Clinical applications of optical coherence tomography in the posterior pole: the 2011 José Manuel Espino Lecture – Part II

Figures & data

Figure 1 (A) Color fundus photograph of geographic atrophy, secondary to age-related macular degeneration, showed a rounded, depigmented area with well-defined margins. (B) Fluorescein angiography demonstrated hyperfluorescence due to a window defect. (C) The Stratus optical coherence tomography image showed backscatter in the zones of atrophy, with marked hyperreflectivity and retinal thinning in the entire zone of atrophy.

Figure 2 Geographic atrophy. (A) Fluorescein angiography demonstrated hyperfluorescence due to a window defect and central sparing. (B) Stratus optical coherence tomography image showing a significant loss of the outer nuclear layer, photoreceptors, and the retinal pigment epithelium, leading to significant hyperreflectivity and backscatter within the choroid.

Figure 3 (A) Color photograph. (B) Cirrus™ optical coherence tomography image.

Notes: In (B), a drusenoid pigment epithelial detachment is a fairly well circumscribed, shallow, and often multiple elevation of the reflective band corresponding to the retinal pigment epithelium/choriocapillaris complex, formed by one or more large drusen or as a result of the slow coalescence of soft drusen.

Figure 4 (A and B) Bilateral drusenoid pigment epithelial detachment is observed on Cirrus™ optical coherence tomography.

Figure 5 Cirrus™ optical coherence tomography scan.

Notes: Baseline visit: a 67-year-old male complained of blurred vision on his left eye. Retinography demonstrated soft confluent drusen within the macular area (top left). The best-corrected visual acuity was 20/50. Cirrus™ optical coherence tomography revealed a drusenoid pigment epithelial detachment, and microcystic hyporeflective spaces within the neurosensory retina and an elevated retinal map (bottom left). Fluorescein angiography did not show any associated choroidal neovascularization (top and bottom right). Reprinted with permission from Gallego-Pinazo R, Marina A, Suelves-Cogollos, et al. Intravitreal ranibizumab for symptomatic drusenoid pigment epithelial detachment without choroidal neovascularization in age-related macular degeneration. Clin Ophthalmol. 2011;5:161–165. Copyright 2011 Dove Medical Press.⁴²

Figure 6 Cirrus™ optical coherence tomography scan.

Notes: The same patient as in Figure 5, at the final visit: the retinal pigment epithelium had returned to a normal contour, and no fluid was evident within the retina 66 weeks after a single injection of intravitreal ranibizumab (top and bottom). The best-corrected visual acuity improved to 20/20 and remained stable through the follow-up period. No visual complaint was referred. Reprinted with permission from Gallego-Pinazo R, Marina A, Suelves-Cogollos, et al. Intravitreal ranibizumab for symptomatic drusenoid pigment epithelial detachment without choroidal neovascularization in age-related macular degeneration. Clin Ophthalmol. 2011;5:161–165. Copyright 2011 Dove Medical Press.⁴²

Figure 7 Stratus optical coherence tomography image.

Notes: (A and B) Comparison between drusenoid PED and soft drusen without PED. (A) Soft drusen are observed as focal elevations in the external, highly reflective band corresponding to the retinal pigment epithelium/choriocapillaris complex. (B) A drusenoid PED is a fairly well circumscribed, shallow, and often multiple elevation of the reflective band corresponding to the retinal pigment epithelium/choriocapillaris complex.
Abbreviation: pigment PED, epithelial detachment.

Figure 8 Stratus optical coherence tomography image.

Notes: A serous pigment epithelial detachment is observed as a smooth domed elevation of the retinal pigment epithelium, with a characteristic sharp angle of pigment epithelial detachment over an optically empty space bound inferiorly by a visible Bruch’s membrane. Subretinal and intraretinal fluid is observed.

Figure 9 In this Cirrus™ optical coherence tomography image, we can see the sharply demarcated classic edges of the dome on a pigment epithelial detachment.

Figure 10 Stratus optical coherence tomography image.

Notes: An area of active neovascularization associated with a pigment epithelial detachment may lead to an associated smaller cuff of subretinal (arrowhead) and intraretinal (thin arrow) fluid.

Figure 11 This Cirrus™ optical coherence tomography section demonstrates an elevation of the macular region with loss of the foveal depression.

Notes: The serous retinal detachment is an optically empty, black, spindle-shaped zone between the retinal pigment epithelium and the neurosensory retina. Anteriorly, the retina is thickened and infiltrated with several central cysts. Posteriorly, a pigment epithelium detachment can be seen, suggesting the presence of an occult choroidal neovascularization.

