Introduction
Early detection of eye conditions is crucial for preventing vision loss and ensuring optimal eye health. Many ocular diseases, such as glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy, may progress silently and can cause significant damage before symptoms become apparent. Timely diagnosis and intervention can dramatically improve patient outcomes, preserving vision and quality of life.
Optical coherence tomography (OCT) has emerged as a powerful tool in the early detection and management of eye diseases. This non-invasive imaging technology provides high-resolution cross-sectional images of the retina, allowing for the detection of subtle structural changes long before clinical symptoms arise. By facilitating early diagnosis, OCT imaging enables prompt treatment and monitoring, which is vital for slowing or halting disease progression.
For eyecare professionals (ECPs), understanding how to leverage OCT imaging for the diagnosis and management of a variety of ocular conditions is a key aspect of clinical practice.
The power of early detection
Effective ophthalmic care depends on the prompt diagnosis and timely intervention of ocular conditions. Numerous studies support the benefits of early detection in preventing vision loss and improving the prognosis of various eye diseases.
Conditions such as glaucoma, AMD, and diabetic retinopathy often progress without noticeable symptoms until significant damage has occurred. By the time symptoms are evident, irreversible vision loss may have already occurred.
Glaucoma, often referred to as the “silent thief of sight,” remains one of the leading causes of blindness worldwide, and approximately 3 million Americans have the disease.1,2 Given the lack of early symptoms, it is estimated that 50% of individuals with glaucoma are unaware they have the condition, highlighting the significant need for advanced diagnostic tools.1
Timely diagnosis and treatment can prevent or possibly slow the progression of optic nerve damage, preserving vision. Research shows that in half of glaucoma cases, early intervention can delay the onset of blindness by 20 years, underscoring the importance of prompt screening and diagnosis.3 Advanced imaging techniques, such as OCT, can assist in the discovery of structural changes in the optic nerve before functional vision loss occurs.
AMD—a leading cause of blindness in older adults—is another example where early intervention is paramount. Data shows that, among patients aged 65-70 years worldwide, AMD may cause severe visual loss and blindness ranging from 9% to 25%.4 With an aging population, the prevalence of this condition is expected to rise with patient cases estimated reaching 288 million by 2040.5
Effective management of AMD depends on early identification. Treatments, such as anti-VEGF injections and new dry AMD therapies (i.e., pegcetacoplan and avacincaptad pegol), are most effective when administered in the disease's initial stages. Patients diagnosed early and treated promptly typically have better visual outcomes compared to those diagnosed with more advanced disease. Further, loss of vision has a significant impact on quality of life and an individual’s ability to maintain daily activities.
In addition to the toll these sight-threatening conditions can have on the health and quality of life of patients, there is also an economic burden to consider. It is estimated that more than 3.4 million Americans, 40 years and older, are blind or visually impaired, and this number is expected to double by 2030.6 Subsequently, approximately 80 million individuals in the U.S. have diseases that can lead to blindness.6 One study estimates that the economic burden of vision loss is $134.2 billion broken down to $98.7 billion in direct costs and $35.5 billion in indirect costs.7
Switching to epidemiological prevalence data, it was found that more than 41% of Medicare fee-for-service (FFS) beneficiaries in 2018 had a claim related to one of the following vision conditions: cataract (33.7%), glaucoma (13.3%), AMD (9.2%), and diabetic retinopathy (3.2%).8 Medicare paid $10.2 billion for these four conditions—AMD: $3.5 billion; cataracts: $3.6 billion; glaucoma: $2.2 billion; and diabetic retinopathy: $0.8 billion.8
These data support the concept that early detection and intervention can not only help patients mitigate the costs of advanced disease, but also lessen the impact of these conditions on the healthcare system as a whole. “Study after study has shown that the earlier a chronic, or even acute, condition is diagnosed, the better the prognosis after treatment,” notes Joseph Pizzimenti, OD, FAAO, FORS, FNAP, an internationally-recognized leading expert in collaborative medical retina care at the Centers for Retina and Macular Disease located in Central Florida. “Having wrestled with retinal diseases like macular degeneration for over three decades, I have witnessed the evolution of detection and treatment techniques firsthand.”
