Transcript for:
OCT Fundamentals and Retinal Anatomy

hi this is mark friedberg i'm the retinal specialist in red bank new jersey i'll be talking about mastering oct interpretation as you know oct is commonly used now both for retina and glaucoma purposes but i'll be focusing on the retina functionality of it as that's my specialty with small references to glaucoma uh as you know octs are used both for their quantitative and qualitative value quantitative refers to measuring the thickness of the retina and quality refers to interpreting the scan to see if there's disease and what that disease might be and the majority of this lecture will focus on the qualitative purposes the quantitative value in other words determining how thick the retina is really is only important uh in following patients as there's a great variability in what retinal thicknesses are normally and it's sometimes hard to know for sure if something is wrong based on just how thick a retina is before we can before we can discuss the pathology of the retina we have to know the normal anatomy and hopefully you can see this pointer on the screen the retina is this structure from here to here and anterior to the retina is the vitreous so the top part of our slide is the vitreous cavity and the eye wall you know the lens would be up top and the cornea even further higher up and the posterior part of the eye wall would be down inferiorly and this top part the vitreous has both a granular appearance and a what i would call a hyporeflective space here hyporeflective is going to refer to dark when you interpret oct scans and hyper reflective will refer to white more intense areas also you could use the words lucent or hypolucene to refer to these dark spaces um and so the vitreous has this granular appearance where it's formed vitreous uh and it has this hypolucent or hyporeflective area where it's liquid vitreous and before you get to the retina you have these thick reflective bands these hyper reflective bands of the vitreous and this is called the cortical vitreous the cortical vitreous is the part of the vitreous that's attached to the retina and when we fix certain pathologic states of the retina such as macular whole we need to lift the cortical vitreous off the retina to fix the hole now actually it's good practice to get rid of the cortical vitreous with almost every retinal condition we deal with macular pucker retinal detachment because the cortical vitreous seems to be involved in the pathology of many retinal conditions when that cortical vitreous pulls on the retina that's how you get a retinal tear if it doesn't go pull completely you get a macular pucker and etc and now we have what's known as vitreomacular traction which we'll get into later where the cortical vitreous is pulling irregularly on the fovea and speaking of the fovea that's this u-shaped uh indentation here in the retina and now we're getting to the structures of the retina the top most layer of the retina is called the internal internal limiting membrane and the internal limiting membrane is sometimes pathologic as well you can't actually see the internal limbing membrane but it's just sitting here on top of what is the ganglion cell layer on the internal limiting membrane i'm sorry the intron is sitting on top of the nerve fiber layer but the internal limiting membrane uh also needs to be removed sometimes for example in macular hole surgery will frequently remove it and it seems to help in closing macular holes yet it doesn't seem to affect vision uh it's controversial whether the insulin membrane should be removed at macular pucker surgery or not we used to think that yes it should be and now some recent studies are saying that maybe it shouldn't be um but in any case the internal membrane is the very anterior most part of the retina then as we go down a little further this thick white area is the nerve fiber layer the nerve fiber layer represent the axons from the ganglion cells which are just beneath the nerve fiber layer gets very thick as you get near the optic nerve here and that's how you know where the optic nerve is by looking as the as the nerve fiber letter is getting thicker on one side that tells you the nerves in that direction the oct won't only won't always show the optic nerve in the cut so the cut might end here but you'd know it was the nerve fiber layer by seeing how thick it got there it doesn't happen as you head out in the temporal direction so this would be a left eye as the optic nerve is here located nasally the ganglion cell layer and the inner plexiform layer are pretty hard to distinguish they're kind of merged together so beneath the nerve fiber layer is the ganglion cell layer which we'll say is here and the neurofiber layer which we'll say is there and they are now used with oct scanning to help recognize glaucoma in its earliest states you can't distinguish them though so it's not like you could say the ganglion cell layer is worn away because you can't really tell if it's the ganglion cell layer or the inner plexiform layer that's worn away and that's one of the problems in interpreting um for glaucoma using the oct to determine the ganglion cell and plexiform layer is that we're not always sure if it's thinned due to glaucoma or whether it's thin to another condition and normals have not well been established as we head a little more posteriorly and you'll notice well if we had a little more posteriorly um we get into what's known as the any the this is the inner nuclear layer the inner nuclear and the outer nuclear have a more hyporeflective appearance than the other parts of the retina so this is the inner nuclear layer that's the outer nuclear layer and between them is the outer plexiform layer and what you'll notice is as you head to the fovea um the ganglion cell the ganglion cell layer and the inoplexiform layer do not exist basically um and underneath the fovea it kind of starts out with the even the inner nuclear layer is not really there it's it's really starts out here with the outer plexiform layer and so as i said we have nerve fiber layer ganglion cell inner plexiform layer inner nuclear later outer plexiform layer outer nuclear layer and then we get to this thin hyper reflective line called the external limiting membrane beneath the external limiting membrane uh we have what's known as the myoid zone and then beneath that is a very important layer there's three hyper reflective lines now hyper reflective lines beneath the external limiting membrane the most anterior hyper reflective line is probably the most important part of the retina uh that's the the junction of the inner segment and outer segment photoreceptors and when it's in the foveal area we call that the ellipsoid zone so this is the ellipsoid zone also known as the inner segment outer segment junction um and it's particularly important in disease states it's often worn away in disease states um it's particularly important with plaquinol toxicity you'll see that is the uh one of the hallmarks where the uh ellipsoid zone is worn away outside the phobia um the next hyper reflective line would be called uh the interdigitation zone and the final hyper reflective line is considered the rpe uh although it's really merged with bruce membrane because you can't really distinguish bruce membrane so the last type of reflective line is the rpe slash brooks membrane complex so we have the ellipsoid zone the interdigitation zone which is the tips of the cone segments and the rpe brux membrane complex and the retina has ended just prior to the rpe so it's really the intertegetation zone is really the posters aspect of the retina and when we measure retinal thickness we're measuring it from the internal limiting membrane to the interdigitation zone or just to the surface of the retinal pigment epithelium however you want to do it i will note that that hyporeflective space in between the ellipsoid zone and the interdigitation zone represents the outer segments of the photoreceptors finally as we head more posteriorly we get to the choroid the choroid is made up of three layers the anterior layer is the choreocapillaris where most of the blood supply is then we have what's known as sattler's layer and finally hauler's layer before we get to the wall of the eyeball which is the sclera and that's our normal anatomy so let's move on now i was showing you a spectral domain oct there are obviously a lot of different types of octs and even the spectral domain octs vary so i'll try in this lecture to show a variety of different otoct scans to help people recognize pathology this is a time domain oct scan the anatomy you can make out is a little more difficult here's the fovea you could see the inner nuclear layer and the outer nuclear layer the hypo reflective lines so you know that the outer plexiform layers in between um where and i find time domain is very good uh you could see the um the inner surface of the retina is over here and this would be the vitreous time domain is very good in the retina itself like seeing fluid within the retina but where it fails is all these layers here are merged together so those three distinct lines that you saw before the ellipsoid zone the intertegetation zone and the rpe complex are all kind of merged in here and so we can't distinguish them so for example you can't tell plaquinol toxicity on the time domain because you can't tell if the uh if the uh ellipsoid zone is worn away um you know it it might look normal because it's in this large hyper reflective band okay now when we look at the retina to determine whether there's pathology we want to look not only at the individual structures to see if they look normal we want to look at the foveal contour we want to look at the shape of the retina you'll notice that this retina has a u-shape as opposed to the previous retinas that were straight across and so the contour is also helpful in determining things about the retina um the reason we have a u shape uh in this eye is because this patient is myopic and when someone has pathologic hymyopia they have a very u-shaped eyeball and so the shape of the eye will often tell you something as well so we want to look not only at the individual layers but the contour of the entire retina now this is a b scan ultrasound um and this is the front part of the eye where the cornea is located here's our lens