8/10/2018 T o b e disc usse d: Clinic a l I ma g ing Upda te : - - PDF document

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8/10/2018 T o b e disc usse d: Clinic a l I ma g ing Upda te : - - PDF document

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8/10/2018 T o b e disc usse d: Clinic a l I ma g ing Upda te : OCT Ang io g ra phy T e c hno lo g y in e a rly g la uc o ma de te c tio n OCT Ang io g ra phy, F undus OCT Ga ng lio n Ce ll Ana lysis 10-2 pe rime try

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SLIDE 1

8/10/2018 1 Clinic a l I ma g ing Upda te :

OCT Ang io g ra phy, F undus Auto fluo re sc e nc e , a nd Be yo nd

CASE Y HAMM, O.D., F AAO UMSL COL L E GE OF OPT OME T RY ANNUAL AUG UST ACADE ME 2018

T

  • b e disc usse d:

OCT Ang io g ra phy

T e c hno lo g y in e a rly g la uc o ma de te c tio n

 OCT

Ga ng lio n Ce ll Ana lysis

 10-2 pe rime try  OCT

A a nd g la uc o ma  F undus a uto fluo re sc e nc e (FAF)  Ultra -Wide fie ld I ma g ing

F ina nc ia l disc lo sure

AL L RE F E RE NCE S T O COMME RCI AL L Y- AVAI L ABL E PRODUCT S ARE I NT E NDE D T O BE NONBI ASE D AND F OR E DUCAT I ONAL PURPOSE S. T HE RE ARE NO RE L E VANT F I NANCIAL OR NON-F I NANCIAL RE L AT I ONSHI PS T O DI SCL OSE .

OCT Ang io g ra phy (OCT A): A c linic a l upda te

F ig ure 3. d e Ca rlo T E , e t a l. A re vie w o f o ptic a l c o he re nc e to mo g ra phy a ng io g ra phy (OCT A). I nt J Re tina Vitre o us. 2015;1(5).

F irst in vitro 1991 F irst in vitro 1991 F irst in vivo 1993 F irst in vivo 1993 T D-OCT 1996 T D-OCT 1996 SD-OCT 2006 SD-OCT 2006 OCT A 2015 OCT A 2015

OCT T e c hno lo g y: A time line Ho w d o e s OCT A wo rk?

Mo tio n Co ntrast I mag ing

Ka sha ni A, Che n C, Ga hm J, e t a l. Optic a l c o he re nc e to mo g ra phy a ng io g ra phy: A c o mpre he nsive re vie w o f c urre nt me tho ds a nd c linic a l a pplic a tio ns. PROGRE SS I N RE T I NAL AND E YE RE SE

  • ARCH. 2017;60:66-100.
  • Suc c e ssive B-sc a ns o f the sa me a re a
  • Re tina l tissue re ma ins unc ha ng e d
  • Mo ve me nt (flo w) o f e rythro c yte s

thro ug h the re tina l va sc ula ture is de te c te d

  • Ma ny diffe re nt a lg o rithms e xist to

c o mpute b lo o d flo w a nd fo rmula te a thre e -dime nsio na l ima g e

  • Ve sse l de nsity
  • F

lo w inde x

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SLIDE 2

8/10/2018 2

T hre e distinc t re tina l va sc ula r la ye rs

  • T

hre e c a pilla ry ne two rks within the re tina :

  • Ra dia l pe ripa pilla ry

c a pillarie s (NF L )

  • I

nne r/ supe rfic ia l c a pilla ry ne two rk (GCL )

  • Oute r/ de e p c a pilla ry

ne two rk (I NL )

F ro m: Re tina l Va sc ula r L a ye rs Ima g e d b y F luo re sc e in Ang io g ra phy a nd Optic a l Co he re nc e T

  • mo g ra phy

Ang io g ra phy. JAMA Ophtha lmo l. 2015;133(1):45-50.