“Thirty years ago, we would take a look with our ophthalmoscope, slit lamp, and condensing lens and identify a patient with moderate- to late-stage macular degeneration; however, by that time a lot of damage had already occurred,” he said. “Thanks to advances in technology, we are now able to detect these diseases sooner, which has been transformative for our profession and puts us in a position to positively impact the well-being of our patients.”
Christopher B. Kruthoff, OD, FAAO of Northwest Eye, sees a high volume of glaucoma, AMD, and geographic atrophy (GA) cases; OCT plays an important role in his collaborative multidisciplinary practice located in Golden Valley, Minnesota. “As it pertains to macular degeneration, this tool supports our ability to monitor disease and identify conversion to wet or neovascular macular degeneration. Additionally, with the advent of treatments for geographic atrophy, OCT helps us identify patients who could benefit from these therapies.”
“In terms of glaucoma, we know that a fair amount of retinal nerve fiber layer loss can occur before we actually get any depression of our visual field; therefore, OCT is critical because we can often uncover changes to the optic nerve that are consistent with glaucoma before there's any visual impact,” he says, while emphasizing that early identification and prompt treatment to prevent further nerve damage may help keep vision loss at bay, or at the very least, prevent loss of functional vision over a patient's lifetime.
Key features & benefits of ZEISS CIRRUS 6000
Optical coherence tomography has revolutionized ophthalmic imaging, offering unparalleled insights into ocular structures with clarity and precision. Among the cutting-edge devices in this field, the ZEISS CIRRUS 6000 OCT stands out, combining advanced technology with a user-friendly design.
The most recent iteration of this device provides high-speed image capture with HD imaging detail and a wider field of view. Rapid image acquisition times can aid in providing more insight into your patient’s condition.
At 100,000 scans per second, optometrists and ophthalmologists have access to faster imaging with greater detail. Compared to prior generations of CIRRUS, this 100 kHz Spectral-Domain OCT/OCTA model offers 270% faster OCT scans and 43% faster OCTA scans. High-speed imaging coupled with FastTrac™ eye-tracking technology helps reduce the chance of motion artifacts, such as those resulting from blinks and saccades.9 OCT cube scans are generated in as little as 0.4 seconds.
A key component of effective diagnosis and treatment is quality, detailed imaging. Eyecare providers (ECPs) using the CIRRUS 6000 can expect high-definition, widefield imaging with 12x12 mm single-shot OCTA cube scan in addition to 8x8, 6x6 and 3x3 mm scans. The device supports up to 2.9 mm scan depth. Additionally, it provides even greater microvascular detail with high-definition AngioPlex scans (8x8 and 6x6 mm).
Dr. Kruthoff finds the faster image acquisition of the CIRRUS 6000 to be incredibly valuable not just for his practice, but for the patient experience as a whole. “Chronic conditions like glaucoma and AMD typically occur in older patients, and those patients can find it difficult to sit in certain positions for a long period of time,” he notes. “And so, the faster image acquisition is especially helpful for our patients to avoid any issues with discomfort, which can then lead to issues of poor patient positioning and fixation as well as poor image acquisitions.
“We are able to get better quality images and faster, which is going to lead to better overall scans and better data for analysis,” Dr. Kruthoff says. “With that comes faster patient flow within the lanes, improved efficiency for our technician staff and, ultimately, happier patients because they are able to complete their clinical exam at a faster rate.”
To elevate ophthalmic practice, the CIRRUS 6000 can seamlessly connect with ZEISS FORUM as well as the Retina and Glaucoma Workplaces. The Retina Workplace integrates imaging data from multiple modalities and allows for the quick catalog of ultra-widefield fundus images with OCT/OCTA images, all on one screen. This can help ECPs capture the full scope of a pathology and generate both qualitative and quantitative analysis results.
With the Glaucoma Workplace, optometrists and ophthalmologists can examine longitudinal data from visual fields and OCT for guided analysis to monitor for disease progression. This platform integrates multiple individual datasets into a single visualization, which helps guide clinical assessments and disease management.
For Dr. Pizzimenti, the CIRRUS 6000 is a critical component of his clinical practice. “We lead with diagnostic testing,” he says. “Early on, following the case history and brief entrance testing, we bring our patients right to the OCT. They will undergo a series of scans within the macula and optic nerve followed by ultra-wide field imaging of their fundus.”
