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Learn · Connect · SucceedJCAHPO Regional Meetings2017

UnderstandingAnterior Segment OCTClinical Applications ofAnterior Segment OCT Sarah Armstrong, CRA, OCT-C, FOPSManager of Ophthalmic ImagingKenneth L. Cohen, MDSterling A. Barrett Distinguished ProfessorKittner Eye CenterDepartment of OphthalmologyUniversity of North Carolina at Chapel HillSchool of MedicineAnatomyVendorsClinical use of AS-OCTTechnical aspectsMeasurementsArtifactsRecent CasesWhat Does Anterior SegmentOCT Do?2-dimensional cross section image of theanterior segmentNo financial interestAnterior Segment AnatomyLimbusIrisCorneaCorneal AnatomyCorneaAir/Tear InterfaceAnterior ChamberTear FilmEpitheliumStromaEndotheliumDSEK with foldHydropsPupilBullous KeratopathyKeratoconusAngleLensCiliary BodyPhoto Credit: Media Resources Centre University Hospitals of Wales Cardiff UKThanks Chris Tetley!Iris and Anterior Chamber AngleLensNatural LensIris CystAnterior Chamber IOLAnterior Chamber IOLClosed AngleElevated IOPIris CystCapsular BlockOpen AngleSlipped LensNarrow Occludable AngleIris NeoplasmMartha Leen, M.D. & Paul Kremer M.D. Achieve Eye and Laser Specialists, Silverdale, WAK-Pro Courtesy Mark Thomas and Ellen Redenbo1

Conjunctiva and NidekRS-3000OptosOCT/SLOOPMI LUMERA 700 and RESCAN 700Scleral nZeissVisante/CirrusConjunctival LesionFiltering BlebCourtesy of Achieve Eye and Laser SpecialistsZeiss CirrusWhy Do I Image theAnterior Segment?1 Week After Phaco and1-Piece Posterior Chamber IOLDislocated IOLIOL in the Capsular BagCauses of the Displaced IOLRelationship BetweenIOL and Capsular Bag? IOL not in capsular bag but in ciliary sulcusRuptured zonulesHole in posterior capsuleBroken hapticCrimped haptic How can I obtain a 2-dimensionsal crosssectional image of the anterior segment ofthe eye?Anterior segment OCTImmersion B-scan ultrasoundAbbott Tecnis 1-Piece IOL2

Relationship BetweenIOL and Capsular Bag?Relationship Betweenthe IOL and the Capsular Bag?Horizontal meridianIOL optic and posterior capsuleAnterior Segment OCTTechnical SpecificationsHaptics located in 10-4 o’clock meridianIOL haptic at 10 o’clock proper position4 o’clock IOL haptic truncatedIOL optic shifted towards 4 o’clockOCT Specification DomainSpectralAxialResTrans ResScanDepthScanLengthLens32,000 4 μm21μm,11μm,7.5μm*2.5mm20mmExt40,0003.9 μm14 μm1.9mm16mmExt27,000 6.0μm20 μm2.02.3mm6mm15 0,0006 μm20 μm3-6mm3-6mmIntCirrusSpectral27,0005 μm15 μm2mm4mmIntVisanteTime2,00018 μm60 μm6mm16mmIntSpectral26,0005.0 μmExtAnterior Segment SpecificationsSpecificationsVisanteSpectralSLD Wavelength1310840-870Optical Power 6500 µW750µWTime and Spectral Domain OCTExtOptovueZeissZeissTime and Spectral Domain OCTRelationship Betweenthe IOL and the Capsular Bag?Anterior Segment SpecificationsSpecificationsVisanteSpectralSLD Wavelength1310840-870Higher Wavelength allows for deeperscan depth and longer scan lengthScan Depth3mm,6mm1.9-2.3mmMore scan depth is able to imagecornea to lensScan Length10mm,16mm1-2,1-6*Longer scan length can image limbusto limbus. *Heidelberg is exception6x163x10The longer wavelength of light and stronger optical power allow TDtechnology to penetrate deeper into the angle.The shorter wavelength of light and lower optical power make itpossible for the SD technology to also image the retina2x62x1Graphic modified from Zeiss3

