184 468 3 (Print Edition) Distributed in Taylor North & and Francis South America by Boca 2000 Raton, NW Corporate FL 33431, Blvd USA Tel.: 800 Within 272 7737; Continental Fax.: 800 USA 374 3401 Tel.: E­mail: 561 Outside 994 orders@crcpress.com 0555; Continental Fax.: 561 USA 361 6018 Distributed in the rest of Thomson the world Publishing (excluding Services the Indian Subcontinent) by Cheriton North Way House Andover, Tel.: Hampshire +44 (0)1264 SP10 332424 5BE, UK E­mail: salesorder.tandf@thomsonpublishingservices.co.uk

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Preface

For several decades now, the ophthalmologists have exploited the great opportunities that a clear media of the eye provides to examine, study and document the retina

in health and disease using a myriad of simple and complex, techniques and technologies including the direct ophthalmoscope, the binocular indirect ophthalmoscope

clinicopathological the and pathogenetic the slit lamp mechanisms biomicroscope correlates of and using the the retinal pathology contact disease. or of non­contact the blinding lenses. and the Development benign retinal of fundus disease. angiography A great body techniques of work by contributed the ocular a pathologists great deal in provided our understanding the necessary of stereoscopic clinicopathologicalinformation. However, examination as clinicians, we we could have tell, always if the viewed lesion retina was preretinal, as a ‘surface’ intraretinal and not or a subretinal, 3­dimensional it was structure, largely speculative that it actually based is, and on our while sensitization we all claimed to the that available on

The advance The OCT emergence in provides, the diagnostics of in Optical real time, of retinal Coherence high­resolution disease Tomography and cross­sectional has found (OCT) rapid in images acceptance the recent of the years among macula has the very changed retina similar specialists. forever, to obtaining the way in we vivo ‘look histopathological at’ or shall we sections. say ‘look It through’ represents the a retina. major information’ however, A while was ago, we soon when were dampened missing we started without by doing the non­availability the the OCT OCT and examination how of the any vital along standard inputs with textbook it the provided, clinical (the and only changed angiographic book the titled way ‘Optical correlation we practiced Coherence of ‘Retina’. our retina Tomography Our patients, excitement we of Ocular soon of working realized Diseases’ ‘the with by this Carmen tool,

A Puliafito, Michael R.Hee, Joel S.Schuman and James G.Fujimoto, being out of print) and meant that every new finding on the OCT saw us rushing to the library

almost on a daily basis to locate any published reports on the subject. chorioretinopathy, diagnosis, the In response this ‘Atlas’, management to various we submacular have therapies and attempted follow pathology and up to interventions of share diabetic and our many experience macular and more above edema, areas of all Stratus that identifying macular are OCT divided hole, the (Tm) correct taut into in posterior various 22 therapeutic chapters. macular hyaloid For approach disorders ease membrane, of in comprehension, where a given vitreofoveal we patient. found we traction, It it finds provide helpful extensive idiopathic in with diagnosing brief application central case and serous summaries, monitoring in fundus tool We to shall probe photographs, like the to mysteries point fluorescein out of that retinal OCT angiography disease. is not a It substitute and has the major OCT for limitations a images thorough and in clinical obtaining the follow examination, images up images through fundus for most a cloudy imaging of the media or patients various or trying that angiographic we to share look at with techniques the the choroidal readers. but pathology. is a great adjunctive We strongly recommend that to obtain optimum information from the OCT, it be best performed by the clinician himself or herself.

Page vi membrane, We shall provided like to acknowledge to us by the with courtesy thanks of the Dr. cases Monique of adult Leys, foveo­vitreal MD, Associate dystrophy, Professor, best West disease Virginia and photodyanamic University Eye therapy Institute, of occult USA. We choroidal are thankful neovascular to Ms. thankful Section Marianne One. to Whitby, Carl We Zeiss shall Carl Meditec also Zeiss like Meditec, Inc. to put and on Dublin, Carl record Zeiss USA our India appreciation for for picture allowing of of Stratus the us untiring to reproduce OCT Mr. (Tm) Arun some and Kapil, for of the all our the material help clinical she from photographer rendered their user’s during who manual the obtained preparation that helped most of of us this the in the Atlas. fundus preparation We and are also of angiographic pictures used in this Atlas. Finally, we wish to thank Mr S.S.Saini for his help in editing the manuscript.

Vishali Gupta Mangat Amod R Dogra Gupta

 

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Contents

SECTION ONE INTRODUCTION TO OCT

 

1. Basics of OCT

3

2. Technique of Acquiring OCT

5

3. Selection of Scan Protocols

7

4. OCT Scan of Normal Macula

13

SECTION TWO OCT PATTERNS IN VARIOUS MACULAR DISEASES

5.

Diabetic Macular Edema

21

6.

Idiopathic Central Serous Chorioretinopathy (ICSC)

47

7.

Macular Hole

75

8.

RetinalVascularOcclusions

90

9.

RetinalVasculitis

109

10.

EpiretinalMembranes

113

11.

Age Related Macular Degeneration

126

12.

Choroidal Neovascular Membranes

157

13.

JuxtafovealTelangiectasia

164

14.

Heredodystrophic Disorders

182

15.

Foveal Hemorrhage

206

16.

Photic Maculopathy

209

17.

Optic Disc Pit

215

18.

Inflammatory Diseases of Retina­choroid

222

19.

RetinalAngiomatosisProliferation

279

20.

RetinalTrauma

283

21.

MacularEvaluationfollowingRetinalDetachmentSurgery

296

22.

Intraocular Metastasis

305

Index

309

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Page 1

Introduction Section One to OCT

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Basics Chapter of OCT 1

Page 3 Basics Chapter of OCT 1 WHAT IS OCT? resolution provides Optical Coherence information using

WHAT IS OCT?

resolution provides Optical Coherence information using light Tomography regarding waves. Since the (OCT) retina retinal is is tomography a easily new diagnostic accessible that is to tool akin the that to external in can vivo perform light, histopathology hence tomography/cross­sectional it is especially of the retina. suited The for conventional imaging retinal disorders. of biologic imaging This tissues techniques is the with first including 10 imaging microns fundus technique axial that photography to the conventional and fluorescein topographic angiography techniques. yield diagnostic information about retinal topography. OCT yields information about retinal tomography that is complementary

Principle

We reflected are all from familiar different with boundaries principle on between which ultrasound microstructures. works The where working the high principle frequency of OCT sound is wave similar is to launched ultrasound into with the eye two with major the differences: help of a probe. The sound wave is

1. It resolution uses light of rather 10 microns than ultrasound. compared The to speed 100­micron of light scale is almost for ultrasound. a million times faster than sound and this difference allows the measurement of structures with

2. Ultrasound needs contact with the tissue under study, whereas OCT does not require any contact.

Page 4

The essential components of the hardware include:

HARDWARE

1. Patient Module

2. 4. 3. Flat Joy Mouse Stick Screen Video Monitor

5. 6. 7. DVD­RAM Keyboard CPU Drive

8. Printer

Monitor 5. 6. 7. DVD­RAM Keyboard CPU Drive 8. Printer HOW DOES OCT WORK? boundaries that

HOW DOES OCT WORK?

boundaries that It is is a non reflected contact, between from non the the invasive microstructures various device layers of where and the also retina a broad gets with scattered band­width the echo differently time near delay infrared from of the tissues light same beam with wavelength (820 different nm) optical that is projected is reflected properties. on to from the It then a retina. reference compares The light mirror the gets echo at a reflected known time delay distance. from of the the The light interferometer measured by a then photodetector, combines the which reflected determines pulses the from distance the retina travelled as well by as various reflecting echoes mirrors, by varying resulting the in distance a phenomenon to the reference known as mirror. interference. This finally This interference produces a range is then of Different time The interferometer delays colors for represent comparison. integrates the degree several of light data points backscattering over 2 mm from of different depth to depths construct of a retina. tomogram of retinal structures. It is a real time tomogram using false color scale. The image thus produced has axial resolution of 10 microns and transverse resolution of 20 microns.

SUGGESTED READINGS

1. Puliafito CA, Hee MR, Schuman JS, Fujimoto JG. Optical Coherence Tomography of Ocular diseases. Slack Inc 1996.

3. 2. Huang Hee MR, D, Izatt Swanson JA, Swanson EA, Lin EA CP et et al. al. Optical Optical Coherence Coherence tomography. tomography of Science the human 1999; retina. 254:1178–81. Arch Ophthalmol 1995; 113:325–32.

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Technique Chapter of Acquiring 2 OCT

Page 5 Technique Chapter of Acquiring 2 OCT TECHNIQUE 1. new various Switch patient options on

TECHNIQUE

1. new various Switch patient options on the (A). system: including This Select activates Patient, all the Acquisition components Protocol, and takes Analysis about 45 Protocol seconds and to display so on. You ‘Start can Window’. select the The appropriate menu and category toolbar in and the make Main data Window entry offers for

2. due external Patient to lack Preparation: fixation of image target intensity. It can is be preferable used. The patient The to dilate internal is asked pupil fixation, to before look however, into examination. the ‘Internal is the Small preferred Fixation’ pupils method target of less as in than it the is 3 ocular more mm reproducible. may lens result with the in images study eye. that In are patients truncated with or poor are of vision, poor the quality For light. be covered internal He is as asked fixation, this to helps fixate the the patient at patient the is green asked to fixate light. to look more The inside location steadily. the of ocular With internal external lens. fixation When fixation target patient method, can looks be the readjusted into patient the ocular has as per to lens, use requirements. he the sees fellow a rectangular The eye to opposite fixate field on eye of the of red target the with patient that a green is can

3. Obtaining The placement scanner, external of a by Scan: the to default, the scan The ocular on activates protocol the lens. area in for of the interest. scan fast acquisition scan Once mode, the can alignment also be known selected is as as scan per alignment requirement. mode. The This Scan mode acquisition is useful window for optimizing gets activated the alignment by a click and on polarization the Scan button. and

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Page 6 satisfactory, in the slow scan one mode can click to acquire ‘Scan Mode’ scans.

satisfactory, in the slow scan one mode can click to acquire ‘Scan Mode’ scans. The button desired to change scans to can slow be scan reviewed, mode analyzed also known and as saved. scan acquisition mode. It is important to note that scanner must be

SUGGESTED READING

1. Stratus OCT Model 3000. User Manual Carl Zeiss Meditec Inc. 2002.

Page 7

Selection Chapter of Scan Protocols 3

Page 7 Selection Chapter of Scan Protocols 3 OCT SCAN PROTOCOLS IN MACULA The are: Stratus

OCT SCAN PROTOCOLS IN MACULA

The are: Stratus OCT offers 19 scan acquisition protocols designed for examination of the Retina or Glaucoma patients. The protocols that are helpful in macular diseases

2. 1. Radial Line lines

4. 3. 5. Raster Macular Fast macular lines thickness thickness map map

6. Repeat

processing used While with selecting certain protocols a scan protocol, for type quantitative one only. has To to get analysis keep the in most protocol. mind accurate the kind The and image of meaningful information processing information, one protocol wishes can to one obtain be needs used in to a with given apply any patient. the scan appropriate type The while analysis protocol. the protocols quantitative Given can below analysis be either is the protocol image list of can be Quantitative Analysis protocols that correlate well with the scan acquisition protocols:

Analysis protocol

Retinal thickness Retinal Map Retinal Thickness/Volume

Selection of scan acquisition protocol

any of the protocol, line scan through the macula Radial lines, Fast Macular thickness map Radial lines, Fast macular thickness map

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Page 8 Line Scan The the length line scan of line gives scan an option is

Line Scan

The the length line scan of line gives scan an option is 5 mm of (A). acquiring The length multiple of the line line scans scan without and the returning angle can to main be altered window. (B), The though default one angle has to is keep 0° and in mind the nasal that position as the scan is defined length increases, as 0°. By the default, resolution decreases. This protocol enables one to acquire multiple scans of different parameters.

as 0°. By the default, resolution decreases. This protocol enables one to acquire multiple scans of

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Radial Lines

default beforesavingthefirstscan.TheradiallinesareusefulforacquiringMacularscanandretinalthickness/volumeanalysis This scan setting protocol has 6 (A) lines consists of 6 mm of 6 length. to 24 equally However spaced the length line scans of these that line can scans be varied can be in changed size and by parameters. adjusting the All size the lines of the pass aiming through circle. a central The change common can be axis. made The only

adjusting the All size the lines of the pass aiming through circle. a central The change

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Macular Thickness Map

This protocol is same helps as in radial measuring lines except the retinal that the thickness. aiming circle has a fixed diameter of 6 mm. The number of lines can be adjusted before saving the first scan. This acquisition

circle has a fixed diameter of 6 mm. The number of lines can be adjusted before

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FAST MACULAR THICKNESS MAP

This quick protocol protocol is that designed takes only for use 1.92 with seconds retinal to thickness acquire six analysis. scans When of 6 mm done length in both each. the The eyes, size it can and be number used for of scans comparative is fixed retinal in this thickness/Volume protocol and cannot analysis. be altered. It is a

used for of scans comparative is fixed retinal in this thickness/Volume protocol and cannot analysis. be

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Raster Lines

This rectangular protocol region, provides the area an option of which of acquiring can be adjusted series of so line as to scans cover that the are entire parallel, area of equally pathology. spaced This and is are especially 6–24 in useful number. in These conditions multiple like line choroidal scans neovascular are placed over a membranes where one wishes to obtain scans at multiple levels. The default setting has 3 mm square with 6 lines.

levels. The default setting has 3 mm square with 6 lines. Repeat (Light one Repeat is

Repeat

(Light one Repeat is monitoring emitting protocol diode) enables retinal and one changes. landmark. to repeat No The any parameter system of the previously except repeats placement all these saved parameters protocols can be changed. using giving same The the same set landmark of settings parameters can as be in placed that the include previous on a point scan scan. of size, This reference. angle, protocol placement This is especially helps of in fixation reproducibility helpful LED when during repeat scan. The previous image can be displayed for accurate placement of landmark.

SUGGESTED READING

1. Stratus OCT Model 3000. User Manual Carl Zeiss Meditec Inc. 2002

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OCT Scan Chapter of Normal 4 Macula

Page 13 OCT Scan Chapter of Normal 4 Macula NORMAL MACULA SCAN On a 10 mm

NORMAL MACULA SCAN

On a 10 mm horizontal line scan passing through the foveal center (A) one can clearly demarcate two major landmarks namely optic disc and fovea. The optic disc is the non­reflective seen anterior towards part the and of right is optic seen of nerve. the as tomogram a dark The space. fovea and The is is seen easily interface to identifiable the left between and is by the easily its non­reflective contour. identifiable The central vitreous by the depression characteristic and backscattering represents thinning retinal the of retinal optic layers head layers. is the cup The vitreo­retinal and vitreous the stalk anterior continuing interface. to the The behind retina is is retinal reflective nerve­fibre layer that represents layer (NFL) Retinal is highly pigment reflective epithelium and increases (RPE) in and thickness choriocapillaries. towards the The optic choroid nerve. The and posterior sclera are boundary not seen well of the on retina tomograms is marked as the by signal a hyper­ attenuates this layer of by photoreceptors the time it reaches are alternating these structures. layers of Just moderate anterior and to RPE­choriocapillaries low reflectivity that represent complex different is a minimally­reflective layers of neurosensory layer that retina. represents The retinal photoreceptors. blood vessels Above within the neurosensory retina show backscatter and also cast a shadow behind.

Image Interpretation

There are two ways of interpreting the OCT scan: Objective and Subjective. For the accurate interpretation of the image, one needs to combine both these modalities.

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Page 14 1. Objective: We are all familiar with the interpretation of fluorescein angiograms where we

1. Objective: We are all familiar with the interpretation of fluorescein angiograms where we categorize the pathology as hypo­ or hyper­fluorescent, or ultrasound B experience, for scan objective where images to assessment. do this are is either to One select hypo­ can the modify or scan hyper­echoic. group, the image select before Likewise appropriate studying. in OCT analysis In scan, this image, protocol we look one and at can the go make reflectivity to “Scan anatomic selection”. pattern correlate of This the like scanned gives ‘pigment a magnified images. epithelial The view best detachment’ of way, the selected in our and image also studythereflectivitypatterns.

Followinglesionsare hyper­reflective:

a. Hard exudates (A): The hard exudates are seen as hyper­reflective shadows in the neurosensory retina that completely block the reflections from the underlying

b. Blood retina. thereflectionsfromtheunderlyingstructures. (B): Blood causes increased scattering. In cases of small and thin hemorrahage, hyper­reflectivity is seen, whereas, if the hemorrhage is thick, it might block

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Page 15 c. Scars: All the fibrotic lesions including disciform scars, choroidal rupture scars, healed choroiditis,

c. Scars: All the fibrotic lesions including disciform scars, choroidal rupture scars, healed choroiditis, etc. are hyper­reflective.

