Transcript A-Case-of-Anterior-Segment-Imaging-in-Acute-Anterior

GRAND ROUNDS
Anterior Segment OCT Imaging in a
case of Acute Anterior Uveitis
Mehreen Adhi, MD
October 21, 2016
Department of Ophthalmology and Visual Sciences
Patient Presentation
Chief Complaint:
• “My left eye hurts really bad and I cannot see anything
out of it”
HPI:
• 55 year old diabetic white gentleman presented to the
retina clinic in August 2016 at the Robley Rex VA
Medical Center with pain, photophobia and blurring of
vision OS for 5 days.
• He was vacationing in Las Vegas when symptoms
came on suddenly
• He had Cyclopentolate from one of his previous flare
ups that he started using before presenting
• Per patient, his left eye had “flared up” at least 3 times
in the past
Patient Presentation
HPI (continued…):
• First episode: June 2013 – resolved with
topical steroids
• Second episode: March 2014 – resolved
with topical steroids
- systemic work up done at this time
• Third episode: December 2015 – resolved
with topical steroids
Patient Presentation
Review of Systems:
• General: no fever, fatigue, weight loss
• Cardiovascular: unremarkable
• Respiratory: no flu-like symptoms,
sinusitis, hemoptysis, shortness of breath
• Gastrointestinal: h/o chronic diarrhea
• Genitourinary: unremarkable
• Neurological: unremarkable
• Musculoskeletal: h/o intermittent back pain
• Integumentary: no rash or skin lesions
Patient Presentation
Review of Systems:
• General: no fever, fatigue, weight loss
• Cardiovascular: unremarkable
• Respiratory: no flu-like symptoms,
sinusitis, hemoptysis, shortness of breath
• Gastrointestinal: h/o chronic diarrhea
• Genitourinary: unremarkable
• Neurological: unremarkable
• Musculoskeletal: h/o intermittent back pain
• Integumentary: no rash or skin lesions
Patient Presentation
Past Ocular History:
• No h/o trauma to either eye; no h/o similar episodes in OD
• Mild non-proliferative diabetic retinopathy OU
• Glaucoma suspect OU: based on cup/disc ratio
• Nuclear sclerotic cataract OU
Past Medical History:
• Diabetes (insulin dependent)
Past Surgical History / Family History:
• Unremarkable
Social History:
• Former smoker; occasional/social alcohol use; no recreational
drugs
Medications:
• Long-acting insulin (Glargine) and pre-prandial insulin sliding scale
Allergies:
• No known drug allergies
External Exam
OD
OS
Bestcorrected
VA
20/20
20/200
Refraction
-1.00 +0.75 x 178
-1.50 sphere
Pupils
3→2mm
IOP
18 mmHg
20 mmHg
EOM
Full
Full
CVF
Full
Full
No rAPD
5mm→unreactive
Anterior Segment Exam
SLE
OD
OS
External/Lids
WNL
WNL
Conj/Sclera
White and quiet
2+ diffuse conjunctival
injection
Cornea
Clear; no KPs
Stromal edema; no KPs
Ant Chamber
Deep and quiet
Deep; 2-3+ flare
Iris
WNL
Post synechiae from
~4:30 to 9:00 o’clock
Lens
1+NS; 1+CC
360 degrees fibrin
membrane overlying the
anterior aspect of the
lens
Gonio
D35rf1+; No PAS
D35rf1+; No PAS; fibrin
inferiorly
Posterior Segment Exam
Fundus
OD
OS
Optic Nerve
Pink and sharp; C/D 0.7
No view
Macula
Few MAs
No view
Vessels
WNL
No view
Periphery
WNL
No view
B-scan:
Vitreous clear;
Retina flat
Clinical Photos
OD
OS
Anterior Segment OCT
Anterior Segment OCT
386 um
282 um
Systemic workup
RPR
Non-reactive
FTA-ABS
Negative
Quantiferon TB
Negative
CBC
WNL
ESR
WNL
HLA-B27
Negative
ANA
Negative
Lyme
Negative
ACE
Negative
RF
Negative
CXR
C-scope and biopsy
WNL
Gross and biopsy WNL
Assessment
• 55 year old diabetic white gentleman with a 5
day history of blurred vision, photophobia
and pain in the left eye; exam significant for
2-3+ anterior chamber flare with a 360
degrees fibrin membrane overlying the
anterior aspect of the lens OS
• Recurrent Acute Non-granulomatous Acute
Uveitis OS
Plan and Follow up
•
•
•
•
Pred acetate ophthalmic solution Q1H OS
Medrol dose pack PO
Cyclopentolate ophthalmic solution TID OS
Alphagan ophthalmic solution BID OS
• Follow up 2 days later: sub-tenon Triescence
OS
• Follow up 3 weeks later….