Figure 12 The combination of a pigment epithelium detachment with accompanying subretinal fluid and intraretinal fluid may be a sign of choroidal neovascularization or retinal angiomatous proliferation, in this Cirrus™ optical coherence tomography image.

Figure 13 (A–D) The histopathologic (artist representation) and clinical correlation of occult and classic choroidal neovascularization to the Gass classification of type I (A and B) and type II membranes (C and D).

Notes: (A) and (C) are Cirrus™ optical coherence tomography images.

Figure 14 Choroidal neovascularization.

Notes: (A) Fundus photography. (B) Fluorescein angiography at an early frame. (C) Fluorescein angiography at a late phase. (D) Cirrus™ optical coherence tomography image. Classic choroidal neovascular membranes typically show a diffuse backscatter and fusiform thickening in the retinal pigment epithelium/Bruch’s membrane/choriocapillaris external band in the area where the membrane is seen. Choroidal neovascularization induces a bulging cone-shaped zone of hyperreflectivity accompanied by posterior shadowing.

Figure 15 Choroidal neovascularization in age-related macular degeneration.

Notes: (A) Fundus photography. (B) Fluorescein angiography at an early frame. (C) Fluorescein angiography at a late frame. (D) On Cirrus™ optical coherence tomography, the central retina is thickened by many well-delineated cysts, confluent in the center and associated with diffuse intraretinal fluid accumulation.

Figure 16 Choroidal neovascularization in age-related macular degeneration.

Notes: (A) Fundus photography. (B) Fluorescein angiography at a late phase. (C) On Cirrus™ optical coherence tomography, occult subretinal neovascularization tends to show as an irregular elevation of the retinal pigment epithelium, with a deeper area of mild backscatter corresponding to fibrous proliferation.

Figure 17 Choroidal neovascularization in age-related macular degeneration.

Notes: (A) Fundus photography of subretinal neovascularization. (B) Cirrus™ optical coherence tomography reveals a large subretinal choroidal neovascularization with subretinal and intraretinal fluid in the macular area.

Figure 18 Cirrus™ optical coherence tomography image shows a hyperreflective band, suggesting residual fibrosis of classic choroidal neovascularization.

Figure 19 Disciform scar in age-related macular degeneration.

Notes: (A) Angiography showed a scarred appearance of the lesion. (B) Stratus optical coherence tomography image showed an extensive fibrotic tissue with a complete atrophy of the outer and inner retinal layers in the macular area.

Figure 20 Vitreomacular traction syndrome and geographic atrophy.

Notes: (A) Fundus photography. (B) Persistent attachment of the hyaloid to the macula, with evidence of vitreomacular traction, on Stratus optical coherence tomography.

Figure 21 Vitreomacular traction syndrome and geographic atrophy.

Notes: (A) Preoperative Stratus optical coherence tomography showed vitreomacular traction with attachment of the posterior hyaloid to the fovea. (B) Postoperative Stratus optical coherence tomography demonstrates relief of the vitreomacular traction.

Figure 22 Laser treatment of subretinal neovascularization leads to atrophic scarring, which appears, on Cirrus™ optical coherence tomography, as highly reflective at the chorioretinal interface.

Figure 23 (A and B) Fluorescein angiography shows diffused diabetic macular edema. (C) Stratus optical coherence tomography illustrates diffuse retinal thickening and cystic spaces, consistent with cystoid macular edema.

Figure 24 Stratus optical coherence tomography image.

Note: The pattern of diabetic macular edema indicates retinal swelling.

Figure 25 Cirrus™ optical coherence tomography image.

Note: The pattern of diabetic macular edema indicates cystoid macular edema.

Figure 26 Stratus optical coherence tomography image.

Note: Well-established cystoid macular edema, which has persisted for more than 1 year, the cystoid spaces fuse to form a large cystoid cavity.

Figure 27 Stratus optical coherence tomography image.

Note: The pattern of diabetic macular edema indicates serous retinal detachment (arrow).

Figure 28 Stratus optical coherence tomography image.

Note: Atrophic chronic cystoid macular edema may lead to the development of a lamellar macular hole (arrow).

Figure 29 Stratus optical coherence tomography image.

Note: In this image, hard exudates, which were located in the outer retinal layers, appear as spots of high reflectivity with low-reflective areas behind them (arrows).