Followinglesionsare hypo­reflective:

a. Serous is devoid fluid of any (C): particulate Retinal edema matter is produces the commonest an optically cause empty of reduced space backscattering with no backscattering. and one can actually point out the site of fluid accumulation. The serous fluid that

b. Hypo­pigmented lesions of RPE

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Page 16 One these must situations remember is diffuse that resulting poor quality in overall scans

One these must situations remember is diffuse that resulting poor quality in overall scans attenuation due to opaque of the media scan. and refractive errors might be falsely interpreted as hyporeflective. However, hypo­reflectivity in

2. Subjective Analysis: The software offers the option of both qualitative and quantitative estimation protocols.

Qualitative: ‘Guassian smoothing’. Various image These modification protocols are protocols essentially can image be used modification prior to objective protocols assessment. and can be These used whenever protocols one include wishes. ‘Normalize’, ‘Align’, ‘Median Smoothing’ and

Quantitative

Retinal either thickness thickness/Volume or volume of (A): the This retina. analysis protocol obtains two circular maps for each eye that depict thickness and volume of retina. One has a choice to display

Page 17 between Retinal the thickness/Volume quadrants and between Tabular the (B): eyes. Gives same information as above and also a data table that gives thickness and volume in each quadrant, comparison Retinal thickness/Volume Change: This protocol helps to assess the changes in the retinal thickness/ volume between the examinations.

SUGGESTED READINGS

1. Puliafito CA, Hee MR, Schuman JS, Fujimoto JG. Optical Coherence Tomography of Ocular diseases Slack Inc. 1996.

3. 2. 4. Huang Hee Stratus MR, D, OCT Izatt Swanson Model JA, Swanson EA, 3000. Lin User EA CP Manual et et al. al. Optical Optical Carl Zeiss Coherence coherence Meditec tomography Tomography. Inc 2002. of Science the human 1999; retina. 254:1178–81. Arch Ophthalmol 1995; 113: 325–32.

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OCT Patterns in Section Various Two Macular Diseases

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Diabetic Chapter Macular 5 Edema

Page 21 Diabetic Chapter Macular 5 Edema Diabetic macular edema is the most common cause of

Diabetic macular edema is the most common cause of moderate visual loss in diabetics. The disease is now believed to be multifactorial in origin with a number of cases systemic with factors underlying including systemic hypertension, disorders poor tends metabolic to be diffuse control and of often diabetes, recalcitrant dyslipidemia to laser and photocoagulation. nephropathy playing In addition, a role there in its pathogenesis. is a focal variety The of macular macular edema edema in that is several characterized manifestations by focal areas at the of ultra microaneurysmal structural levels leak within and the is usually retinal layers. seen in The patients conventional with good two­dimensional systemic control. imaging Since techniques the edema is including multifactorial fundus in photographs origin, it produces and retinal layers fluorescein and layers. corresponds angiography OCT provides to give intraretinal an a topographic insight fluid into accumulation. the view underlying of the retina Cystoid retinal that layers macular helps that in delineating edema yields is very represented the useful treatable information. by lesions decreased but The intraretinal are reduced not able backscattering reflectivity to depict the and is changes closely seen mostly occurring resembles in the within the outer the retinal histopathology traction, taut posterior description. hyloid The membrane, hard exudates serous appear detachment as areas under of increased the fovea reflectivity and lamellar with macular a trail holes of shadow in these behind. eyes. In addition, OCT is also able to diagnose macular

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ROLE OF OCT IN DIABETIC MACULAR EDEMA

A. Defining the Disease Pattern

In our experience, we found that diabetic macular edema had 5 distinct patterns that could be defined on OCT alone. These were:

2. 1. Cystoid Sponge­like macular retinal edema thickness

4. 5. 3. Foveal Taut Subfoveal posterior tractional serous hyloid retinal retinal membrane. detachment detachment

B. Longitudinal Tracking of Tissue Alteration following An Intervention

OCT layers. is OCT a very also useful helps tool in in quantifying monitoring the response retinal thickness. to any intervention One can measure very closely. central This foveal indeed thickness gives an in ultrastructural microns and measure detail of the the retinal changes volume. taking In place addition, within retinal the retinal mapping also gives quadrant­wise information about retinal thickness. The quantification makes it easier to monitor the response to therapy.

C. Defining Indications for Pars Plana Vitrectomy

We tractional serous found detachment detachment OCT to be were a and very relative Taut reliable Posterior indications tool in Hyloid defining where Membrane PPV the indications was were indicated the for definite only pars if plana indications the cystoid vitrectomy of or surgery edema in diabetic serous while macular patterns detachment edema. 2 and was 3, In i.e., a our result cystoid experience, of co­existing macular patterns edema mechanical 4 and and 5, subfoveal i.e. traction. foveal

A. PATTERNS OF DIABETIC MACULAR EDEMA ON OCT

to understanding By conceptualize conventional and the techniques pathogenesis. structural of changes retinal OCT examination, is in a the useful underlying tool we in see monitoring tissues. diabetic The macular response OCT almost edema to an gives intervention as a the two in dimensional vivo in clinically histopathology pathology. significant of By the macular looking retinal edema at layers the (CSME). surface that helps of It the in gives the retina better quantitative alone, disease we try information addition to the regarding fluorescein the tissue angiography thickness helped in the us follow­up in the management of CSME. Thus, of CSME OCT patients. helps in better decision­making. Following series of cases illustrate as to how OCT in Patterns of diabetic macular edema. In our experience there are 5 different patterns of diabetic macular edema on OCT. These are:

1. Sponge like thickening of retinal layers: This was mostly confined to the outer retinal layers due to backscattering from intraretinal fluid accumulation.

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Case 5.1: CSME with Sponge­like Thickening

this Case A 52­year­old eye Summary was 20/100. Indian Fluorescein type II diabetic angiography was seen (B) with revealed non­proliferative microaneurysms diabetic with retinopathy late leakage both consistent eyes with with significant macular macular edema. edema right eye (A). The visual acuity in

macular edema. edema right eye (A). The visual acuity in hard Optical A vertical exudates Coherence

hard Optical A vertical exudates Coherence OCT (arrows) Scan Tomography (C) were revealed seen macular as hyper­reflective thickening lesions with reduced within optical the retinal backscatter layers with due shadowing to accumulation effect. of fluid in the outer retinal layers. The circinate rings of

backscatter layers with due shadowing to accumulation effect. of fluid in the outer retinal layers. The

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Case 5.2: CSME with Sponge­like Thickening

A eye Case 50­year­old was Summary 20/20. Indian Fluorescein type II angiography diabetic was (B) seen revealed with non­proliferative microaneurysms diabetic with late retinopathy leakage consistent both eyes with with macular significant edema. macular edema left eye (A). The visual acuity in this

edema. macular edema left eye (A). The visual acuity in this OCT the Optical fovea. (C)

OCT the Optical fovea. (C) Coherence revealed The foveal sponge­like Tomography contour was thickening normal. of The the hyper­reflective fovea with hyporeflectivity shadows seen from within outer the retinal retinal layers layers suggesting (arrows) intraretinal were from fluid hard accumulation exudates. seen mostly temporal to

retinal layers layers suggesting (arrows) intraretinal were from fluid hard accumulation exudates. seen mostly temporal to

Page 25

2. Large long standing cystoid cases, spaces these involving cysts fuse variable to involve depth almost of the entire retina length with of intervening the retina. septae: The cystoid spaces are initially confined to the outer retina mainly, but in

Case 5.3: CSME with Cystoid Macular Edema

A 20/200. Case 54­year­old Summary Fundus woman showed with CSME 20 years (A). Fluorescein history of Non­Insulin­Dependent­Diabetes angiography showed late leakage Mellitus (B). (NIDDM) was examined. Her best­corrected vision in the right eye was

examined. Her best­corrected vision in the right eye was OCT adjoining Optical line Coherence retina scan

OCT adjoining Optical line Coherence retina scan through were Tomography smaller the fovea in size (C) and showed were macular arranged thickening mainly in with the outer two nearly retinal full­thickness layers cystoid spaces under the fovea with intervening septae. The cysts in the

outer two nearly retinal full­thickness layers cystoid spaces under the fovea with intervening septae. The cysts

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Case 5.4: CSME with Cystoid Spaces

A Case with 38­year­old cystoid Summary spaces diabetic in the woman late phase was seen (B). with non­proliferative diabetic retinopathy with cystoid macular edema (A). Fluorescein angiography revealed diffuse leakage

edema (A). Fluorescein angiography revealed diffuse leakage Macular Optical Coherence thickness OCT Tomography scan

Macular Optical Coherence thickness OCT Tomography scan through various angles confirmed the cystoid spaces with intervening septae (C and D).

thickness OCT Tomography scan through various angles confirmed the cystoid spaces with intervening septae (C and

Page 27

Page 27 3. Subfoveal Serous detachment. Case 5.5: CSME with Subfoveal Serous Retinal Detachment A best­corrected

3. Subfoveal Serous detachment.

Case 5.5: CSME with Subfoveal Serous Retinal Detachment

A best­corrected Case 50­year­old Summary visual man was acuity seen was with 20/200 non­proliferative in the right eye. diabetic Fluorescein retinopathy angiography and macular of the edema right (A). eye revealed He had received microaneurysms two sessions with of leak grid in laser the late photocoagulation. phase (B). His

revealed He had received microaneurysms two sessions with of leak grid in laser the late photocoagulation.

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Optical Coherence Tomography

OCT (C) revealed increased macular thickening of 480 microns in the foveal center with hyporeflective areas corresponding to cysts in the retina. In addition, there was

an area of hyporeflectivity in the subfoveal region consistent with subfoveal serous retinal detachment (arrow).

consistent with subfoveal serous retinal detachment (arrow). Case 5.6: Laser Induced Serous Retinal Detachment

Case 5.6: Laser Induced Serous Retinal Detachment

angiography Case A 46­year­old Summary of woman the left eye was revealed seen with microaneurysms proliferative diabetic in the retinopathy early phase and that macular showed leak edema in the (A). late Her phase best­corrected and neovascularization visual acuity was elsewhere 20/20 (NVE) in the left (B). eye. Fluorescein

Her phase best­corrected and neovascularization visual acuity was elsewhere 20/20 (NVE) in the left (B). eye.

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Horizontal layers. Optical No Coherence serous line OCT detachment Tomography scan through was the seen foveal at this center stage. (C) showed ‘sponge­likeretinalthickening’ (pattern 1, sponge­like) with reduced backscatter from the outer retinal

with reduced backscatter from the outer retinal The an interval patient of received one week. focal

The an interval patient of received one week. focal Following laser photocoagulation PRP, her vision and was panretinal reduced photocoagulation to 20/60. Repeat OCT (PRP) scan beginning showed in increased the nasal retina. retinal The thickness PRP was measuring completed 390 in microns three sittings in the foveal done at center membrane with (PHM) hyporeflective was seen areas anteriorly corresponding that was to attached the retinal to the cysts foveal with center. intervening septae and serous foveal detachment (patterns 2 and 3) (D). The posterior hyaloid

cysts foveal with center. intervening septae and serous foveal detachment (patterns 2 and 3) (D). The

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4. fractional Foveo­vitreal the traction. detachment Laser traction photocoagulation of fovea may result in detachment may only worsen of the the fovea. macular This can edema be diagnosed in such eyes. easily on OCT. This is an indication for pars plana vitrectomy to release

Case 5.7: CSME with Tractional Foveal Detachment

Case Summary edema. Clinically A 65­year­old His we best­corrected failed man was to visualize seen visual with acuity a non­proliferative foveo­vitreal was 20/200 traction. in diabetic the right retinopathy eye. Fluorescein and macular angiography edema (A). of the He right had received eye revealed grid microaneurysms laser 6 months ago with with leak worsening in the late of phase macular (B).

with with leak worsening in the late of phase macular (B). Optical Coherence Tomography OCT lamina

Optical Coherence Tomography OCT lamina surely line worsen of vitreoschisis scan the through detachment caused 45 degrees focal and the (C) traction macular showed on the increased edema. fovea resulting retinal thickening in underlying with tractional vitreoschisis, retinal i.e. detachment. splitting of Laser posterior photocoagulation vitreous phase of into macula two lamellae. in this setting The posterior would

of Laser posterior photocoagulation vitreous phase of into macula two lamellae. in this setting The posterior

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5. when Taut CSME posterior subclinical. with TPHM hyloid In is advanced generally membrane cases, non­responsive (TPHM): it can be TPHM diagnosed to laser may and clinically result an indication in as recalcitrant taut, shiny, for pars macular glistening plana edema vitrectomy. membrane with foveal OCT with helps retinal detachment in striae identification that on biomicroscopic can be diagnosed of TPHM retinal easily that examination. may on OCT, not be even apparent clinically.

Case 5.8: CSME with Clinically Unapparent TPHM.

Case Summary 3 with A sessions 45­year­old leak in of the grid man late laser phase with photocoagulation. type with II neovascularization diabetes of His 14 best­corrected years elsewhere duration visual (NVE) was seen acuity (B). with was proliferative 20/300 in the diabetic left eye. retinopathy Fluorescein and angiography macular edema of the (A). left He eye had revealed unsuccessfully microaneurysms received

Fluorescein and angiography macular edema of the (A). left He eye had revealed unsuccessfully microaneurysms received

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OCT andunderlyingfovealretinaldetachment. Optical line Coherence scan (C and Tomography D) showed increased retinal thickening in the center of macula measuring 720 microns with Taut posterior hyloid membrane (TPHM) (arrow)

microns with Taut posterior hyloid membrane (TPHM) (arrow) B. MANAGEMENT AND LONGITUDINAL MACULAR TRACKING EDEMA ON

B. MANAGEMENT AND LONGITUDINAL MACULAR TRACKING EDEMA ON OF OCT TISSUE CHANGES IN DIABETIC

Case 5.9: OCT Following Focal Laser Photocoagulation

A­50­year­old angiography Case Summary (B). Type The II patient diabetic underwent man was laser seen photocoagulation with clinically significant for the same. macular edema in the right eye (A) that showed areas of focal leakage on fluorescein

reflective Vertical Optical OCT Coherence hard line exudates. scan Tomography (C) showed increased retinal thickness measuring 290 microns with reduced backscattering due to intraretinal fluid accumulation and hyper­ foveal hard Three exudates contour months were with following retinal seen as thickness laser hyper­reflective photocoagulation, reduced shadows. to 180 his microns macular in edema the foveal showed center. resolution The superior with few retina residual showed hard reduced exudates backscattering (D). Repeat from OCT the scan outer (E) retinal showed layers. normal The

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Case 5.10: Focal Laser Photocoagulation Induced Subfoveal Serous Retinal Detachment

A Case 46­year­old Summary man with type II diabetes was seen with CSME in the left eye (A). His best­corrected visual acuity was 20/30.

OCT reflective Optical line Coherence hard scan exudates. through Tomography the fovea (B) showed the central retinal thickness measuring 232 microns with reduced backscatter from the outer retinal layers and hyper­

the central retinal thickness measuring 232 microns with reduced backscatter from the outer retinal layers and

Page 35 (D) The showed patient retinal received thickness focal increased laser photocoagulation to 650 microns of with the microaneurysms subfoveal serous in retinal this eye. detachment Six weeks and later, overlying his visual cystoid acuity spaces in this in eye the was inner 20/40 retina. (C). Repeat OCT scan

and later, overlying his visual cystoid acuity spaces in this in eye the was inner 20/40

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Case 5.11: OCT Guided Pars Plana Vitrectomy for Taut Posterior Hyloid Membrane (TPHM)

A Case visual 52­year­old Summary acuity was man 20/100 was seen in this with eye. recalcitrant Fluorescein CSME angiography in the left (B) eye revealed that had diffuse not responded leak from to microaneurysms multiple sessions and of capillary grid laser bed photocoagulation with leak from NVE (A). His along best­corrected the upper temporal arcade.