Shorter Scan LengthBetter ResolutionImportance of Scan Length DSEKLonger scanlength givesbetter overviewLimbus to limbus imaging is necessary toensure proper attachment of the donor tissue Scleral Contact Lens FittingNeeded to view the entire lens in one image GlaucomaThe following two slides show one individualwearing a 13.50 soft contact lensAble to measure both angles from one image.Detached DSEK ComparisonLonger vs Shorter Scan Length16mm10mm6mm6mmCourtesy Team Doheny EyeNew Corneal TransplantationTechniquesScleral Contact LensGlaucomaWhy Does this Patient HaveCorneal Edema?Fuchs’ Corneal DystrophyText Fuchs’ dystrophyInherited disease of corneal endotheliumEndothelium dysfunctional edemaPumps H20 out of corneaThickness 550 µ transparentPachymetry Specular microscopyHazy corneaStromal and epithelial edemaGuttae4

Penetrating KeratoplastyProblemsNew TreatmentDSEK: Descemet’s StrippingEndothelial KeratoplastyPenetrating Keratoplasty Diseased endothelium and Descemt’smembrane removed (30 μ) Donor endothelium and stroma inserted( 150 μ) Small incision (5 mm) Rapid healing and visual rehabilitation in30 to 60 daysEpithelial defectFull thickness corneal transplant360 corneal incision and sutures1 year for visual rehabilitationIrregular healing of full thickness incisionVisually disabling astigmatismDSEK VideoOCT to Monitor Health of DSEKDSEK 4 Weeks Post-op1D1038 μ1W618 μ1M687 μUltrasound Pachymetry IncorrectDSEK 4 Weeks PostopUltrasound pachymetry 549 μVisante Flap Tool Normal thickness 550 μ 30 μ endothelium and Descemet’smembrane removed 180 μ donor cornea implanted Pachymetry after DSEK should be at least700 μCorneal thickness 769 μ5

Detached DSEK 1 Day PostopDSEK ReattachmentAir InjectionAnterior Segment OCT DESK attachment would indicate primarydonor failureRequire graft replacement DSEK detachmentReattach graft with airMalpositioned DSEK1 day postop1 week postop7 weeks postop4.5 months postopWhat Else Can be MeasuredWith the OCT?Malpositioned DSEK180 meridian90 meridianSlipped inferiorlyAvailable Measurements of theAnterior SegmentProtocol Need protocol for what is imaged There are no criteria Must define and establish Corneal thicknessAnterior chamber depthAnterior chamber angleIncisionTumor size and depthAutomated Global PachymetryGlobal PachymetryPachmate Pachymetry16 line scans2048 data points in one map1 data point770 μ6

Corneal ThicknessAnterior Chamber DepthPre-OpMeasuring AnglesPost-Op3.61 mm5.16 mmCorneal thickness 769 μMeasuring AnglesClear Corneal IncisionClear Corneal Incision AOD: angle-opening distance TIA: trabecular-iris angle TISA: trabecular-iris space areaDescemet’s detachmentEndothelial gapeIris TumorsArtifact on the ScanMust understand what is real andwhat is an artifactEndothelial misalignmentEpithelial misalignmentEpithelial gapeLack of coaptationArtifacts Corneal ReflexInverted Image (in Spectral Domain)ShadowingImage AveragingAlgorithm FailurePachymetry: Corneal surface linesPachymetry: LidsUnable to use measurement features in Raw Mode7

Corneal ReflexInverted ImageSpectral DomainShadowingShadowingImage AveragingAveragingEnhanced High Res Cornea ModeTop: Non-averaged ScansBottom: Averaged ScansMeasuring with AveragingDewarpingEnhanced High Res Cornea ModeEnhanced ModeAlgorithm Failure Due to Lidssuperiorinferior8

Algorithm Failure Due to LidsAlgorithm FailureDue to Corneal Surface LinesVisualize Depth of Corneal ScarVisualize Depth of Corneal ScarFlattening of corneal surface over scarDSEK with a scarCorneal and ConjunctivalIntraepithelial NeoplasiaOCT is a Tool Useful for FollowingClinical ProblemsOcular Surface Tumors Does the tumor extend into the cornea,sclera, and anterior chamber angle? Plan operative procedureExcellent detail of corneaCorneal and ConjunctivalIntaepithelial NeoplasiaInfectious Keratitis Hazy corneaDifficult to see extent of corneal involvementMonitor response to medical therapyFollow disease process9