Figure 30 Stratus optical coherence tomography image.

Note: Reflection from the retinal pigment epithelium and choriocapillaris appears slightly disrupted (arrows) in the areas of previous focal laser photocoagulation treatment.

Figure 31 (A and B) Subhyaloid hemorrhage absorbs and reflects much of the Stratus optical coherence tomography light and hence, creates a large shadow obscuring the underlying structures.

Figure 32 (A) Fundus photography, (B) fluorescein angiogram, and (C) Stratus optical coherence tomography of proliferative diabetic retinopathy with preretinal membranes (thin, reflective bands anterior to the retina) and cystoid macular edema.

Figure 33 (A) Fundus photography, (B) fibrovascular proliferations of the optic disc (B-line), and (C) Cirrus™ optical coherence tomography of proliferative diabetic retinopathy with retinal traction and tractional detachment (C-line).

Figure 34 (A) Fundus photography, (B) fluorescein angiogram, and (C) Stratus optical coherence tomography of proliferative diabetic retinopathy with retinal traction and detachment.

Figure 35 Stratus optical coherence tomography image.

Notes: The distinction between preretinal fibrosis and a detached posterior vitreous is made on the basis of reflectivity. The posterior hyaloid typically (arrow) has a lower reflectivity than a preretinal membrane (arrowhead).

Figure 36 Retinal thinning (arrow) corresponding to retinal atrophy can be defined by Stratus optical coherence tomography, in the region of photocoagulation treatment.

Figure 37 Stratus optical coherence tomography image.

Note: The image shows highly reflective diabetic fibrovascular proliferation of the optic disc.

Figure 38 Stratus optical coherence tomography can determine the vitreous state.

Notes: The images show (A) fibrovascular proliferations of the optic disc; (B) thickening of the posterior hyaloid, which is especially hyperreflective and is attached to the optic disc; and (C) the optic disc without vitreous traction.

Figure 39 Cirrus™ optical coherence tomography.

Note: Central serous chorioretinopathy is characterized by serous detachments of the neurosensory retina in the macular region.

Figure 40 Central serous chorioretinopathy.

Notes: (A–C) Color photograph and fluorescein angiography early and late frames. (D) Stratus optical coherence tomography shows serous detachments of the neurosensory retina in the macular region.

Figure 41 Central serous chorioretinopathy.

Notes: (A) Fluorescein angiography demonstrating the leakage site at the retinal pigment epithelium, and neurosensory retinal detachment. (B) Stratus OCT demonstrates a pocket of serous fluid elevating the neurosensory retina. At the edge of this retinal detachment, there is a focal elevation of the retinal pigment epithelium over a clear space. This corresponds to the small area of retinal pigment epithelium serous detachment in the paramacular area, clearly seen in the OCT image.
Abbreviation: OCT, optical coherence tomography.

Figure 42 Central serous chorioretinopathy.

Notes: (A) Color fundus photograph in central serous chorioretinopathy. (B) Retinal pigment epithelium serous detachment and neurosensory retinal detachment are clearly observed on this Cirrus™ optical coherence tomography image.

Figure 43 Central retinal artery occlusion.

Notes: (A) Color fundus photograph demonstrating whitening of the retina and a “cherry-red” spot. (B) Fluorescein angiogram reveals poor retinal vascular filling. The leading edge of dye within the superior arterial system is distinctly abnormal and indicates hypoperfusion. (C) Stratus optical coherence tomography image: the horizontal optical coherence tomography scan shows increased thickness and reflectivity of the inner retinal layers (arrow); this high reflectivity causes shadowing of the optical signals of the outer retinal layers and the retinal pigment epithelium/choriocapillaris complex (arrow head). The retinal thickness map demonstrates increased central thickness (293 microns), especially nasal to the fovea, due to intracellular edema and ischemia of the papillomacular bundle (insert).

Figure 44 Branch retinal vein occlusion with macular edema.

Notes: (A) Fundus photograph. (B) Stratus optical coherence tomography image. The horizontal optical coherence tomography scan showed diffuse retinal thickening and low-reflective spaces consistent with macular cysts.

Figure 45 Central retinal vein occlusion with macular edema.

Notes: (A) Fundus photograph. (B) The Cirrus™ optical coherence tomography scan showed a thickened elevated macula with numerous low-reflective cystic spaces representing fluid accumulation. A detachment of the neurosensory retina, with subretinal fluid accumulation is observed underneath the fovea.

Figure 46 Acute central retinal vein occlusion with macular edema.