this is the back surface of the lens this is the vitreous cavity the retina would be here lining the internal lining of the b scan wall here and you can see that the retina has a funny indentation and that's a posterior staphyloma on oct scan uh we can also recognize posterior scapuloma again our vitreous cavities up above our phobia has this u-shape this is a myopic eye you could see the shape of the retina has myopia and not only that when we look at the posterior wall so we're not seeing our layers all that well here on this oct this is not a great quality but here's the nuclear layer the outer nuclear layer and that's two of the things i often look at in the oct because they can orient you very quickly the internuclear and outer nuclear layer you know the outer plex form layer is the hyper reflective area in between and that tells you since that's the outer nuclear layer we now have the external limiting membrane and the those three individual hyper-reflective lines representing the photoreceptors the interdigitation zone in the rpe and it's kind of merged here so you can't see but you know the rpn's here so this is the choroid and you can see this is the wall of the eyeball and it's hard to picture but this is a posterior staphyloma right here so this oct is showing us a posterior staphyloma okay now when we look at the oct scan the next thing we want to do besides look at the contour and you can see this is that this eye is it's straight ahead the contour um so this is not an eye that has pathologic hymyopia when we look at the the eye we try to see what's different from the normal retina so the first thing is i tend to i'll probably the other obviously our eyes dart out to this but just for a few normal things as we head down in the vitreous we see this hyper reflective line this is the cortical vitreous um lifted off the retina here and probably attached to the retina here so there's a an incomplete vitreous detachment the optic disc is over here we notice that the retina has an abnormal contour on its anterior surface and the reason it has that abnormal contour is there's this this hyper reflectivity within the retina so the question is what causes hyporeflectivity well most of the time it's due to fluid um however uh you can see it hyper reflectivity of tissue is absent so if the if there wasn't anything here if there wasn't any tissue here this we could be looking at vitreous coming all the way in but usually it represents fluid and so in the case of fluid we say to ourselves well why would there be fluid within the retina and this is within the retina again this is a time domain oct showing the fluid very well this is our hyper reflective lines at the bottom so our photoreceptors are here so the fluids above the photoreceptors as a matter of fact it's from the outer nuclear layer all the way up through to the internal limiting membrane um that fluid is located um and so this is intra intra retinal edema now intraretinal edema uh can be due to many causes um the most common reason is from diabetic macular edema or cystoid macular edema um so we'll see intra-retinal fluid from diabetes we'll see it in a patient who's post-op who's got cystoid macular edema we can see it in people who have vein occlusions and those are probably the most likely so again intra-retinal fluid from diabetic macular edema post-op or vein occlusion but you can also see it in uveitis people get cme um you could see it in hyper from hypertensive retinopathy you could see it in retinitis pigmentosa they'll sometimes get cme less commonly you'll see it from a multiple myeloma can cause it or tumors can cause intraretinal edema um you don't have to see multiple myeloma in the retina like it's not like a choroidal tumor we see a mass the patient could just have fluid um and then there are medications that can cause fluid within the retinal like this one of the big ones these days is jillennia jolenia is a medication used for multiple sclerosis and we're often used to neurologists will send patients to my office and ask me to to screen patients periodically for jolenia toxicity and this is what you're looking for macular edema so i'll usually give them a an initial eye exam and i'll often have them come back for an oct scan three months and six months later or maybe i'll give them an exam at six months because the oct will often pick up the macular edema from gelenia toxicity other causes of macular edema niacin which is in a lot of statin drugs can cause macular edema tamoxifen tamoxifen typically causes intra-retinal crystals but it could also cause macular edema there's a medicine called blackly toxil which is used to treat cancer which can cause medical edema so macular edema especially bilateral when they don't have a vein occlusion or diabetes they didn't recently have surgery and they don't have uveitis or hypertension or retinitis pigmentosa start thinking of medications and then less likely multiple myeloma here is a spectral domain oct showing the same thing this is a patient who has macular edema the retina is thickened um you could see the hyporeflectivity in the inner layers of the retina and this is due to macular edema now here's an oct scan that shows hyper reflectivity in different areas first what do i notice when i look at the oct well you can see um the oct has an abnormal contour and that's because of this hyper reflectivity down here you can also see hyper reflectivity in these vertical patterns like this and you can also see this hyper reflectivity from the cortical vitreous being elevated off the retina in this location but being partially attached in this location so what i often do to see where the fluid is located is i'll often go to the side of the retina where it might be normal so for example here or over here the retina looks like it's normal and i'll follow my no and i'll distinguish my normal layers on the side to see where the break in the retina is occurring where the pathology is so if you go to the normal if you go to the normal side here what i recognize is the outer nuclear layer is somewhere in here this is the inner nuclear layer this is the outer nuclear layer and so these are going to be those three lines and this is the this over here actually represents the photoreceptor layer it's not we don't see all three on this cut and when we go back to the other side what you do see is maybe two hyper reflective lines and this represents the photoreceptor inner segment outer segment junction if we're in the fovea it would be called the ellipsoid zone and the one just beneath it represents the rpe brooks complex and what you can see when you get over here is the inner segment outer segment line disappears over here the rpe bruce membrane line sort of continues so in asking me where is this fluid located i'm going to say the reason the inner segment outer segment photoreceptor line disappears is it's going up here it may be worn away or whatever but it's lifted and it's lifted so this hypo reflectivity is under the ellipsoid zone or under the inner segment outer segment or under the retina but not under the rpe so this is sub retinal fluid as opposed to sub rpe fluid now we're also seeing shadowing or hyporeflectivity here and this is passing through many layers and this app actually represents shadowing of normal retinal vessels this is a normal oct finding so these hyper reflective lines these vertical lines are normal this is because they're blood vessels located anteriorly that are just casting a shadow from the oct scan so what the pathologic in this slide is we have sub-retinal fluid now what can cause sub-retinal fluid um the most common causes of sub-retinal fluid are wet macular degeneration so when somebody grows a carotid neovascular membrane or central serous retinopathy both cause fluid under the retina but you can also get fluid under the retina from a retinal detachment less commonly you can get it from tumors and less commonly again from multiple myeloma um so when you see fluid under the retina what you're really seeing is a retinal detachment but it's a localized retinal detachment it ends here and it ends here it doesn't extend out to the retinal periphery it's located in the macula only if we were to see this extend out we wouldn't know where it extended to but we know it's confined to here and here on this cut so this would represent either wet macular degeneration or central serous retinopathy the vast majority of the time i did leave out one other thing macro aneurysms could also leak fluid under the record so really the differential would be wet amd central serous retinopathy macro aneurysm and then less likely rental detachment from a tear in the periphery tumor or multiple myeloma this is fluid under the retina here's another example of um hypolucency within the retina um we see this area here that's hyporeflective or hyperloose and whatever you want to call it again these are blood vessels just casting shadows that's what that represents um but this is the path a lot this is the pathology here in this retina and the question becomes again where is it because the location again determines what the possible causes are so what can again i like to go to the side make out what you can make out and then head towards the pathology so this looks like it's pretty normal over here we see our external limiting membrane we see our photoreceptor inner segment outer segment junction also known as the ellipsoid zone interdigitation zone and here's the rpe brooks complex and as we follow it along we see that the ellipsoid zone is becoming elevated above this thing so the fluid and again loosen c is usually not always usually fluid so the hyporeflectivity so the fluid is going to be beneath the ellipsoid zone beneath the photoreceptors it's beneath the retina now the question is is it beneath the retinal pigment epithelium or is it just beneath the retina you see the difference as i said before when it's beneath the retina but above the retinal pigment epithelium you think of wet amd you think of central cirrus tumors rental detachment macro aneurysm um and by the way i said before that you know if it's uh you know it's not going to be rattled attention it doesn't extend out i'm sorry on what i said because it could extend out in the third dimension the 3d so you don't know for sure it's not a rental detachment so you always have to