Ancillary Testing in

Neuro-ophthalmology :
OCT et al.
Bonnie M. Keung, MD
Neuro-ophthalmology Clinic

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 Objectives
• Review of retinal and optic nerve anatomy
• To understand the role of OCT technology in
neuro-ophthalmology and neurology
– Demyelinating disease
– Optic nerve edema vs pseudopapilledema
– Compression of the optic nerve
• Basic interpretation of OCT RNFL and GCC

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 OCT
• Ancillary test in neuro-ophthalmology clinic
• OCT is a quick, non-contact, non-contrast
technique for imaging tissues at a 3D micron-
level resolution
• O = Optical = Light (infrared light)
• C = Coherence = monochromatic light
• T = Tomography = slices

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 Resolution of OCT

http://obel.ee.uwa.edu.au/research/fundamentals/introduction-oct/

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 OCT
• There are four generations
– 3rd generation: Time domain
– 4th generation: Spectral domain
• Routinely used in ophthalmology
– Glaucoma
– Retinal pathology

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Kimbrel EA, Lanza R. Current status of pluripotent stem cells: moving the first therapies to the clinic.
Nat Rev Drug Discov. 2015 Oct;14(10):681-92

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http://www.siumed.edu/~dking2/ssb/EE020b.htm

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Duker JS, et al. Handbook of Retinal OCT. 2014

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 OCT: imaging the macula
Case
• 50 yo neurosurgeon presents with central
vision loss OS x 2 weeks, metamorphopsia
• PMH: seasonal allergies
• Meds: intranasal steroid spray

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 OCT: imaging the macula
Case
• Exam
– VA 20/20, 20/60
– No RAPD

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OCT: imaging the macula

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OCT: imaging the macula

Duker JS, et al.

Handbook of Retinal
OCT. 2014

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 OCT: imaging the macula
Central Serous Chorioretinopathy
(CSCR)
• Build up of sub-retinal fluid in macula
• Related to increased corticosteroid exposure,
stress, type A personality
• Resolves spontaneously in a few months

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OCT: macula to nerve

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 OCT: RNFL
Retinal Nerve Fiber Layer

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 OCT: RNFL
Retinal Nerve Fiber Layer

Lamirel C,et al. Optical coherence tomography (OCT) in optic neuritis and multiple sclerosis.
Rev Neurol (Paris). 2010 Dec;166(12):978-86.

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OCT: print out

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OCT: RNFL

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 OCT: GCC
Ganglion Cell Complex

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 CASE
• 23 yo with right sided headache x 10 days,
followed by 24 hours of progressive vision loss
OD. Eye pain OD with movement.
• EXAM
– VA hand motion OD
– large RAPD OD
– Fundus exam: swelling of the optic nerve

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 CASE
Goldmann Visual Field OD

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 Case
Goldmann Visual Field OS

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OCT RNFL

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OCT GCC

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OCT Macula

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CASE

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 CASE – Optic neuritis
Anterior and retrobulbar
• Received IV solumedrol: 1 g daily x 5 days
• 1 month follow up
– No pain
– VA 20/20 OD and 20/20 OS

• Was OCT really necessary?

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OCT- Optic Neuritis with Disc swelling -
Acute

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OCT- Optic Neuritis with Disc swelling
1 month later…

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 OCT & Optic neuritis
• Loss of up to 20 microns per optic neuritis
• RNFL thinning occurs later
– 3-6 months

Costello F et al. Quantifying axonal loss after optic neuritis with optical coherence
tomography. Ann Neurol 2006 59:963-969

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 OCT & Optic Neuritis
• Optic neuritis
– RNFL 75 u = threshold value for visual recovery*

Costello F, et al. Tracking retinal nerve fiber layer loss after optic neuritis: a prospective study using optical
coherence tomography. Mult Scler. 2008 Aug;14(7):893-905

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 OCT & Optic Neuritis
• Case of using GCL, in optic neuritis MS
• Not affected by swelling of the nerve
• Earlier loss

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 OCT and Multiple Sclerosis (MS)
• OCT in non-ON eyes showed thinning in RNFL
compared to controls
• OCT predicts MS disability in patient without ON
– RNFL < 88 u
• 2x risk of disability worsening in 1-3 years
• 4x risk of disability worsening in 3-5 years
• OCT of GCC thinning reliably mirrors brain
degeneration
– More strongly associated with progressive MS
Martinez-Lapiscina EH, et al. Retinal thickness measured with optical coherence tomography and risk of disability
worsening in multiple sclerosis: a cohort study. Lancet Neurol. 2016 May;15(6):574-84.

