Three years ago, Heidelberg ran a series of events around the UK where local ophthalmologists brought along interesting patients from their clinic who were then assessed live in front of the audience using the Spectralis (see Optician 14.04.2016). The results were then displayed and discussed among the delegates. This format proved exciting and informative, so I was pleased to see that a similar tour had been planned for this spring. Here are the details of the patients presented when the tour made it to Exeter recently.
Patient cases
The guest presenter was Dr Mitra Tavakoli, an optometrist and senior lecturer in Medicine at University of Exeter Medical School. She first gave some history of each of the three patients and then each was scanned, the Spectralis linked to the data projector so all could watch the live scan as it was being described.
Patient 1
History
The first patient was a 64-year-old female non-smoker. Her complaint had been an awareness of a ‘blob in her right eye’ since October 2017. Her acuities had remained unaffected over this time and measured in logMAR as follows:
R: -0.10
L: -0.06
Medical history found she had hyperthyroidism, anaemia, and hypertension, all managed with medication. Ocular assessment showed the left eye to be unremarkable, while for the right eye the following observations were made:
Anterior Segment: normal.
Fundus: no haemorrhaging, no exudate, slight elevation under the right superior arcade vessels.
OCT: an area of elevation with subretinal fluid was detected (see figures 1 to 4).
Figure 2: BluePeak autofluorescence image showing some retinal pigment epithelium disruption
Fluorescein angiography: results were inconclusive and OCT-angiography was requested to ‘rule out eccentric disciform lesions and choroidal polypoidal lesions’.
Figure 3: OCT live scan showing two sites of retinal elevation around the position of the suspect lesion
Figure 4: OCT-A assessment of the right eye
Live findings
No abnormality was shown in the left eye via 3D representation (figure 5) but it clearly revealed the area of elevation in the right eye (figure 6).
Figure 5: 3D representation of left retina
Figure 6: 3D representation of right area showing area of elevation
Line scans for the left eye proved unremarkable (figures 7 and 8).
Figure 7: Foveal line scan for left eye
Figure 8: Line scan of left eye superior to fovea
The infrared image of the right eye showed the lesion of suspicion still to be present (figure 9).
Figure 9: Infra-red image of right eye
A line scan through the right fovea was normal (figure 10), while line scans through the area of suspicion clearly show retinal atrophy, thickening, elevation and sub-retinal fluid (figures 11 to 14). Figure 15 is the thickness map for both eyes and a discrete area of thickening is seen around the lesion.
Figure 10: Foveal line scan for right eye is unremarkable, hence the good acuity
Differential diagnosis: choroidal neovascularisation, central serous chorioretinopathy, exudative retinal detachment. Investigations are ongoing to define the final diagnosis.
Figure 11: Horizontal line scan showing retinal elevation
Figure 12: Horizontal line scan showing retinal elevation
Figure 13: Horizontal line scan showing retinal elevation
Figure 14: Horizontal line scan showing retinal elevation
Figure 15: Thickness map of both eyes. Note the discrete (green) area of thickening superior temporal to the fovea in the right eye
Patient 2
History
The second patient was a 72-year-old female non-smoker. She had been diagnosed with bilateral dry AMD in Canada six years ago after a routine eye examination. Her medical history included diagnoses of coeliac disease and arthritis. Her mother was known to also have had AMD, and neither had had any treatments for the condition to this point. Though acuity and fields were normal, there had been a generalised reduction in colour vision.
Figure 16: Multicolor scan of right eye
MultiColor (figure 16), infrared (figure 17), green reflectance (figure 18) and blue reflectance (figure 19) canning laser ophthalmoscopy images of the right eye all showed central mottled pigmentary changes.
Figure 17: Infra-red scan of right eye
Figure 18: Green reflectance scan of right eye
Figure 19: Blue reflectance scan of right eye
MultiColor (figure 20) and green reflectance of the left eye showed similar, is slightly larger diameter, pale lesions around the posterior pole.
Figure 20: MultiColor scan of the left eye
Figure 21: Green reflectance scan of the right eye
Live findings
Vertical line scans of the right fovea (figure 22) and left fovea (figure 23) clearly show the discrete elevations, and cause of each of the mottling patches, to be drusenoid in nature.
Figure 22: Vertical line scan of the right fovea
Figure 23: Vertical line scan of the left fovea
Two distinct patterns of drusenoid change can be seen. Figure 24 shows drusen below the level of the retinal pigment epithelium (RPE) and these are described as basal laminar drusen. Subtle changes anterior to the RPE (figure 25) are described as reticular drusen. Changes same in the other eye.
Figure 24: Basal laminar drusen
The scans confirmed the original diagnosis of dry AMD. Advice about dietary modification and supplementation was appropriate along with regular monitoring.
Figure 25: Reticular drusen
Patient 3
History
The final patient was a 77-year-old female non-smoker. Other than osteoporosis, her general health was excellent. In June 2015, the patient had been diagnosed with wet AMD in the right eye. She had been treated with Lucentis injections (three times) followed, from September 2015 to January 2016, by three similar injections in the left eye. In May 2017, she had been discharged from hospital care and was to be monitored by regular routine eye examination by community optometry. She was taking MacuShield supplement.
Figure 26: Autofluorescence image of the right eye
BluePeak autofluorescence of the right eye showed areas of atrophy as black patches (figure 26). Volume scan of the macular region in the right eye showed the RPE elevation (figure 27). Figures 28 and 29 show similar for the left eye.
Figure 27: Volume scan of the right macula
Figure 28: Autofluorescence of the left eye
Figure 29: Volume scan of the left eye (note – the online version of this figure shows the video of the scan as it moves across the area under suspicion)
Figure 30
Figure 31
Live findings
Foveal line scans of each fovea (figures 30 and 31) showed historic elevation with fibrovascular pigment epithelial detachment, outer segments well intact and changes underneath the RPE. There was no evidence of any further leakage.
Thanks to Emily Malbon (Heidelberg) for supply of the data. For information on future events, go to www.heidelbergengineering.co.uk.