look clinically at the patient to make sure when you have fluid under the retina it's not a retinal detachment in any case so where is this located so here's our retina basically our photoreceptors so the retina is all above this and here's the retinal pigment epithelium we're following it along and it's still above the retinal pigment epithelium so it's in the sub-retinal space beneath the photoreceptors above the retinal pigment epithelium this is sub-retinal fluid again it's one of the diagnoses that we were talking about before meaning central serous macular degeneration etc um and so location again becomes very important here's another example just showing another kind of oct scan um you can see uh again a little harder to make out the layers this might be a time domain oct as a matter of fact it is um and now it's a little harder to know where the fluid is but this is the hyper reflective line so you know that at least part of the sorry about that uh at least part of the uh fluid is located above the pigment epithelium because if some of the hyper reflective line is here then the retinal pigment epithelium must be here the question is is it all here well you don't get fluid above the photoreceptors unless it's within the retina core itself so this is also sub-retinal fluid if you you know we can't make out exactly where the inner segment outer segment line is but i can tell you it's being lifted up and this is sub retinal fluid once again beneath the retina but above the pigment epithelium uh just another example with a different type of oct scan now here's a patient who has these hypo reflective areas in many different parts of the retina um so we have it here here here here and there different layers so now let's see if we can discern where they all are you can tell just by looking off to the side here that okay again this is a combination of the inner s this is a combination of the ellipsoid zone or i should say the the photoreceptors otherwise known as the ellipsoid zone a combination of that with the pigment epithelium is here and we can see that the it looks like well we know the photoreceptors are here and probably the retinal pigment epithelium is up here as well because you don't see any of it going in here so this is a retinal pigment epithelial detachment this area down here there's fluid beneath the retinal pigment epithelium now this was the only finding i would tell you that retinal pigment epithelial detachments are can occur for no reason at all but they can also be seen with wet amd uh they can also be seen with central cirrus um you don't get them with retinal detachment you don't get them with um some of the other causes of subretinal fluid like multiple myeloma you only get them with basically central serous and wet amd but it's not a definite sign of wet amd and when you and we don't usually treat it in other words if we're treating a patient who has wet amd um and we see this i won't give more treatment based on that alone whereas i will give more treatment based on sub-retinal fluid alone so this is sub retinal pigment epithelial fluid over here but you can see there's other fluid here above this area and now this would be considered sub retinal fluid again this is a time domain oct it's a little harder to tell but i can tell you that this is a retinal pigment epithelial detachment because all the layers go up here and this is fluid beneath that so this is beneath the pigment epithelium i can tell you that the photoreceptor line is over here in other words the ellipsoid zone is still here so this is fluid above the photoreceptors but beneath most of the retina well actually i don't know where the photoreceptors are they made actually i take that back i know that the pigment epithelium is going here so this is fluid above the retinal pigment epithelium but i can just tell you this is subretinal fluid from experience and i can tell you when you look over here at this area there's retina beneath that other than just the ellipsoid zone here's the outer nuclear layer and you can tell this fluids within or even more anterior than the outer nuclear layer so this person has intra retinal fluid here and here sub retinal fluid here and sub pigment epithelial fluid here so this is fluid in all locations and that's a typical finding with wet macular degeneration okay here's another oct scan now this is a spectral domain oct just being shown in color it's just different than some of the ones i've shown you before and again to figure out where some of these things are we start on the side and again the location of fluid is absolutely crucial in diagnosis and treatment we start on the side and we can see this is the outer nuclear layer again that's one of the easiest things to identify in the retina are the inner nuclear layer the outer nuclear layer those two layers give me my location so i'm going to come down here here's our outer nuclear layer this would be the external limiting membrane this top part not the heavy orange but this lighter yellowish greenish here that's the layer of the photoreceptors okay so this is where our ellipsoid zone is and that dark orange is going to be the pigment epithelium uh the retinal pigment epithelium and as we get over here the retinal pigment epithelium is being elevated as well as the photoreceptors and this is sub retinal pigment epithelium again this is hypolucency beneath the retinal pigment epithelium this is a retinal pigment epithelial detachment so in other words this is fluid beneath the retinal pigment epithelium now on the other side of the photoreceptor line we have sub retinal fluid so this is fluid beneath the retina so we have subretinal fluid sub retinal pigment epithelial fluid again a patient with macular degeneration okay now we're showing you the clinical slide here and you can see there's blood and now we're going to take a look at this oct scan here um and by the way you know if we look at the clinical slide you you could see the blood vessels the retinal blood vessels are riding over this blood and they are not getting interfered with so i can see the extent of that blood vessel as it comes over the blood uh so i know this is sub-retinal blood um i don't know if it's beneath the pigment epithelium but it's sub-retinal it could be sub-retinal pigmented epithelium it's not on top of the retina it's not it's not on top of the retina it's deep to the red of this blood when we look at the oct scan again our pathologies over here and you can see uh this is sub retinal fluid again this is a retinal pigment epithelial detachment only notice it's not all black in here so it's not all hypo reflective we also have these colored echoes and this is the blood so we've got blood here beneath the retinal pigment so we have a retinal pigmented epithelial detachment and we have sub retinal pigment epithelial blood this is a hemorrhagic retinal pigment epithelial detachment and this here is a little bit of sub retinal fluid again this is our outer segment and these are outer nuclear layer and internuclear layer here is our juncture this is the three uh brilliant lines the um ellipsoid zone the interdigitation zone and the retinal pigment of him all kind of merged together and as we come along here the this hypo reflectivity is on top of those layers so this is sub-retinal fluid so sub-retinal fluid outer segment layer inner segment layer i'm sorry outer nuclear layer internuclear layer um and this is sub rpe so blood and fluid beneath the retinal pigment epithelium again a very common is a very common feature wet macular degeneration okay now now we have a retina that has pathology that's a little different um again uh here's the normal retina let's go to the side here on the left on your left we have our normal layers you can make them out again i go right to the outer nuclear layer and the inner nuclear layer to help guide me um and then i know that these are there's the external limiting membrane this is the ellipsoid zone this is the retinal pigment epithelium brooks membrane junction we've got our choroid down here we're going to come along it's nice to follow i i i tend to follow the ellipsoid zone because you want to know if it's disrupted and it is it's gone here all right so we've got some damage over here there's no ellipsoid zone this is just the retinal pigment epithelium and you see these little these little lumps here in the pigment epithelium these are druzen so drusen often manifest as little small elevations of the retinal pigment epithelium right over there but the more the pathology is coming in over here as we come in this way you could see all of this now i guess one of the most marked things is see this area of hyper reflectivity you might automatically say this is fluid but you notice it has a nice circular hyper reflective area around this um and so you've got this hypo reflectivity surrounded by hyper reflectivity we have like three of these and these are called retinal tubules um and the important point in the reason we have even mentioned retinal tubules is because it looks like fluid and in a patient with macular degeneration wet macular degeneration um who's been treated if we see these findings we won't retreat based on them um the retinal tubules are just found in wet macular degeneration they're not an indication that more treatment is needed whereas fluid whether it's in the retina or under the retina is an indication usually that wet macular degeneration needs more treatment so if this was a patient with wet macular degeneration in whom i was giving injections to and i wanted to see if they had fluid and i saw these areas i would not give more treatment based on that whereas i would give more treatment um if there was fluid under the retina or within the retina and again i would not give more treatment if if i saw the retinal pigment epithelium was elevated that's not an indication to treat only fluid within or on or under the retina itself not under the pigment epithelium um and this could be considered a small retinal pigmental detachment over here or you can consider a very large drusen um and you could see this hyper reflective this is like an extra hyper reflective layer here that's generally not present this is probably part of the choroidal neovascular membrane complex uh that was treated you know patients with wet macular degeneration grow a blood vessel