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ASCRS ♦ ASOA Symposium & Congress
Technicians & Nurses Program
May 6-10, 2016 – New Orleans
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Sarah Moyer, CRA, OCT-C, FOPSManager of Ophthalmic Imaging
Kenneth L. Cohen, MDSterling A. Barrett Distinguished Professor
Kittner Eye CenterDepartment of OphthalmologyUniversity of North Carolina at Chapel HillSchool of Medicine
Clinical Applications of Anterior Segment OCT
No financial interest
Understanding Anterior Segment OCT
• Anatomy
• Vendors
• Clinical use of AS-OCT
• Technical aspects
• Measurements
• Artifacts
• Recent Cases
What Does Anterior SegmentOCT Do?
2-dimensional cross section image of the anterior segment
Anterior Segment AnatomyLimbus Cornea
Angle
Anterior ChamberIris
LensPupil
Ciliary Body
Corneal AnatomyAir / tear interface
EpitheliumTear Film
StromaEndothelium
Keratoconus
Bullous Keratopathy
Hydrops
DSEK with fold
Cornea
Photo Credit: Media Resources Centre University Hospitals of Wales Cardiff UKThanks Chris Tetley!
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Iris Cyst
Iris Neoplasm
Open Angle
Closed AngleElevated IOP
Iris and Anterior Chamber Angle
Iris Cyst
Narrow Occludable Angle
Martha Leen, M.D. & Paul Kremer M.D. Achieve Eye and Laser Specialists, Silverdale, WA
LensAnterior Chamber IOL
Slipped Lens
Capsular Block
Natural Lens
K-Pro Courtesy Mark Thomas and Ellen Redenbo
Conjunctiva and Sclera
Conjunctival Lesion
Scleral BucklePterygium
Filtering BlebCourtesy of Achieve Eye and Laser Specialists
BioptigenEnvisu
Heidelberg Spectralis
Nidek RS-3000
Optos OCT/SLO
Optovue Avanti /RT-Vue /iVue
TopconSL Scan-1 / OCT-2000
ZeissVisante / Cirrus
OPMI LUMERA 700 and RESCAN 700 Why Do I Image theAnterior Segment?
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1 Week After Phaco and 1-Piece Posterior Chamber IOL
Dislocated IOLIOL in the Capsular Bag
Abbott Tecnis 1-Piece IOL
Causes of the Dislocted IOL
• IOL not in capsular bag but in ciliary sulcus
• Ruptured zonules
• Hole in posterior capsule
• Broken haptic
• Crimped haptic
Relationship Between IOL and Capsular Bag?
• How can I obtain a 2-dimensionsal cross-sectional image of the anterior segment of the eye?
Anterior segment OCT
Immersion B-scan ultrasound
Relationship Between IOL and Capsular Bag?
Horizontal meridianIOL optic and posterior capsule
Anterior Segment OCTTechnical Specifications
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Manufactuer Model Domain Scans/secAxial Res Trans Res
Scan Depth
Scan Length Lens
BioptigenEnvisu R2300 Spectral 32,000 <4 μm
21μm, 11μm, 7.5μm* 2.5mm 20mm Ext
HeidelbergSpectrali
s Spectral 40,000 3.9 μm 14 μm 1.9mm 16mm Ext
OptosOptos
OCT/SLOSpectral
27,000<6.0 μm 20 μm
2.0-2.3mm
6mmExt
Optovue iVue Spectral 26,000 5.0 μm 15 μm2-
2.3mm 12mm Ext
Optovue RT-Vue Spectral 26,000 5.0 μm 15 μm2-
2.3mm 12mm Ext
Zeiss Cirrus Spectral 27,000 5 μm 15 μm 2mm 4mm Int
Zeiss Visante Time 2,000 18 μm 60 μm 6mm 16mm Int
OCT Specification Comparisons
Not currently FDA approved with AS-OCT from the following manufactures:
Nidek, Optopol, Tomey, and Topcon (as of March 2012)
Time and Spectral Domain OCT
Anterior Segment Specifications
Specifications Visante Spectral
SLD Wavelength 1310 840-870
Optical Power < 6500 µW 750µW
The longer wavelength of light and stronger optical power allow TD technology to penetrate deeper into the angle.
The shorter wavelength of light and lower optical power make it possible for the SD technology to also image the retina
Anterior Segment SpecificationsSpecifications Visante Spectral
SLD Wavelength 1310 840-870
Scan Depth 3mm,6mm 1.9-2.3mm
Scan Length 10mm, 16mm
1-2,1-6*
Higher Wavelength allows for deeper scan depth and longer scan length
More scan depth is able to image cornea to lens
Longer scan length can image limbus to limbus. *Heidelberg is exception
Graphic modified from Zeiss
6x16 3x10
2x6 2x1
Shorter Scan LengthBetter Resolution
The following two slides show one individual wearing a +13.50 soft contact lens
21 Months Postop DSEKHeidelberg
Opacities in interface
Avoid the corneal reflex
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Fuchs’ DystrophyHeidelberg
15 degrees
20 degrees
Guttae more visible with high magnification
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Longer scan length gives
better overview
Importance of Scan Length
• DSEKLimbus to limbus imaging is necessary to ensure proper attachment of the donor tissue
• Scleral Contact Lens FittingNeeded to view the entire lens in one image
• GlaucomaAble to measure both angles from one image.