Va sc ula r la ye rs c o mpa re d to histo lo g ic a l se c tio n

F ro m: Cha la m K V, Sa mb ha v K . Op tic a l Co he re nc e T

  • mo g ra phy Ang io g ra phy in Re tina l

Dise a se s. Jo urnal o f Ophthalmic & Visio n Re se arc h. 2016;11(1):84-92.

T he va rio us OCT A pla tfo rms

  • Opto vue (Ang io Vue )
  • SSADA a lg o rithm
  • Ze iss (Ang io Ple x)
  • OMAG a lg o rithm
  • No t ye t c o mme rc ia lly a va ila b le :
  • Nide k (Ang io Sc a n)
  • He ide lb e rg (Spe c tra lis OCT

2)

  • T
  • pc o n DRI

OCT T rito n (Swe pt So urc e )

Whic h syste m is b e st?

  • De Vitis L

A, e t a l. (2016)

  • AngioPle x (Ze iss) vs. AngioVue (Opto Vue )
  • Ang io Ple x: sho rte r e xe c utio n time , hig he r pe rc e nta g e o f re lia b le ima g e s with

fe we r mo tio n a rtifa c ts

  • Munk MR, e t a l. (2017)
  • Co mpa re d fo ur de vic e s: Ze iss Cirrus, Opto Vue RT

Vue , T

  • pc o n T

rito n SS-OCT , a nd the He ide lb e rg Spe c tra lis pro to type

  • No sig nific a nt diffe re nc e s in mo tio n a rtifa c ts
  • Ove ra ll ra nking : Ze iss (90% ), Opto Vue (60%), T
  • pc o n (40%), He ide lb e rg (10%)
  • Ra nking s diffe re d de pe nding o n pa ra me te r b e ing e va lua te d
  • E

a c h mo d e l ha s c e rta in stre ng ths

Pe rfo rming OCT A

  • T

wo sc a n size s

  • 3x3 o r 6x6 mm
  • Ang io g ra phy Ana lysis
  • T

wo e n fa c e a na lyse s

  • AngioPle x
  • Str

uc tur e

  • Cro ss-se c tio na l “flo w” ima g e (ra ste r sc a n)

http:/ / re tina to d a y.c o m/ 2017/ 03/ a -ro le -fo r-o c ta -in-d a ily-re tina -pra c tic e

E n fac e se g me nte d OCT A

Vitre o re tina l inte rfa c e (VRI )

Fro m IL M e xte nd ing 300µm a nte rio rly  Supe rfic ia l: NF L , GCL , a nd I PL  De e p: I NL , OPL  Ava sc ula r: Pho to re c e pto rs, RPE  Cho rio c a pilla ris

20µm se c tio n po ste rio r to the RPE  Cho ro id

50µm se g me nt b e lo w the c ho rio c a pilla ris 

Ang io Ple x: 6 pre de fine d a ng io g ra ms

https:/ / www.re vie wo fo pto me try.c o m/ a rtic le / ima g ing -mo tio n-a -re vie w-o f-o c ta

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SLIDE 3

8/10/2018 3

  • A. Co lo r e n fac e OCT

A sho wing a CNVM

  • B. Cro ss se c tio n with

c o lo r c o d e s

  • C. E

n fac e o f e a c h re tina l la ye r inne r re tina  o ute r

Ang io g ra phy Ana lysis

Ma c ula 6x6 mm

E n fac e Ana lysis

Ma c ula 6x6 mm

F

  • ve a l Ava sc ula r Zo ne (F

AZ)

  • De no te s the va sc ula r-fre e fo ve a
  • 400-700 µm in dia me te r
  • Hussa in e t al.
  • 660 µm (Supe rfic ia l)
  • 914 µm (De e p)
  • Pre vio usly o nly visib le with fluo re sc e in

a ng io g ra phy

  • E

nla rg e d in mic ro va sc ula r isc he mic dise a se (e x. dia b e te s)

OCT Ang io g ra phy

  • Pros
  • Convenience, safety
  • High-resolution visualization of vessel

architecture, ischemia

  • Isolation of specific layers for precise

localization (3-D)