under their eye and this is probably a combination of that blood vessel with scar tissue maybe even blood uh present there uh you might say is that an area of fluid does that need treatment i'm going to tell you that's probably a retinal tubule as well i can kind of make out a hyper reflective line around it so i think there's four tubules or maybe even five one there might be a second there two three four five um this might even be one it's hard to know for sure and this is uh well it might be a little fluid eye maybe a little cyst and so the bottom line is there's a lot of disorganization here but i'm not sure i would retreat this patient if i was treating him for what macular degeneration so uh important to distinguish retinal tubules from fluid okay now here's a retina that's clearly pathologic as well and i'm keeping to my promise by showing a diversity of different types of oct scans because a lot of your oct scans will look like this as opposed to some of the ones i showed you before and and this is obviously in color um so uh the red arrows here um this arrow shows you these linear lines let's let's get our normal anatomy if we can as close as possible unfortunately when i look to the sides i'm not able to find normal anatomy in this slide so we have to try to figure out where we are we know that the vitreous cavity is up above and we know that this is our inner limiting membrane maybe this nerve fiber layer there but that's about it then you have these hyporeflective spaces which look a little different from fluid you know i get the feeling there is fluid in there but you notice these these columns um uh and you know basically uh what this is is uh fluid within the inner retina but this is an appearance you see with retinoschisis so what we're looking at here is a split in the retina um we have some of our retina up here some of our retina over here um and so uh we're gonna ignore this this is for another lecture i don't want to get into that right now um but uh you could see when you see this split in the inner retina you know it's x-linked retinose case as opposed to acquired retinoschisis so this is actually a young child who has retinoschesis um and these are schis cavities and the way you distinguish retinoschisis is they have these columns these these vertical linear lines separating what looks like fluid and again this is retinoschesis a split in the retina um and more retinas just split all over the place basically um uh again this is another case of retinosis and you could see these columns these these linear vertical lines splitting up the fluid that's retinosis not just fluid and that slides out of focus now here's another condition affecting the macula and when we look at the clinical slide we see this uh yellowish roundish area uh with foveal involvement in the central macula um and when we look at the oct scan um well maybe we should just tell you what this is this is yeah this is a case of best disease um it could best disease is an inherited condition there's two types there's there's regular old best disease um and this is it uh that occurs in young kids and you could tell this the fundus of a young kid and it's an inherited condition that can cause some loss of vision the vision is often not terrible uh when we have this and this is called a vitelliform lesion um as as years go by this can break down into pigment epithelial degeneration where the vision can get worse um there's also an adult onset patella form or adult onset best disease or adult-onset foveal patella form dystrophy um it's both of the conditions affect both eyes um it tends to be less severe when it's acquired whether rather than whether it's inherited um best disease is inherited they're both inherited but the adult form obviously is less severe develops later in life and here's an oct scan of that same patient and we have some good quality scanning here on the side i'll ask a few questions first of all you should be able to tell this is our fovea you should be able to tell whether this is a left eye or a right and the way you tell is where is the disc well again the nerve fiber layer gets thicker as it goes towards the disc the disc is here the phobia is here so this must be a left eye and so when we're looking in the papillomacular bundle since this is the left eye we know this is the pamphlet macular bundle we could see the normal anatomy so we're going to follow here's our external limiting membrane over here here's our ellipsoid zone our inner our interdigitation zone and here's the rpe bruce membrane complex this third hyper reflective line so we're gonna follow the ellipsoid zone which is our photoreceptors and it's going up here in our pathologic area and so the pathology is beneath the ellipsoid zone it's beneath the photoreceptors so it's sub-retinal everything above the retina is okay may be compressed a little bit by this elevation but it's okay here's our pigment epithelium down at the base so this is a sub-retinal abnormality although the pigment epithelium is disrupted here um and the difference between so this could be interpreted as a retinal pigment epithelial detachment if we didn't have any other information you could say well maybe that's just some blood and it could be but this is what a lesion of a teleform lesion looks like um and you can see uh it's beneath the retina um above the retinal pigment epithelium and it's got this material inside it and here is adult-onset foveal the teleform dystrophy or adult onset best disease um and we'll see what the oct scan looks like in that and again this should be a bilateral condition sometimes it's even less obvious than this sometimes it's just um some pigment epithelial degeneration okay now so we have these oct scans of the adult onset uh best petite lesion and one thing i should say about these best lesions are they're very well defined you know they're not vague you see them clearly and they're often they often have a hyper reflective line around them again they have that um this hyper reflectivity within the lesion uh and it's sub-retinal and i tell you one thing that does happen in this slide shows it is these lesions flatten out over time as i said they become degeneration of the pigment epithelium and the lesions go away and here's a classic example here's the patient when the patient's first seen in august of 2011 um and again here's the pigment epithelium here's the ellipsoid zone it's sub-retinal they've got this hyper-reflective material within it uh it's well defined and over time as we proceed you're getting more hyper-reflective material in it and now the cavity starts to collapse and you could see at the last date november 1st 2012 the phobias assumed the normal configuration again the lesion has basically vanished um this disruption of some of the outer layer retinal tissues here and now uh we have some hyper reflectivity that's irregular beneath it in the choroid and this is due to pigment epithelial degeneration and we're going to get into retinal pigment epithelial degeneration a little bit later in this talk okay now we're moving on um and uh here's a time domain oct scan um and again the time domain is very good for everything anterior to the ellipsoid zone which can't ever be made out here's our vitreous cavity and what we notice this is our internal limiting membrane and and nerve fiber layer there's a discontinuity here in the retina the nerve fiber layer the internal membrane do not connect and that discontinuity extends all the way through the retina down to this hyper reflective bend in other words the entire retina is involved and at the end you notice it has this um this configuration here like uh table legs one going this way one going the other way and this is a full thickness macular hole it's a small one but there's a hole and it's full thickness it extends all the way down to the base here notice the surface is basically at this hyper reflective line and you have these hypo reflective spaces within the retina itself these are little cysts or little pockets of fluid um you often see that with a macular hole and so uh this is a macular hole um and this is intra-retinal fluid intra intr it's within the retina for it to be subreddit we have to be beneath here here's a spectral domain uh oct scan showing the same thing um again um we have the vitreous cavity um this is you can make out the cortical vitreous up here it's detached from the macula there's a full thickness opening in the macula it goes all the way down to these hyper reflective lines that's a full thickness macular hole and again is that classic table shaped um almost like sub-retinal abnormality and we have these intra-retinal cystic or fluid spaces here's a patient who presents with a decreased vision in the right eye and the clinical picture shows you hemorrhage in the inferior half of the eye if we draw a line through the optic nerve through the phobia we draw this horizontal line you could see that the pathology is basically all in the inferior half of the retina and when we look at the superior half of the retina it's basically normal so you see all the hemorrhage located to the inferior half of the retina additionally the other abnormality we see is when you look at the retinal veins the infra-temporal retinal vein here is dilated and tortuous in comparison to this vein here this has a smoother chorus and this is abnormal um and there's a compression here of this vein if you look at it you can see it's compressed there and this patient has a branch retinal vein occlusion that's infecting the inferior half of the retina so the question is why is this patient's vision decreased we don't see any hemorrhage in the foveal center there's no i can tell you there's no neovascularization in the retina so we do an oct scan and this scan was done this is if i were to tell you the direction this is the inferior half of the retina and we're heading up here we hit the fovea and this is the superior half of the retina and so the oct scan also shows the stark contrast between the inferior retina and the superior retina this is a typical oct scan of a vein occlusion if you're going from the inferior to the superior direction because in the superior direction this oct is a little bit out of focus but in the superior direction you could see the retina has a much more normal thickness um you could almost make out the