Practical Retinal OCT Bruno Lumbroso, Marco Rispoli
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1PRACTICAL RETINAL OCT
2PRACTICAL RETINAL OCT
Bruno Lumbroso MD Director Centro Oftalmologico Mediterraneo for Retinal Diseases Rome, Italy Marco Rispoli MD Centro Oftalmologico Mediterraneo for Retinal Diseases Rome, Italy
3
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Practical Retinal OCT
First Edition: 2015
9789351525325
Printed at
4Preface
Diagnoses must be the product of logical processes. Ocular imaging should be interpreted by logical methods of analysis and synthesis. I published analytical manuals on fluorangiography, indocyanine green angiography, OCT, Angio OCT and lately, “en face” OCT.
A rational method should be the basis of OCT interpretation. This manual illustrates a logical and simple analysis and interpretation method of OCT imaging, clearly stating the steps required to reach a diagnosis.
OCT sits next to the slit lamp in all ophthalmic offices and all ophthalmologists, optometrists, ophthalmic technicians and orthoptists must know how to use it. OCT highlights retinal and choroidal alterations in morphology, structure and reflectivity and facilitates the study of the various retinal layers, both separately and globally.
The images presented in this manual were recorded mainly with Optovue OCT (RTVue and XR Avanti OCT), and also with Heidelberg Spectralis. These instruments are both reliable and easy to use. There are high resolution optical sections, in sagittal view with the choroid visible to the sclera, with or without image averaging, or in frontal view, “en face”, adapted the curvature of the fundus and other 3D images.
Illustrated with drawings, outlines, and sagittal and frontal (“en face”) OCT images, this concise manual intends to show how to read and interpret OCTs, documenting and diagnosing the most common retinal pathologies. Simplified outlines are provided to facilitate the classification of morphological alterations.
Several tables offer guidance through the most difficult diagnoses.
Bruno Lumbroso
Marco Rispoli
5Acknowledgments
I would like to thank Dr Marco Rispoli for his many years of invaluable collaboration, unerring imaging and image selection, and help with the chapters of this volume.
My thanks also go to Donata Piccioli, the graphic artist who has illustrated all of my scientific works and textbooks, for the precision of her beautiful drawings and the patience with which she has imaged my rudimentary schematic outlines.
My gratitude to Jay Wei, Bill Shields and Paul Kealey of Optovue (USA), who encouraged me to write the first edition of this practical and simple manual.
Bruno Lumbroso
8Logical Method of OCT Analysis and Interpretation
The application of the classical Cartesian method of analysis to OCT is not self-evident. In fact, the images obtained with various imaging approaches are so complex and intricate that they cannot be simply considered a puzzle solved only by sorting.
OCT analysis must deconstruct the image into shapes, thickness and volume (morphology), and internal architecture, framework and stratification (structure). Furthermore, one must consider the interaction of high, medium and low reflectivity with both internal structure and morphology, as well as the effects of abnormal formations (fluid accumulations, exudates, hemorrhages, neoformations, etc.). These abnormal elements are bound by and adapt to the retinal and choroidal inner barriers, creating shadows that further modify scan appearances and cause reflectivity variations.
Retinal diseases can upset retinal architecture and morphology beyond recognition and interpretation. This in turn complicates any automatic segmentation attempts, whereas manual segmentation is error-prone and not always reliable. The quantification of morphological limits is as easy as they are distinct.
This manual states the basic principles of analysis. The drawings render inner architecture, framework and stratification. The outlines present a simplified version of common morphological features, both normal and pathologic, thus aiding their classification. High resolution optical sections, in sagittal view with the choroid visible to the sclera, with or without image averaging, or in frontal view, “en face”, compensated for the curvature of the fundus, illustrate possible reflectivity and abnormal formations. OCT scans are in black and white, in order to acquire a higher number of details.
Numerous tables, organized by pathologic features (beige) and diagnostic indications (light blue), suggest at-a-glance the most frequent diagnoses, while reminding the less evident or rarer diseases.
13Index of Tables
PATHOLOGIC FEATURES
Normal structure: reflectivity of normal tissues
19
Retinal architecture
19
Qualitative analysis
22
Morphologic alterations
38
Retinal profile cross-section scan
39
Nuclear and plexiform layers
43
Inner nuclear layer
43
Outer nuclear layer
43
External limiting membrane
43
External limiting membrane
43
Inner/outer photoreceptor segment junction (ellipsoid zone)
44
Inner/outer photoreceptor segment junction (ellipsoid zone)
44
Retinal pigment epithelium
44
Bruch's membrane
44
Elevation or cystic space contents
50
Low reflectivity structures
51
Abnormal formations
56
Abnormal structures and formations
58
Analytic qualitative study of high reflectivity abnormal formations, by retinal level
59
Shadow effect—screen effect
60
Quantitative analytical retinal study
66
DIAGNOSTIC INDICATIONS
Physiologic causes of choroidal reduced thickness
19
Causes of retinoschisis
42
14
Lesions of outer layers and photoreceptors
45
Subretinal deposits
45
Differential diagnosis of isolated lesions of outer layers and photoreceptors
45
Lesions of inner layers
45
Common causes of macular edemas
50
Causes of cystoid macular edemas
51
Differential diagnosis of macular cystoid edema
51
Diabetic maculopathies
51
Causes of serous neuroretinal elevation
53
Causes of serous retinal pigment epithelium detachment
54
Causes of cotton wool exudates
56
Causes of hard exudates
57
Causes of neovascular membranes
58
Choroidal thickness variations
66
Clinical interest of 3D OCTs
68