Slipped DSEK Comparison Longer vs Shorter Scan Length
Courtesy Team Doheny Eye
16mm 10mm
6mm6mm
Text
Scleral Contact Lens Glaucoma
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New Corneal Transplantation Techniques
Why Does this Patient Have Corneal Edema?
Hazy cornea Stromal and epithelial edema
Fuchs’ Corneal Dystrophy
• Fuchs’ dystrophy
Inherited disease of corneal endothelium
Endothelium dysfunctional → edema
Pumps H20 out of cornea
Thickness 550 µ → transparent
Pachymetry
• Specular microscopyGuttae
Penetrating Keratoplasty
Epithelial defect
Full thickness corneal transplant360° corneal incision and sutures
Penetrating Keratoplasty
1 year for visual rehabilitationIrregular healing of full thickness incision
Visually disabling astigmatism
New TreatmentDSEK: Descemet’s Stripping
Endothelial Keratoplasty• Diseased endothelium and Descemt’s
membrane removed (30 μ)
• Donor endothelium and stroma inserted (~150 μ)
• Small incision (5 mm)
• Rapid healing and visual rehabilitation in
30 to 60 days
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DSEK Video OCT to Monitor Health of DSEK
1 D
1 W
1 M
1038 μ
687 μ
618 μ
DSEK 4 Weeks Post-op
Ultrasound pachymetry 549 μ
Ultrasound Pachymetry Incorrect
• Normal thickness 550 μ
• 30 μ endothelium and Descemet’s membrane removed
• 180 μ donor cornea implanted
• Pachymetry after DSEK should be at least 700 μ
DSEK 4 Weeks Postop Visante Flap Tool
Corneal thickness 769 μ
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Detached DSEK 1 Day Postop Anterior Segment OCT
• DESK attachment would indicate primary donor failure
Require graft replacement
• DSEK detachment
Reattach graft with air
DSEK ReattachmentAir Injection
1 day postop 1 week postop
7 weeks postop 4.5 months postop
Malpositioned DSEK
Malpositioned DSEK
180° meridian
90° meridian
Slipped inferiorly
What Else Can be Measured With the OCT?
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Available Measurements of theAnterior Segment
• Corneal thickness
• Anterior chamber depth
• Anterior chamber angle
• Incision
• Tumor size and depth
Automated Global Pachymetry
770 μ
Pachmate Pachymetry1 data point
Global Pachymetry16 line scans2048 data points in one map
Corneal Thickness
Corneal thickness 769 μ
Anterior Chamber Depth
Post-Op
5.16 mm3.61 mm
Pre-Op
Measuring Angles Measuring Angles
• AOD: angle-opening distance
• TIA: trabecular-iris angle
• TISA: trabecular-iris space area
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Clear Corneal Incision Clear Corneal Incision
Descemet’s detachment Endothelial misalignment Epithelial misalignment
Endothelial gape Epithelial gape Lack of coaptation
Iris Tumors
Unable to use measurement features in Raw Mode
Must understand what is real and what is an artifact
Artifact on the Scan
Artifacts
• Corneal Reflex
• Inverted Image (in Spectral Domain)
• Shadowing
• Image Averaging
• Algorithm FailurePachymetry: Corneal surface lines
Pachymetry: Lids
Corneal Reflex
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21 Months Postop DSEKHeidelberg
Opacities in interface
Avoid the corneal reflex
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Inverted ImageSpectral Domain
Shadowing Shadowing
Image Averaging
Top: Non-averaged ScansBottom: Averaged Scans
Averaging
Enhanced High Res Cornea Mode
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Measuring with Averaging
Enhanced High Res Cornea Mode
Dewarping
Enhanced Mode
Algorithm Failure Due to Lids
superior inferior
Algorithm Failure Due to Lids
Algorithm FailureDue to Corneal Surface Lines
OCT is a Tool Useful for Following Clinical Problems
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Visualize Depth of Corneal Scar
DSEK with a scar
Visualize Depth of Corneal Scar
Excellent detail of cornea
Flattening of corneal surface over scar
Ocular Surface Tumors
• Does the tumor extend into the cornea, sclera, and anterior chamber angle?
