oct in optom practice ho - weo media · • csme od noted on clinical exam widefield re4na clinic...

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OCTintheOptometricPrac4ce

StevenFerrucci,OD,FAAOChief,OptometrySepulvedaVA

Professor,SCCO/MBKU

Disclosure Statement

•  Speakers bureau/Advisory Board – Alcon – B&L – Centervue – Genentech – MacuLogix – Optovue –  Science Based Health

OCT

•  AMD•  DME•  ERM/VMT•  CSR•  MaculaedemafromBRVO/CRVO•  Plaquenilscreening•  MacularHoles•  Glaucoma

Newstuff

•  Morescans– Upto70K

•  Widefield– 12x9mmvs.standard6x6mm

•  OCTangiography•  Anteriorsegment

– Angles– Pachymetry– Epithelialmapping

RETINA AMD

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DryAMD

•  83yomale•  Followed>13yearsfordryAMD

– VA20/25OUsince2013•  AREDS2BID:reportsgoodcompliance•  Notesvisionhasgo]enblurrier•  MetamorphosiaOUx2mos

Widefield

Assessment/plan

•  DRYAMDOS>OD•  Stage3OU

– Mul4pleconfluentdrusenOU

•  NofluidonOCT•  Con4nueAREDS2BID•  HAG•  RTC3mosforrepeatOCT

WetAMD

•  81yearoldmale•  h/oPOAGforyears

– T½andLatanaprost•  h/odryAMDOUforyears

– LastVA:20/40OD,20/30OS– RarelydoesHAG

•  Type2DMforyears– Nore4nopathyorCSME

WetAMD

•  Infor3mosfollow-up•  Reportslostglasses•  VAToday:

– 20/40OD– 20/70OS– Didnotno4ceachangeun4lcheckedinclinic– Again,rarelydoesAmsler

OCT-Widefield

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OCT-AOS Re4naClinic

•  WetAMDOS•  Avas4nseriesx3OS.•  RepeatOCT/OCT-Aafer3rdinjec4on

AMD•  ChangeinVAormetamorphopsiashouldalwaysbetakenseriously– OCTtoruleoutfluid–  FA/OCT-Aifneeded

•  EvidenceofhemeorfluidshouldbereferredASAPfortreatment–  Earliertreatment/smallerlesionsizecorrelateswithbe]erfinalvisualacuity

CHANGEINVAORMETAMORPHPSIAINDRYAMDPTISCONVERSIONTOWETUNTILRULEDOUT!!!

DIABETES/DME

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DMcase1

•  47yoAAmale•  Type2DMx10years

– Glipizide,mejormin– LastA1c9.9

•  LEE:5yearsagoatLenscrafers•  VA20/20OU•  CSMEsuspectedODtemporaltomacula

Widefield

Assessment/plan

•  MildNPDROU•  Mildnon-centralDMEOD,noDMEOS•  PtedreBScontrol

– Ptstatesadjus4ngmedswithPCPaswespeak

•  RTC3-4mosrepeatOCTOD•  Refertore4naifincreasingedemaordecreasingVA

DMcase2

•  63yearoldmale•  Type2DMx10years

–  Insulinx3years– LastA1c9.7(h)

•  VA20/30-OD,20/25+OS•  CSMEODnotedonclinicalexam

Widefield Re4naClinic

•  CenterinvolvedDMEOD•  Discusswithre4naclinic•  An4-Vegfx3•  RepeatOCTafer3rdinjec4on•  PtedreBS/BPcontrol

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DMcase3

•  50yearoldmale•  Type2DMx20years

–  LastA1c8.7–  Insulinandliraglu4de(Victoza)

•  ReducedVAODx9mos•  h/oinjec4onsODlastyear•  Toldearlierthisyearnomoreinjec4onsneeded.•  UnclearwhyVAdecreasedOD•  ScheduleFA