(A). His along best­corrected the upper temporal arcade. Optical Coherence Tomography vitreoretinal membrane OCT (C)

Optical Coherence Tomography vitreoretinal membrane OCT (C) showed folds. interface The loss suggesting neurosensory of foveal contour a taut retina posterior with showed increased hyloid hyporeflective membrane retinal thickening (TPHM) areas suggestive in (arrow) the center of causing cysts of macula in foldings the measuring retina of underlying that 610 could microns retina be probably probably with a caused hyper­reflective representing by traction internal membrane by TPHM. limiting at the

be probably probably with a caused hyper­reflective representing by traction internal membrane by TPHM. limiting at

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The retinal thickness map analysis showed a thickening of 470 microns in the foveal center (D).

showed a thickening of 470 microns in the foveal center (D). Based OCT contributing scan on

Based OCT contributing scan on OCT (F) significantly showed findings, no the to hyper­reflective the patient persistent was elected macular membrane to edema undergo at the that pars vitreo­retinal had plana failed vitrectomy to interface respond in to though this the eye. conventional the Four retinal days folds laser after and photocoagulation. surgery, cysts were his visual persistent. acuity Thus, improved in this to patient, 20/80 TPHM (E). Repeat was

surgery, cysts were his visual persistent. acuity Thus, improved in this to patient, 20/80 TPHM (E).

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Page 38 The retinal map thickness chart 4 days postoperatively showed central foveal thickness reduced to

The retinal map thickness chart 4 days postoperatively showed central foveal thickness reduced to 331 microns (G).

Page 38 The retinal map thickness chart 4 days postoperatively showed central foveal thickness reduced to

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retinal this Two patient weeks traction postoperatively, OCT and played resolution a his crucial of best retinal corrected role folds in (I). deciding visual Retinal acuity an mapping appropriate was 20/60 done (H). 2 management weeks Repeat postoperatively OCT strategy. scan (horizontal) showed a central showed retinal the normal thickness foveal measuring contour 233 with microns. no hyloid Thus, causing in

contour 233 with microns. no hyloid Thus, causing in Case 5.12: Intravitreal Triamcinolone Acetonide in Diabetic

Case 5.12: Intravitreal Triamcinolone Acetonide in Diabetic Macular Edema

Case Summary multiple microaneurysmswithirregularfovealavascularzone(B). A 52­year­old sessions man of with grid laser non­insulin­dependent photocoagulation diabetes (A). His best­corrected mellitus of 20 years visual duration acuity was was 20/200 seen with in this recalcitrant eye. Fluorescein CSME in angiography the left eye revealed that had diffuse not responded leak from to

OCT (C). Optical The showed Coherence patient loss elected of Tomography foveal to receive contour intravitreal with retinal triamcinolone thickness measuring acetonide 560 4 mg. microns Follow­up in the scan foveal at center. 3 weeks OCT showed also demonstrated reduction in the cystic foveal spaces thickness within to the 273 retinal layers

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photocoagulation foveal microns contour, and the disappearance visual was done. acuity Follow­up improved of retinal to OCT cysts 20/80 with at 8 (D). weeks reduction The and microaneurysms in then macular at 12 weeks edema now showed (E, could F). be further better improvement delineated on in fluorescein visual acuity angiography to 20/30. for OCT which demonstrated supplement return of

delineated on in fluorescein visual acuity angiography to 20/30. for OCT which demonstrated supplement return of

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C. OCT GUIDED INDICATIONS OF PARS PLANA VITRECTOMY

Case 5.13: OCT Guided Pars Plana Vitrectomy for Subfoveal Serous Retinal Detachment

A Fluorescein Case 39­year Summary old angiography man had proliferative (B) revealed diabetic leak from retinopathy NVD and and NVE. CSME with nasal traction in the left eye (A). His best­corrected visual acuity was 20/200 in this eye.

His best­corrected visual acuity was 20/200 in this eye. OCT serous Optical line retinal Coherence scan

OCT serous Optical line retinal Coherence scan detachment through Tomography the under foveal the center fovea showed (C). loss of foveal contour with retinal thickness measuring 360 microns through the foveal center. There was associated

360 microns through the foveal center. There was associated The patient underwent pars plana vitrectomy (PPV).

The patient underwent pars plana vitrectomy (PPV). Three months later, his visual acuity had improved to 20/30 with resolution of CSME (D, E).

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Page 42 persistence an Repeat indication OCT of scan residual for done PPV. fluid 3 However,

persistence an Repeat indication OCT of scan residual for done PPV. fluid 3 However, months nasal to later the OCT showed fovea. scan In reduced showed this patient, foveal an associated thickness the clinical serous in the examination center macular measuring had detachment, shown 270 microns an possibly extramacular with induced resolution tractional by of extramacular serous detachment, retinal traction detachment conventionally that (F) resolved and not immediately on removal of traction by PPV. The OCT played a major role in defining an indication for PPV.

and not immediately on removal of traction by PPV. The OCT played a major role in

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Case 5.14: Pars Plana Vitrectomy for Taut Posterior Hyloid Membrane

Case Summary A retinal 42­year­old blood reduced Type II but diabetic she developed woman was recalcitrant seen with CSME proliferative with taut diabetic posterior retinopathy hyloid membrane with CSME (TPHM) (A). She that underwent didn’t respond PRP for to grid the same, laser photocoagulation following which her (B). pre­

same, laser photocoagulation following which her (B). pre­ Optical Coherence Tomography hyporeflective hyloid OCT R/E

Optical Coherence Tomography hyporeflective hyloid OCT R/E membrane (C) showed spaces was suggestive loss attached of foveal to of the cystoid contour foveal macular center with retinal probably edema. thickness Another resulting measuring hyporeflective in foveal 740 traction. microns area under in the the foveal fovea center. was suggestive The neurosensory of serous retina retinal showed detachment. the presence The posterior

fovea center. was suggestive The neurosensory of serous retina retinal showed detachment. the presence The posterior

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resolution as hyporeflectivity Patient underwent of retinal in thickening the R/E outer pars retinal plana and CME vitrectomy. layers (E). suggestive The Two central months of fluid. foveal later, thickness her visual was acuity reduced had to improved 270 microns to 20/40 and there with was resolution persistence of CSME of serous (D). Repeat retinal detachment OCT showed as well

of serous (D). Repeat retinal detachment OCT showed as well Over the next 7 months, the

Over the next 7 months, the macular edema reappeared with the reappearance of cystoid spaces, increase in serous detachment and the presence of hyper­reflective metabolically and membrane all the aspects on unstable the retinal need that to surface taken could care (F, have G). of resulted The in the patient management in deterioration was also of diagnosed as these was patients. documented to have nephropathy on OCT. This and case was illustrates advised for that the diabetic management macular for edema the same. is multifactorial She was found in etiology to be

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Page 45 CONCLUSIONS decision From these regarding cases, it the becomes management apparent strategy that OCT

CONCLUSIONS

decision From these regarding cases, it the becomes management apparent strategy that OCT was has based a definitive on OCT findings role to play that in mostly the routine complemented management fluorescein of diabetic angiography. macular edema. Pattern In 1, many i.e. sponge­like of these patients, thickening the was helps an being indication in an close indication for monitoring focal/grid for PPV. following laser Patterns photocoagulation. the 4 and injection. 5, i.e. Pattern tractional Pattern 3, 2, i.e. foveal i.e. subfoveal cystoid detachment macular serous and retinal edema TPHM detachment shows either a alone good could response or in be conjunction laser to induced intravitreal with or caused patterns triamcinolone by 2 associated and 3 acetonide constitute traction, where an indication the OCT latter forsurgicalintervention.

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SUGGESTED READINGS

1. Massin Ophthalmol P, Duguid 2003; 135:169–77. G, Erginay A, Haouchine B, Gaudric A. Optical coherence tomography for evaluating diabetic macular edema before and after vitrectomy. Am J

2. 3. Hee Goebel MR, W, Puliafito Kretzchmar­Gross CA, Duker JS T. Retinal et al. Topography thickness in of diabetic diabetic retinopathy: macular edema A study with using optical optical coherence coherence tomography. tomography Ophthalmology (OCT). Retina 1998; 2002; 105:360–70. 22:759–67.

4. Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol. 1999 127:688–93.

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Idiopathic Central Serous Chapter Chorioretinopathy 6 (ICSC)

Central Serous Chapter Chorioretinopathy 6 (ICSC) Idiopathic the neurosensory Central retina Serous and

Idiopathic the neurosensory Central retina Serous and Chorioretinopathy Retinal Pigment Epithelium (ICSC) is typically (RPE). The a disease disease of is young more and common middle in aged patients males with that Type is characterized A personalities. by the There accumulation may be associated of fluid pigment between epithelial hyperfluorescent Expanding detachment Dot dot sign: increases (PED) The seen fluorescein in the in some late phase diffuses cases. with Fluorescein out diffusion of the choriocapillaris angiography of the dye. helps as a in round the diagnosis spot of hyperfluorescence and has well described that corresponds patterns, i.e. to the size of RPE. The Smock­stack sign: In less than 10% of the cases, the dye streams upward to form umbrella pattern of fluorescein staining.

OCT IN ICSC A. OCT Patterns in Typical ICSC

Like fluorescein angiography, OCT also shows certain characteristic features in typical ICSC including:

1. Serous fluid was retinal seen to detachment: get absorbed This in 4–8 is characterized weeks leaving by no the residual elevation changes of neurosensory behind. retina due to fluid accumulation between the RPE and neurosensory retina. This

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2.

PED Serous angiography. in retinal almost The all detachment PED cases was of ICSC. very with slow As pigment would to regress epithelial be shown and in detachment: in few the patients following Contrary it was cases, persistent to the the PED popular even in these after belief patients a year that following PED corresponded was the an initial uncommon to the episode. point feature of leak of seen ICSC, on fluorescein OCT depicted

B. OCT in Diagnosing Complications of ICSC

ICSC depicted could on OCT be complicated that helps not by choroidal only in making neovascular early diagnosis membrane, and subretinal management fibrin, but RPE also rip in prognosticating or neurosensory the atrophy outcome of the in these fovea. patients. All these features can be accurately

C. OCT in Atypical ICSC

1. Small PEDs: In few patients, PED may be very small that cannot be diagnosed on conventional techniques of fundus examination. We found OCT to be a very

2. useful OCT Chronic is tool very ICSC: in sensitive diagnosing Long in standing depicting small PED ICSC small in shows such changes cases flask­shaped of and neurosensory to differentiate mottled retina. areas it from OCT of depigmentation. other also lesions helps in including differentiating Fluorescein macular angiography pigment cysts. epithelial In cases shows where detachment mottled serous areas from detachment of serous hyperfluorescence detachment. is very small, that fade persist with during minimal even late though fluid phase beneath the of associated angiograms. it. These serous changes These fluid cases in is RPE minimal may could at or times represent absent. be misdiagnosed We, either in resolving our experience, due PED to lack or found more of suspicion. that likely, the the RPE OCT ‘sick­RPE’, in is these helpful patients thus in these indicating was cases irregular that by depicting the and sick thrown RPE PEDs into is that folds

3. probably ICSC differential Because in of elderly: responsible diagnosis the sharp It is demarcation for at a well this chronicity age established would between of the include fact disease. the that neurosensory Age ICSC related can macular occur retina in and degeneration, the serous elderly fluid, patients metastatic OCT above helps deposits, 50 in confirming years etc. of OCT age the where helps existence the in differentiating presentation of subretinal might these fluid be diseases that atypical. can from differentiate Also ICSC. the ICSC from other RPE and choriocapillary abnormalities.

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OCT PATTERNS INTYPICAL ICSC

Pattern 1: Serous Retinal Detachment

Case 6.1: ICSC with Serous Retinal Detachment

A Fluorescein Case 51­year­old Summary angiography woman was showed seen with expanding complaints dot sign, of diminished thus confirming vision the in her diagnosis right eye of of ICSC 2 months (A). duration. Her best corrected visual acuity was 20/40 in this eye.

the in her diagnosis right eye of of ICSC 2 months (A). duration. Her best corrected

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Optical fluidunderthefovea(B). A horizontal Coherence line scan Tomography through the fovea showed elevation of neurosensory retina with an optically clear space underneath that corresponded to the presence of serous

Follow­up Examination

Over a follow­up of 6 weeks, patient felt better, the visual acuity was improved to 20/25. Repeat OCT showed resolution of serous fluid with return of foveal contour

to normal (C).

acuity was improved to 20/25. Repeat OCT showed resolution of serous fluid with return of foveal

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Pattern 2: ICSC with Multiple Pigment Epithelial Detachments (PEDs)

Case 6.2: ICSC with PEDs

Case Summary visual Fluorescein A 30­year­old acuity angiography was woman 20/70. was Fundus showed seen right with multiple eye the diagnosis showed areas of the hyperfluorescence of presence pigment of epithelial serous with fluid detachment hypofluorescence in the center right eye with corresponding for a linear, which hypopigmented laser to fibrin photocoagulation (B–D). band suggestive was done of elsewhere. fibrinous exudation Her best corrected (A).

to fibrin photocoagulation (B–D). band suggestive was done of elsewhere. fibrinous exudation Her best corrected (A).

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OCT band Optical was right Coherence seen eye through as hyper­reflective Tomography the foveal center band showed on OCT the (not presence shown in of the PED picture). under the fovea measuring 410 microns in height with surrounding serous fluid (E). The fibrinous

in height with surrounding serous fluid (E). The fibrinous Repeat corresponding Follow­up OCT scan clinically 6

Repeat corresponding Follow­up OCT scan clinically 6 months to the later area (F) of showed laser scars. resolution The RPE of serous at the sites fluid of with PED persistent was a bit PED. irregular. However, there was a hyper­reflective area temporal to the fovea

fluid of with PED persistent was a bit PED. irregular. However, there was a hyper­reflective area

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OCT IN DIAGNOSING COMPLICATIONS OF ICSC

Case 6.3: ICSC with Serous RD and PEDs in One Eye and Fibrinous Exudation in the Opposite Eye

A picture Case 32­year­old Summary and fluorescein man presented angiography, with decreased a diagnosis vision of ICSC of 10 was days established duration in (A, the B). right eye. His best corrected visual acuity was 20/40 in this eye. Based on clinical

visual acuity was 20/40 in this eye. Based on clinical Horizontal measuring Optical Coherence 270 OCT

Horizontal measuring Optical Coherence 270 OCT microns scan Tomography through in height foveal with center PED corresponding in the right eye to (C) the showed hyper­reflective the presence spot of nasal hyporeflective to the fovea area on fluorescein under the fovea angiography. suggestive of serous fluid accumulation

nasal hyporeflective to the fovea area on fluorescein under the fovea angiography. suggestive of serous fluid

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Eight angiography Follow­up weeks later, showed his multiple visual acuity hyperfluorescent in this eye had spots improved suggestive to 20/25; of pigment the serous epithelial detachment detachments and fibrinous (E) exudation had resolved clinically (D). Repeat fluorescein

exudation had resolved clinically (D). Repeat fluorescein Repeat microns OCT (F). The at this PED stage

Repeat microns OCT (F). The at this PED stage persisted through at one 6 months such hyperfluorescent follow­up, though spot the showed height resolution was reduced of to serous 120 microns fluid with (G). persistent PED, the height of which was reduced to 150

resolution was reduced of to serous 120 microns fluid with (G). persistent PED, the height of

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Page 55 The picture patient and fluorescein also complained angiography of decreased (H, I), vision a

The picture patient and fluorescein also complained angiography of decreased (H, I), vision a diagnosis in his left of ICSC eye of with 3 months fibrinous duration. exudation His was best established. corrected visual acuity in the left eye was 20/200. Based on clinical

visual acuity in the left eye was 20/200. Based on clinical 20/200. OCT Optical A diagnosis

20/200. OCT Optical A diagnosis scan The Coherence at fibrin 45 of degrees bilateral had Tomography partially showed ICSC resolved with the presence left (K) fibrinous and of serous repeat exudation fluorescein retinal was detachment made angiography and with patient a (L) hyper­reflective was showed kept under few areas follow­up. area of in hyperfluorescence. the center Eight weeks corresponding later, his clinically visual acuity to fibrinous in the left exudation eye was (J). fluid Repeat while OCT a vertical scan scan through passing the center through of the fovea fibrin (M) (N) showed showed normal hyper­reflectivity foveal contour (arrow) with a with thin underlying hyporeflective area streak of hyporeflectivity under the fovea suggestive suggestive of underlying of underlying serous serous fluid.

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Page 56 Focal laser photocoagulation was applied to the hyperfluorescent spot along the upper temporal vessel.

Focal laser photocoagulation was applied to the hyperfluorescent spot along the upper temporal vessel.

