CRYO, PDT & WIDE ANGLE

FUNDUS CAMERA

MODERATOR-
PRESENTOR- DR.
DR. JAY SINGH DEVASHISH
SIR
Wide Field Retinal Imaging Systems
Introduction

Create a 2D image of 3D retinal tissue.

It helps to view the retinal disease and plan treatment according to the pathology.

diagnosis and management of ocular and systemic disorders like DR, HTN retinopathy, ARMD,
vascular pathologies (vascular occlusions, vasculitis, etc), RD, systemic infections, leukemias,
systemic malignancies with ocular metastasis, and others.
The Evolution in Retinal Imaging

Evolved at a remarkable pace in the last two decades.

WFI :beyond 50 degrees field area.

UWFI: upto 200 degrees as in Optos: capable of imaging over 80% of the retinal surface area.

Can be photographed with small pupils.

The modern systems allowing 100° to 200° view of
fundus include:

• Pomerantzeff camera- Equator-plus camera:

image 148 degrees : use two illuminating fiber
bundles, one for the central field and one for the
periphery, at different locations on the cornea and
different inclinations of incidence: limitations-
absence of high resolution and brilliance/bright
artefacts. The patient was imaged in sitting
position.
• Retcam (Contact)- maximum 130 degrees. The patient is usually supine, but images
can be captured in adult or cooperative patients in sitting position also.
• Optos camera
(Noncontact)- Maximum
200 degrees. Patient is
imaged in sitting position or
in cases of babies in flying
baby position. It gives
pseudocolor images.
• Heidelberg
Spectralis with the
Staurenghi lens
(Noncontact for 105
degree and contact for
150 degree Staurenghi
lens)- Pseudocolor
images.
• Clarus 500
(Noncontact)- 133º in
single image and 200º
in two images -
noncontact imaging -
true color imaging and
autofluorescence modes
(blue, green and
infrared)
Advantages of modern digital WFI and UWFI systems:

Ease of image
Shorter image Faster image
Enhanced resolution duplication,
processing time acquisition
manipulation and

Better acquisition in Non-compliant

Possibility of image
eyes with cataract young pediatric Patients with very
transmission via
than a traditional patients to dilated small pupils
electronic route
fundus camera retinal examination

Simultaneous
imaging of central
and peripheral
retina;
 • The integration of the CSLO and OCT has produced a
dynamic new instrument, the OCT ophthalmoscope,
which simultaneously images the fundus in numerous
ways with point to point correlation.
Confocal scanning
laser
ophthalmoscopy • CSLO systems use laser light to illuminate the retina,
instead of bright flashes of light. This reduces scatter
imaging (CSLO) of light in images acquired.
systems
Examples of cSLO-based UWFI systems include:
• the Optos camera
• the Spectralis
Multimodal Imaging with WFI and UFWI systems

It offers simultaneous acquisition of-

• FFA
• ICGA
• red-free photography
• fundus photography, color fundus stereo imaging
• adaptics optics CSLO
• hyperspectral retinal imaging
• FAF; including blue-reflectance (BAF), infrared reflectance (IRAF)
or green reflectance (GAF).
Applications of WFI and UWFI in Ocular Conditions
Retinal Vascular Occlusions
Retinal Vasculitis
Pediatric Retinal Disorders
Posterior Uveitis
Peripheral Retinal Detachments
Peripheral Retinal Degenerations
Peripheral retinoschisis
Familial Exudative Vitreoretinopathy (FEVR)
Eales' disease
Acute Retinal Necrosis

Retinal detachments - exudative and tractional

Peripheral retinal lesions which predispose to retinal detachment

Screening for diabetic retinopathy

Scenerios when scleral depression may be contraindicated

Ocular tumors
Limitations of WFI and UWFI

Difficulty to precisely measure the retinal surface area in order

to estimation size and dimensions of retinal lesions.

Image artifacts

Conversion of a 3D surface to 2D image is still a challenge in

retinal imaging
 Research prototype: swept source OCT with speeds as
high as 6700000 A scans/sec. With such high speed
OCTs, 4-D intraoperative OCT may not be very distant.
The Future
Direction
frequency-swept light source called as the vertical
cavity surface emitting laser: very high imaging range of
up to 50mm: image the entire eye, including anterior
segment, lens, vitreous, retina, choroid and sclera in a
single OCT – A 3D OCT image of the entire eye!
Cryotherapy

Extraocular technique: Freezing the eye to create inflammation in the area of

application.

The primary advantage- ability to penetrate the sclera and to create a retinal
adhesion without causing scleral necrosis.

Cryosurgery also allowed transconjunctival prophylactic coagulation of

peripheral lesions without causing necrosis of the intervening tissues.

The reluctance to employ cryosurgery was the uncertainty of the strength of

the cryopexy-induced adhesion
 cryoprobe is a plastic insulated pencil-like device with
a metallic tip :end of the shaft at 90°.

Nitrous oxide gas is transferred to the probe.

PROCEDURE The cooling effect is obtained by expansion of the gas

in the probe tip (Joule-Thompson effect).

Working pressures-between 400 and 625 psi and yield

temperatures at the tip between -30°C and -60°C.
 prophylactic treatment of retinal breaks

retinal breaks combined with segmental buckling

a retinal break combined with a temporary balloon buckle

INDICATION pancryocoagulation in the photocoagulated diabetic eye

retinopathy of prematurity

tumors (e.g. retinoblastoma and angioma)

• How does the strength of the cryopexy-induced adhesion compare
with that produced by diathermy?