retinal layers but again the scans out of focus is not a great scan but when we look here the retina inferiorly is much more thickened there's a lot of hyporeflectivity within the retina this is all from fluid that's within the retina sometimes they have fluid beneath the red and it's a little hard to tell where this fluid is located because i can't clearly see where the ellipsoid zone is but i'm going to guess it's still down here and this is probably intraretinal fluid this is probably the outer nuclear layer here um but obviously there's a lot of fluid within the retina the retina is greatly thickened this patient has macular edema due to their vein occlusion uh the treatment would be intravitreal injections of medication in most cases when the fluid involves the foveal center will inject lucentis or ilea or avastin um you could also treat it with intravitreal injections of steroids like azerdex um it's a very good choice even sometimes tri essence uh which is like you know kenalog or triumph synolone is the generic um can help this you could try lasering the inferior half of the retina you know laser doesn't tend to work quite as well and i would say that the intravitreal injections of lucentis avest and earlier are the first choice here's a patient um who complains of decreased vision eight weeks after cataract surgery they say that their vision was really good that first several weeks and all of a sudden they noticed they're not seeing as well and when you look at the clinical picture uh you could see the fovea just looks a little irregular it's a little hard to say for sure what you're looking at on a two-dimensional view um but we obtain an oct scan and the oct scan shows you these hypo reflective spaces within the retina and this is definitely within the retina this is intra intra intra retinal here is our normal retinal appearance this orangish greenish band is a combination of the ellipsoid zone and the retinal pigment epithelium and you could see that the fluid the hyporeflectivity is above the ellipsoid zone it's above the photoreceptors it's within the retina so it's involving the outer nuclear layer and the inner nuclear layer and this is intraretinal fluid this is cystoid macular edema these are intraretinal cystoid spaces as you know cystoid macular edema is common after cataract surgery for no reason at all you can also see it with vein occlusions with diabetes with hypertension with uveitis with retinitis pigmentosa um traction these are the reasons you'll get cme sometimes you see it as a side effect of medication um uh there are a few medications like niacin and jillenia and paclitaxel which can all cause cystoid macular edema as well um in a post-op patient i initially try to treat them with um topical steroid like bread forte four times today along with a non-steroidal anti-inflammatory drop i.e keto rolex four times a day or never neck once a day or whichever you know you like i usually use a combination of the two medications for about four to six weeks if there's absolutely no improvement whatsoever at that point um i'll consider injecting a steroid into their eye although it depends on the cause but if it's post-op cme i'll use the steroid you know for a diabetic or a patient with a vein occlusion again i'll use either a vast and lucentis or ilea here's a patient who complains of blurred vision in both eyes um and this patient is young this is a 25 year old female and she was spending the afternoon in her backyard on a beautiful day doing not a whole lot of anything but laying there and she notices blurred vision in both eyes and here's her right eye and here's her left eye and the pathology is a little more obvious in the left eye you could see uh when you look at her phobia there's that yellowish spot um and when we get an oct scan what we see is this hyper reflectivity that extends from the foveal umbo here from the bottom part of the fovea right through down to the pigment epithelium and this disruption of the ellipsoid zone you can see it's cut off by this hyper reflectivity um and this is a case of solar retinopathy this is the other eye this is i showed you the left eye first that was the more involved um and here's the right eye and the reason we know this is the right eye again is you can see the nerve fiber layer gets thickened as it approaches the optic disc so the disc would be here the phobia would be here this is the right eye and it's a more subtle abnormality in the right eye but you could see that hyperreflectivity extending down through the ellipsoid zone through the photoreceptor zone some of these patients will recover and some of them will not um and when the ellipsoid zone is affected like that it sometimes just doesn't come back and this girl had vision of 20 60 in the left and 20 30 in the right and her vision did gradually improve to about 2025 over time um there's no treatment for solar retinopathy that we know of but these are classic oct findings seeing this hyper linear this hyper reflective linear appearance heading in the vertical direction now here's a question for you here's a patient who comes in complaining a decreased vision and we see the following and the question is what is it and i should give you 10 seconds to think about it and i'll go into but here's the pathology that we see again i like to start off it's like with the normal retina over here we're following it along uh we follow here's the here's the external elimination so here we have the outer nuclear layer externally membrane here is the ellipsoid zone here's the pigment epithelium let's follow the ellipsoid zone and it is almost completely intact and above it the external limiting membrane is almost completely intact and here's the outer nuclear layer and the pathology starts in the really in the upper half of the outer nuclear there's a little bit of outer nuclear layer left over there and so what we see is affecting the inner retina basically there's a hole a defect in the inner retina the retinal edges are nice and round it's an irregular hole and therefore we're going to call this a lamellar macular hole it is not full thickness it does not go all the way down to the pigment epithelium there are tissues in between so that's how we know it's lamellar and i should mention that patients with solar retinopathy will often develop lamellar holes later on um this is not the same patient as before though um and uh this is something you can leave they often have an accompanying pre-retinal membrane um and this is something you could if the patient's content with their vision it may not progress if you leave this condition alone um on the other hand uh sometimes patients have very poor vision as low as 2200 and you know depending on how the patient feels about their vision i do operate on these patients on occasion i mean if it's a 20 40 happy patient the answer is i'm going to leave them alone on the other hand if it's a 2100 unhappy patient um the terectomy surgery is successful in a large percentage of these cases um and so this is a lamellar macular hole not a full thickness again full thickness would be more regular you'd see it extend down to the pigment epithelium and it often has that table top i described it before finding its base uh well that concludes our oct lecture i hope that you all enjoyed it this is dr mark friedberg signing off okay so here's a patient who clinically has these sub-retinal reddish lines that go in funny directions and reason i say subretinal again look at the retinal blood vessels they ride on top of those lines you could see the retinal blood vessel without any interference but you can't see the lines because they're beneath the retina matter of fact they're in the choroid um and in and even anterior brook's membrane um and these are called angioid streaks and here's another example although it's not quite as clear of angioid streaks running in funny directions and angioid streaks uh can be found for a variety of reasons one of which is a condition where the skin particularly in the neck and underneath the armpit and the axilla is excessive they're like excessive folds in the skin and this is called pseudoxanthomolasticum so pseudoxanthomaelasticum is one of the causes of angioid streaks probably the most common and pseudozoanthelmolasticum is also associated with cardiovascular problems and gastrointestinal bleeds they're at high risk for gi bleeds so if you make this diagnosis if you see somebody with android streaks and they have excessive skin folds um and even if they don't have excessive skin told they should be sent for a skin biopsy if there's any uncertainty because they'll then need to be followed uh you know by a gastroenterologist by cardiologist uh because of the potential for more severe problems but there's some severe problems they can get in the eye and this is a 68 year old woman who had had an oct scan in the past and when we look at her old oct scan if we follow the orange line this is the retinal pigment epithelium brooks membrane where they're merged together and you can't distinguish them there's a gap right here i actually don't see my gap because i'm not showing my pointer there's a gap right here and there's another gap right there and that is consistent with angioid streaks you have breaks in brooke's membrane that's what an angioid streak is and here's a higher magnification of that break in brooke's membrane and this is all from her past only now she presents and she's complaining of metamorphia and examination by oct scan shows this gap this this angioid streak but not only there is a gap but now there's not only only a gap in the rooks membrane pigment epithelium but there's this hyper reflective material that has basically grown through this gap under the retina and you can see there's subretinal fluid adjacent to it and subretinal fluid over here uh and this is a subretinal neovascular or we can call it a choroidal but it's really subretinal neovascular membrane um as you know i am those who have seen me talk before uh subretinal or coronal neovascular membranes are most commonly seen with macular degeneration but you can also see them with ocular histoplasmosis you can get them with angioid streaks obviously you can get them in patients who are highly myopic uh you could also see them sometimes associated with other rarer reasons trauma from lacquer if you have