here we go so when we talk about dry macular degeneration we mostly talk about two different things and i wasn't sure how to approach this so i started with fungus findings and then segwayed into the oct findings so there's two rpe abnormalities you get drusen and pigment abnormalities um although the pigment abnormalities are considered more of the rpe findings for events and then retinol abnormalities we'll go over this over and over again it's just one of those little things soft grooves in there's small grooves in medium and large which are different sizes and then there's druzenoid peds which are 350 microns across and then there's this new entity shallow irregular rp elevations which are great in a thousand microns across and mostly i wanted this so i could show you guys examples uh reticular pseudo juice and calcified drusen or atrophic crews and i don't really have a great example of those so i mostly wanted this to be a picture show soft reason look like this picture this is the left and right eye of the patient i saw this week with a little soft rusin i have a close-up here so the characteristics of soft drusen are you see the bright rpe line kind of going over the jerusalem and the jerusalem deposits is all this stuff underneath the rpu and then like david mentioned in that talk you get this double layer sign where you can sometimes see brooks membrane although it's probably not all of brook's membrane because i think the basement membrane of the rp is probably up here and then this is probably more the basement membrane of the choreo papillaries so these are typical soft drews and you see the retina kind of going over them and this person should have good vision one thing you want to start looking at is the external limiting membrane when you're looking at these which is this inner light line so you've got your rpe line which is actually this one and then you've got the ellipsoid zone here and then the external engine membrane the rpe line in a normal oct and i without disease is usually split into two kind of like it is over here but when you get into here it kind of runs together so it's tricky so that's soft reason and then the other characterization is confluent jerusalem which is just soft draws and running together there's a funny image this is one of my patients with a lot of druze and they're absent in the middle um so here's apps and drews and then you get these confluences just running together so you see there's the books membrane back here and then you got your rp up here and then you get all this junk underneath reticular pseudo jerusalem are totally different and some people think these some people call them subreddit like deposits um they're not jerusalem they're if they're pseudo jerusalem so they're these funny looking spots not in the center you see them better on the infrared image these little dark spots on the infrared they tend to be kind of up here sometimes down here and then on the oct they're actually in front of the rpe so it's distinct so here's your rpe line here and then here's these little reticular pseudo juice these are pretty common when you get into your really old patients when you get 85 95 year olds you'll almost always see reticular sugar juice and they have not been integrated well into the braiding scheme here's another case an 88 year old patient with four night vision it's pretty common to have before night vision you see these little spots up here on the infrared they're more visible and then when you look at the oct you see the rpe line's pretty straight and then in front of the art in front of the rpe line you get these little bumps so those are reticular suitable and they're different from soft trees so those are kind of your two main drews and there's the soft drizzle this is this shallow irregular rp elevation the sire which is a new thing which i think david in that lecture said that phil rosenfeld calls this the double layer sign so you got the rp coming up it looks like kind of you would see in soft jerusalem but then you've got the brooks line down here and then you've got this material but this is really big this is like probably 2 000 microns across and then there's another thing over here so these are greater than 1000 microns across they're small and they tend to harbor neovascular membranes about a quarter of the time this is excuse me there's a color picture in an icg of this patient and the icg shows a neovascular complex but it's so it's non-exitative neovascular complex but sometimes these are dry so that's a shallow irregular rp elevation or a double regulator so those are your drusen and then rp abnormalities are are categorized separately for classifications and also for the purposes of learning so there's the rpe abnormalities always confuse me a little bit so there's focal hyperpigmentation focal hypopigmentation and geographic atrophy i had to really dig for these and i had to take all these new pictures because i don't want to take pictures of drawing um so that's exciting yep quick question about the sire you said it's a non-exudative neovascular complex that's a new thing at 25 of the time there's a neovascular membrane this patient has one and so this is considered a neovascular membrane here it is a neomaster membrane here you see it on the icg um but there's no fluid so if there's no fluid there's no lipid and there's no blood it's considered non-exitated and this is this was something you couldn't do with fluorescein so it's a new thing and it's especially new with oct and geography so there's a new category and this has been characterized i want this if you go out a year or two years one or two years the risk of them converting to exudative is about five or ten percent david referenced the study that his friends i think up at tufts did where they tried treating these patients to see if it changed the outcome it didn't seem to matter very much the fact is they're pretty benign this patient i think this specific patient has been seeing me for five or more years with the same lesion and actually has really good vision um 20 25 vision there's been this thing there's been a thing in ophthalmology for a while that in some neovascular membranes in some people may be physiologic they may actually help nourish the retina which is kind of a weird concept there's an old pathology study histopathology study very old