External Exam
OD
OS
Bestcorrected
VA
20/20
20/20
Refraction
-1.00 +0.75 x 178
-1.50 sphere
Pupils
3→2mm
IOP
13 mmHg
14 mmHg
EOM
Full
Full
CVF
Full
Full
No rAPD
5mm→unreactive
Anterior Segment Exam
SLE
OD
OS
External/Lids
WNL
WNL
Conj/Sclera
White and quiet
Sub-tenon Triesence
Cornea
Clear; no KPs
Clear; no KPs
Ant Chamber
Deep and quiet
Deep and quiet; no cell
or flare
Iris
WNL
Post synechiae at ~4:00
and 5:00 o’clock
1+NS; 1+CC
1+ NS; 1+CC; fibrin
membrane previously
present on anterior
aspect of lens no more
visible
Lens
Posterior Segment Exam
Fundus
OD
OS
Optic Nerve
Pink and sharp; C/D 0.7
Pink and sharp; C/D 0.7
Macula
Few MAs
Few MAs
Vessels
WNL
WNL
Periphery
WNL
WNL
Clinical Photos
OD
OS
Anterior Segment OCT
Anterior Segment OCT
Discussion
• Anterior segment optical coherence
tomography (AS-OCT) allows the
visualization of various features of the
anterior segment
• In-vivo cross-sectional imaging of the anterior
segment from AS-OCT is particularly useful in
the presence of corneal opacity and ocular
inflammation
• Non-invasive ancillary test for assessment of
features of anterior uveitis, its complications,
and response to treatment
Discussion
• Corneal thickness/edema
Healthy subject
Acute anterior uveitis
Discussion
• Corneal thickness/edema
Healthy subject
Acute anterior uveitis
Discussion
Anterior segment optical coherence tomography in
acute anterior uveitis
Anterior segment optical coherence tomography in
Arq. Bras. Oftalmol. vol.77 no.1 São Paulo Jan./Feb. 2014
acute anterior uveitis
http://dx.doi.org/10.5935/0004-2749.20140002
Cristiana Agra, Lydianne
Agra, Jeanine Dantas, Tiago Eugênio
Faria e Arantes, João Lins de Andrade Neto
Purpose: To analyze the corneal thickness and anterior chamber (AC) angle using anterior
Arq. tomography
Bras. Oftalmol.
2014;with
77:1
segment optical coherence
(AS-OCT)Feb
in patients
acute anterior uveitis (AAU).
Methods: Twenty two patients (24 eyes) were included. All patients underwent complete
ophthalmological examination, applanation tonometry and AS-OCT at diagnosis and fifteen
days after treatment.
Results: Average corneal thickness before treatment was 564.2 ± 44.2 µm, 580.0 ± 44.3 µm
and 580.1 ± 2.9 µm, respectively in central, pericentral and paracentral cornea. Fifteen days
after treatment a significant decrease of corneal thickness was observed, with 529.5 ± 33.1 µm
(p=0.0091) and 542.6 ± 33.6 µm (p=0.0068), respectively in central and pericentral cornea;
paracentral corneal thickness (557.8 ± 35.3 µm) thinning did not reach statistical significance
(p=0.1253). There was no significant change in temporal AC angle between visits, 44.3 ± 14.4
degrees before treatment and 44.7 ± 14.7 degrees fifteen days after (p=0.9343), and mean
intraocular pressure, 10.8 ± 4.5 mmHg before treatment and 12.3 ± 3.0 mmHg fifteen days after
(p=0.1874).
Conclusion: In the studied group, AS-OCT detected a decrease of corneal thickness after AAU
treatment. Temporal AC angle and intraocular pressure did not change during the studied
period.
Discussion
• Keratic precipitates
Discussion
• Fibrin membrane
Discussion
• Inflammatory cells in the anterior chamber
Discussion
High-speed optical coherence tomography for imaging
High-speed
opticalinflammatory
coherence tomography
for imaging
anterior chamber
reaction in uveitis:
clinical
correlation and
grading.
anterior chamber inflammatory
reaction
in uveitis: clinical
Agarwal A1correlation
, Ashokkumar D,and
Jacobgrading.
S, Agarwal A, Saravanan Y.
Agarwal A, Ashokkumar D, Jacob S, et al
Am J Ophthalmol. 2009 Mar;147(3):413-416.e3.
Am J Ophthalmol
2009 Mar;147(3):413-416.e3.
PURPOSE: To evaluate the anterior chamber (AC) inflammatory reaction by anterior
segment high-speed optical coherence tomography (OCT).
DESIGN: A prospective, nonrandomized, observational case series.
METHODS: Sixty-two eyes of 45 patients were studied for AC reaction clinically and by
anterior segment OCT. Hyperreflective spots suggesting the presence of cells in the AC
from the OCT images were counted manually and by a custom made automated
software using MATLAB (Mathworks, Natick, Massachusetts, USA) and correlated with
clinical grading of AC cells using Standardization of Uveitis Nomenclature criteria.