somebody who has trauma of coronal rupture uh they can grow through the rupture eventually as a subreddit on the vascular membrane sometimes from inflammatory conditions or tumors those things are less likely so when you see a subreddit only vascular membrane you don't know the cause look for angioid streaks uh look for drusen that might be consistent with macular degeneration look to see if they're highly myopic see if they have signs of ocular histoplasmosis the punched out choroidal lesions and the peripapillary scarring to help determine why they have a choroidal neovascular membrane they can all these membranes can also occur for no reason at all you know what we call idiopathic and the treatment is the generally is either going to be laser if it's outside the fovea or anti-vegf meaning a vast and lucentis or ilea injections to prevent the person from losing vision and to hopefully get back vision for them uh so when you see angioid streaks um you have to worry about uh coronal neovascular membranes and you have to look for ehlers-danlos syndrome pseudoxanthome elasticum um paget's disease of bone and sickle cell anemia those are really the big four that produce angioid streaks now here's a patient uh who complains of metamorphosis as well and this patient has let's follow our normal retina it all looks normal here it's here it's over here that we got our problem and here's our pigment epithelium our ellipsoid zone is up here it's fairly intact the interdigitation zones up here and we have sub retinal fluid and a lot of it retina is very elevated and the concerning thing here is that this patient is complaining of metamorphosia um and not only that they feel they've lost some peripheral vision and this patient could easily be mistaken for other conditions that produce sub retinal fluid such as a coronal neovascular membrane but the difference is we don't see where this fluid is extending to and this is actually a rental detachment um this is a patient with a rental detachment and rental detachment refers to fluid under the retina as well as uh from these other conditions where you get fluid under the retina the difference is in a rental detachment there's a tear somewhere in the retina we can't see it because our oct skin is only showing us the macula the tear is out in the periphery the fluid got in to the sub-retinal space through the peripheral tear and it tracked down all the way here into the macula and once it gets under here person's going to be 2200 or worse most likely so this is a retinal detachments oct scan can pick up a rental detachment so don't get burned you got to look at the patient clinically you got to try to figure out why they have that fluid under their retina another example of fluid under the retina here's our pigment epithelium this is our inner retinal layers and a little harder to distinguish because it's a time domain oct but the bottom line is the fluids on top of the pigment epithelium this is sub retinal fluid and this is another example of a retinal detachment the fluid is extending out to the periphery and we just don't see what's going on in the periphery and another example the retina is detached it's going out to the periphery and we have some interretinal fluid as well now here's another patient we have fluid not only here's our pigment epithelium the retinal pigment film's traveling here so this fluid up here is sub retinal fluid that's also retinal fluid but here the pigment epithelium gets elevated so this person has not only sub retinal fluid but a retinal pigment epithelial detachment so you don't usually see retinal pigment at the tail detachments with retinal detachments so if you see but i mean you can have two conditions but you can't explain a retinal pigment if it failed attachment by a retinal detachment now not only that this person's subretinal fluid it has this this sharp angle at the end where it seems to extend to um and this is also a patient who complains of metamorphoxia and they have this subretinal fluid this pigment of the field attachment this is central serous retinopathy and central serous retinopathy produces fluid under the retina as well so fluid under the retina could be due to all these conditions retinal detachment central cirrus wet macular degeneration what distinguishes central cirrus is number one we don't see it extend out to the periphery although you could miss it on a cut you know it could be extending in a different direction uh number two you don't get retinal pigmentation attachments with rental detections you do with central serous and you do with macular degeneration but in central serous retinopathy look at the inner look at the ellipsoid zone the photoreceptors they're going up here it's the lines completely intact it's not disrupted like you see with wet macular degeneration and you don't see that hyper reflective growth anywhere and and the layers of the retina they're all they look normal they're just elevated and that's typical for central serous retinopathy you have an intact ellipsoid zone and a pigment epithelial detachment that's nice and smooth there's no hyper reflective mass anywhere the retinal layers are intact this is an oct scan of what looks like someone with central cirrus um and notice they'll all complain of the same metamorphopsia because the metamorphosio complaint is fluid under the retina so when you have a 50 year old or a 40 year old patient who's complaining of metamorphosia you may think central serous but you don't know what's actually causing it all these conditions obviously there's age variations with all these conditions and an oct scan can be helpful as can the clinical exam now here's another patient and here's the clinical exam and i'm showing you the oct scan that cuts through this layer here and here's the oct and notice this person also has subretinal fluid it's right there that's sub-retinal fluid and so the difference here is look how disorganized everything is this is not central serous retinopathy okay it's not clean the retinal layers are not all it here the retinal layers are intact and here they're not um and the reason they're not is something here there's this hyper reflective lesion that's grown under the retina and this is either blood or a coronal neovascular membrane or something um but you know you don't see blood with central cirrus uh you don't see sub-retinal blood with a rental detachment and this is wet macular degeneration sub-retinal fluid intra-retinal fluid disorganization of the layers the ellipsoid zone is lost over here we don't know where it is it's been destroyed the person has drusen so we know this is a case of wet macular degeneration so here's an oct scan um that shows uh small elevations of the pikmin epithelium and photoreceptors um you could see over here along the ellipsoid line little bumps in the road um and this is consistent with jerusalem or pigment epithelial of small areas of pigment epithelial elevation um this is not such an obvious case these would be very small pinpointers and clinically when you look at the photo uh on the left um black and white photo you know you barely see the druzen so you can pick them up on the oct sometimes before you can pick them up clinically now in a patient who has more obvious trusin such as this patient here we call these intermediate size trusin uh the oct scan will be a little more obvious as well now when we look at the ellipsoid zone you could see these little lumps these little it's not a perfectly straight line it's disturbed and here's the pigment epithelium that's elevated um and again this is drusen and pigment epithelial elevation to small degree you know you really can't always distinguish between drusen and small areas of pigment epithelium uh but they're obviously both indicative of dry disease now here's a a more obvious case a very pronounced case of druzen and these would be very large druzen um and you know this is our outer nuclear layer here and you can see these drusen are pushing up severely the the the photoreceptor line as well as the the layers the inter-judicial interpretation line and so forth but again this is dry macular degeneration just abundant drusen that are large and here's what it might look like on the zeiss machine um these are druzen over here um or we can call it you know slight elevations of the pigment epithelium however you want to look at if the pigment epithelium is elevated here again this is not wet disease there's no fluid in order to define wet disease you'd want to see fluid within the retina or underneath the retina separating the pigment epithelium from the retina but we don't have any fluid in here or over here um so this is just dry macular degeneration um now when we talk about you know one of the main reasons we do octs is to distinguish sometimes dry from wet disease and determine whether additional treatment is needed or not in patients who are being treated with wet disease and so we first need to distinguish what are findings you could see with macular degeneration that would just be indicative of dry disease so on the left i have a fundus autofluorescence over here and on the right we have our oct scan uh the fun disorder fluorescence is showing these hypo reflective areas and this represents atrophy of the retinal pigment epithelium there is no retinal pigment epithelium here it's gone you could call it rpe degeneration you can call it rp atrophy uh the bottom line is the pigment epithelium has lipofuchsin in it and when when it's not present a fun disorder fluorescence will repeal will will appear hyporeflective um and that's what we're seeing here these hypo reflective spaces due to lack of lipo few skin because the pigment epithelium is not present there so when we look at our oct scan number one shows us uh hyper reflectivity in the choroidal layers so again here's the pigment epithelial line the lowest line of our three lines you can't distinguish them on this oct scan very well but beneath that is the choroid and this is all choroid and what we're doing is we're seeing these hyper reflective shadows uh being cast posteriorly and that's consistent with retinal pigment epithelial degeneration so when you see that that means retinal pigment epithelial degeneration this is our outer nuclear layer here it is not fluid okay so how do we know we'll look all the way to the side over here you can