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Page 57 under Six weeks fovea later, (Q). his visual acuity was still 20/200 (O) with

under Six weeks fovea later, (Q). his visual acuity was still 20/200 (O) with angiogram showing hypofluorescence corresponding to laser photocoagulation (P) and no serous detachment fibrin serous More along fluid laser (not the was upper shown). applied temporal to the vessel residual (R). hyperfluorescent Horizontal line scan spots. (S) Six through months the later, foveal his center visual showed acuity had normal improved looking to 20/50 fovea. with Repeat normal vertical looking scan fovea showed and only organized fibrin, no

improved looking to 20/50 fovea. with Repeat normal vertical looking scan fovea showed and only organized

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Case 6.4: Chronic ICSC with Cystoid Macular Edema (CME)

Case Summary: ICSC with CME A Fundus 56­year­old right eye man showed presented depigmentation with complaints temporal of diminished to fovea with vision few in areas both of his hyperpigmentation eyes of 6 months duration. (A) that showed His best hyperfluorescence corrected visual acuity on fluorescein was 20/200 angiography in the right (B). eye.

on fluorescein was 20/200 angiography in the right (B). eye. Optical hypo­reflective Optical coherence Coherence

Optical hypo­reflective Optical coherence Coherence areas tomography Tomography arranged in showed cyst­like hypo­reflective pattern in the area outer under layers the of fovea the nasal suggestive retina (C). of serous retinal detachment measuring 450 microns in height. There were few

the of fovea the nasal suggestive retina (C). of serous retinal detachment measuring 450 microns in

Page 60 fluorescein In view of angiography chronicity of (E) the showed disease, hyperfluorescence patient elected to that receive was focal less compared laser photocoagulation to the previous of one the (B). leak. Four weeks later, his visual acuity was 20/125 (D). Repeat

Four weeks later, his visual acuity was 20/125 (D). Repeat Repeat nasal to OCT the fovea

Repeat nasal to OCT the fovea scans and (F and few G) cystoid showed spaces resolution were seen of serous as hyporeflective retinal detachment areas in under the outer the fovea, retina temporal though a small to the area fovea. of detachment seen as hyporeflective area was seen The left eye also had chronic ICSC (H) that showed hyperfluorescence on fluorescein angiography (I).

area was seen The left eye also had chronic ICSC (H) that showed hyperfluorescence on fluorescein

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Page 61 suggestive the Optical pattern coherence of of intraretinal small tomography serous cysts retinal at

suggestive the Optical pattern coherence of of intraretinal small tomography serous cysts retinal at scan different detachment. (J) showed levels. Overlying the loss of this foveal detachment contour, were presence seen various of small hypo­reflective pigment epithelial areas detachments with intervening with an hyper­reflective overlying hyporeflective walls conforming band to fluid Four in the weeks neurosensory later, following retina laser (K). photocoagulation of the hyperfluorescent spot, the repeat OCT showed resolution of cysts with persistent PED and some serous

of the hyperfluorescent spot, the repeat OCT showed resolution of cysts with persistent PED and some

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Case 6.5: ICSC with Idiopathic Polypoidal Choroidal Vasculopathy

Case A 45­year­old Summary man was seen in 1991 with complaints of decreased vision in the right eye of one month duration. His best corrected visual acuity was 20/60. Fundus

(B) showed of 20/20. showed ICSC Ten the years with presence PED later, (A) of he subfoveal presented that was confirmed hemorrahage again with on complaints suggesting fluorescein of choroidal angiography. blurred vision neovascular The in the ICSC same membrane showed eye of spontaneous 10 (CNVM). days duration. resolution His visual in 6 weeks acuity and in this patient eye was regained 20/40 a and visual fundus acuity CNVM The patient which received was lasered intravitreal and patient TPA regained injection a to vision clear of the 20/20 hemorrahage (C). following which a fluorescein angiogram was done (not shown) that showed a juxtafoveal

Seven (D). Follow­up months later, the patient came back with metamorphopsia and a visual acuity of 20/30. Fundus examination showed the recurrence of CNVM nasal to the fovea

back with metamorphopsia and a visual acuity of 20/30. Fundus examination showed the recurrence of CNVM

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Indocyanine choroidal Fluorescein vasculopathy angiography green angiography (IPCV). showed (F, the G) presence showed of multiple, a hyperfluorescent rounded, saccular, spot in hyperfluorescent the center of blocked spots fluorescence (arrows) arranged corresponding in a bunch to suggestive subretinal hemorrahage of idiopathic polypoidal (E).

fluorescence (arrows) arranged corresponding in a bunch to suggestive subretinal hemorrahage of idiopathic polypoidal (E).

Page 64 OCT with an scan overlying (H) through hyporeflective these polyps area showed corresponding multiple to irregular, the area hyper­reflective of bleed seen clinically. areas at the level of choriocapillaries­RPE complex corresponding to polyps clinically

complex corresponding to polyps clinically An OCT overlay scan showed was prepared resolution to

An OCT overlay scan showed was prepared resolution to delineate of the hyporeflective these areas (I) area and with thermal flattening laser of photocoagulation the hyper­reflective of these areas was (J) done. Eight weeks later, following laser photocoagulation, repeat

the hyper­reflective of these areas was (J) done. Eight weeks later, following laser photocoagulation, repeat

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Over Follow­up Repeat a follow­up vertical of OCT one line year, scan the (L) patient showed maintained normal fovea a visual with acuity no serous of 20/20. fluid The or saccular fundus showed dilatations. a laser scar corresponding to the area of IPCV (K).

no serous of 20/20. fluid The or saccular fundus showed dilatations. a laser scar corresponding to

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Case 6.6: ICSC with RPE Rip

retinal a A Case few 30­year­old Summary areas detachment of focal man (A, presented leak B). (C) His with best corrected bilateral Idiopathic visual acuity Central was Serous 20/100 Chorioretinopathy in the right eye. On (ICSC) fluorescein with subretinal angiography fibrin RPE and rip right shows eye transmission RPE tear with hyperfluorescence inferior exudative and

RPE tear with hyperfluorescence inferior exudative and Vertical Optical OCT Coherence line Scan Tomography

Vertical Optical OCT Coherence line Scan Tomography (D) shows PED, serous RD and RPE disruption just above the foveal center (arrows). Horizontal OCT line Scan passing through the area of between rip Four (E) shows days the rip later adherence and the optic rip of progressed disc fibrin and to hypofluorescence the and margin retinal of striations the corresponding RPE were rip (arrow). directed to RPE towards rip (G–I). contracting fibrin (F). Indocyanine green angiography showed hyperfluorescent areas

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Repeat OCT at this stage was done (J) Solid arrows enclose area of RPE rip with subretinal fluid (arrow head). Note rolled over RPE. The rip continued to with pulmonarytuberculosis. progress exuberant over next fibrin two and weeks minimal to become subretinal 360 fluid degrees in the (K area and of L). RPE Repeat rip temporal OCT scan to foveal done center. two weeks Patient later was (M) treated showed with detached anti­tuberculosis RPE just chemotherapy nasal to the foveal for center

Patient later was (M) treated showed with detached anti­tuberculosis RPE just chemotherapy nasal to the foveal

Page 69 Four fluorescein months angiography later, his best­corrected (P, Q). visual acuity was 20/160 in the right eye and fundus showed healed scar in the right eye (N, O) that showed hyperfluorescence on

acuity was 20/160 in the right eye and fundus showed healed scar in the right eye

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contour, Repeat Over OCT next no serous eight showed months, fluid normal or PED he foveal maintained and contour hyper­reflective a best with corrected rolled choroid up visual RPE corresponding and acuity minimal of 20/30 to subretinal scars with (T). a healed fluid as scar was in indicated the fundus by (S). the presence The corresponding of hyporeflective OCT showed band (R). normal foveal

was in indicated the fundus by (S). the presence The corresponding of hyporeflective OCT showed band

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Case 6.7: Foveal Atrophy in ICSC

hyperfluorescence Case A 26­year­old Summary man (arrow). was seen with right eye chronic ICSC with visual acuity of 20/200 (A). Fluorescein angiography of the right eye (B) showed an area of mottled ICSC. The OCT line scan (C) through the fovea showed foveal atrophy with central foveal thickness measuring 78 microns suggesting foveal atrophy following chronic

78 microns suggesting foveal atrophy following chronic C. OCT IN ATYPICAL ICSC Case 6.8: Atypical ICSC

C. OCT IN ATYPICAL ICSC

Case 6.8: Atypical ICSC in Elderly

eye Case A 64­year­old showed Summary the man presence was seen of multiple with decreased hard exudates vision (A) in both that showed his eyes hyperfluorescence for one year duration. on fluorescein His best­corrected angiography visual (B). acuity was 20/60 in the right eye. Fundus in this corresponded CNVM. OCT scan through to the hyperfluorescent various angles (C–H) spot seen showed on fluorescein the hyporeflective angiography. area under The moderate the fovea backscatter that was suggestive seen within of serous the PED fluid was with suggestive a small PED of possibly nasal to an the occult fovea that

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Case 6.9: Atypical ICSC in Diabetes

A there Case 46­year­old were Summary three Type discrete II diabetic areas of was hyperfluorescence seen with the clinical that showed diagnosis pooling of clinically of the significant dye in the later macular phases edema that (A). was On unlike fluorescein leak from angiography, the microaneurysms besides microaneurysms, or dilated capillary bed (B–D).

On unlike fluorescein leak from angiography, the microaneurysms besides microaneurysms, or dilated capillary bed (B–D).

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OCT suggesting Optical line Coherence scan shallow through PED. Tomography the In areas addition, of dye there pooling was (E) a hyporeflective showed mild band elevation just anterior of the hyper­reflective to it suggesting layer the presence corresponding of a probable to RPE fluid with underlying pocket of ICSC. hyporeflective band

fluid with underlying pocket of ICSC. hyporeflective band CONCLUSIONS From repeated In short, these we easily

CONCLUSIONS

From repeated In short, these we easily cases, found and it that the becomes (A) repeat PED clear mode is that a ensures very OCT common reproducibility is a very feature useful of of tool both the in scan typical monitoring from as well the the same as structural atypical area. This changes ICSC reduces (B). in OCT the the underlying need is helpful for repeat retina. in diagnosis fluorescein Since it the is complications a angiography noninvasive in tool, of these ICSC it can patients. (C) be OCT is helpful in diagnosing Atypical cases.

SUGGESTED READINGS

1. Wang M, Sander B, Larsen M. Retinal Atrophy in Idiopathic Central Serous Chorioretinopathy. Am J Ophthalmol 2002, 133 :787–93.

2. 3. Hee Wang Ophthalmol MR, M, Puliafito Larsen Scand M, 1999; CA, Sander Wong 77:402–05. R, C Lund­Andersen et al. Optical coherence H. Central tomography serous chorioretinopathy of central serous with chorioretinopathy. foveal detachment Am demonstrated J Ophthalmol by 1995; optical 120:65–74. coherence tomography. Acta

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Macular Chapter Hole 7

Page 75 Macular Chapter Hole 7 OCT is a very useful tool in the diagnosis and

OCT is a very useful tool in the diagnosis and management of macular holes. It helps by providing a cross­section of retina that helps in many ways.

1. It retinal helps pigment in differentiating epithelium various or neurosensory retinal lesions retina that and cannot epiretinal be clinically membrane distinguished, with pseudo­hole. i.e. lamellar Full or thickness full thickness macular macular holes holes, show a macular breach cysts, in all the foveal layers detachments of retina of while characterized lamellar by macular the presence hole shows of a well­defined, only partial loss round, of tissue localized with steep area of foveal hypo­reflectivity contour. Retinal in the pigment outer retinal epithelium layers/subretinally. (RPE) detachments and macular cysts are

2. OCT evidence that the helps discrete that in the staging linear presence of signal macular of (DLS) a localized holes seen that perifoveal on helps OCT in is evaluating vitreous the signal detachment surgical from posterior intervention. is a rule vitreous in the It has face. earliest clarified OCT stages has the of led pathoanatomy macular to a new hole classification of formation. the macular of It macular has holes. been It holes shown has provided as experimentally follows: new Stage Stage Stage 1B: 2: 1A: Fullthicknessretinaldehiscence. Impending Foveal pseudocyst macular hole characterized by disruption of outer retina In inner a recently fovea that proposed allows seepage ‘hydration of fluid theory’ vitreous of the into macular the spongy hole genesis, layer of it the has macula, been suggested thus creating that following a cavity in the the posterior inner retina. hyaloid The traction, fluid there is a tear in the

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extends with. dissects inwards. and spreads The into swollen the outer retina retinal then layers, elevates which and retracts. causes enlargement If there is posterior of the macular vitreous hole. detachment, Since RPE the and separated Bruchs vitreous membrane pulls are a tag rigid, of inner the swollen retina along retina

3. 5. 4. OCT OCT OCT is gives helps an excellent quantitative in diagnosing modality information vitreofoveal for studying regarding traction vitreoretinal the in the diameter fellow interface of eyes macular and of the is helpful hole patients that in with helps studying macular in prognosticating the holes. progression response of the macular to surgical hole intervention. in the fellow eyes.

7. 6. OCT Following helps PPV, in providing two patterns other information of hole closure like have the presence been described of cystic on changes OCT: in the adjacent retina, presence of surrounding subretinal fluid etc. Type Type 1 2 closure: closure: Close Close without with neurosensory neurosensory deficit. deficit. The smaller sized holes have better prognosis because they tend to show type 1 closure pattern.

In clinical practice, OCT has 4 major roles:

B. A. Understanding In disease staging disease pathogenesis

C. D. Follow­up Prognosticating following the surgical surgery outcome.

A. OCT IN STAGING OF MACULAR HOLES THEORY BASED ON PERIFOVEAL VITREOUS DETACHMENT

Case 7.1: Stage 1 A Macular Hole: Foveal Pseudocyst

A­70­year­old­woman Case Fundus Summary was unremarkable underwent (A). She routine had a stage check­up 2 macular of her hole left eye. in the Her opposite best­corrected eye. visual acuity was 20/30 in this eye and she had posterior subcapscular cataract.

OCT seen Optical in line the Coherence scan inner of part the Tomography of fovea the showed foveola (B). a perifoveal OCT helped detachment in diagnosing of the posterior the foveal hyloid pseudocyst that was still in attached this patient, to the which center is of the the first foveola. step An in the intraretinal formation pseudocyst of macular was hole.

center is of the the first foveola. step An in the intraretinal formation pseudocyst of macular

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Page 77 Case 7.2: Stage 1 B Impending Macular Hole Case 76­year­old Summary man complained of

Case 7.2: Stage 1 B Impending Macular Hole

Case 76­year­old Summary man complained of metamorphopsia of one month duration. His best corrected visual acuity in the right eye was 20/30. He also gave history of angiography revealed an area of punctate hyperfluorescence (B).

undergoing pars plana vitrectomy in the opposite eye 6 years back for macular hole. Fundus showed a slight alteration in the macular color (arrows) (A). Fluorescein

A

alteration in the macular color (arrows) (A). Fluorescein A Optical A vertical Coherence OCT image Tomography

Optical A vertical Coherence OCT image Tomography through the fixation showed loss of foveal contour. There was perifoveal detachment of posterior hyaloid membrane that remained attached to

the center of the foveola. The foveal traction has resulted in disruption of foveal pit and hyporeflectivity in the inner retinal layers suggesting an intraretinal cyst, i.e. stage

IB macular hole (C). In this patient, the macula looked apparently normal on biomicrocsopy except mild discoloration of the fovea. OCT was able to

detect the significant changes occurring in the retina suggesting that the foveal pseudocyst had expanded posteriorly causing partial disruption of the

outer macular retinal hole. layer at the umbo. The continued traction from perifoveal vitreous causes opening of the roof of pseudocyst, thus resulting in stage 2

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Page 78 Case 7.3: Stage 2 Lamellar Macular Hole Case Summary (B) the A 52­year­old showed

Case 7.3: Stage 2 Lamellar Macular Hole

Case Summary (B) the A 52­year­old showed development retinal woman dehiscence of Stage presented 2 confined macular with floaters to hole. the inner in the retinal right eye layers of suggestive 5 months duration. of lamellar She macular had macular hole. The hole avulsion and her best­corrected of the roof of visual foveal acuity pseudocyst was 20/100 has (A). resulted OCT in

and her best­corrected of the roof of visual foveal acuity pseudocyst was 20/100 has (A). resulted

Page 79 The 20/50 patient (C) and underwent OCT showed R/E pars closure plana of vitrectomy macular hole with with internal return limiting of foveal membrane contour peeling (D). and SF6 internal tamponade. Three weeks later, her vision had improved to

limiting of foveal membrane contour peeling (D). and SF6 internal tamponade. Three weeks later, her vision

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Case 7.4: Stage 2 Macular Hole

macular A Case 56­year­old Summary hole (A). woman Watzke complained Allen sign of was decreased positive. vision of three months duration. Her best­corrected visual acuity in the right eye was 20/200. Fundus showed stage II Optical Coherence Tomography measuring measured Horizontal on 390 OCT OCT microns scan was through 390 from microns. the the bottom fovea (B) of the showed hole along full thickness with cystic retinal changes dehiscence characterized consistent by with hyporeflective stage II macular spaces hole. in the Surrounding neurosensory retina retina. showed The diameter thickening of hole as

stage II macular spaces hole. in the Surrounding neurosensory retina retina. showed The diameter thickening of

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Page 81 The restoration patient of underwent photoreceptor right eye layer. pars The plana perifoveal vitrectomy

The restoration patient of underwent photoreceptor right eye layer. pars The plana perifoveal vitrectomy retinal with thickening internal limiting and cystic membrane changes showed peeling. resolution. Repeat OCT The (C) visual done acuity 3 weeks improved later showed to 20/30. closure of hole with

Case 7.5: Idiopathic Macular Hole with Retinal Detachment

A­72­year­old Case Summary woman was seen with left eye macular hole with surrounding cuff of fluid (A).