Fungal Corneal UlcerPre-op Phaco IOL CalculationAnterior Chamber DepthAnterior Chamber Depth Important for IOL calculation Theoretical prediction formula: Haigis Required to predict the post-opposition of the IOL Correct IOL power can be inserted 0.05 mm ACD error 0.03 diopterIOL power errorIOLMasterVisante4.10 mmACD difference 1.8 mm 1.08 dioptersAnterior segment measurement for IOL calculationEssential Iris AtrophyIrregular PupilOCT Defines Clinical ProblemAssists ManagmentOCTPASAnatomy: Normal ciliary bodyUBMPeripheral anterior synechiae Depth of corneal scarAmount and depth of corneal inflammationPosition of DSEK graftShape of corneaLocation of IOLMeasurements of anterior segmentAnatomy of the anterior segmentHoles in irisTraumatic CataractTraumatic Cataract VideoConfirms EtiologyHelps With Management10

Corneal Edema with HydrationCorneal Edema withHydration of Phaco Incision Video482µCD: 1845OCT to Confirm Etiology and Management1 day post-opPellucid Marginal CornealDegeneration1 month post-opsKeratoconusDiagnosis of Corneal ShapeConfirms Clinical Diagnosis541µ 525µ 534µ 581µCenter PeripheryFemtosecond LaserCataract SurgeryInput Plan of Operation408µ 382µ 420µ 482µCenter PeripheryHow Does the Laser Work?Spot Size and BubblesNew Use of Anterior Segment OCTMeasures the Anterior SegmentLaser Guided SurgeryComputer Assisted Treatment PlanCataract Surgery11

Real Time OCT to Guide LaserAnterior Segment and CataractLocalized With OCT1200 A-scans/secondTotal 10,000 scansTri-Planar Cataract IncisionLocalized with OCT400 µ safety zoneLaser Assisted CataractSurgeryCapsulotomyLaser Assisted Cataract SurgeryCapsulotomyFragmentation of cataractOphthalmic Photographers’ Societywww.opsweb.orgMid-Year ProgramDenver, COSpring, 2018Sequence of TreatmentLens FragmentationIncisions1 Week Post-Op Laser IncisionArcuate keratotomyAstigmatism managementOphthalmic Photographers’ SocietyEducationOPS Annual Program National and regionallectures, symposia andworkshops Educational scholarshipsNew Orleans, LouisianaNovember 10-13, 201712

Ophthalmic Photographers’ SocietyOnline EducationWebinars via www.opsweb.orgSEPTEMBERDECEMBEROphthalmic Photographers’ SocietyCertificationCertified Retinal Angiographer (CRA) accredited by NCCAOptical Coherence Tomographer-Certified(OCT-C)Ophthalmic Photographers’ SocietyCommunity Professional JournalCareer CenterActive online community (forums, blogs, interest groups)Social media presence (Facebook, Twitter, Pinterest)EyeCareCE via https://eyecarece.jcahpo.org/ANYTIMEThanks for your help!AbbottTrevor WilsonUNC DoctorsBruce Baldwin, OD, Ph.DCraig Fowler, MDDavid Russell, MDGeorge Escaravage, MDGraham Lyles, MDIsaac Porter, MDJonathan Dutton, MDKenneth Cohen, MDUNC PhotographersDebra Cantrell, COARona Lyn Esquejo-Leon, CRAPhotographersDoheny Eye InstituteBruno Bertoni, CRA, OCT-CTamera Davis, CRAHenry Ford Health SystemsAlexis Smith, OCT-C, CRAUniversity of California- DavisEllen Redenbo, CRA, ROUBKarishma ChandraUniversity of Florida Eye InstituteJohn Carpentier, CRA, OCT-CWills Eye InstituteSandor Ferenczy, CRASusan ProiettaBioptigenEric Buckland, Ph.DSunita Sayeram, MSJoseph VanceHeidelbergTim SteffensOptovueBill DillworthMark ThomasCarl Denis, CRAZeissGreg HoffmeyerRick TorneyTracy MooreGary Michalec, CRA, COACherri RittersmKenneth L. Cohen, MDSterling A. BarrettDistinguished ProfessorSarah Amrstrong, CRA, OCT-C, FOPSManger, Ophthalmic Imagingsmoyer@gmail.comKittner Eye Center, University of North Carolina Chapel Hill, NC13

Kittner Eye Center, University of North Carolina Chapel Hill, NC. Author: Mischelle Squire Created Date: 4/18/2017 3:55:16 PM .