see this is a normal retina over there that's the outer nuclear layer it becomes confusing as you get in here you're thinking to yourself is this fluid and is that the outer nuclear layer the answer is no that's actually the inner nuclear layer and this is the outer nuclear layer and it's just disturbed over here and so this oct scan you know had you been looking for wet macular degeneration the conclusion here is no this is dry disease we've got pigment epithelial degeneration um we have drusen you see the circle drusen over here and this is just a disturbance in the outer nuclear layer a disturbance in the ellipsoid zone this is just dry macular degeneration or wet disease that doesn't need treatment anymore one or the other so clinically we have this patient here who has rpe atrophy or rp degeneration you can see the coronal blood vessels real well there's atrophy of the rp and probably the choreocapillaris as well in this whole segment sorry about the blurring of the slide and here is what it looks like on the oct scan that area of atrophy uh or pigment epithelial degeneration extends from the pigment of helium down through the choroid this hyper reflectivity again we've got druzen right over there a fairly large one here's what a uh i find sometimes the hyper reflectivity this is at time domain oct scan again the the disadvantage of the time domain is you can't see though you can't distinguish the photoreceptor line from the rpe but it's very good at showing hyper reflectivity in the choroid consistent with retinal pigment of field degeneration okay so the question now is you know what are we looking at is this dry disease diseases this wet disease is this another condition well here's our clinical picture um and what we have here is a patient who has sub-retinal blood i know it's sub-retinal because i can see the retinal blood vessel come over it um it's not the blood vessel is not obstructed as it got into the blood over here um it ends as this one ends here um because they end at the phobia they don't go through the fovea but it's on the blood is sub-retinal beneath the retina and i can tell you just from experience that this gray greenish thing is probably either a choroidal neovascular membrane and i would bet on that or it could be retinal pigment epithelial elevation and i can see a little area around it that probably represents subretinal fluid and as a matter of fact i know it is just because i see so many eyes with this stuff so this is a subretinal neovascular membrane with subretinal hemorrhage and sub-retinal fluid and these sub-retinal or choroidal neovascular membranes are what can destroy central vision uh in macular degeneration you have to ask yourself though what else can produce this because i don't see a lot of druze in here i see this rpe atrophy area so what else could produce a carotid neovascular membrane well you can get it from ocular histoplasmosis usually you'll see some rpe degenerative changes around the disc you can get it from high myopia you can get it from uh patients who've had trauma that have choroidal ruptures they sometimes grow through that you can get it from angioid streaks those are probably the big ones um macular degeneration ocular histoplasmosis high myopia angioid streaks and less commonly uh from a coronal rupture from trauma but there are other rare reasons inflammatory conditions for example tumors okay here's our fluorescent angiogram you can see this area that i suspected clinically was a coronal neovascular membrane has brilliant hyperfluorescence and this is looking more like a choroidal neovascular membrane and one of the ways i can tell is it'll probably leak later in the study and you could see this blockage on the fluorescein due to the blood blood blocks the fluorescein and you can see this is subretinal blood look at the blood vessel come over it it's clearly under the blood vessel that tells us it's sub-retinal blood and here's our time domain oct and what it's showing us is here is the this hyper reflective line this orangish line uh the three layers the ellipsoid zone the interdigitation zone and the rpe and it's broken up here something has grown through it and that's a choroidal neovascular membrane that's grown through the membrane there's a little bit of subretinal fluid here on its side and this is a condition that needs to be treated or will cause further visual loss i'm sure it's caused a lot of visual loss already but without treatment it will progress and so the treatment that we will usually administer are interventional injections of either ilea lucentis or avastin okay um so we have uh more things here uh here's a patient with the fluorescent angiogram and it's showing me this this little spot here on the floor scene this is early this is late you can see it leaks fluorescein late that's consistent with the carotid neovascular membrane here's our oct scan um again let's start out where it's normal and we can distinguish our layers and go along and see what happens to each one if we start with the retinal pigment epithelium the bottom of the three brilliant lines the horizontal lines we come along and there's a space above the pigment epithelium that's hyporeflective now the question is is that fluid or is that the outer nuclear layer well here's the outer nuclear layer up there so that has to be sub retinal fluid it's beneath the ellipsoid zone which is going to come up over this way it's sub-retinal because it's not beneath the pigmented epithelium but it's beneath the retina subretinal fluid we'll continue with the pigment epithelium and look where it goes it's going up this way and this might be bruce membrane over here from which it got separated and this is a retinal pigmented field attachment uh where the pigmented film gets elevated um this going in this direction we've got the retinal pigment epithelium it gets elevated uh well this is a harder example um but actually i'm sorry this is the retinal pigmented epithelium over here this line it's thicker and that sub-retinal fluid is beneath the retina um and also beneath the retina here see our our ellipsoid zone is destroyed it's hard to really make out where it is but it's probably in here somewhere um and the ellipsoid zone is going up over here if you look at this is the external limiting membrane this thin line and the ellipsoid zone would be the align just beneath it and there's something beneath the photoreceptors this is a choroidal neovascular membrane that we see here on the angiogram and here again we have outlined very well the carotenoidal neovascular membrane subretinal fluid subretinal fluid pigment at the field attachment um loss of the inner segment outer segment line or ellipsoid zone whatever you want to call it wet mankiller degeneration or another cause of wet disease okay moving on um now as i told you before the vitreous cavity is up above and this is our nerve fiber layer so the retina is over here here's our normal retina and it's normal here um but there's another line up over here and this is the vitreous cortex the cortical vitreous that we saw earlier was down over here on the normal slide um and it could be normal when it's up here in other words the cortical vitreous can pull away when someone has a vitreous detachment the cortical vitreous pulls away from the retina as it did here and as it did here but it didn't pull away from the phobia it got caught and it's pulling on the phobia and this is called vitriol macular traction where the vitreous is pulling on the retina and it's elevating the retina um and it's causing a schesis cavity remember i explained when we have these columns that schis so it's causing the retina to be split it's lifting up the inner retina and the outer retina is staying down below and it's got a schisis cavity because of vitriol macular traction now some people sometimes say what's the difference between vitro macular traction and vitriol vma vitromacular adherence well adherence would be where the vitreous is just inherent to the retina for example this was not pulled up and you even had this one area where it was inherent it would be called vitro macular adherence it's not traction unless it's producing pathology within the retina in which case it is uh what would you do in this situation well um there are several choices number one you could just watch the patient if their vision is good there's a chance it will release spontaneously choice number two is we can inject either a medicine called jetria also known as aquaplasmin which can sever this attachment um number three we can inject a gas bubble sometimes the bubble just will get down in here and just push it up um and number four we can do surgery where we peel this off of the retina and then hopefully with any of those things hopefully the retina will go back to resume its normal configuration here's an example where the vitreous has pulled on the retina we had vitreomacular traction but what's happened here is it's pulled open a hole in the retina we've got a full thickness defect notice it goes all the way down to the pigment epithelium that is a full thickness macular hole and we have a cuff of subretinal fluid on the side a typical finding as i explained before and here is some intraretinal cysts or intra-retinal fluid you often see that with macular holes so this is vitromolecular attraction that caused immaculate hull the options of treatment would be the same as i explained before where the vitreous was pulling in your head uh macular schisis now you have a macular hole same options you could still either a observe although it's going to get worse if you observe it'll become permanent b inject gentria c inject a gas bubble d do a vitrectomy and fix it um the odds are greatest with the patrectomy surgery jetri is very expensive but it's a non-surgical procedure which some people may prefer okay another example of vitreomacular traction here is our cortical vitreous it's lifted off here it's lifted off there but we have attachment over here and it's pulling on the retina and you can see it's causing all this pathology in the red and it seems to be affecting the inner retinal layers predominantly the outer retina has basically stayed intact and it's possible this person could have reasonable vision um although sometimes it also depends on how long it's been present and so forth so what is it producing