Notes: (A) Fundus photograph. (B) Horizontal Stratus optical coherence tomography scans showed an elevated macula with diffuse retinal thickening and low-reflective spaces consistent with macular cysts and intra-subretinal fluid. (C) The retinal thickness map demonstrates increased central thickness (773 microns).

Figure 47 (A) Acute branch retinal vein occlusion with macular edema: the horizontal Stratus optical coherence tomography scan showed numerous hyporeflective spaces within the outer plexiform layer; intraretinal thickening leads to a loss of foveal contour. (B) A decrease of central macular thickness was observed 1 week after intravitreal bevacizumab therapy. (C) A normal macular thickness was seen 2 months after initial therapy.

Figure 48 Myopic degeneration with retinoschisis.

Notes: (A) The color fundus photograph distinctly shows a myopic crescent as a white, sharply defined area where the inner surface of the sclera is seen. Retinoschisis inferior to the optic disc was not differentiated ophthalmoscopically. (B) A horizontal Stratus optical coherence tomography scan obtained inferior to the optic disc demonstrates a splitting of the neurosensory retina (arrow) and the separation of full-thickness neurosensory retina from the underlying retinal pigment epithelium (arrowhead).

Figure 49 (A) Histological cross section of CME. (B) SD-OCT cross section of pseudophakic CME with retinal thickening, cystic intraretinal, and subretinal fluid.

Note: Cirrus™ OCT allows precise characterization of the lesions, which previously could only be appreciated on histologic sections.
Abbreviations: CME, cystoid macular edema; OCT, optical coherence tomography; SD, spectral domain.

Figure 50 (A) Fluorescein angiography of CME in the recirculation phase of the angiogram demonstrates a classic petaloid leakage pattern of pseudophakic CME. (B) Cirrus™ optical coherence tomography demonstrates cystic macular changes as low-reflective spaces (dark spaces), more prominently at the level of the outer retinal layers.

Abbreviation: CME, cystoid macular edema.

Figure 51 Sequential Stratus OCT images from a 64-year-old man with a 4-month history of loss of vision, to 20/160, in his right eye, in whom refractory pseudophakic cystoid macular edema had developed.

Notes: (A) Horizontal OCT scan obtained through the fovea revealing a loss of the normal foveal contour, diffuse macular thickening, and areas of low intraretinal reflectivity consistent with intraretinal cysts and fluid accumulation. The retinal map analysis revealed a foveal thickness of 595 μm. The patient underwent an intravitreal injection of bevacizumab at a dose of 2.5 mg in this eye. (B) OCT scans revealing complete resolution of the cystic spaces and with restoration of foveal anatomic features at 1 month after the bevacizumab injection. The retinal map analysis indicates a central foveal thickness of 260 μm. VA improved to 20/63. (C) Six months after the injection, the OCT scan showed marked improvement in foveal thickness (229 μm) and contour. The VA was 20/32. (D) OCT scans showing a normal-appearing macula at 12 months after injection. The foveal thickness decreased to 202 μm, and VA was 20/32. Reprinted with permission form Arevalo JF, Maia M, Garcia-Amaris RA, et al; Pan-American Collaborative Retina Study Group. Intravitreal bevacizumab for refractory pseudophakic cystoid macular edema: the Pan-American Collaborative Retina Study Group results. Ophthalmology. 2009;116(8):1481–1487. Copyright 2009 elsevier.¹⁰⁸
Abbreviations: OCT, optical coherence tomography; VA, visual acuity.

Figure 52 (A) Color fundus photograph of localized parafoveal telangiectasis. (B) Cirrus™ optical coherence tomography image shows an intraretinal cyst as a low-reflective intraretinal area, secondary to the parafoveal telangiectasis.

Figure 53 (A) Color fundus photograph of localized parafoveal telangiectasis. (B–D) Fluorescein angiography shows hyperfluorescence (D) due to late extravasation of the fluorescein dye. (E) The Cirrus™ optical coherence tomography image shows a intraretinal cyst as a low-reflective intraretinal area, secondary to parafoveal telangiectasis.

Figure 54 Fluorescein angiograms of the right (A) and left (B) eyes of a patient with hydroxychloroquine maculopathy. (C–D) Spectral domain Cirrus™ optical coherence tomography scans of the same two eyes.

Notes: Lack of retinal pigment through to the choroidal circulation is shown as a ringlike retinal depigmentation in the angiograms. The Spectral domain Cirrus™ optical coherence tomography shows significant thinning of the outer retinal structures in the foveal region of both the right (C) and left (D) eyes.