• Is there a difference in strength of an adhesion produced by light,

medium, and heavy applications of cryopexy or diathermy?

• On what day is maximum adhesion obtained?

Light cryosurgical application
• Choroid blanches and the lesion is barely perceptible after
removing the cryoprobe.

Medium cryosurgical application

• Retina first turns white. With removal of the cryoprobe, the white
area of the retina fades, leaving a faint gray area representing
intraretinal edema

Heavy cryosurgical application

• This involves sustained freezing for 3 seconds after the retina first
turns white. When the probe is removed, an opaque lesion persists.
Three distinct levels of adhesive strength corresponded to light,
medium, and heavy applications.

A light cryosurgical lesion resisted an average pull of 300 mg, a

medium lesion resisted 575 mg, and a heavy lesion resisted 1175 mg .

The cryosurgical adhesion gained strength rapidly after the second

day and the diathermy lesion after the fourth day.

Diathermy lesions reached their maximum adhesive strength by the

tenth day and cryosurgery by the twelfth day.
Anatomic mechanisms that produce retinal adhesions after cryosurgery :

1) Interdigitation of newly formed rods with villi of the RPE, producing a mild adhesion.

2) Desmosomal connection between the Muller cells and the smooth surface of new RPE or the
basement membrane of RPE, resulting in a strong adhesion.

3) Infiltrative or chorioretinal adhesion in which processes of Muller cells infiltrate the collagen
lamellae of Bruch's membrane to yield a very strong adhesion with a thin fragile retina.
• a) day 1

• b) day 4

• c) week 2

• d) week 4

• e) month 2
Cryotherapy is like glue where laser is more like a stapler.

During a week following cryotherapy combined with pneumatic

retinopexy, positioning is important because the bubble holds the
retina in place while the cryotherapy adhesion matures.
 The probe can perforate thin (blue)
sclera.
Conjunctival chemosis.
COMPLICATIONS
Breakdown of the blood-aqueous
barrier.
Dispersion of RPE results from
excessive freezing.
Photodynamic Therapy (PDT)
Introduction

• Introduced to ophthalmology- 1990s, using intravenously administered verteporfin,

followed by the application of low power and long duration infrared laser.

• Induce occlusion of abnormal microvasculature in both CNVM and choroidal

tumors.

• The initial indication- CNV secondary to AMD, however, it is now second-line to

anti-VEGF therapy. 
Drug/Laser Mechanism of Action
Verteporfin Drug Information

Verteporfin with a molar mass of 718.794 and a half-life of about 5 hours.

approved in 2000 by the FDA, indicated for CNV in classic subfoveal neovascular
AMD, pathologic myopia, and ocular histoplasmosis.

longer wavelength absorption of 690 nm

It’s relatively quick half-life allows it to be rapidly cleared from the body
Verteporfin Mechanism of Action
Injection of a photosensitizing agent.

Activation by low intensity light.

Photochemical interaction produces singlet oxygen

and superoxide anions.

Cellular damage, vascular occlusion, thrombosis.

 Age-Related Macular Degeneration (Wet Form)
Central Serous Chorioretinopathy
Polypoidal Choroidal Vasculopathy
Indications Peripapillary Choroidal Neovascularization
Choroidal Hemangiomas
Retinal Capillary Hemangioblastomas
Choroidal Melanoma
Choroidal Metastasis
Procedure

Standard Laser Settings and Protocol at 689 nm light

Dose: 6 mg/m2 body surface area

Fluence (full): 50 J/cm2

Irradiance: 600 mW/cm2

Time: 83 seconds
Verteporfin is administered via intravenous
infusion of 30ml over 10 minutes

15 minutes after the initiation of the infusion,

laser light is delivered over 83 seconds using a
laser contact lens on the treatment eye under TA. Steps:
Spot size:1000 microns larger than the GLD of the
lesion.

PDT laser spot: does not extend within 200

microns of the optic nerve head border.
 To reduce incidence of post-procedure scarring and choroidal
hypoperfusion.

Safety
Enhanced” various modifications of the PDT regime: half (3mg/m2)
verteporfin dose, half (25J/cm2) fluence laser.

Settings • Post-treatment
Patients are followed every 4-12 weeks. Patients may be tested
with fluorescence and/or indocyanine green angiography
(FA/ICG) angiography to investigate the efficacy of treatment
and guide additional treatment sessions.
porphyria

severe hepatic function impairment

known hypersensitivity to verteporfin

CONTRAINDICATIONS
uncontrolled hypertension

unstable cardiovascular disease

active hepatitis.
 2) Systemic side effects

Injection site adverse events

Risks/Side
Effects Transient photosensitivity reactions

Infusion related back pain

2) Ocular side effects

Transient visual disturbances

Subretinal hemorrhage
Increased fibrosis associated with CNV
Increased RPE atrophy
Eye pain
Severe visual loss which may occur within one week
 Complications

1) Secondary CNV
2) Reactive hyperplasia of the RPE
3) Optic atrophy

• Fortunately, secondary CNV is successfully treated with intravitreal anti-VEGF agents.

• Although 1-4% of patients may develop a decrease in vision, this is typically transient and risks
are decreased with reduced dose/fluence settings.
THANK YOU