OCT Optical scan Coherence of the left eye Tomography (B) showed macular hole with hyporeflective space underneath suggesting the presence of retinal detachment.

Tomography (B) showed macular hole with hyporeflective space underneath suggesting the presence of retinal detachment.

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Case 7.6: Macular Hole with Retinal Detachment

Case Summary A­62­year­old OCTlinescan(B)throughthefovealcentershowsfullthicknessmacularholewithunderlyingretinaldetachment. diabetic woman was seen with tractional macular hole and retinal detachment (A).

diabetic woman was seen with tractional macular hole and retinal detachment (A).

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B. OCT IN DISEASE PATHOGENESIS

The and 2. two The most hydration prevalent theory. current theories in the pathogenesis of macular hole are: 1, Perifoveal vitreous detachment theory that has been shown in the preceding cases

Case 7.7: The Hydration Theory

Case Summary edge A 60­year­old The (B) OCT (arrows). shows man accumulation was seen with of right the eye fluid small within macular the retinal hole layers with prefoveolar with partially opacity detached suggesting posterior operculum hyaloid membrane (A). that was attached to the optic disc and foveal

membrane (A). that was attached to the optic disc and foveal retracts operculum The fluid the

retracts operculum The fluid the migrates overlying suspended into internal in the the outer detached limiting plexiform membrane posterior layer. hyloid The and rigidity inner (D). retina of Bruchs complex membrane­RPE (C). The posterior complex hyloid causes separation the inward might movement pull a tag of of inner the swollen retinal retina tissue that seen elevates as the avulsed and

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Page 84 C. FOLLOW­UP FOLLOWING SURGERY Case 7.8: Stage 2 Macular Hole with Operculum A showed

C. FOLLOW­UP FOLLOWING SURGERY

Case 7.8: Stage 2 Macular Hole with Operculum

A showed Case 72­year­old Summary a macular woman hole presented with positive with Watzke’ssign(A). complaints of difficulty in reading from the right eye for the last one month. Her best­corrected visual acuity was 20/80. Fundus microns OCT (B) anterior showed to the the retina presence (thick of arrow) full thickness that seemed retinal to dehiscence cause traction with on an the overlying fovea, presumably operculum (thin resulting arrow). in the The formation posterior of hyloid the hole. membrane was seen lying 240

operculum (thin resulting arrow). in the The formation posterior of hyloid the hole. membrane was seen

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Page 85 ThepatientunderwentrighteyeparsplanavitrectomywithinternallimitingmembranepeelingandC 3 F 8 temponade.

ThepatientunderwentrighteyeparsplanavitrectomywithinternallimitingmembranepeelingandC 3 F 8 temponade. Three weeks later, her visual acuity had improved to 20/40 and repeat OCT showed closure of the hole (C, D).

to 20/40 and repeat OCT showed closure of the hole (C, D). PATTERNS OF CLOSURE OF

PATTERNS OF CLOSURE OF MACULAR HOLES

Case 7.9: Pattern 1 Closure

Pattern Case Summary 1 closure: normal foveal contour with restoration of photoreceptor layer indicating closure without neurosensory deficit.

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Page 86 Case 7.10: Pattern 1 Closure with Restoration of Photoreceptor Layer (A and B)

Case 7.10: Pattern 1 Closure with Restoration of Photoreceptor Layer (A and B)

Page 86 Case 7.10: Pattern 1 Closure with Restoration of Photoreceptor Layer (A and B)

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Case 7.11: Pattern 2

Case Summary Closure Note the of macular pre­op large hole without size of the restoration hole; large of photoreceptor sized holes commonly layer (A, close B). without restoration of photoreceptor layer.

hole; large of photoreceptor sized holes commonly layer (A, close B). without restoration of photoreceptor layer.

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Case 7.12: Pattern 2

Closure Case Summary of macular hole without restoration of photoreceptor layer (A, B). Note the V­shaped foveal contour with absent photoreceptor layer under the fovea.

contour with absent photoreceptor layer under the fovea. D. PROGNOSTICATING SUCCESS OF MACULAR HOLE SURGERY The

D. PROGNOSTICATING SUCCESS OF MACULAR HOLE SURGERY

The neurosensory Calculation diameter of of retina. Hole macular Hole Form hole form Factor is factor a predictor (HFF) of of surgical less than success. 0.5 is The reported larger to holes be associated are associated with poor with surgical poor visual closure outcome rates. and closure without restoration of

Page 89

Page 89 CONCLUSIONS It is beyond doubt that OCT is contributory in almost every stage of

CONCLUSIONS

It is beyond doubt that OCT is contributory in almost every stage of macular hole management.

1. Starting We factors have playing from discussed giving a role. the insight perifoveal into the vitreous pathogenesis, traction various and hydration theories theories are being and proposed apparently as the we pathogenesis are now able of to macular study the hole vitreoretinal may be multifactorial interface with with the help number of OCT. of

2. 3. OCT OCT helps is a very in monitoring useful tool the in diagnosing hole closure the following early stages pars of plana macular vitrectomy. holes even when the biomicroscopic examination is normal.

4. Calculation of hole size preoperatively can help one predict the prognosis following surgery.

SUGGESTED READINGS

1. 2. Hee Ullrich MR, S, Puliafito Haritoglou CA, C, Carlton Gass C W et et al. al. Macular Optical hole coherence size as a tomography prognostic of factor macular in macular holes. hole Ophthalmol surgery. 1995; Br J Ophthalmol 102:748–56. 2002; 86:390–93.

3. 4. Johnson Chauhan MW. DS, Antcliff Improvements RJ, Rai in PA, understanding et al. Papillofoveal and treatment traction of in macular macular holes. hole formation. Curr opin Ophthalmol Arch Ophthalmol 2002; 2000; 13:152–60. 118:32–38.

6. 5. Imani Tornambe M, Iijima PE Macular H, Gotoh hole T, genesis: Tsukahara The S. Hydration Optical coherence Theory. Retina tomography 2003; of 23:421–24. successfully repired idiopathic macular holes. Am J Ophthalmol 1999; 128:621–27.

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Retinal Vascular Chapter Occlusions 8

Page 90 Retinal Vascular Chapter Occlusions 8 The vascular occlusions can be either arterial or venous.

The vascular occlusions can be either arterial or venous.

during retinal modality OCT detachment, the plays to natural study a major the history cystoid response role helps in macular studying of one the to edema, macula decide the macula state to the any management of in intervention vitreo­retinal various venous strategies namely, interface occlusions. for intravitreal including these The eyes. triamcinolone epiretinal quantification The macula membranes acetonide and in venous tomography and injection, occlusions lamellar of sheathotomy, macular macular shows edema intraretinal hole etc. formation. as is fluid demonstrated It accumulation, is an excellent on OCT serous regains In retinal its original arterial reflectivity occlusions, over OCT a period documents of time. either macular edema or atrophy. The area of ischemic pale retina appears hyper­reflective during acute phase and

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Case 8.1: Branch Retinal Vein Occlusion

A BRVO Case 55­year­old Summary (A). Fluorescein woman was angiography seen with showed visual loss late in leakage her right of eye dye of in 15 the days infero­temporal onset. Her best quadrant corrected and visual in the fovea acuity (B). was 20/90. Fundus showed R/E lower temporal

acuity (B). was 20/90. Fundus showed R/E lower temporal Optical Coherence Tomography intravitreal OCT macular

Optical Coherence Tomography intravitreal OCT macular showed photocoagulation triamcinolone loss of foveal acetonide was contour done 4 with to mg. the hyporeflective Four leaking weeks microaneurysms. later, spaces her corresponding visual acuity improved probably to to 20/40 serous and fluid OCT in the showed neurosensory reduction retina in macular (C). The edema patient (D). elected Three to months receive later,

in the showed neurosensory reduction retina in macular (C). The edema patient (D). elected Three to

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hyporeflective showed The macular the initial spaces edema resolution in started the outer reappearing following retina corresponding intravitreal 4 months after triamcinolone probably intravitreal to cysts injection acetonide. (E). The and OCT However, repeat helped OCT the done in effect monitoring at 6 of months triamcinolone response showed reappearance to acetonide the intervention was of macular only in transient this edema patient. with with It reappearance of edema after 4 months.

with with It reappearance of edema after 4 months. Case 8.2: OCT in Macular BRVO A

Case 8.2: OCT in Macular BRVO

A Case showed 65­years­old Summary hyperflurescence woman was corresponding seen with left to eye the macular territory BRVO of macular with vein cuticular (B–D). drusens (A). Her visual acuity in this eye was counting fingers. Fluorescein angiography

with vein cuticular (B–D). drusens (A). Her visual acuity in this eye was counting fingers. Fluorescein

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OCT mapping Optical scan Coherence showed through increased the Tomography fovea retinal showed thickeness hyporeflective (F) in the areas central with 6 intervening mm retina. hyper­reflective walls consistent with cysts in the neurosensory retina (E). The retinal Fluorescein The patient still received showed intravitreal leakage, though triamcinolone it was less acetonide than before 4 mg. (G, Two H). weeks later, her vistual acuity was counting fingers. She had pigmented scar in the center.

than before 4 mg. (G, Two H). weeks later, her vistual acuity was counting fingers. She

Page 94 improvement Repeat OCT by scan quantifying showed normal the retinal foveal thickness. contour, reduction in retinal thickness with resolution of cystoid spaces (I, J). The OCT helped in documenting precise tomography neurosensory Six months done retina later, at (L). she this showed OCT stage showed helped resolved in normal monitoring edema foveal clinically contour, response (K). irregular The to therapy vision, RPE however, at beneath the ultrastructural did the not fovea improve corresponding level. due to the to presence the scar and of a absence macular of scar. cystoid Optical spaces coherence in the

level. due to the to presence the scar and of a absence macular of scar. cystoid

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Page 95 Case 8.3: OCT in Hemispheric CRVO A His Case 57­year­old best Summary corrected type

Case 8.3: OCT in Hemispheric CRVO

A His Case 57­year­old best Summary corrected type visual II diabetic acuity patient was 20/200. with non­proliferative Fluorescein angiography diabetic retinopathy showed hyperfluorescence developed hemispheric in the inferior central half retinal and vein in the occlusion macula in (B–D). the inferior half of right eye (A).

in the inferior central half retinal and vein in the occlusion macula in (B–D). the inferior

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OCT Optical corresponding through Coherence the probably fovea Tomography at to different intraretinal angles cysts showed (E, F). the presence of retinal thickening in the macula with hypo­reflective areas separated by hyper­reflective septae

(E, F). the presence of retinal thickening in the macula with hypo­reflective areas separated by hyper­reflective

Page 97 retinal The cysts patient (G, received H). intravitreal triamcinolone acetonide 4 mg. Seventy two hours later, repeat OCT showed reduction in the retinal thickening with resolution of

reduction in the retinal thickening with resolution of Six for proliferative weeks following diabetic triamcinolone

Six for proliferative weeks following diabetic triamcinolone retinopathy. injection, Over a follow grid laser up of photocoagulation four months, patient of the maintained macula was a done. visual Three acuity months of 20/30 later, and he OCT was shows subjected no macular to panretinal edema photocoagulation (I, J).

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Page 98 separated retinal Six months, surface. by later, hyper­reflective The however OCT was he helpful

separated retinal Six months, surface. by later, hyper­reflective The however OCT was he helpful longitudinal had decreased in documenting lines vision suggestive again the response and of cystoid repeat to OCT intervention, spaces (K) with showed intervening thus obviating reappearance septae. the Also need of retinal seen for repeated thickening was posterior fluorescein with hyloid full angiography. thickness membrane hypo­reflective 176 microns in areas front of

was posterior fluorescein with hyloid full angiography. thickness membrane hypo­reflective 176 microns in areas front of

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CENTRAL RETINAL VEIN OCCLUSION

Case 8.4: Intravitreal Triamcinolone Acetonide in Non­ischemic CRVO with Cystoid Macular Edema

A dye Case 35­year­old leak Summary in the posterior woman was pole seen with with accumulation non­ischemic in the CRVO cystic and spaces cystoid in the macular late phase edema (B). (A). Her visual acuity was reduced to 20/70. Fluorescein angiography showed

acuity was reduced to 20/70. Fluorescein angiography showed Optical Coherence Tomography consistent serous Horizontal

Optical Coherence Tomography consistent serous Horizontal retinal with OCT detachment cystic line scan spaces through under at various the the fovea foveal levels (thick center in the arrow). (C) neurosensory showed loss retina of foveal and another contour, hyporeflective central retinal area thickening beneath measuring the cysts under 585 microns, the foveal multiple center hypo­reflective that was suggestive areas of

beneath measuring the cysts under 585 microns, the foveal multiple center hypo­reflective that was suggestive areas

Page 100 fluoresceinangiography(E). The patient received intravitreal triamcinolone acetonide 4 mg. Eighteen weeks later; her visual acuity had improved to 20/20 (D). No leakage was seen in repeat Repeat OCT (F) showed resolution of cystoid spaces as well as of foveal serous detachment. The central foveal thickness was reduced to 280 microns.

of cystoid spaces as well as of foveal serous detachment. The central foveal thickness was reduced

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Case 8.5: CRVO with Taut Posterior Hyloid Membrane

A which Case 45­year­old Summary she had undergone woman was grid seen laser with elsewhere. visual acuity Posterior of counting pole showed fingers in taut her posterior right eye hyloid of one membrane year duration. causing The an right apparent eye showed traction old on central the retina retinal (A). vein Fluorescein occlusion for angiography (B) showed hyperfluorescence temporal to the fovea with hyperfluorescence in the posterior pole in late phase.

with hyperfluorescence in the posterior pole in late phase. Optical Coherence Tomography causing arrows). OCT scans

Optical Coherence Tomography causing arrows). OCT scans traction through between different the disc angles and passing macula through resulting the in foveal the development center (C) of showed internal vitreoschisis limiting membrane of the posterior folds seen hyloid as villi­like membrane projections (thick arrows) of the inner with posterior retinal layers lamella (thin

seen hyloid as villi­like membrane projections (thick arrows) of the inner with posterior retinal layers lamella

Page 102 20/60. The Fundus patient underwent showed cystoid pars plana spaces vitrectomy in the center in this (D) eye that to showed remove dye the pooling traction in caused the late by phase the posterior of angiogram hyloid. (E). Eight weeks postoperatively, she had a visual acuity of

(E). Eight weeks postoperatively, she had a visual acuity of Repeat OCT done at 4 weeks

Repeat OCT done at 4 weeks showed foveal thickness measuring 460 microns with multiple hyporeflective areas seen at the level of both inner and outer retina, layers NSAID arranged suggestive for in cystic the same. of pattern intraretinal consistent fluid with accumulation. cystoid macular Note the edema absence seen of on posterior fluorescein hyloid angiography. membrane In that addition, was surgically there was removed reduced (F). backscattering The patient was from initiated the outer on retinal topical

was surgically there was removed reduced (F). backscattering The patient was from initiated the outer on

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OCT IN BRANCH RETINAL ARTERY OCCLUSION (BRAO)

Case 8.6: BRAO

Case Summary opacification evidence A 20­year­old of macular of girl inferior presented edema retina even with (A) during with complaints delayed late phase of arterial diminished of angiography filling vision in the (C). in nasal her as left well eye as of inferior two days retinal duration. circulation Her visual on fluorescein acuity was angiography 20/40 in this (B). eye. However Fundus showed there was retinal no

Her visual on fluorescein acuity was angiography 20/40 in this (B). eye. However Fundus showed there

Page 104

OCT Optical done Coherence at this stage Tomography through various angles (D) showed hyper­reflectivity in the inner retinal layers of the inferior retina, corresponding to the opaque retina clinically.

hyper­reflectivity in the inner retinal layers of the inferior retina, corresponding to the opaque retina clinically.