RESULTS: In manual method, mean hyperreflective spots were 3 +/- 1.8 in grade 1, 12
+/- 3.5 in grade 2, 33.8 +/- 10.2 in grade 3, and 61.4 +/- 9.6 in grade 4. Automated
method showed mean 3 +/- 1.9 hyperreflective spots in grade 1, 12.4 +/- 3.6 in grade 2,
33.2 +/- 9.6 in grade 3, and 74.8 +/- 17 in grade 4. Significant difference seen in mean
values between the manual and automated method in grade 4 (P = .009). AC cells were
detected in 12 (19.3%) eyes with corneal edema with central corneal thickness ranging
from 702 to 1020 microns (mean, 843 +/- 109 microns). Out of 62 eyes, grade 4
aqueous flare was detected by OCT imaging in 7 eyes and clinically in 5 eyes.
CONCLUSION: Anterior segment OCT can be used as an imaging modality in detecting
AC inflammatory reaction in uveitis and also in eyes with decreased corneal clarity and
compromised AC visualization attributable to corneal edema. Automated method is
sensitive in higher grades of uveitis.
Discussion
Automated Analysis of Anterior Chamber
Automated
Analysis of Anterior Chamber
Inflammation by Spectral-Domain Optical Coherence
Inflammation byTomography.
Spectral-Domain Optical
1
1
Sharma S , Lowder
CY , Vasanji
A2, Baynes K1, Kaiser PK1,
Coherence
Tomography.
Srivastava SK3.
Sharma
S, Lowder
CY,
Baynes K, et al
Ophthalmology.
2015
Jul;122(7):1464-70
Ophthalmology 2015 Jul;122(7):1464-70
PURPOSE: This study was designed to determine the feasibility of anterior segment optical
coherence tomography (AS-OCT) to objectively image and quantify the degree of AC
inflammation.
DESIGN: Prospective evaluation of a diagnostic test.
PARTICIPANTS: Patients with anterior segment involving uveitis.
METHODS: Observational case series of patients with uveitis. Single-line and 3-dimensional
(3D) volume AS-OCT scans were manually graded to evaluate for the presence or absence of
cells in the AC. Clinical grading scores were correlated to the number of cells seen in each line
scan. An automated algorithm was developed to measure the number of cells seen in the 3D
volume scan and compared with manual measurements and clinical grading scores.
MAIN OUTCOME MEASURES: Degree of anterior segment inflammation.
RESULTS: A total of 114 eyes from 76 patients were imaged, 83 eyes with line scans and 31
eyes with volume scans. The average number of cells on line scans was 0.13 for grade 0, 1.2 for
grade 1/2+, 2.6 for grade 1+, 5.7 for grade 2+, 15.5 for grade 3+, and 41.2 for grade 4+.
Spearman correlation coefficient comparing clinical grade with the individual AS-OCT line
scans was 0.967 (P < 0.0001). The range of cells in the automated cell count of 3D volume scans
was 13.60 to 1222; the range for manual cell counts was from 9.2 to 2245. The Spearman
correlation coefficients were r = 0.7765 (P < 0.0001) and r = 0.7484 (P < 0.0001) comparing the
manual and automated cell counts with the clinical grade, respectively. Spearman correlation
coefficient comparing the automatic cell counts with manual cell count in the 3D volume scan
was 0.997 (P < 0.0001).
CONCLUSIONS: Anterior segment OCT can be used to image and grade the degree of AC
inflammation. Clinical grading strongly correlates with the number of cells on AS-OCT line
scans and volume scans. The automated algorithm to measure cell count had a high correlation to
manual measurement of cells in the 3D volume scans. This modality could be used to objectively
grade response to treatment.
Conclusions
• Anterior segment optical coherence
tomography (AS-OCT) may be a useful
non-invasive ancillary test in patients with
anterior uveitis
• Features such as corneal
thickness/edema, keratic precipitates,
fibrin deposition and anterior chamber
inflammation may be useful parameters to
assess treatment response
Acknowledgements
• Shorye Payne MD
• Mary and Tammy
• Drs. Syed, Fernandez, Kassm, Breaux,
Piri, Mueller
References
1. Cristiana Agra, Lydianne Agra, Jeanine Dantas, Tiago Eugênio Faria
e Arantes, João Lins de Andrade Neto. Anterior segment optical coherence
tomography in acute anterior uveitis. Arq. Bras. Oftalmol. Feb 2014; 77:1
2. Agarwal A, Ashokkumar D, Jacob S, et al. High-speed optical coherence
tomography for imaging anterior chamber inflammatory reaction in uveitis:
clinical correlation and grading. Am J Ophthalmol. 2009;147:413–416. e413.
3. Sharma S, Lowder CY, Vasanji A, Baynes K, Kaiser PK, et al. Automated
Analysis of Anterior Chamber Inflammation by Spectral-Domain Optical
Coherence Tomography. Ophthalmology 2015 Jul;122(7):1464-70.
4. Regatieri CV, Alwassia A, Zhang JY, et al. Use of Optical Coherence
Tomography in the Diagnosis and Management of Uveitis. Int Ophthalmol
Clin 2012 Fall; 52(4): 33-34
5. Lowder CY, Li Y, Perez VL, DH Anterior Chamber Cell Grading with HighSpeed Optical Coherence Tomography. Invest Ophthalmol Vis Sci. 2004;45
E-Abstract 3372.
Thank you