probably 40 or 50 years old where i think dick green found neovascular membranes of an enormous number of highs of elderly people so it may be that you're sprouting these little things to help the retina but anyway see it's non-exiting which is a very weird idea um oh sure rp abnormalities you've got focal hypo and hyperpigmentation geographic energy the cutoff i don't think you need to know this the cutoff for geographic entry is 175 microns it's actually in the textbook i have to go back to the textbook to find that people usually use that so focal hyperpigmentation i've what on an oct it looks like these little hyper intraretinal hyper reflective spots so here's a patient with these big druzen or drizenoid pvds here's a little pigment spot here and then here's what it looks like on oc2 so and as far as we understand that that's rpe kind of detaching or pigment pigment and detaching from the rpe and kind of migrating into the retina and this is often a precursor of geographic atrophy or atrophy is it incorrect to call those pigment migrations no no i think that would be probably accurate to people um it's hard it's uh when you're reading an image though you don't want to get too far along so if you have all of this you can say oh these are pigment migrations but if you have just an oct just call them interretinal hyper-reflective spots which is actually come into common parlance so there's several things that can be intra-retinal hyper-reflective spots but one of the big ones and you can see a little shadowing underneath it this is another little hyperpigmentation kind of again there's a little disruption of the rpe by this bump here and then there's a little spot there and then if you look under this is pretty subtle that's not a really good one this was a better one this is these are all leveling from the last four days so this is a patient at a bunch of these little pigment spots and when you scan them you can pick up these little intra-retinal hyper-reflective spots so that's focal hyperpigmentation vocal hypopigmentation is a little tougher i i i think it's just little atrophy spots over perusing sometimes it's i have trouble calling focal hypopigmentation um or spots that are too small to be called geographic attribute so this is a little light spot you might say that's a druze but it's a little irregular with some hyperpigmentation so i thought that might be one here's one with two spots the same eye there's a bump over here and then there's sort of a little atrophic area starting over here and so this is the first spot over here and this is the second spot over here so i consider those little areas of hypopigmentation you know if this is normal pigment oops if this is normal pigment here then that's light so um and then here's a patient with geographic atrophy here you see the little apache geographic attribute of the fovea and then here you see on oct all the findings where you have you lose your retinal layers here so you got your retinal layers coming into inside and then there you don't have them your rpe kind of goes away there you're just looking at the membrane or some pigment and rte there's even like a little outer retinal tubulation guys starting and then you get the hyper transmission so you get this reverse shadowing energy and then geographic actually this is a 94 year old one with mild vision loss and again you can see sort of the atrophy here every light is going through and then these little incomplete areas of geographic actually kind of all over the place and then here's another patient with small areas of geographic atrophy and you see the light going through the loss of the normal architecture your outer retina is starting to come out totally pigmented epideal attachments i couldn't find a serous ped but i do have a pattern dystrophy pattern dystrophies are interesting because the the deposits in front of the rpe so here you got your rp you got the little irregularity and then you have this pseudo vitelli form lesion we call it with the hyper reflective material under the retina and then i'm going to quickly go through retinal fibers this will just take this is the internal interventional hyper-reflective spot we talked about with the pigment right there and then here's an outer retinal tubulation so you get these little circles that are hyper reflective all the way around and they look like a cyst but they're not so here's a patient with geographic atrophy and a little bit of outer retinal tubulation and if you follow these they look like tubes if you if you do whatever unfast octs or you kind of do some functional c2s they run through the left you can get subrental fluid and dry amd this is a dry amd patient i've been following for a while so you've got these druzens so people think this is like a drape i think it's probably more that the rpe is just kind of sick here and can't get rid of the fluid i do find they tend to be sort of toward the middle of the phobia i think the very center of the phobia has some trouble with with fluid and certain disease entities and um this is a dry so you've got to be a little cautious would you treat that no absolutely not and i have an icg and nowadays you can do oct angiography to confirm that it's dry the other thing to warn you which i didn't put in this talk because i wanted to be short is is you can have dry amd and other diseases like i have a fascinating patient with dry amd immaculatory education who's been to a lot of retinal people and the good ones the ones that recognize the macular tylene dictator tell her you don't have what a d and the other one say oh yeah what ap because it looks like blood and b and you can't get pseudo fake cma so that's why sometimes if you have something that looks like or diabetics i've seen i actually had a patient recently with diabetic and a very good rhetoric specialist thought it was wedding retrieve but it was diabetes so just because you have amd and you have fluid doesn't mean it's from that like that chloride's a little thick but yeah and then outer retinal atrophies are very common so you look at you see your outer nuclear layer here's all your layers they're intact and then you go here and you get this you've got loss of your nuclear layer you get loss of the external membrane and like i said the external membrane tends to go with vision so we'd like to look at that and that is it