Oct- RETINA...7/15/2019 1 PINAKIN DAVEY OD, PhD, FAAO Professor Western University of Health Sciences Optovue Research, consulting, speaker Topcon Research Is like practicing Optometry

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PINAKIN DAVEY OD, PhD, FAAO

Professor

Western University of Health Sciences

▪ Optovue Research, consulting, speaker

▪ Topcon Research

▪ Is like practicing Optometry on a deserted island ▪ Anterior segment

▪ Cornea

▪ Angle

▪ Posterior segment

▪ Vitreous

▪ Retina

▪ Glaucoma

▪ Glaucoma in USA 2.7 million; 50% undiagnosed

▪ Glaucoma suspects 4 times more than glaucoma

▪ 64.3 million world wide; 76 million by 2020 ; 111.8 by 2040

▪ AMD in USA 1.75 million 2004; 3 million by 2020

▪ 196 million world wide 2020; 288 million 2040

▪ Diabetes 30.3 million diabetes or 84 million prediabetes in USA

▪ 4.2 million adults had DR and 655,000 had vision-threatening DR.

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Nerve Fibre Layer (NFL)

Ganglion Cell Layer

Inner Plexiform Layer

Inner Nuclear Layer

Outer Plexiform Layer

Outer Nuclear Layer

Ex. Limiting Membrane

Photoreceptor IS/OS

Retinal Pigment Epithelium

Internal Limiting

Membrane (ILM)

Bruch’s Membrane

Choroid

Retinal Pigment Epithelium

Fast processing:

• <7 secs. for a volume of

400x400 A-scans

Improving en face slab

definition

• Appropriate Deep Vascular Complex (DVC) slab from

IPL to OPL

• Custom slab with user

selection of boundaries

• Consistent Outer Retina

en face slab from OPL to

BRM for CNV evaluation

1. ILM

2. NFL

3. IPL

4. INL

5. OPL

6. IS/OS

7. RPE

8. Bruch’s

(BRM)

Superficial (SVC) Deep (DVC) Outer Retina ChoriocapillarisRetina

ILM to IPL-10 IPL-10 toOPL+10 ILM toOPL+10 OPL+10 to BRM-10 BRM-10 to BRM+30

▪ Age related macular degeneration

▪ Epiretinal membrane

▪ Diabetic retionopathy/Diabetic Macular Edema

▪ Vitreomacular traction/ Macular hole

▪ Nevus

▪ RPE dropouts/ Scar/ Chorioretinal hypertrophy

▪ Glaucoma

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▪ Retinal thickening <500 micron from center of fovea

Or

▪ Hard exudates < 500 micron from fovea with adjacent thickening

Or

▪ Retinal thickening >1 disc size in area < 1 disc diameter from center of fovea

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Brings structure and function together

▪ Uses motion contrast to detect blood flow

▪ Rapidly acquire multiple cross-sectional images from a single location on the retina

▪ Flow is the difference between two sequential scans

▪ Flow = Frame #1 – Frame #2

Without MCTWith MCT

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OCT Angiography: Function

OCT: Structure

Normal Optic Disc Moderate Glaucoma Severe Glaucoma

Trend Analysis: GCC + ONH Optic Disc En Face View

Previously diagnosed patient. Images courtesy of Michel Puech, MD, FRCS

ANGIOMONTAGE PROVIDES A WIDER FIELD OF VIEW

6x6 mm

AngioDisc

6x6 mm

AngioRetina

AngioVue HD

Montage for

imaging outside the

macula.

10x6 mm FOV with

outstanding

resolution of retinal

vasculature in the

macula and optic

disc.

ANGIOVUEHD HIGH-RESOLUTION AUTOMATIC MONTAGE

Images courtesy of Adil El Maftouhi, O.D., Lyon, France

▪ IN 2012 DIABETES WAS THE DIRECT CAUSE OF 1.5 MILLION DEATHS.