Page 105 The areas of inner layer hyper­reflectivity were persistent at one week (E) whereas at 3 weeks follow­up, the inner retina did not show any hyper­reflectivity (F).

the inner retina did not show any hyper­reflectivity (F). Two retinal Follow­up months layers later, now

Two retinal Follow­up months layers later, now (G). the patient had regained a visual acuity of 20/20 with normal retinal perfusion on fluorescein angiography. There was no hyper­reflectivity in the inner The OCT in this patient documented that the ischemic retina becomes hyper­reflective compared to the non­ischemic retina.

OCT in this patient documented that the ischemic retina becomes hyper­reflective compared to the non­ischemic retina.

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OCT IN CENTRAL RETINAL VEIN OCCLUSION OCCLUSION (BRAO) (CRVO) WITH BRANCH RETINAL VEIN

Case 8.7: CRVO with BRAO

Case Summary

A glaucoma hypofluorescent 65­year­old following man areas was ischemic in seen the superior with central retinal retinal retina hemorrhages corresponding vein occlusion in the to (CRVO). retinal superior hemorrahages His half visual of the acuity retina with in in delayed the his left left hyperfluorescence eye eye at (A). presentation He had lost in was the vision 20/90. macula in Fluorescein the suggestive opposite angio­graphy eye of macular due to neovascular edema showed (B–D).

20/90. macula in Fluorescein the suggestive opposite angio­graphy eye of macular due to neovascular edema showed

Page 107

Optical Coherence Tomography neurosensory OCT a hyper­reflective scan at different retina; band those angles at the under (E) vitreoretinal the showed fovea loss interface were of full foveal anteriorly thickness contour suggestive while with those central probably in foveal the extrafoveal of thickness posterior region measuring hyloid were membrane 560 present microns. mostly attachment There in the were (arrow). outer hypo­reflective retinal layers. areas In addition, seen in there the was The patient had elevated homocystein levels and was treated for the same.

elevated homocystein levels and was treated for the same. enhanced One Over month next reflex later,

enhanced One Over month next reflex later, three from patient months, the developed posterior the visual hyloid fresh acuity upper membrane deteriorated temporal at the vein to vitreoretinal 20/300. occlusion Repeat with interface. OCT occlusion (J) This at edema of various branch failed angles retinal to showed respond artery supplying foveal to oral thickness corticosteroids. the macula increased (arrow) to 690 (F–I). microns with

artery supplying foveal to oral thickness corticosteroids. the macula increased (arrow) to 690 (F–I). microns with

Page 108

Page 108 CONCLUSIONS occlusions patients The development that as helps it helps of in macular quantifying

CONCLUSIONS

occlusions patients The development that as helps it helps of in macular quantifying in delineating edema the the is macular quite extent common edema of occlusion, and in venous is helpful capillary occlusions. in non­perfusion monitoring Fluorescein response and neovascularization. angiography to therapy. is Also an important it OCT helps is in complementary tool depicting in the epiretinal management to fluorescein membranes of retinal angiography as vascular well as in taut these posteriorhyloidmembranethatmightmeritsurgicalremoval.

SUGGESTED READING

1. Spaide RF, Lee JK, Klancnik JM, Gross NE. Optical coherence tomography of branch retinal vein occlusion. Retina 2003; 23; 343–347.

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Retinal Chapter Vasculitis 9

Page 109 Retinal Chapter Vasculitis 9 Retinal evaluating vasculitis the macula is a common in these

Retinal evaluating vasculitis the macula is a common in these patients. cause of Macular visual loss edema in young including adults. cystoid It has macular characteristic edema clinical is known and to angiographic occur in retinal features. vasculitis. Optical OCT Coherence is helpful Tomography in diagnosing is macular helpful in edema, objectively. cystoid macular edema, epiretinal membranes, pseudo macular hole and tractional retinal detachment. It also is helpful in monitoring response to treatment

Case 9.1: Retinal Vasculitis

A showed Case 40­year­old Summary vasculitis man along presented the lower with temporal decreased vessel vision with in his hemorrhages left eye of and one cotton­wool month duration. spots His along best the corrected lower temporal visual acuity vessels was and 20/60 macular in the edema left eye. (A). Fundus Fluorescein left eye angiography showed hypofluorescence corresponding to retinal hemorrhages and staining of retinal vessel walls (B). Optical OCT suggestive of the Coherence of left fluid eye accumulation. (C) Tomography showed increased retinal thickening with loss of foveal contour and reduced backscattering with hyporeflective space in the outer retina

Page 110

Page 110 The showed patient reduction had isolated of edema idiopathic (D, E). vasculitis for which

The showed patient reduction had isolated of edema idiopathic (D, E). vasculitis for which he was treated with oral corticosteroids. Six weeks later, his visual acuity had improved to 20/60 and OCT

for which he was treated with oral corticosteroids. Six weeks later, his visual acuity had improved

Page 111

Page 111 The showed oral the corticosteroids reappearance were of macular tapered edema at this stage

The showed oral the corticosteroids reappearance were of macular tapered edema at this stage with that cystoid led to spaces deterioration (F). Detached of vision posterior in this hyaloid eye. Clinical membrane picture could did not be show seen anteriorly. any activation The of oral the corticosteroids vasculitis but OCT were re­ started following which the edema resolved again and repeat OCT done 8 months later maintained resolution (G).

were re­ started following which the edema resolved again and repeat OCT done 8 months later

Page 112

Page 112 CONCLUSIONS The identifying macula cystoid in retinal macular vasculitis edema can and show is

CONCLUSIONS

The identifying macula cystoid in retinal macular vasculitis edema can and show is a either great macular non­invasive edema tool or ischemia. in monitoring OCT response is helpful to in an the intervention. diagnosis and quantification of macular edema. It also helps in

Page 113

Epiretinal Chapter Membranes 10

Page 113 Epiretinal Chapter Membranes 10 translucent distortion, Epiretinal membranes they over can a period be

translucent distortion, Epiretinal membranes they over can a period be comprise classified of time of as and thin, Grade their translucent 0: contraction cellophane membranes might maculopathy, produce that are edema, Grade seen on degeneration 1: Crinkled the inner retinal cellophane or cystoid surface maculopathy, spaces in the in macular the underlying Grade area. 2: These macular retina. membranes According pucker. These can to the become membranes severity semi­ of may retinal have of cystoid OCT the associated membrane macular helps by with edema, giving to the pseudo retina. vitreofoveal the cross­sectional or OCT true macular demonstrates traction, view hole. macular of the Development the extent hole, macula etc. of in the This of these membrane, choroidal helps eyes in that prognosticating neovascular vitreoretinal helps in assessing membrane interface, the outcome the may status severity of be of surgery another of posterior changes in sequelae. these hyloid in the eyes. membrane, underlying associated retina and the changes adhesiveness like surface The epiretinal and; b) globally membranes adherent have where been classified no area of as: separation a) clearly can separable be seen where easily a between clear space the is ERM visible and between inner retinal the epiretinal surface. membrane (ERM) and inner retinal

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Case 10.1: Grade 1 Crinkled Cellophane Maculopathy

A­64­year­old fine, Case superficial Summary man radiating was retinal seen with folds complaints suggesting of the distorted presence vision of an in epiretinal his right membrane eye of one month (A). duration. His best corrected visual acuity was 20/30. Fundus showed

His best corrected visual acuity was 20/30. Fundus showed The distortion Optical OCT Coherence of scan

The distortion Optical OCT Coherence of scan neurosensory (B, C) Tomography through retinal various layers. angles The membrane showed the caused presence traction of hyperreflective on the underlying band retina at the that vitreo­retinal was seen as interface in­foldings. with OCT traction helped on the in underlying giving information retina resulting in regarding the status of underlying retinal traction in this patient that would justify surgery at this stage.

in regarding the status of underlying retinal traction in this patient that would justify surgery at

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Page 115 Case 10.2 Grade 2 ERM: Macular Pucker A (A). Case 30­year­old­man Fluorescein Summary angiography

Case 10.2 Grade 2 ERM: Macular Pucker

A (A). Case 30­year­old­man Fluorescein Summary angiography was seen showed with decreased dye leakage vision from in his the right underlying eye of 2 retina months (B). duration. Clinically, a greyish membrane was seen on the inner retinal surface (arrows)

membrane was seen on the inner retinal surface (arrows) traction the OCT Optical edge line as

traction the OCT Optical edge line as Coherence of scan well the through as membrane traction Tomography the on fovea that the underlying (C) could showed help retina the the presence surgeon (arrow). of The to a enter hyper­reflective temporal the right edge of plane membrane the membrane of cleavage extending could during from be well optic surgery. delineated. disc both nasally OCT in and this temporally patient helped causing in peripapillary identifying

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Page 116 Case 10.3: Epiretinal Membrane with Underlying Retinal Edema A­59­year­old Case Summary man was seen

Case 10.3: Epiretinal Membrane with Underlying Retinal Edema

A­59­year­old Case Summary man was seen as a case of ERM right eye with a visual acuity of 20/200. Fundus and fluorescein angiography confirmed epiretinal membrane (A–D).

of ERM right eye with a visual acuity of 20/200. Fundus and fluorescein angiography confirmed epiretinal

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Optical Coherence Tomography OCT reduced OCT line backscatter was scan helpful through from in the diagnosing the fovea outer (E) retinal underlying showed layers the suggesting presence retinal edema of underlying a hyper­reflective that could retinal help edema membrane in prognosticating that corresponded on the surface the to of the outcome retina hyperfluorescence bridging following across surgery. seen the on fovea. fluorescein In addition, angiography. there was

on fovea. fluorescein In addition, angiography. there was Case 10.4: ERM: Crinkled Cellophane Maculopathy A red

Case 10.4: ERM: Crinkled Cellophane Maculopathy

A red Case 51­year­old free Summary photo showed man was the seen presence with distortion of cellophane of vision membrane in his left over eye the of retinal 6 months surface duration. (A, B). His The best fluorescein corrected angiography visual acuity showed was 20/40 staining in the in left the eye. late Fundoscopy phase (C, D). and

corrected angiography visual acuity showed was 20/40 staining in the in left the eye. late Fundoscopy

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Page 118 OCT patient Optical of regained the Coherence left eye a visual (E) Tomography showed

OCT patient Optical of regained the Coherence left eye a visual (E) Tomography showed acuity of a 20/30 hyper­reflective following PPV membrane (F). Note intimately the absence adherent of to underlying the underlying structural retina with changes distortion that of indicate underlying a better inner retinal prognosis layers following only. The surgery.

distortion that of indicate underlying a better inner retinal prognosis layers following only. The surgery.

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Case 10.5: ERM with PVD and True Macular Hole

A Case 56­years­old Summary woman was seen with epiretinal membrane, stage III macular hole left eye and positive Watzke’s sign (A).

III macular hole left eye and positive Watzke’s sign (A). Optical Coherence Tomography approximately Horizontal OCT

Optical Coherence Tomography approximately Horizontal OCT 540 line microns scan (B) from demonstrated the bottom stage of the III hole. macular Following hole with pars complete plana vitrectomy posterior (PPV), vitreous the detachment. hole showed The partial posterior closure hyloid with membrane persistent cystic was seen spaces situated (C).

detachment. hole showed The partial posterior closure hyloid with membrane persistent cystic was seen spaces situated

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Case 10.6: Globally Adherent ERM

A Case 48­year­old Summary woman was seen with ERM in her right eye (A). Her best corrected visual acuity was 20/ 200 in this eye.

OCT intervening Optical line Coherence scan space of the in between. Tomography right eye passing above the fovea (B) showed a hyper­reflective membrane that was intimately adherent to the underlying retina with no

above the fovea (B) showed a hyper­reflective membrane that was intimately adherent to the underlying retina

Page 121 same The area patient (D) underwent showed the pars absence plana of vitrectomy ERM. with ERM peeling. Two weeks later, her best corrected visual acuity was 20/80 (C). Repeat OCT scan through the

ERM. with ERM peeling. Two weeks later, her best corrected visual acuity was 20/80 (C). Repeat

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Case 10.7: Secondary ERM following Scleral Buckle Surgery

Case Summary acuity membrane. A 60­year­old in this The eye woman fluorescein was counting had undergone angiography fingers. retinal Fundus (B) showed reattachment right eye corresponding (A) surgery showed in hyperfluorescence. a the yellowish­grey right eye two membrane years ago on following the retinal which surface she with had poor straightening visual gain. of retinal Her best vessels corrected towards visual the

OCT probablyinternallimitingmembranefolds. Optical line Coherence scan (C) showed Tomography increased retinal thickness with hyper­reflectivity at the vitreoretinal interface. The innermost retinal layer was thrown in the folds suggesting

with hyper­reflectivity at the vitreoretinal interface. The innermost retinal layer was thrown in the folds suggesting

Page 123 The contour patient with underwent few residual PPV folds for temporal ERM peeling. to fovea. Three weeks later, her visual acuity was improved to 20/100 (D). Repeat OCT scan (E) showed a near­normal foveal OCT helps in tracking longitudinal follow­up following surgery.

(D). Repeat OCT scan (E) showed a near­normal foveal OCT helps in tracking longitudinal follow­up following

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Case 10.8: Secondary ERM with lamellar macular hole following endogenous endophthalmitis

A cellophane Case 60­year­old Summary membrane man underwent on the surface pars plana of retina vitrectomy with a residual in the right retinal eye abscess for pseudomonas associated endogenous with retinal endophthalmitis. hemorrhage seen Two temporal months to the following fovea (A). surgery, he showed a fine The OCT scan passing through the center of the fovea (B) showed some loss of foveal contour with an overlying epiretinal membrane.

scan passing through the center of the fovea (B) showed some loss of foveal contour with

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Three presence months of lamellar later, the macular fundus hole showed that was clearer not seen media clinically. with residual In this scar patient, temporal OCT to the helped fovea in and demonstrating an epiretinal membrane an inner lamellar (C). Repeat hole OCT that scan was (D) not demonstrated seen clinically. the

scan was (D) not demonstrated seen clinically. the CONCLUSIONS In epiretinal membranes, OCT helps in the

CONCLUSIONS

In epiretinal membranes, OCT helps in the following ways:

1. 2. It This prognosticating helps is a in useful confirming tool the to outcome. the identify diagnosis the structural of the epiretinal alterations membranes. in the underlying retina that could play a role in making decision regarding the surgical intervention as well as

3. It also helps in longitudinal tracking of these eyes following pars plana vitrectomy, thus obviating the need for repeat fluorescein angiography.

SUGGESTED READING

1. Wilkins JR, Puliafito CA, Hee MR et al. Characterization of epiretinal membranes using optical coherence tomography. Ophthalmology 1996; 103:2142–51.

Page 126

Age Related Chapter Macula? 11 Degeneration

Page 126 Age Related Chapter Macula? 11 Degeneration OCT IN AGE RELATED MACULAR DEGENERATION Age categorized

OCT IN AGE RELATED MACULAR DEGENERATION

Age categorized related as: macular degeneration (ARMD) is a disease that primarily affects choriocapillaris, Bruch’s membrane and retinal pigment epithelium (RPE). It can be

NON­NEOVASCULAR ARMD

Drusens

borders retinaandwithinBruch’s The drusens with may no optical be hard shadowing membrane. or soft. Soft underneath. drusens, These on OCT, findings are seen are as consistent areas of with focal the elevation belief that of RPE. drusens These result appear due to as accumulation modulations of in material the RPE under associated the neurosensory with shallow These drusens can be differentiated from serous pigment epithelium detachments (PED) as the latter show optical shadowing of choroid under the PED.