Figure 55 (A and C) Color fundus photograph and fluorescein angiogram of the right eye demonstrate papilledema, subhyaloid and retinal hemorrhages, and extensive peripapillary lipid exudation in the posterior pole, secondary to radiation retinopathy. (B and D) Spectral domain optical Cirrus™ coherence tomography image of the same eye, with noticeably increased nasal retinal thickness and hard exudates in the inner nuclear layer, outer plexiform layer, and outer nuclear layer.

Figure 56 (A) Color fundus photograph, (B) fluorescein angiogram, (C) B-scan ultrasound, and (D) Cirrus™ optical coherence tomography image demonstrate commotio retinae and an intraocular foreign body.

Figure 57 (A) Color fundus photograph of a retinochoroidal coloboma. (B) Normal foveal contour. (C) Cirrus™ optical coherence tomography shows the typical features of retinochoroidal coloboma with the lack of retinal and choroidal tissues, and light backscatter.

Note: The black and white lines depict the direction of the line scan.

Figure 58 Foveal hypoplasia in albinism.

Notes: (A) Fundus color and (B) red-free photographs of the left eye show a clear view of choroidal vasculature due to the hypopigmentation of the retinal pigment epithelium, a pale retina, foveal hypoplasia, and an indistinct optic disc margin. (C) Cirrus™ optical coherence tomography image of the same eye, showing the absence of the normal macular depression and high reflectivity across the fovea. The white line depicts the direction of the OCT scan.

Figure 59 (A and B) Fundus color photographs of both eyes show scattered preretinal hemorrhages at the macula and surrounding the optic disk, secondary to medullary aplasia. (C) The Cirrus™ OCT image shows increased thickness and reflectivity due to the presence of blood over the inner retinal layers, causing shadowing of the optical signals of the outer retinal layers and the retinal pigment epithelium/choriocapillaris complex.

Note: The white line demonstrates the direction of the OCT scan.
Abbreviation: OCT, optical coherence tomography.

Figure 60 (A) Fluorescein angiography shows leakage from the aneurysm and surrounding area that is blocked by preretinal and retinal hemorrhage. (B) Spectral-domain Cirrus™ optical coherence tomography showing an active retinal arterial macroaneurysm.

Notes: Increased central retinal thickness and subfoveal elevation of the sensory retina is seen in (B).

Figure 61 (A) Fundus color photograph shows retinal arterial macroaneurysm and surrounding lipid deposits 1 month after presentation. (B) Cirrus™ optical coherence tomography image shows the retinal arterial macroaneurysm located in the superficial layers and accompanied by multiple lipid deposits, predominantly seen in the outer plexiform layer.

Note: The white line depicts the direction of the OCT scan.

Figure 62 Coats’ disease.

Notes: (A and B) Fundus color photograph, at presentation, shows subretinal lipid exudates extending posteriorly and exudative retinal detachment in the right eye. (C) The Cirrus™ optical coherence tomography image shows neurosensorial retinal detachment, intraretinal fluid, and multiple lipid exudates in the outer retinal layer. The white line depicts the direction of the OCT scan.

Figure 63 Spectral-domain Cirrus™ optical coherence tomography image demonstrates the presence of two subretinal bubbles of perfluorocarbon liquid (white arrows) after vitreoretinal surgery.

Figure 64 Spectralis® optical coherence tomography image (Courtesy of Roberto Gallego-Pinazo, MD).

Notes: Foveal-centered EDI OCT image of a 72-year-old Caucasian male with a 26-year history of central serous chorioretinopathy and with a present acute episode of serous foveal detachment. The subfoveal choroidal thickness measured 437 microns.
Abbreviation: EDI OCT, enhanced depth imaging optical coherence tomography.

Figure 65 Spectralis® optical coherence tomography image (Courtesy of Roberto Gallego-Pinazo, MD).

Notes: Foveal-centered EDI OCT image of a 63-year-old highly myopic Caucasian male who developed type 2 neovascularization. The subfoveal choroidal thickness measured 136 microns.
Abbreviation: EDI OCT, enhanced depth imaging optical coherence tomography.

Gallego-PinazoRMarinaASuelves-CogollosIntravitreal ranibizumab for symptomatic drusenoid pigment epithelial detachment without choroidal neovascularization in age-related macular degenerationClin Ophthalmol2011516116521383943

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