▪ AN ADDITIONAL 2.2 MILLION DEATHS WERE CAUSED IN THE SAME YEAR BY HIGHER-THAT-OPTIMAL LEVELS OF BLOOD GLUCOSE , THROUGH AN INCREASED RISK OF CARDIOVASCULAR AND OTHER DISEASES.

▪ MORE THAN 30 MILLION PEOPLE IN THE UNITED STATES HAVE DIABETES, AND 1 IN 4 OF THEM DON’T KNOW IT.

▪ MORE THAN 84 MILLION ADULTS IN THE UNITED STATES HAVE PREDIABETES AND 90% DON’T KNOW THAT THEY HAVE IT.

▪ DIABETES IS THE 7TH LEADING CAUSE OF DEATH IN THE UNITED STATES

Quantitative OCTA parameters reveal subclinical macular vasculature change in diabetic eyes that do not manifest clinical retinopathy.2

2. Alibhai, Agha & M. Moult, Eric & Shahzad, Rida & Rebhun, Carl & Moreira-Neto, Carlos & McGowan, Mitchell & Lee, Diane & Lee, Byungkun & Baumal, Caroline & Witkin, Andre & Reichel, Elias &

Duker, Jay & G. Fujimoto, James & K. Waheed, Nadia. (2017). Quantifying Microvascular Changes Using OCT Angiography in Diabetic Eyes without Clinical Evidence of Retinopathy.

Ophthalmology Retina. 2. 10.1016/j.oret.2017.09.011.

Images courtesy of Julie Rodman, OD, FAAO

Diabetic Eye Normal Eye

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Patients with DM more likely to have a larger FAZ than healthy eyes.3

3. Di, G., Weihong, Y., Xiao, Z. et al. Graefes Arch Clin Exp Ophthalmology (2016) 254: 873. https://doi.org/10.1007/s00417-015-3143-7

Images courtesy of Julie Rodman, OD, FAAO

Diabetic Eye

FAZ Area: 0.443mm2

Normal Eye

FAZ Area: 0.172mm2

▪ Based on full retinal vasculature (superficial and deep vascular complexes)

▪ Available for 3x3mm and 6x6mm HD scans

▪ Highly repeatable including in diseased eyes1

▪ Measurements

• FAZ: Area of foveal avascular zone

• PERIM: Foveal avascular zone perimeter in mm

• FD: Vessel density (%) within a 300μm width perimeter surrounding the FAZ

▪ Clinical Applications

• Diabetic retinopathy

1. Emami-Naeini P, Chang M, Park S. Repeatability of OCT Angiography Retinal Vascular Density Measurement in Retinal Vascular Disease. Poster presented at: ARVO; 2018; Honolulu, Hawaii.

▪ Computes the percentage of area occupied by OCTA-detected vasculature based on the

▪ Retina

▪ Superficial vascular complex

▪ Deep vascular complex

▪ Optic Disc

▪ Radial peripapillary capillary slab



▪ Images courtesy of Richard Rosen, MD

Severe NPDR

0.14530.2391

Normal Mild NPDR

0.1963 0.1889

Moderate NPDR

0.1647

Severe NPDR PDR

FAZ: 0.171mm2 FAZ: 0.241mm2 FAZ: 0.303mm2Mild NPDR

0.285

Moderate NPDR

0.313

Severe NPDR

0.400

PDR

0.574

FAZ size and FAZ vessel density are correlated significantly with disease severity in DR.1

1. Nesper PL, Roberts PK, Onishi AC, et al. Quantifying Microvascular Abnormalities With Increasing Severity of Diabetic Retinopathy Using Optical Coherence Tomography Angiography.

Investigative Ophthalmology & Visual Science. 2017;58(6):BIO307-BIO315. doi:10.1167/iovs.17-21787.

https://doi.org/10.1007/s00417-015-3143-7

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Vessel Density Decreases Significantly with Disease Severity4

2015 2016 20174. Nesper PL, Roberts PK, Onishi AC, et al. Quantifying Microvascular Abnormalities With Increasing Severity of Diabetic Retinopathy Using Optical Coherence Tomography Angiography.