  • Ability to monitor ischemia, vessel

regression with subsequent scans

  • Cons
  • Small area analyzed
  • Prone to artifacts
  • Snapshot in time

F luo re sc e in Ang io g ra phy

  • Pros
  • Blood flow over time (early/late,

pooling, leaking)

  • Better visualization in cases of

very high or low flow (MA’s)

  • Gold standard
  • Cons
  • Potential adverse affects
  • Poor visualization of 2 of the 3

vascular networks (Spaide 2015)

  • FA mainly shows the inner capillary

network

  • Little to no visualization of the radial

peripapillary network, deep capillary network

F A vs OCT A

  • MA’ s  F

A

  • Ca pilla ry

de ta il, no npe rfusio n  OCT A

Fro m: K ue hle we in L , e t a l. Ima g ing a re a s o f re tina l no npe rfusio n in isc he mic b ra nc h re tina l ve in o c c lusio n with swe pt-so urc e OCT mic ro a ng io g ra phy. Ophtha lmic Surg e ry, L a se rs a nd Ima g ing Re tina . 2015;46(2):249-252

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SLIDE 4

8/10/2018 4

Artifa c ts

  • I

ma g e a rtifa c ts

  • Me dia o pa c itie s
  • Pro je c tio n Artifa c ts
  • Ve sse ls fro m a b o ve
  • Mo tio n a rtifa c ts
  • White line s
  • Blink a rtifa c ts
  • Bla c k line s

6x6 Re tina l Ang io g ra m Cho rio c a pilla ris se g me nta tio n with “g ho st ve ssle s”

Clinic a l utiliza tio n o f OCT A

SPE CIF IC OCUL AR DISE ASE S AND CONDIT I ONS CASE E XAMPL E S

Dia b e tic e va lua tio n & mo nito ring

  • Va sc ula r c ha ng e s ma y b e visua lize d e a rlie r tha n o n fundus e xa m
  • Hig h-re so lutio n a na lysis o f dia b e tic mic ro a ng io pa thy
  • Ca pilla ry no npe rfusio n, I

RMA, ne o va sc ula riza tio n

  • Mo nito ring o f dise a se
  • I

nc re a se d F AZ

  • Ma c ula r c a pilla ry pe rfusio n de nsity

F AZ me a sure me nt

F AZ e nla rg e me nt a nd va sc ula r re mo de ling in a dia b e tic pa tie nt

He a lthy F AZ Dia b e tic e ye with c a pilla ry no npe rfusio n (a rro w, a ste risks) Dia b e tic e ye with e nla rg e d F AZ, va sc ula r re mo de ling (a rro w)

Fro m: de Ca rlo T E, Chin AT , Bo nini Filho MA, e t a l. De te c tio n o f mic ro va sc ula r c ha ng e s in e ye s o f pa tie nts with dia b e te s b ut no t c linic a l dia b e tic re tino pa thy using o ptic a l c o he re nc e to mo g ra phy a ng io g ra phy. Re tina. 2015;35:2364-2370.

Qua ntifying mic ro va sc ula r c ha ng e

 AngioPle x Me trix™  Ide ntify pa tie nts pro g re ssing in dise a se . E valuate c e ntra l mic ro va sc ula r pe rfusio n c ha ng e s. Asse ss c ha ng e s o ve r time . Visualize c ha ng e s in F

AZ size a nd g e o me try.

https://www.zeiss.com

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SLIDE 5

8/10/2018 5

Fro m: Ag e my SA, e t a l. Re tina l Va sc ular Pe rfusio n De nsity Ma pping Using Optic a l Co he re nc e T

  • mo g ra phy

Ang io g ra phy in No rma ls a nd Dia b e tic Re tino pa thy Pa tie nts. Re tina. 2015;35:2353-2363.

Ag e -Re la te d Ma c ula r De g e ne ra tio n

  • De te c tion o f CNV
  • Diffe r

e ntiation o f druse no id PE D vs. CNV

  • Monitor

ing o f pa tie nts with kno wn CNV

  • Must b e we a ry o f a rtifa c ts

Fro m: de Ca rlo e t al. A re vie w o f o ptic a l c o he re nc e to mo g ra phy a ng io g ra phy (OCT A). Inte rna tio na l Jo urna l o f Re tina a nd Vitre o us (2015) 1:5. Fro m:: Sp a id e RF, F ujimo to JG, Wa he e d NK . I ma g e Artifa c ts in Op tic a l Co he re nc e Ang io g ra p hy. Re tina (Philade lphia, Pa). 2015;35(11):2163-2180.