DMcase3

•  ModerateNPDROU•  NocenterinvolvedDMEOD•  MacularischemiaOD>>OSonOCTA

– NoneedtodoFA– Notreatmentavailable

•  Op4mizeacuity•  Op4mizeBP/BScontrol•  RTC3mos.RepeatOCT/OCTA

DM/DME

•  ReferifcenterinvolvedDME/CSMEevidentonOCTin1-2weeks

•  Ifnotcenterinvolved,followcloselyin3-6mos

•  OCTifunexplainedvisionlossinptwithdiabetes– Lookforischemia

•  PtedreroleofBS/BPcontrol•  Treatment:FMLvs.serialan4-VEGF

ERM

ERM

•  68yearoldmale•  h/oochtnongenericlatanprostqhsOUx3years

–  PretxIOPs≈30–  Posttreatmentmidteens–  VFfullOU

•  InforIOPcheck.•  Doingwell,goodcompliance,butnotesmilddecreaseVAODwithmetamorphosiawhenreadingsmallprint

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EnFace ERM#2

•  83yearoldmale•  Catarctsxoux2015•  NotesOSblurrierthanOD•  HTN•  BCVA20/20OD,20/25Os

ERMCase#3•  70yoHispanicmale•  NotesdecreasedVAODsincepreviousexam

–  Lastyear20/20OU•  MildHTN,earlycataracts•  BCVA

–  20/30OD–  20/20OS

ERM#3

•  Assessment– ERMOD

•  Plan– WillmonitorduetogoodVA– RTC6mos

ERM

AGE INCIDENCE

<60 1.7%

60-69 7.2%

70-79 11.6%

80+ 9.3%

BLUEMOUNTAINEYESTUDY,AUSTRALIA

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ERM

•  Consider surgery if: – VA 20/40ish or worse – Symptomatic – Visual need of patient

•  Make sure you have an experienced surgeon!!

VMT

VMTcase

•  82yearoldmale•  Inforyearlyexam

– Notesnochangeinvision– h/omildtomoderatecataracts,VA20/30OU

•  VAtoday– 20/40OD-onelinedecrease– 20/30OS-stable

VMTCASE

•  VMTOSwith20/40acuity

•  Discussionreop4ons– Surgery– Monitor

•  Ptelectstomonitor,asnotbotheredbyvisionandwouldliketoavoidsurgery

•  RTC3moswithrepeatOCT.Ptagreeswithplan

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VMTCASE2

•  70yearoldmaleinforrou4neexam•  Notesmildchangeindistancevision,botheyes,sincelastexam1yrago

•  Thinksheneedsnewglasses•  20/20OD,20/50OS

– PtsurprisedthatVAOSwasdecreased.Didnotno4ceun4lexamtoday

VMTCASE2

•  VMTOSwith20/50acuity

•  Discussionreop4ons– Surgery– Monitor

•  Ptelectstomonitor,asnotbotheredbyvisionandwouldliketoavoidsurgery

•  RTC3moswithrepeatOCT.Ptagreeswithplan

VMT: when to refer •  Natural progression of disease is rather

variable – Slow progression possible with near

normal acuity – Approx 10% will have spontaneous PVD

and resolution within 30 days •  Therefore, close monitoring my be advised

for some patients

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VMT: when to refer

•  In patients with poor vision, or symptomatic, a pars planar vitrectomy (PPV) may be considered – Duration, severity should also be

considered •  Jetrea (ocriplasmin) as option? •  Literature reports up to a 75% success rate

and improvement of vision following PPV MACULARHOLES

LMH

•  78yearoldmale•  HadcataractsurgeryOS5yearsagoandunhappywithresults– FeelsvisionOSisworsenowthanbeforesurgery– Nopreopdataavailable– Unclearifeverexplainedtocataractsurgeonordiscussedwithhimreasonforvisionloss

– Unclearwhattes4ngwas/wasnotdone

LMH•  BCVA20/20OD,20/30OS•  MildNSCOD•  PCIOLOS.Clearandwellcentered•  Postpole:

Widefield LMH•  LamellarMaculaHoleOS

–  Alsocalledpar4althicknessmacularhole•  Pted.•  Monitorin3mos.•  RepeatOCT•  Considerre4nareferralifworsens

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CSR

CSR

•  37yearoldmale•  BlurredvisionOSx5days

– BlackspotcentrallyOS– Spotseems“warped”

•  BCVA– 20/80OD– 20/20OS

•  Medhx:albuterolPRNforasthma

CSR

•  CSROD•  Askaboutsteroids

– Albuterol?•  Askaboutstress?•  RTCforFAn/a

Followup

•  Ptpresents1moslaterforFA•  FeelsVAhasimprovedODsignificantly

•  20/20!!•  FAcancelled!