Saidha, S., et al (2015), Optical coherence tomography reflects brain atrophy in multiple sclerosis: A four-year study.
Ann Neurol., 78: 801–813

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 OCT and NMOSD
• Average RNFL loss after MS-ON= 20 u
• Average RNFL loss after NMO-ON = 55-83 u

• Fellow eye in NMO less affected

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 OCT? Papilledema vs
Pseudopapilledema
CASE
• 20 yo female with history of migraine with
aura, 3 months of worsened headache.
• Seen by optometry, referred urgently for
papilledema with VA 20/20 OD and OS.
Mother requesting that MRI be done right
now.

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 OCT? Papilledema vs
Pseudopapilledema
EXAM
VA: 20/20 OD and OS, no dyschromatopsia
Motility: full, orthophoric

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 OCT? Papilledema vs
Pseudopapilledema
+HVF testing = normal
+OCT =
+CT scan (old) =

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 Optic Disc Drusen (ODD)
• Autosomally dominant inherited
• Intracellular and extracellular deposits that
become calcified over time.
• Scalloped disc margins

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 Optic Disc Drusen (ODD)
• 0.3%-2% of population
• Usually asymptomatic, or some visual field
defects

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OCT? Papilledema vs
Pseudopapilledema

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 Papilledema vs Pseudopapilledema
Drusen
• ? OCT
• Fundus EXAM!
• B scan
• CT scan
• Fluorescein angiogram (FANG)
• Fundus auto-fluorescence (FAF)
• Lumbar puncture
• Enhanced depth OCT (EDI-OCT)

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 The Fundus EXAM
Papilledema
• Disc vessels are obscured
• Elevation goes beyond disc
• Hemorrhages, exudates
• Not familial
Pseudopapilledema
• Overt superficial drusen
• Disc vessels clear
• Elevation confined to disc
• Usually no hemorrhages
• Drusen- autosomal
dominant
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The Fundus EXAM

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B-scan

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 CT scan

https://radiologykey.com/the-orbit/

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Fluorescein Angiogram

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Fundus Autofluorescence (FAF)

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 Enhanced depth OCT (EDI-OCT)

Silverman AL, Tatham AJ, Medeiros FA, Weinreb RN. Assessment of optic nerve head drusen using enhanced depth
imaging and swept source optical coherence tomography. J Neuroophthalmol. 2014 Jun;34(2):198-205

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 OCT: Papilledema
CASE
• 23 yo obese female
• 2 weeks of headache, shoulder pain, double
vision
• Mason General
– CT (-), MRV (-), LP = 49 cm H20
– Acetazolamide 1500 mg daily
• Optometrist calls
– VA 20/80 OD, 20/70 OS

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OCT: Papilledema

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 OCT: Papilledema
EXAM
• 250#
• Esotropia
• Stage 4 disc swelling

https://clinicalgate.com/use-of-the-hand-held-ophthalmoscope/

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Goldmann Visual Field OD

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Goldmann Visual Field OS

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 OCT: Papilledema
DIAGNOSIS:
• IIH, visual dysfunction

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IIH: Idiopathic Intracranial
Hypertension

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 OCT: Papilledema
DIAGNOSIS:
• IIH, visual dysfunction
PLAN:
• Acetazolamide 3500 mg daily
• Weight loss
• Close follow up
– Serial visual fields
– Serial OCTs

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OCT: Papilledema

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Follow-up Goldmann Visual Field

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 OCT: Pseudopapilledema vs
Papilledema
• OCT can be used to aid in the differentiation
between pseudopapilledema and papilledema
– Still lean on fundus exam, HPI
– Buried Drusen
• B scan, CT scan, FANG, FAF
• In cases of IIH, OCT can objectively track RNFL
elevation and help explain progress to patient

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 OCT: Pituitary Adenoma
CASE
• 56 y/o veteran with frontal and retro-orbital
headache, many weeks
• First received anti-biotics for presumed sinusitis
• Three days later, “blurred vision OS > OD”

• VA: 20/25 OD, 20/60 OS

• Normal ophthalmologic examination
– Ophthalmology attending: “He did have a trace RAPD
OS”

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Junctional Scotoma

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 OCT: Pituitary Adenoma
• Significant
improvement in visual
field if baseline OCT
– RNFL was normal
– if > 75-80 microns

Danesh-Meyer HV, et al. In vivo retinal nerve fiber layer thickness measured by optical coherence tomography predicts
visual recovery after surgery for parachiasmal tumors. Invest Ophthalmol Vis Sci. 2008 May;49(5):1879-85

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