• Plan operative procedure
Corneal and ConjunctivalIntraepithelial Neoplasia
Corneal and ConjunctivalIntaepithelial Neoplasia Infectious Keratitis
• Hazy cornea
• Difficult to see extent of corneal involvement
• Monitor response to medical therapy
• Follow disease process
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Fungal Corneal Ulcer Anterior Chamber Depth
• Important for IOL calculation
• Theoretical prediction formula: Haigis
• Required to predict the post-op position of the IOL
• Correct IOL power can be inserted
• 0.05 mm ACD error = 0.03 diopter IOL power error
Pre-op Phaco IOL CalculationAnterior Chamber Depth
IOLMaster Visante
4.10 mm
ACD difference = 1.8 mm = 1.08 diopters
Anterior segment measurement for IOL calculation
Irregular Pupil
Peripheral anterior synechiae Holes in iris
PASAnatomy: Normal ciliary body
OCT
UBM
Essential Iris Atrophy OCT Defines Clinical ProblemAssists Managment
• Depth of corneal scar
• Amount and depth of corneal inflammation
• Position of DSEK graft
• Shape of cornea
• Location of IOL
• Measurements of anterior segment
• Anatomy of the anterior segment
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Traumatic Cataract Traumatic Cataract Video
Confirms Etiology
Helps With Management
Corneal Edema with Hydration
OCT to Confirm Etiology and Management
Corneal Edema with Hydration of Phaco Incision Video
CD: 1845
482µ
1 day post-op 1 month post-op s
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Diagnosis of Corneal ShapeConfirms Clinical Diagnosis
541µ→525µ→534µ→581µ
Pellucid Marginal Corneal Degeneration
Center → Periphery
Keratoconus
408µ→382µ→420µ→482µCenter → Periphery
Femtosecond LaserCataract Surgery
New Use of Anterior Segment OCT
Intraoperative OCT Guided Surgery
What Does LACS Do?
Computer Assisted Treatment PlanCataract Surgery
How Does the Laser Do This?Real Time Intraoperative OCT
1200 A-scans/secondTotal ~10,000 scans
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Intraoperative OCTIntegrated into the Laser
OCT MeasurementsLaser Settings
How Does the Laser Work?Spot Size
Treatment
Capsulotomy Lens Fragmentation Incisions
Laser Assisted Cataract Surgery
Laser Assisted Cataract Surgery
CapsulotomyFragmentation of cataract
Arcuate keratotomyAstigmatism management
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Abbott Catalys® Laser IncisionIntraoperative OCT
1 Week Postop Laser Incision
Manual Keratome Blade IncisionIntraoperative OCT
Ophthalmic Photographers’ Society
www.opsweb.org Ophthalmic Photographers’ Society Education
• National and regional lectures, symposia and workshops• Educational scholarships
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Ophthalmic Photographers’ Society Education
Ophthalmic Photographers’ Society Education
• Online Education: Webinars and EyeCareCE
JUNE6/2/16 7:00p Pooja Jani MD The Hitchhiker’s Guide to Tele-Ophthalmology6/7/16 8:00p Rosalind Stevens MD Diabetic Retinopathy: The Big Picture6/9/16 8:00p Denice Barsness CRA, COMT, ROUB, CDOS Imaging for Diabetes6/14/16 8:00p Lori Guerette CRA, COA So That’s What That Is, Unusual
OphthamologySEPTEMBER9/8/16 9:00 pm EST Csaba Martonyi FOPS Photo Slit Lamp Biomicrography9/13/16 9:00 pm EST Brandon Ayres MD Anterior Segment Application9/20/16 9:00 pm EST Taylor Pannell CRA, OCT-C Gonioscopy Tips
DECEMBEROCT-Angiography!!
www.opsweb.org to register
Certified Retinal Angiographer (CRA) -accredited by NCCA
Optical Coherence Tomographer-Certified (OCT-C)
Ophthalmic Photographers’ Society Certification
Ophthalmic Photographers’ Society Community
• Professional Journal
• Career Center
• Active online community (forums, blogs, interest groups)
• Social media presence (Facebook, Twitter, Pinterest)
Thanks for your help!
UNC DoctorsBruce Baldwin, OD, Ph.DCraig Fowler, MDDavid Russell, MDGeorge Escaravage, MDGraham Lyles, MDIsaac Porter, MDJonathan Dutton, MDKenneth Cohen, MD
UNC PhotographersDebra Cantrell, COARona Lyn Esquejo-Leon, CRA
PhotographersDoheny Eye Institute
Bruno Bertoni, CRA, OCT-CTamera Davis, CRA
Henry Ford Health Systems Alexis Smith, OCT-C, CRA
University of California- DavisEllen Redenbo, CRA, ROUBKarishma Chandra
University of Florida Eye Institute John Carpentier, CRA, OCT-C
Wills Eye InstituteSandor Ferenczy, CRASusan Proietta
AbbottTrevor Wilson
BioptigenEric Buckland, Ph.DSunita Sayeram, MSJoseph Vance
HeidelbergTim Steffens
OptovueBill DillworthMark ThomasCarl Denis, CRA
ZeissGreg HoffmeyerRick TorneyTracy MooreGary Michalec, CRA, COACherri Ritter sm
Kenneth L. Cohen, MDSterling A. Barrett Distinguished Professor
Sarah Moyer, CRA, OCT-CManager of Ophthalmic Imaging
Kittner Eye Center, University of North Carolina Chapel Hill, NC