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Outer Retinal Tubulation

Outer Retinal Tubulation. Imoro Zeba Braimah, MBChB, FGCS, FWACS Paper presented at the Medical Knowledge Fiesta, GCPS, 15 th September 2016. INTRODUCTION. SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY. INTRODUCTION. Branching tubular structures- outer nuclear layer of retina

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Outer Retinal Tubulation

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  1. Outer Retinal Tubulation Imoro Zeba Braimah, MBChB, FGCS, FWACS Paper presented at the Medical Knowledge Fiesta, GCPS, 15th September 2016.

  2. INTRODUCTION • SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

  3. INTRODUCTION • Branching tubular structures- outer nuclear layer of retina • round or ovoid hyporeflective spaces with hyperreflective borders on SD-OCT. SD-OCT= spectral-domain optical coherence tomography, ORT=outer retinal tubulation, CME= cystoid macular edema Image courtesy of Sandrine A. Zweifel 1. Zweifel SA, Engelbert M, Laud K, et al: Outer retinal tubulation: a novel optical coherence tomography finding. Arch Ophthalmol 2009; 127: 1596–1602.

  4. Case • 66 years, Male with Choroidal Neovascular membrane both eyes-5yrs duration. • Came for follow up – April 2016 • Had monthly injections of intravitreal anti-vascular endothelial growth factors (anti-VEGF) agents in right eye • bevacizumab-12 injections • Ranibizumab-6 injections.

  5. Past History • First seen in KBTH-16/05/2014- sudden painless loss of vision Right eye, micropsia, metamorphopsia and inability to read– 2 days duration. • Had diabetes mellitus and hypertension under control

  6. C A B Fundus Photograph and SD-OCT at presentation E D F

  7. Diagnosis and Treatment • Diagnosis- Choroidal neovascular membrane(CNVM) Both eyes. Right active, left eye fibrotic. • Plan of treatment • Intravitreal injection of anti-VEGF right eye • Observe left eye

  8. B A C F E D Images A,B,C- Shows SD OCT Scans of the right eye at presentation and Images D, E, and F- shows the SD OCT scans after 3 injections of intravitreal bevacizumab in same eye

  9. 15 Months after Initial Bevacizumab Injection • Acuity right eye 6/18 • Intravitreal bevacizumab stopped and Ranibizumab started September 2015

  10. 24 Months after Initial Bevacizumab Injection • SD-OCT of both eyes with ORT in the left eye

  11. 26 Months after Initial Bevacizumab injection

  12. 27 Months after Initial Bevacizumab Injection SD-OCT Right eye showing new onset PED and Left Eye showing ORT

  13. 29/08/2016 28 months SD-OCT RIGHT EYE WITH HEMORRHAGIC PED AND LEFT EYE WITH ORT

  14. Diagnosis • Right Eye Choroidal neovascular membrane(CNVM)with persistent Intraretinal fluid and pigment epithelial detachment • Left Eye fibrotic CNVM with OUTER RETINAL TUBULATION

  15. OUTER RETINAL TUBULATION(ORT) • Occur due to rearrangement of degenerating/surviving photoreceptors • Advanced degenerative retinal disorders. Image courtesy of Sandrine A. Zweifel 1. Zweifel SA, Engelbert M, Laud K, et al: Outer retinal tubulation: a novel optical coherence tomography finding. Arch Ophthalmol 2009; 127: 1596–1602.

  16. DISEASE ASSOCIATIONS • Neovascular AMD(nvAMD) • Gyrate atrophy • Pseudoxantoma elasticum • Bietti crystalline dystrophy • Pattern dystrophy • Stargardts disease • Retinitis pigmentosa • Best Disease • Adult vitelliform foveomacular dystrophy Zweifel et al 2009 Goldberg et al 2013 Iriyama et al 2013 Dolz-Marco et al 2013 Braimah et al 2016

  17. Clinical Significance of ORT • May simulate Cystoid macular edema and subtretinal fluid • Associated with poor visual acuity outcome in nvAMD • Indicator of disease severity Lee et al 2014 Faria- Correia et al 2013 Espina et al 2015 Goldberg et al 2013

  18. Composite image of the right eye of a 32-year-old man with Best disease with stable ORT over a follow-up of 3 years

  19. CONCLUSION • ORT was identified in the left eye with fibrotic CNVM and worse visual acuity. • It is important to identify ORT in eyes with CNVM to avoid unnecessary treatment

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