Va sc ula r F lo w Ana lysis

Ca se e xa mple :

84-yr-o ld white ma le

Dry AMD x 14 ye a rs

  • So ft, c o a le sc e d druse n
  • RPE

pig me nt c lumping , dro po ut

  • BCVA 20/ 60- OD, 20/ 40- OS

OCT HD 21 L ine ra ste r

  • Co nflue nt druse n, c ystic c ha ng e s
  • Dry re tina l disruptio n o r RAP le sio n?

Va sc ula r F lo w Ana lysis Billing & Co ding fo r OCT A

Curre ntly, no b illing c o de se pa ra te fro m g e ne ra l OCT ima g ing e xists.

 CPT 92134: Sc a nning c o mpute rize d o phtha lmic dia g no stic ima g ing ,

po ste rio r se g me nt, with inte rpre ta tio n a nd re po rt, unila te ra l o r b ila te ra l; re tina .

Me dic a re re imb urse me nt is the sa me a s o the r OCT sc a ns.

Muc h lo we r re imb urse me nt tha n dye -b a se d a ng io g ra phy.

But upg ra de to OCT A so ftwa re c o sts $$$$

 And inte rpre ta tio n ta ke s time !

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SLIDE 6

8/10/2018 6

F uture a pplic a tio ns o f OCT A

L

  • o king a he a d…
  • I

ntro duc tio n o f c o mme rc ia lly-a va ila b le swe pt so urc e OCT A

  • Hig he r q ua lity ima g e s, fa ste r ima g e a c q uisitio n
  • Swe pt-So urc e te c hno lo g y will like ly re pla c e SD-OCT

(e ve ntua lly)

  • I

nc re a se d de ve lo pme nt o f OCT A a na lysis so ftwa re

  • Ante rio r se g me nt ima g ing pro to typ e s
  • Ma ny po te ntia l future implic a tio ns
  • I

de ntific a tio n o f pre -c linic a l Alzhe ime r’ s

F ro m: Ante rio r Se g me nt Ang io g ra phy with 1050 nm Swe pt-So urc e Optic a l Co he re nc e T

  • mo g ra phy Inve st. Ophtha lmo l. Vis. Sc i.. 2015;56(7 ):4512.

VI ST A a lg o rithm o f SS-OCT pro to type sho ws re la tive flo w spe e ds o n c o lo r-c o de d ma p.

Fro m: Arya M, Wa he e d NK . Upc o ming Adva nc e s in Optic a l Co he re nc e T

  • mo g ra phy Ang io g ra phy. Re tinal

Physic ian, Vo lume : 15, Issue : Ja n/ Fe b 2018, pa g e (s): 40, 42

OCT A in summa ry

  • OCT

A, while no t a re pla c e me nt fo r F A, a d d s hig h-re so lutio n, thre e -d ime nsio na l info rma tio n to the c linic a l pic ture .

  • OCT

A a llo ws fo r e a rly d e te c tio n o f mic ro va sc ula r da ma g e in dia b e te s, with inc re a se d F AZ o b se rve d in d ia b e tic s re g a rd le ss o f the pre se nc e o f c linic a l re tino pa thy.

  • F

lo w ind e x, ve sse l d e nsity: ne w pa ra me te rs fo r g la uc o ma d x

  • Artifa c ts c o ntinue to po se a c ha lle ng e in a c c ura te inte rpre ta tio n.
  • T

he re is still a lo ng wa y to g o in te rms o f syste m c o ng ruity, no rma tive da ta b a se a c c umula tio n, a nd und e rsta nd ing o f wha t it a ll me a ns in the c o nte xt o f o c ula r d ise a se .

  • But the o utlo o k is pro mising !