IsthisCSR?

•  Ptnotesacuteonsetofbent/crookedlinesOD.•  Norealchangenvision•  Lastexam4yearsagoatCOSTCO

CSR•  Whentoworry/refer

–  IfVAworsethan20/70–  Ifptdemographicsdonotsupport–  Ifdoesnotresolvein6mos–  Ifgetsworseratherthanbe]er–  FA/OCTdoesnotsupportdiagnosis–  “Justdoesn’tfeelright”–  Ptisunabletoacceptvision/prognosis

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VEINOCCLUSIONS

CRVO•  75yearoldmale•  Presentsfor3mosglccheckand24-2

–  NTGx2010–  LatanaprostqhsOU–  Hasnotusedx1mos.IOP19mmOU(14ishwhentreated)

•  ReportsnotedblurredvisionOSabout2weeksago–  OD20/20–  OS20/200

•  Type2DMandHTN–  A1C7.4–  BP134/84

Raster Re4naClinic

•  CRVOOSwithgrossmacularedema•  Avas4nseriesOSx4•  RepeatOCT1mosaferlastinjec4on

BRVOcase

•  69yohispanicmale•  PresentsforyearlyDMexam.

– Nocomplaints

•  HTN,DM,Obesity– A1c5.4– BP154/81– BMI43.61

•  VA20/20OU

BRVOcase

•  IncreasingedemaODonOCT– Approachingmacula

•  VAremains20/20•  Ptgivenop4onoffollowingvs.injec4on,Ptelectstofollow

•  RTC4mosforrepeatOCT

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CRVO/BRVO•  Referifmaculaedemawithin1week

–  Laservs.injec4oninBRVO–  Injec4onCRVO–  Steroids?

•  Systemicworkuprecommended– DM– HTN–  Cholesterolpanel–  Caro4dDoppler

•  LookforNV/NVI/NVA/NVGesp.inCRVO,esp.ifischemic

PLAQUENIL

Plaquenil

•  31yoAAfemale•  SentfromRheumatologyclinic

– “ptonplaquenil.Pleasedore4nalscreenincludingOCT”

•  +Lupus•  200mgHCQBIDx7years•  20/20OU

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Case

•  Normalre4nanoevidenceofplaquenilmaculopathy

•  Le]erbacktorheumatologyclinic•  Pted•  RTC1yr

Plaquenil•  Beawareofnewguidelines

–  Rheumatologyclinic/PCPsaware– HD-OCT,FAFrecommended–  1stscreeningwithin1styear,thenafer5years

•  Riskfactors–  >10years–  Concurrenttamoxifenuse–  Concurrentkidneydisease– Doseabove5mg/kgofREALbodyweight

•  Incidencesilllow,probably≈1%

GLAUCOMA

Glaucoma

•  70yoAAmale•  FollowedasGlCsuspectx4years•  Posi4vefamilyhistory

– Mom,maternalGM

•  C/D:OD0.45;OS0.50•  IOPs:18-23OD;19-23OS•  Ini4al24-2VF:nodefects

Ini4al24-2VF:August2012 Todaysexam

•  NoComplaints•  VA20/20OU•  IOP22mmOD,23OS•  1+NSCOU

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24-2 RightEye

Assessment/Plan

•  POAGOD>OS•  StartgenericlatanoprostQHSOU

– Goal≈16mmOU(30%reduc4on)– Ptedresideeffectsofg]s

•  RTC6weeksforIOPcheck

ANTERIORSEG

Normalangleanatomy Angleclosure

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EpithelialMapping

NORMAL

Conclusion

•  OCThasbeenagamechangerinmyprac4ce•  Helpmakebe]erreferrals•  Helpkeeppa4entslonger•  Helpstakebe]ercareofyourpa4ents•  Onceyougetone,notsurehowyoulivedwithout!!!