2015 2016 2017

FAZ Area Increases Significantly with Disease

Severity4

FAZ: 0.171mm2 FAZ: 0.241mm2 FAZ: 0.303mm2

4. Nesper PL, Roberts PK, Onishi AC, et al. Quantifying Microvascular Abnormalities With Increasing Severity of Diabetic Retinopathy Using Optical Coherence Tomography Angiography.


▪ Based on outer retina slab or choriocapillaris slab


▪ Option to measure within a circular boundary or contoured boundary

▪ Measurements

• Select Area: Total area within the circle or contoured boundary

• Flow Area: Percent of total area occupied by vessels within the circle or contoured boundary


• CNV

▪ Based on outer retina slab or choriocapillaris slab


▪ Option to measure within a circular boundary or contoured boundary

▪ Measurements

• Select Area: Total area within the circle or contoured boundary

• Flow Area: Percent of total area occupied by vessels within the circle or contoured boundary


• CNV

▪ Based on superficial vascular complex


▪ Measures total area of selected non-flow regions



• Vein and artery occlusion

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▪ Based on full retinal vasculature (superficial and deep vascular complexes)



▪ Measurements

• FAZ: Area of foveal avascular zone

• PERIM: Foveal avascular zone perimeter in mm

• FD: Vessel density (%) within a 300μm width perimeter surrounding the FAZ




▪Manage your Dry AMD patients using OCTA.

▪Retain patients in your office and bill for an office visit and OCT when medically necessary.

▪Manage AMD patients and refer out to your retina doctors when they turn to Wet AMD.

Superficial Capillary Plexus

3µm Below ILM → 15 µm

Below IPL

Deep Capillary Plexus

15µm Below ILM → 70 µm

Below IPL

Outer Retina

70µm Below IPL → 30 µm

Below RPE Reference

Choriocapillaris

30 µm Below RPE Reference → 60 µm

Below RPE Reference

New vessels develop in the choroid

New vessels located below RPE and above Bruch’s membrane

Choroid

Bruch’s

Membrane

RPE

▪ New vessels develop in choroid

▪ New vessels located above the RPE and above Bruch’s membrane

Choroid

Bruch’s Membrane

RPE

Superficial Capillary Plexus ChoriocapillarisFluorescein Angiography

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Scan Quality: 9/10 Scan Quality: 9/10 Scan Quality: 7/10 Scan Quality: 6/10

Scan Quality: 5/10 Scan Quality: 3/10 Scan Quality: 3/10 Scan Quality: 2/10

Motion Motion Poor focus Low signal

SQ ≥ 6

SQ < 6

SW7.0:Montageautomatique

▪ Images courtesy of Dan Esmaili, MD, Adil El Maftouhi, and Robert Weinreb, MD

Diabetic Eye with Capillary

Dropout (6x6mm)

CNV in Pigment Epithelial

Detachment (3x3mm)

Radial Peripapillary Capillary

Dropout in Moderate

Glaucoma (4.5x4.5mm)

Choriocapillaris

Larger format 6x6 mm HD

scan (400x400) for better

assessment of vasculature

extending beyond the central

3x3 mm region.

AngioVueHD High-Resolution OCTA*

▪ Image courtesy of Adil El Maftouhi

DualTracTM Motion Correction*

• 70% reduction in motion artifacts compared to tracking alone

▪ Images courtesy of Adil El Maftouhi

Eye Motion Artifact

Without DualTrac With DualTrac

Epiretinal Membrane

(12x9mm)

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▪ Image courtesy of Adil El Maftouhi

21 Line Raster

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Oct- RETINA...7/15/2019 1 PINAKIN DAVEY OD, PhD, FAAO Professor Western University of Health Sciences Optovue Research, consulting, speaker Topcon Research Is like practicing Optometry