Geographic Atrophy

Geographic increased optical atrophy reflectivity is an advanced from the stage choroid of non­neovascular due to increased ARMD penetration characterized of the light by through well demarcated overlying atrophic pigment retina. epithelial/choriocapillaris atrophy. OCT shows

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Neovascular ARMD

Neovascular retina/pigment ARMD epithelium is characterized or fibrovascular by classic scar. or occult choroidal neovascular membrane or mixed form, serous/hemorrhagic detachment of neurosensory

1. Classic Choroidal Neovascular Membrane (CNVM): The normal RPE­choriocapillaris form a highly reflective continuous band. In well defined CNVM, there is

2. accompanying Occult disruption/thickening CNVM: subretinal This is of characterized this fluid/ band retinal with by edema the the thickened disruption that helps edges in them RPE­choriocapillaris demarcating to be differentiated the boundaries complex from pigmentary of where CNVM. the atrophy. boundaries are poorly defined. These membranes also have

3. 4. Fibrovascular Serous PED: These Pigment are seen Epithelial as elevation Detachment of RPE with (PED): an optically This is seen clear as space elevation underneath. of RPE The with underlying a clear demarcation choroid shows between reflection/optical RPE and underlying shadowing. structures that

5. Hemorrhagic appear reflections. as yellow/green. PEDs: The In this, findings the optical are same shadowing as serous from PED the except underlying that the choroid backscattering is absent. from RPE attenuates towards the outer retina with absent choroidal

OCT helps in the management of ARMD in the following ways:

A. disease. Disease Since categorization: the management OCT protocol gives an insight in these into patients the localization depends on of the pathology category, with OCT changes in addition occurring to fundus at the photography ultra structural and level fluorescein that helps angiography in categorizing helps the in disease angiography categorization and indocyanin that is green the most angiography; crucial step it in alone the management. cannot establish However, the diagnostic it must category. be noted that OCT is complementary to clinical examination, fluorescein

B. picking Early occult up the CNVM: CNVM In in patients these patients. with soft We, confluent in our experience, drusens, occult found CNVM OCT very can often useful be in missed diagnosing on fluorescein these occult angiography. CNVMs as OCT a step is between a very helpful fluorescein device in

D. C. angiographyandindocyaninegreenangiography. (PDT). Associated Response Following to changes: treatment: PDT, OCT 5 OCT stages helps helps have in depicting in been monitoring described: additional response features to thermal like cystoid laser photocoagulation, macular edema, RPE transpupillary rip, neurosensory thermotherapy atrophy (TTT) of retina, and etc. photodynamic therapy Stage subretinalfluid. I: This is seen within one week of therapy and is an acute response to treatment characterized by acute inflammatory response with increase in Stage Stage of active III: II: choroidal This This is is seen seen neovascularization between between 1–4 4–12 weeks weeks CNV of (Stage of treatment treatment III a) and or and more is is characterized characterized fibrous tissue by by with resolution the minimal presence of serous subretinal of either fluid fluid greater with suggesting restoration subretinal inactivity of fluid foveal to fibrous (Stage contour. III tissue b). suggestive Stage Stage IV: V: Is Is the characterized final stage showing by the presence resolution of of cystoid subretinal spaces. fluid and finally the retina becomes thin and fibrous tissue also merges with it.

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DISEASE CATEGORIZATION

Case 11.1: Intermediate­risk Non­neovascular ARMD

A sized Case 59­year­old drusens, Summary with man few was large seen drusens with bilateral (125 drusens. microns) His and best­corrected few calcified visual drusens acuity and was some 20/30 areas in of the RPE right atrophy eye. The (A). fundus The drusens in the right as well eye as showed the area extensive of RPE medium atrophy were hyperfluorescent on fluorescein angiography (B).

right as well eye as showed the area extensive of RPE medium atrophy were hyperfluorescent on

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OCT into Optical the line overlying Coherence scan inferior photoreceptor Tomography to the fovea layer. passing The through area of RPE the area atrophy of RPE showed atrophy hyper­reflectivity and calcified drusens from underlying (C) showed choroid. hard drusens as small disruptions in the RPE projecting

hard drusens as small disruptions in the RPE projecting Case 11.2: Soft Drusens, High Risk Non­neovascular

Case 11.2: Soft Drusens, High Risk Non­neovascular ARMD

A microns Case 56­years­old Summary in size (A). man This was eye seen has with 18–20% drusens risk in the of developing right eye with CNV a visual over next acuity 3–5 of years. 20/40. Fundus showed soft drusens that were predominately indistinct and >125

visual over next acuity 3–5 of years. 20/40. Fundus showed soft drusens that were predominately indistinct

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OCT CNV. Optical line Coherence scan through Tomography the drusens (B) showed irregular elevations of RPE (arrows) with no shadow from the underlying choroid. These drusens carry high­risk of

the underlying choroid. These drusens carry high­risk of Case 11.3: CNVM Contiguous to Geographic Atrophy A

Case 11.3: CNVM Contiguous to Geographic Atrophy

A fluorescein Case 56­year­old Summary angiography woman was (B), seen the membrane with an area showed of geographic early hyperfluorescence atrophy with a choroidal that increased neovascular in the late membrane phase (C). developing adjacent to the area of atrophy (A). On

a choroidal that increased neovascular in the late membrane phase (C). developing adjacent to the area

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The suggesting Optical horizontal Coherence a fibrovascular OCT line Tomography scan complex through of the a classic CNVM CNVM showed (D, increased E). retinal thickness temporal to the fovea with increased reflectivity from the outer retinal layers

showed (D, increased E). retinal thickness temporal to the fovea with increased reflectivity from the outer

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Case 11.4: Fibrovascular PED

A Case 57­year­old Summary man was seen with a visual acuity of 20/80 in the left eye. His fundus showed a small yellowish, pigment epithelium detachment (A).

Horizontal beneath Optical suggesting Coherence line scan the passing Tomography presence through of either the center cloudy of exudates the PED or (B) a showed fibrovascular elevation PED. of the hyper­reflective band corresponding to RPE with moderate­high backscatter

a showed fibrovascular elevation PED. of the hyper­reflective band corresponding to RPE with moderate­high backscatter

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Case 11.5: Fibrovascular Pigment Epithelial Detachment

A the Case 76­year­old late Summary phase (B). man Indocyanine was seen with green fibrovascular angiography pigment showed epithelial hyperfluorescence detachment (PED) corresponding in the left to eye the (A). area The of PED fluorescein (C, D). angiography showed hyperfluorescence only in

The Optical OCT Coherence line scan through Tomography the center of the lesion (E) showed the presence of fibrovascular pigment epithelial detachment with adjoining serous fluid.

center of the lesion (E) showed the presence of fibrovascular pigment epithelial detachment with adjoining serous

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Case 11.6: Disciform Scar in ARMD

A­65­year­old surrounding Case Summary the woman atrophic was area seen (A). with a visual acuity of counting fingers in the right eye. Fundus right eye showed a well demarcated area of disciform scar with drusens

showed a well demarcated area of disciform scar with drusens OCT Optical subretinalfluid. scan Coherence (B)

OCT Optical subretinalfluid. scan Coherence (B) showed Tomography an area of increased reflectivity from underlying choroid that was consistent with the atrophy of overlying RPE. There was no associated

reflectivity from underlying choroid that was consistent with the atrophy of overlying RPE. There was no

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The left eye of the patient showed multiple small­medium sized drusens with only one large drusen 125 microns in size (C).

with only one large drusen ≥ 125 microns in size (C). OCT Optical line Coherence scan

OCT Optical line Coherence scan (D) showed Tomography multiple areas of irregular retinal pigment epithelium consistent with small, hard drusens.

scan (D) showed Tomography multiple areas of irregular retinal pigment epithelium consistent with small, hard drusens.

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B. EARLY OCCULT CNVM

Case 11.7: Confluent, Soft Drusens with OCCULT CNVM

Case Summary A Fundus there 62­year­old was showed an area woman the of presence hyperfluorescence was seen of soft with confluent complaints suggesting drusens, of an diminished underlying majority vision being CNVM >125 in both (B). microns her eyes (A). of The one year drusens duration. were hyperfluorescent Her best corrected on visual fluorescein acuity angiography. was 20/60 in In the addition right eye.

acuity angiography. was 20/60 in In the addition right eye. Optical Coherence Tomography choroid. OCT attenuated

Optical Coherence Tomography choroid. OCT attenuated (C, There D) and showed was optical also soft backscatter an drusens area of as hyporeflectivity was areas seen of in focal the elevation sub­RPE under the of space fovea RPE suggestive suggestive that appeared of of an subretinal as underlying modulations fluid. CNVM. The in the reflections RPE. There from was the no choroid optical underlying shadowing RPE from detachment underlying were not OCT helped in diagnosing an underlying occult CNVM in this patient.

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Page 137 In on the fluorescein left eye (E), angiography. the patient had drusens with a

In on the fluorescein left eye (E), angiography. the patient had drusens with a small greenish­grey area in the center suggesting an underlying occult CNV (arrow). This area was hyperfluorescent

with a small greenish­grey area in the center suggesting an underlying occult CNV (arrow). This area

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OCT backscatter Optical scan Coherence just was below seen Tomography extending the fovea (F) from showed the underlying modulations choroid in the into RPE the suggestive sub­RPE space of drusens. suggestive The reflective of occult CNV. band corresponding to the RPE was detached and an optical

band corresponding to the RPE was detached and an optical C. Associated Changes Case 11.8: CNVM

C. Associated Changes

Case 11.8: CNVM with Cystoid Spaces

A Case 56­year­old Summary man was seen with a visual acuity of counting fingers and a large subfoveal predominately classic membrane in the left eye (A).

seen with a visual acuity of counting fingers and a large subfoveal predominately classic membrane in

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OCT Optical cystoid left spaces Coherence eye through in the overlying Tomography 45° angle retina. (B) showed These the cystoid presence spaces of a were large better fibrovascular defined complex on OCT with and accumulation were not so of well serous appreciated fluid in the on adjoining fluorescein retina angiography and the presence due of to hyperf luorescence in the late phase.

presence due of to hyperf luorescence in the late phase. D. RESPONSE TO THERAPY Case 11.9:

D. RESPONSE TO THERAPY

Case 11.9: Transpupillary Thermotherapy for Occult CNVM

Case Summary A inferior hypofluorescence 62­year­old to the fovea man in with complained the area central of greyish­yellow of bleed. blurring ICG of (C) vision exudation. showed in his the left The extent eye visual of of 2 acuity the months CNV was duration. (arrows). 20/70. Fluorescein The fundus of angiography the left eye (B) (A) showed showed an few area drusens of hyperfluorescence with subretinal hemorrhage with

of angiography the left eye (B) (A) showed showed an few area drusens of hyperfluorescence with

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Page 140 The Optical underlying vertical Coherence choroid line scan did Tomography through not show the

The Optical underlying vertical Coherence choroid line scan did Tomography through not show the any fovea backscatter. (D) showed However, an area of the elevated space beneath retinal pigment the elevated epithelium RPE showed (RPE). The mild overlying backscatter neurosensory suggestive of retina exudation showed or thickening. fibrovascular The proliferation. Because of the sub­RPE location of the CNVM, the diagnosis of occult CNVM was made and patient was offered transpupillary thermotherapy (TTT).

location of the CNVM, the diagnosis of occult CNVM was made and patient was offered transpupillary

Page 141 Three acuity weeks had improved following to TTT 20/30. (E), The his patient visual has acuity maintained in this eye the was same 20/60. status The over hemorrhage 7 months follow­up was absorbed with and no minimal recurrences. scar could be seen. Six weeks later (F), his visual

scar could be seen. Six weeks later (F), his visual Repeat probably OCT the reactionary scan

Repeat probably OCT the reactionary scan done 3 edema weeks following after TTT TTT. (G) showed Repeat an scan increase at 6 weeks in the (H), hyper­reflectivity however, showed overlying disappearance the area of of this CNV reaction with few with overlying almost near­normal cystoid spaces, contour representing of RPE.

the area of of this CNV reaction with few with overlying almost near­normal cystoid spaces, contour

Page 142

Page 142 Case 11.10: Transpupillary Thermotherapy for Subfoveal Occult CNVM with Minimally Classic Component Case Summary

Case 11.10: Transpupillary Thermotherapy for Subfoveal Occult CNVM with Minimally Classic Component

Case Summary A fluorescein The 58­year­old ICG (C) angiography showed man was the seen (B), entire the with membrane. CNVM micropsia showed in his mixed left eye hyperfluorescence of 20 days duration. with The an area fundus of increased (A) showed hyperfluorescence a greyish­yellow suggestive area inferonasal of the classic to the fovea component (arrow). (arrow). On

hyperfluorescence a greyish­yellow suggestive area inferonasal of the classic to the fovea component (arrow). (arrow). On

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Page 143 Optical Coherence Tomography proliferation. showed The horizontal a serous The OCT PED. outer scan

Optical Coherence Tomography proliferation. showed The horizontal a serous The OCT PED. outer scan retina through nasal the to CNVM this showed (D) showed reduced disruption optical backscattering in the RPE layer suggesting with patchy intraretinal reflections fluid accumulation. from choriocapillaries The scan suggesting line passing fibrovascular below the fovea (E)

suggesting line passing fibrovascular below the fovea (E) The patient elected to receive TTT for this

The patient elected to receive TTT for this CNVM. Two months later, his best corrected visual acuity was 20/30. Fundus did not show any CNVM or scar (F).

Repeat PED Optical seen OCT Coherence inferiorly done at was Tomography 2 months however, following persistent TTT (not (G) shown). showed return of retinal thickness to normal. The RPE in the area of CNVM showed mild disruption (arrow). The

Page 144

Page 144 Case 11.11: Classic CNVM: Worsening on TTT A discrete Case 52­year­old Summary hyperfluorescence man

Case 11.11: Classic CNVM: Worsening on TTT

A discrete Case 52­year­old Summary hyperfluorescence man was seen (B) with a visual acuity of 20/200 in the left eye with subfoveal CNVM (A). The fluorescein angiography showed a well­defined area of

The fluorescein angiography showed a well­defined area of OCT Optical CNVM. scan Coherence The (C) foveal

OCT Optical CNVM. scan Coherence The (C) foveal showed retinal Tomography disruption thickness in the was RPE 480 with microns. focal The area detached of enhanced posterior reflectivity hyloid seen was beneath seen anterior the foveal to it. center The patient within elected the retinal to receive layers suggestive transpupillary of a classic thermotherapy as he could not afford PDT.

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Page 145 Repeat Three OCT months scan later, (D) done repeat four OCT weeks scan following

Repeat Three OCT months scan later, (D) done repeat four OCT weeks scan following (E) showed TTT, the appearance did not show of any subretinal reduction fluid in seen the classic on either component side of CNVM, of the CNVM. indicating worsening following TTT.

reduction fluid in seen the classic on either component side of CNVM, of the CNVM. indicating

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Case 11.12: Cystoid Macular Edema following Transpupillary Thermotherapy for Juxtafoveal Classic CNVM

A mixed Case 57­year­old Summary fluorescence woman with was late seen hyperfluorescence with left eye juxtafoveal (B–D). CNVM (A). Her visual acuity in this eye was 20/80. The fluorescein angiography showed an initial area of

Horizontal space Optical suggesting Coherence OCT line an intraretinal Tomography scan (E) passing cyst. These through findings the CNVM were consistent showed an with area classic of increased CNVM. hyper­reflectivity in the outer retinal layers with an overlying hyporeflective

an with area classic of increased CNVM. hyper­reflectivity in the outer retinal layers with an overlying

Page 147 The patient underwent TTT for this CNVM. Three months later, her visual acuity was reduced to 20/ 100. Both fundus photograph and fluorescein angiograms showed

an

of

cystoid Repeat increase OCT spaces in the scan following area (H) of showed CNVM TTT. the with presence overlying of cystoid large cystoid spaces spaces (F, G). seen as hyporeflective areas with intervening hyper­reflective septae suggesting the development

hyper­reflective septae suggesting the development Case 11.13: Persistent CNVM following Thermal Laser for

Case 11.13: Persistent CNVM following Thermal Laser for Extrafoveal Classic CNVM

Case PED A 60­year­old (thin Summary arrow) woman temporal was to seen the with fovea decreased and a small vision extrafoveal in the right classic eye of CNVM 14 days (thick duration. arrows). Fundus and fluorescein angiography of the right eye (A) showed a large

OCT reflectivity Optical line Coherence scan in the through neurosensory Tomography the lesions retina (B) suggesting showed an a area classic of large CNVM. PED The with patient adjoining received pocket thermal of serous laser fluid. photocoagulation In addition, there for the was extrafoveal an area of CNVM. moderate to intense hyper­

Page 148

Page 148

Page 149

Two weeks later, the fundus showed persistence of CNVM at the foveal edge that was confirmed on fluorescein angiography (C).

edge that was confirmed on fluorescein angiography (C). Repeat OCT scan showed the growth of CNVM

Repeat OCT scan showed the growth of CNVM towards the fovea (D).

edge that was confirmed on fluorescein angiography (C). Repeat OCT scan showed the growth of CNVM

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Case 11.14: Photodynamic Therapy for Juxtafoveal Recurrent Choroidal Neovascular Membrane (Courtesy of Dr. Monique Leys, West Virginia University Eye Institute, Morgantown, USA.)