here well we have intraretinal fluid there's an irregularity of the retinal surface so the retinal surface is affected by this and there's thickening of the retina you can see this is not a normal retinal thickness this is a normal retinal thickness to the right of the slide here the retinas thickened vitreomacular traction again producing the same symptoms and again the options of therapy are the same um you could also argue well what about an injection of say avastin which is good at getting rid of fluid within the retina or lucentis or ilea well you could try that but if this is the cause that's not likely going to go away and if it does it'll probably recur but it is an option okay so what do we have here well number one you can see that this is a u-shaped eye in the back consistent with high myopia um and so this is a highly myopic patient i can tell you the optic disc must be over here but the nerve fiber layer gets thick over here and the inner limiting membrane which is the top surface of the nerve fiber layer and can't be distinguished is here but there's actually another layer now you could say is that the cortical vitreous and i'm going to tell you no it's not um you could see from those other slides the cortical vitreous a little different looking this is a pre-retinal membrane or an epiretinal membrane and these epiretinal membranes or pre-retinal membranes can cause macular puckers they can pull and twist the retina and it's hard to see it in the photo on your left it's just a small photo but it's a little distortion of the macula because there's a pre-retinal or epiretinal membrane present here's another example of a pre-retinal membrane on the surface of the retina and the retinal surface is all irregular um it's pulling on the retina it's causing intraretinal fluid or even perhaps some schisis if you'd like because we have some columns there um the retina is thickened the surface is irregular this would be a macular pucker um and this patient's vision will probably be very distorted they'll probably complain of uh metamorphosia okay so here's a patient who has uh basically a normal retina except if you look at the ellipsoid zone the this line right here the layer of the photoreceptor the inner segment outer segment jog tune also known as the ellipsoid zone as we get over here just adjacent to the phobia there's atrophy right there where is the ellipsoid zone you could see the external limiting membrane comes down and dips you see the rpe but our ellipsoid zone disappears and then the ellipsoid zone reappears over here and then it disappears again over here so it's not in the phobia that it's being affected it's paraphobia adjacent to the fovea and this is a patient who's taking plaquemine this is a classic finding in plaquinol toxicity um so as you know it's recently been recommended that patients with who are on plaquenil um be monitored uh with a clinical exam a visual field a 10-2 and either a spectral domain oct or a fundus autofluorescence or an erg or you could do more than one if you'd like and this is going to be usually the easiest and fastest way to pick it up um well oct is very good at recognizing plaquinol toxicity and this is the most common finding atrophy of the paraphobial ellipsoid zone that is a classic oct for somebody who's on plaquenil it doesn't affect the foveal center early it's usually right adjacent to it on the two sides now there are other findings you can get um you could have thinning of the outer nuclear layer and you do if you actually look at it here this is our outer nuclear layer and it gets kind of thin over here in that same area and that's typical that happens just outside the fovea so we often have loss of the ellipsoid zone thinning of the outer nuclear layer um and downward displacement of the inner retinal layers look what happened here the inner retinal layers are being displaced downward because the outer nuclear layer is gone they're coming down so these are the three findings you typically see with plaquemineral toxicity on an oct loss of the intersection and outer segment junction here the inner the outer nuclear layer gets thinned and there's downward displacement of the inner retinal layers now the real question becomes does oct pick up plaquenil toxicity prior to clinical exam and prior to humper visual field testing and the answer is sometimes sometimes the field will be the first finding sometimes the exam or the exam not as commonly usually you'll if you know if you see it on exam you're going to see it on oct but if you a visual field can often pick up plaquinol toxicity prior to an oct so if you have a normal oct scan and i emphasize this is a very important point if you have a normal and you need to use a spectral domain oct because you can't distinguish these layers with a time domain so if you have a normal spectral domain oct it does not eliminate the possibility of plaquemineral toxicity so if you have field loss which is just outside central fixation because again if it's peripheral that gets affected first and it is it's going to usually be just outside fixation as the earliest changes um that and you get us no ct because you're not sure if the field is real or not a normal oct does not exclude black window toxicity so oct is not exquisitely sensitive but it's very specific if you see these findings that's plaque window toxicity but if you don't see the findings if he looks and you see a normal oct scan then it doesn't tell you anything um so that's why it's important you do all the testing that's why you need essential essential 10 too i personally get fundus autofluorescence and sdoct as well as humphrey visual field testing um uh because you want to pick this stuff up as early as possible um now there have also been studies that say um it's possible that not just the qualitative findings on oct but perhaps the quantitative findings as well can be used um and so they measure um the the retina you know these these oct scans can measure from the internal limiting membrane down to the rpe um and basically if the retina is thinned um and it's usually you know thinning less than say 260 microns that is possibly suggestive of flaqueno toxicity as well although it's a lot less specific okay so now that you've learned as much as you've learned i'm going to show you cases with the hopes that we can apply this to real world life here's a patient who comes in uh they have this pigmented lesion uh sitting in the superior macula uh you can see it right here and we have this orange pigment on top of the lesion and the question is what are we dealing with we do an oct scan of it and what we see is here's the the oct scan this line shows you through where the cut is taken so it's in this direction if you see the arrow that arrow means we're starting here and going this way meaning we're starting here and going that way so this would correspond to the top part of this scan and this would correspond to the arrow part and the top part is being cut through this pigmented lesion that we saw clinically and that would be over here and you could see it's a very elevated area here's the retina the retina looks normal the pathology is deep to the retina um it's in the choroid and the choroid is elevated up because something's here and that's this and as we come along in the retina the pathology that we pick up is this hyporeflectivity now where is it that's the question um and the answer is uh it's beneath the retina but above the pigment epithelium let's go to our normal retina we follow our pigment epithelium that's staying down here so this hyporeflectivity which is fluid is above the pigment epithelium but it's beneath the ellipsoid zone this is sub-retinal fluid and when you have a pigmented lesion that has orange pigment on its surface and sub-retinal fluid you need to be concerned about melanoma and that's exactly what that was even though it was a flat looking lesion this is a patient with a carotid melanoma with sub-retinal fluid now here's a picture of a full thickness macular hole that we see clinically here's the base of the hole and around it you can see this cuff of sub-retinal fluid um and again here's an oct scan again showing again this is a spectral domain just a different kind with color the hole goes all the way through there's no retinal tissue left here we've got the table legs which are often you know this is this is usually the cuff of subretinal fluid that you're seeing clinically so this is the fluid we saw the cuff around the base this was the base of the hole and those table legs that i call them or the cuff of subretinal fluid around the hole sometimes you could see these cysts within the retina itself adjacent to the hole and notice here in the vitreous there's a little piece of retina that's been pulled up this is an operculum uh the vitreous here's the cortical vitreous pulled up um some of the retina and probably caused the hole so it was victory attraction that caused the hole in this case now in contrast to a full thickness macular hole notice the difference here's a vitreous cavity here's our opening in the retina notice that there is retinal tissue left over this is not a full thickness hole this is a lamellar molecular hole the hole does not extend all that would have to extend all the way down to the photoreceptor line here for it to be a full thickness hole no it does have a cyst in the retina here an intra-retinal cyst you can see over here on the surface of the retina we have a hyper reflective line notice this is not on the retina itself you can see a little space between the retina and this line over here whereas the this line is directly on the retina over here this is a pre-retinal membrane uh or an epiretinal membrane so when we have a macular pucker for example you'll see this or when the surface wrinkling retinopathy you have this pre-retinal membrane on the surface of the retina and you can see it doesn't the retina is thrown into folds a little bit so that it's not inherent over here but it is inherent over here and that's often found in accompanying lamellar macular holes you could see it with full thickness macular holes as well and uh all right we're moving on to something else here this is a clinical slide of druzen um we're looking at drew's in here in the retina and here's a fluorescent angiogram which shows the same druzen more obviously you