Bruno Lumbroso MD
Director Centro Oftalmologico Mediterraneo for Retinal Diseases Rome, Italy
Marco Rispoli MD
Centro Oftalmologico Mediterraneo for Retinal Diseases Rome, Italy
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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 | |
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 |