A (A). Case 56­year­old Fluorescein Summary man angiography was seen with (B) showed recurrent CNV choroidal at the neovascular edge of previous membrane photocoagulation (CNVM) with scar. a scar of krypton laser photocoagulation done for extrafoveal CNVM

of previous membrane photocoagulation (CNVM) with scar. a scar of krypton laser photocoagulation done for extrafoveal

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Horizontal therapywithverteporfin. Optical Coherence OCT line Tomography scan through the area of CNVM (C) showed a small occult CNV with associated serous detachment (arrow). The patient received photodynamic

serous detachment (arrow). The patient received photodynamic Four weeks later, repeat fundus photograph and OCT scan

Four weeks later, repeat fundus photograph and OCT scan showed resolution of serous fluid (D, E).

received photodynamic Four weeks later, repeat fundus photograph and OCT scan showed resolution of serous fluid

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Case 11.15: Photodynamic Therapy for Juxtafoveal CNVM

A showed Case 50­year­old Summary a juxtafoveal woman choroidal was seen neovascular with floaters membrane in the left (A). eye There of 10 days were duration. no drusens Her indicating best­corrected that probably visual acuity the membrane was 20/20. was The idiopathic fundus and rather fluorescein than age­related. angiography

visual acuity the membrane was 20/20. was The idiopathic fundus and rather fluorescein than age­related. angiography

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OCT disrupted Optical scan Coherence RPE (B) showed was an Tomography area juxtafoveal of moderate increased reflectivity retinal with thickness small with cystic mild spaces backscattering in the overlying from retina outer retinal suggestive layers of and a predominately disruption in classic RPE layer. CNVM. Just anterior to the

disruption in classic RPE layer. CNVM. Just anterior to the The patient received photodynamic therapy for

The patient received photodynamic therapy for this CNVM. Twelve weeks later, her visual acuity was 20/20 (C).

to the The patient received photodynamic therapy for this CNVM. Twelve weeks later, her visual acuity

Page 154 Repeat and no intraretinal OCT (D, E) fluid showed indicating return stage of foveal 3b of thickness resolution to following normal with PDT. presence of area of moderately increased reflectivity corresponding to fibrovascular scar (arrow)

normal with PDT. presence of area of moderately increased reflectivity corresponding to fibrovascular scar (arrow)

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Case 11.16: Fuchs’ Spot

A D). Case 54­year­old Summary lady was referred as ARMD. Fundoscopy showed a Fuchs’ spot and a Lacquer crack (A) that was hyperfluorescent on fluorescein angiography (B–

that was hyperfluorescent on fluorescein angiography (B– OCT epithelialhyperplasia. Optical line Coherence scan

OCT epithelialhyperplasia. Optical line Coherence scan of the Tomography right eye (E) showed choroidal neovascular tissue just nasal to the fovea discontinuity in the RPE­choriocapillary complex and retinal pigment

choroidal neovascular tissue just nasal to the fovea discontinuity in the RPE­choriocapillary complex and retinal pigment

Page 156

CONCLUSIONS

There are three aspects in the management of ARMD patients:

1. Disease categorization

2. 3. Monitor Management response issues to that the therapy depend and on the to define disease indications category. for retreatment. monitoring angiography OCT aids in response the and practical indocyanin to the management various green angiography therapies of these that patients that are helps available. by us helping in In prompt our in experience, categorization disease categorization. we of have ARMD, started picking using it up as the an associated investigative secondary tool between changes fluorescein and also closely

SUGGESTED READINGS

1. Rogers Ophthalmol AH, 2002; Martidis 134:566–576. A, Greenberg PA, Puliafito CA. Optical Coherence Tomography findings following photodynamic therapy of choroidal neovascularization. Am J

2. Costa subfoveal RA, choroidal Farah ME, neovascularization. Cardillo JA et al. Retina Immediate 2003; indocyanine 23:59–65. green angiography and optical coherence tomography evaluation after photodynamic therapy for

3. Puliafito CA, Hee MR, Lin CP et al. Imaging of macular disease with optical coherence tomography. Ophthalmology 1995; 102:217–219.

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Choroidal Neovascular Chapter 12 Membranes

Page 157 Choroidal Neovascular Chapter 12 Membranes OPTICAL COHERENCETOMOGRAPHY IN CHOROIDAL NEOVASCULAR MEMBRANES

OPTICAL COHERENCETOMOGRAPHY IN CHOROIDAL NEOVASCULAR MEMBRANES

retina seen Optical as giving hyporeflective coherence information tomography spaces. at tissue There is structural a very might important level. be associated The tool choroidal in cystoid the management neovascularization spaces in of the choroidal retina. is seen The neovascular as present highly section reflective, membranes deals bright with (CNVM). red CNVMs band It provides in other the retina. than in Age­related vivo The histopathology associated macular serous of fluid the is degeneration. Majority of these CNVMs are of classic variety. OCT provides the following information:

A. B. To To study rule out the the in presence vivo characteristics of underlying of CNVM CNVM in in patients different with diseases. hemorrhagic pigment epithelium detachments.

C. To study response to therapy. This has already been shown in chapter 11 (Cases 11.9 to 11.15).

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A. TO RULE OUT THE PRESENCE PIGMENT OF UNDERLYING EPITHELIUM CNVM DETACHMENTS IN PATIENTS WITH HEMORRHAGIC

Case 12.1: Hemorrhagic Pigment Epithelial Detachment

Case Summary hemorrhagic ring. A 50­year­old PED woman with was hard seen exudates with decreased (A). Fluorescein vision angiography in her left eye (B) of showed one month the duration. presence Her of hyperfluorescent best corrected visual spot in acuity the center was 20/200. surrounded The fundus by a hypofluorescent L/E showed

surrounded The fundus by a hypofluorescent L/E showed OCT neovascularization Optical scan Coherence through

OCT neovascularization Optical scan Coherence through was fovea Tomography seen (C) in showed this patient. loss of foveal contour with PED (arrow) with attenuation of underlying choroidal reflection. No evidence of choroidal

loss of foveal contour with PED (arrow) with attenuation of underlying choroidal reflection. No evidence of

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B. TO STUDY THE IN VIVO CHARACTERISTICS OF CNVM IN DIFFERENT DISEASES

Case 12.2: CNVM in Angioid Streaks

Case Summary A fluorescence 45­year­old in woman the early was phase seen with with late the hyperfluorescence. diagnosis of angoid The streaks peripapillary and choroidal angioid neovascular streaks too membrane showed hyperfluorescence in the right eye (A). on angiography The CNVM (B). showed mixed

the right eye (A). on angiography The CNVM (B). showed mixed OCT (arrow) Optical scan with

OCT (arrow) Optical scan with Coherence through overlying different Tomography cysts angles corresponding (C, D) showed to the area increased of CNVM retinal seen thickness clinically. nasal to fovea with an area of moderate hyper­reflectivity in the outer retinal layers

retinal seen thickness clinically. nasal to fovea with an area of moderate hyper­reflectivity in the outer

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Page 160 The superonasal left eye to too the showed fovea the corresponding presence of to

The superonasal left eye to too the showed fovea the corresponding presence of to peripapillary the CNVM angioid seen clinically. streaks with The angioid CNVM streaks that was were extrafoveal hyperfluorescent. (E). Fluorescein angiography (F) showed hyperfluorescence

(E). Fluorescein angiography (F) showed hyperfluorescence OCT seen Optical clinically. scan Coherence superonasal

OCT seen Optical clinically. scan Coherence superonasal OCT also Tomography to showed fovea (G, hyporeflective H) showed an area area under of moderately the fovea suggestive intense hyper­reflectivity of subretinal fluid. in the The outer OCT retinal was able layers to (arrow) demonstrate corresponding the presence to the area of fluid of CNVM under the fovea in this patient that was not seen clinically or angiographically.

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Case 12.3: Peripapillary CNVM in Retinal Vasculitis

Case A 13­year­old Summary boy was seen with peripheral vasculitis, microaneurysms and angiomatous proliferation on disc. No areas of capillary non­perfusion were seen in the

periphery. any inflammation. He had Fundus already showed received angiomatous oral corticosteroids lesions on for optic vasculitis. nerve His head best with corrected a peripapillary visual yellowish­white acuity in the right subretinal eye was 20/30. lesion that The was anterior hyperfluorescent segment did on not show

angiography (A). His work­up for tuberculosis, sarcoidosis, Bartonella, syphilis, HIV, collagen vascular disorders and Toxoplasma were negative. A working diagnosis

of IRVAN (Idiopathic Retinal Vasculitis, Angiomatosis and Neuroretinitis) was made.

were negative. A working diagnosis of IRVAN (Idiopathic Retinal Vasculitis, Angiomatosis and Neuroretinitis) was made.

Page 163 reflective A vertical backscatter OCT line scan in the passing neurosensory just temporal retina to with the adjoining optic disc hyporeflective (B) confirmed area the suggesting presence of the juxtapapillary presence of CNVM fluid. by showing the presence of moderately hyper­

of CNVM fluid. by showing the presence of moderately hyper­ CONCLUSIONS It has been highlighted in

CONCLUSIONS

It has been highlighted in the previous chapter too, that OCT defines the several features of the membrane and is a good tool for monitoring response to the therapy.

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Juxtafoveal Chapter Telangiectasia 13

Page 164 Juxtafoveal Chapter Telangiectasia 13 Patientswithjuxtafovealtelangiectasia(JFT)fallintovarioussubgroups: rich

Patientswithjuxtafovealtelangiectasia(JFT)fallintovarioussubgroups: rich Group exudation 1A: Unilateral at the outer congenital margin of parafoveal the area of telangiectasis: telangiectasis. These patients suffer from a localized mild form of focal telangiectasia with the presence of yellow, lipid­ generally Group within 1B: Unilateral, 2 clock hours idiopathic, or less focal at the juxtafoveal edge of foveal telangiectasis: avascular These zone. are middle­aged men having exudation from a minute area of capillary telangiectasis, Group Stage 1: 2A: No Bilateral, biomicroscopic idiopathic, abnormality. acquired parafoveal Fluorescein telangiectasis: angiography shows This is minimal seen in 5th­6th or no capillary decade of dilatation life and in involves the early both and the mild sexes staining equally. in the It late has phase. 5 stages:

retina. Stage Stage 2: 3: Slight Clinically retinal shows greying parafoveolar with minimal dilated or and absent blunted telangiectatic retinal venules vessels. and Fluorescein refractile angiography deposits. Fluorescein shows mild angiography capillary telangiectasis. shows capillary dilation with leak in outer Stage 4: In this stage, the stellate foci of black RPE hypertrophy are seen at the posterior end of retinal venules.

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cells. the It Stage formation is This believed 5: is In seen of this that right­angled as stage telangiectasia diffuse subretinal staining venules. in neovascularization of the This fluorescein capillary further wall leads into causes occurs the to damaged degeneration reduced in the parafoveal cells. metabolic and The atrophy changes area. exchange Cystoid of in these the which edema cells capillary in with turn and bed overlying causes yellow may nutritional induce exudates photoreceptors altered are deficiencies seen pattern resembling only of to in venous the subretinal retinal the flow, lamellar cells neovascularization. resulting including macular clinically hole. Muller

This choroidal causes neovascular RPE cells to membrane. migrate along These right new­vessels angles venules are believed and form to be hyperplastic retinal rather black than plaques. choroidal, Finally thus new are vessels also termed proliferate as retinal in the angiomatous subretinal space proliferation and form (RAP) type II (See Group Group Chapter 2B: 3A and 19). JuvenileoccultfamilialidiopathicJFT. 3B are rare and thus not discussed here.

OCT IN JFT

The diagnosis of JFT is essentially based on fluorescein angiography that helps in the grouping and staging of the disease. OCT showed the following features in JFT:

1. OCT retina showed in many hyporeflective eyes may not show spaces thickening in the inner corresponding or outer retina to the in stage leakage 2 and seen 3 of on group fluorescein 2A JFT. angiography These spaces that again probably substantiates represent the the theory atrophy that of the Mullers fluorescein cells. The

2. OCT newvesselscalledRetinalAngiomatousProliferation(RAP). extravascates was helpful in the in retinal depicting layers cystoid due to spaces the atrophy and neovascular of retinal cells. membranes in the retina. The neovascularization in JFT is believed to be due to proliferation of retinal

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Case 13.1: Group 2A, Bilateral, Idiopathic, Acquired Parafoveal Telangiectasis: Stage 2

Case Summary showed phase. A 55­year­old a greyish­green woman was area seen temporal with decreased to the fovea vision (A). in Fluorescein both her eyes angiography of one year (B–D) duration. showed Her telangiectatic best corrected vessels visual temporal acuity was to the 20/50 fovea in the with right staining eye. Fundus in the late

fovea in the with right staining eye. Fundus in the late OCT staining Optical scan Coherence

OCT staining Optical scan Coherence seen through on f fovea luorescein Tomography (E) showed angiography, a small hyporeflective there was no area increased at the level thickness of RPE­photoreceptor on OCT, thus complex indicating suggesting that the a diffuse localized staining loss of on these fluorescein layers. Despite the angiography Fundus and that fluorescein seems angiography to occur at the of the middle opposite and eye outer too retina showed is features probably of juxtafoveal the result of telangiectasia diffusion of (F). fluorescein into the damaged retinal cells.

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Optical underlying leakage coherence seen layer on of fluorescein tomography choriocapillaris, angiography, (G) showed probably the representing no presence increased of RPE small thickening atrophy. hyporeflective The was nasal seen lesions retina on OCT under showed suggesting the a fovea. localized Also that area there the of dye was disrupted pooling thinning RPE­photoreceptor in and juxtafoveal separation of telangiectasia layer. RPE layer Despite from is due the to The extravasation patient was of diagnosed the dye as and acquired not because Group of 2A leakage, juxtafoveal thus Telangiectasia confirming the and belief no treatment that laser was photocoagulation offered. does not have a role.

confirming the and belief no treatment that laser was photocoagulation offered. does not have a role.

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Case 13.2: Group 2A Stage 4 Juxtafoveal Telangiectasia (JFT)

Case Summary hyperpigmentation A­45­year­old woman at the was end seen of right with angled bilateral, venules acquired (arrow). JFT. The Her fluorescein best corrected angiography visual acuity showed was telangiectasia 20/80 in the right in the eye. early Right phase eye with fundus late showed staining black of the stellate dye (B, foci C). of

showed staining black of the stellate dye (B, foci C). of Horizontal Optical Coherence line scan

Horizontal Optical Coherence line scan through Tomography the pigmented scar (D) showed hyperplasia of retinal pigment epithelium (RPE) extending in the inner retinal layers.

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Page 170 Vertical line scan through the fovea (E) showed multiple red colored hyper­reflective dots suggesting

Vertical line scan through the fovea (E) showed multiple red colored hyper­reflective dots suggesting telangiectatic vessels in the inner retinal layers.

(E) showed multiple red colored hyper­reflective dots suggesting telangiectatic vessels in the inner retinal layers.

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Case 13.3: Group 2A, Stage 5 JFT

Case Summary crystalline underlying A 54­year­old deposits choroidal man with was neovascular dull seen foveal with membrane blurring reflex. Fluorescein of (CNVM). vision caused angiography by bilateral, (B–D) acquired, showed perifoveal mottled hyperfluorescence telangiectasis. His that fundus increased (A) showed in the late right phase angled suggesting venules, pale the presence yellow of

phase angled suggesting venules, pale the presence yellow of The presence vertical of a OCT classic

The presence vertical of a OCT classic line choroidal scan through neovascular the fovea membrane. (E) showed increased hyper­reflectivityfromtheouterretinallayerswithoverlyingcystoidspaces,thussuggestingthe

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Case 13.4: Group 2A Parafoveal Telangiectasia with Choroidal Neovascular Membrane

A D). Case 44­year­old Summary man was seen with right eye juxtafoveal telangiectasia and choroidal neovascular membrane diagnosed on fundoscopy and fluorescein angiography (A–

diagnosed on fundoscopy and fluorescein angiography (A– Optical Coherence Tomography reduced OCT advised scan

Optical Coherence Tomography reduced OCT advised scan photodynamic backscattering of this eye showed from therapy the an (PDT) overlying area of but hyper­reflectivity refused layers suggesting for the same. in retinal the outer edema retinal (E). layers The retinal under thickness the fovea was suggesting increased subfoveal due to intraretinal choroidal neovascular fluid accumulation. membrane The with patient was

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Case 13.5: Group 2A, Stage 5 with Hypertrophic Scar of Neovascular Membrane

Case Summary A whereas 46­year­old One year vertical later, man scan the was patient through seen was with the seen fovea bilateral with showed juxtafoveal hypertrophic localized telangiectasis scar defects (D). in Vertical RPE and a with choroidal OCT cystic scan neovascular spaces through under the membrane the scar fovea (E) showed (A–C). (F). hyper­reflective The patient was layers lost to corresponding follow up for one to the year. scar

showed (A–C). (F). hyper­reflective The patient was layers lost to corresponding follow up for one to

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Case 13.6: Intravitreal Triamcinolone Acetonide in Group 2A JFT

A telangiectasia Case 60­year­old Summary was woman made was based seen on with clinical metamorphopsia appearance and in fluorescein her left eye angiography of 2 weeks duration. (A–D). Her best corrected visual acuity was 20/100. A diagnosis of Juxtafoveal

left eye angiography of 2 weeks duration. (A–D). Her best corrected visual acuity was 20/100. A

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