Some Dumb Name Sign Pattern Recognition in the OCT Era I have - - PowerPoint PPT Presentation

12/4/2015 1

• H. Richard McDonald MD

Brandon Lujan MD West Coast Retina San Francisco, CA

Some Dumb Name Sign Pattern Recognition in the OCT Era

Financial Disclosures

I have nothing to disclose

1 2 3 4 BVO DME Drusen ERM

12/4/2015 2

1 4 3 2 Sjogren’s Reticular Dystrophy Amalric’s Triangular Syndrome GCA VKH CSR

Pattern Recognition

Once you know the pattern, it’s easier to recognize the disease You see what you know The more you know, the more you see

Optical Coherence Tomography

12/4/2015 3 Case One Case Two Case Three Case Four

12/4/2015 4 Diagnoses?

2 Courtesy of Christine Curcio, Ph.D. Original in IOVS 2011

Courtesy of Christine Curcio, PhD

What if you don’t know the pattern? Normal OCT

RPE Interdigitation Zone (COST) Ellipsoid Zone (IS/OS) External Limiting Membrane Outer Nuclear Layer Outer Plexiform Layer Inner Nuclear Layer Inner Plexiform Layer Ganglion Layer Nerve Fiber Layer

You have to count the layers Case One

12/4/2015 5 Severe Fibrinous CSR

Transplant patient on prednisone

26 year old pregnant woman

20/50

The central leak has a geyser-like effect, blowing the fibrin out of the way Fibrin Subretinal fluid

Batman Sign

Fibrinous CSR

12/4/2015 6 Case Two

Hemorrhage, perivenular whitening, cotton wool spot associated with non ischemic CRVO

20/20

Patchy INL hyper-reflectivity caused by Deep retinal capillary ischemia

SD-OCT

5/200

Intraretinal and subretinal fluid En Face OCT through the INL reveals perivenular hyper-reflectivity associated with the ischemia

12/4/2015 7 Dash Sign

Paracentral acute middle maculopathy (PAMM): a new variant of acute macular neuroretinopathy associated with retinal capillary ischemia. Sarraf D, et al. JAMA Ophthalmol 2013;131:1275-1287. PAMM is deep capillary ischemia, which is thought to represent a variant of AMN Multimodal imaging findings in retinal deep capillary ischemia. Yu S, et al. Retina 2013:Nov 14. [Epub ahead of print]. PAMM is found in other ischemic etiologies, similar to that seen in our CRVO case

Case Three

Subretinal fluid with fibrin layer and possibly photoreceptor outer segments Hyper reflectivity caused by Retinitis

Eyes with ocular toxoplasmosis may present with HORCS (Huge Outer Retinal Cystoid Space) Evaluation of cystoid change phenotypes in Ocular Toxoplasmosis using optical coherence tomography Ouyang Y, et al., PLoS One 2014;9:e86626

12/4/2015 8 HORCS?

(Huge Outer Retinal Cystoid Space) Really, follow the ELM! The inflammatory process results in exuberant SRF formation causing photoreceptor delamination. The regeneration of PROS may act like a crystal and may be a scaffold for fibrin deposition, resulting in “teeth.”

Jaws Sign

HM 20/25

Case Four Optical Coherence Tomography

The OCT appears similar in both eyes.

HM 20/25

If you don’t know the pattern, you must count the layers!

12/4/2015 9 Dull gray Inner Plexiform Layer Bright Nerve Fiber Layer What’s going on?

Normal

Bright Inner Plexiform Layer NO Nerve Fiber Layer Our patient has no nerve fiber layer!

Normal Our Patient

Pituitary Tumor!

Tumor resected Vision improved to 20/40

12/4/2015 10 It’s not always what’s there that is the problem It may be what’s not there

Normal Our Patient

Dog Not Barking Sign!

• H. Richard McDonald MD

Brandon Lujan MD West Coast Retina San Francisco, CA

Some Dumb Name Sign Pattern Recognition in the OCT Era