Using the integrated, multi-modality Retina Workplace, Dr. Pizzimenti and colleagues can view the data before even seeing the patient. “This is a huge advantage and gives me a clear idea of what to look for and where to look for it, which streamlines our patient care.”
If warranted, Dr. Pizzimenti will then rescan patients with OCTA and this data is added to the patient database and Retinal Workplace for further review. “Now we're able to examine the fundus photos using various filters, including fundus autofluorescence, which can be very helpful in AMD and numerous other conditions,” he explains.
“With all of this information at our fingertips, my job is much easier. It helps with workflow and makes the office more efficient. I am able to make accurate clinical decisions in a very short period of time, which assists in the prompt diagnosis and treatment of our patients.”
The reference database
Another unique feature of this device is its comprehensive reference database for macular, RNFL, GC/IPL thickness, and ONH, which supports diagnosis and treatment planning. This continually growing database has more than tripled in size since previous versions, with a library containing 870 patients. It also provides a more customized assessment by taking into account different optic disc sizes (small, medium, and large) in addition to age.
ECPs can leverage this database to compare measurements with a reference range for healthy eyes aged 18 to 88, interpolated from quantile regressions using additional statistical models.9
With access to a wide range of clinically validated applications for the retina, glaucoma, and anterior segment, ECPs can be confident in their treatment decisions. The CIRRUS 6000 automatically stores patient’s historical data, providing clinicians with a variety of change assessments. This includes macular thickness change maps that can offer a concise picture of each patient’s progress and response to treatment.
The CIRRUS suite of glaucoma analysis tools helps providers better identify and manage patients at all stages, from glaucoma suspects and mild disease to severe glaucoma. A unique feature is the Guided Progression Analysis™ (GPA™), which delivers both event and trend-based analyses. Further, the elegance of this software allows it to detect progression when it falls outside of the range of expected variability and quantifies the rate of change for crucial RNFL, ONH, and GCL/IPL parameters.
In addition to the various features mentioned above, including speed of scan acquisition, widefield imaging, and extensive reference database, the CIRRUS 6000 stands out for its ease of use and simple interface, according to Dr. Pizzimenti. “We have found that staff members are able to learn the technology and how to acquire excellent scans very quickly. This is critical for a busy practice where delays can have a significant impact on overall patient care.”
Tackling cybersecurity
In an increasingly digital world, the healthcare sector has become a prime target for cyberattacks. Medical devices represent a vulnerable entry point and can be exposed to various threats, such as data breaches, malware and viruses, and unauthorized access.
Mitigating these risks might take a multifaceted approach and must be a priority for all stakeholders. Secure software development, network security, data encryption, access control and authentication, and regulatory compliance are all key factors of strong cybersecurity.
Human error still remains a significant risk factor. Regular training and awareness programs for medical staff can help lessen this risk. For instance, educating staff about the dangers of phishing and how to recognize suspicious emails can prevent malware infections. Consequently, consistent and recurrent training schedules on best practices for using and securing OCT machines can also help minimize vulnerabilities.
Manufacturers of these medical instruments have, by default, become software companies, says Dr. Pizzimenti, “Optometrists and ophthalmologists are no longer just buying an OCT. They are purchasing an entire software package and with that comes an increased risk of security breaches.”
Therefore, that extra assurance and commitment from the company to say, “we have this piece of equipment that not only enhances your clinical practice, but also comes with safeguards to keep your patients’ medical information safe, is crucial,” notes Dr. Pizzimenti.
The CIRRUS 6000 is equipped with core cybersecurity features to meet evolving compliance and security needs. These include enhanced password security, enterprise-scale security requirements, and more.
Encrypting data both at rest and in transit is essential to protect sensitive information from unauthorized access. ECPs using the CIRRUS 6000 can feel confident that their data is secure with data encryption and DICOM Transport Layer Secure (TLS) protocol.
Other key cybersecurity features include a new InterBase ultra-fast embeddable database for additional data security and instant disaster recovery. CIRRUS 6000 supports Windows 10 configuration to run in Federal Information Processing Standards (FIPS) mode.
“Ensuring the privacy of patient data is of paramount importance,” emphasizes Dr. Pizzimenti. “Patients entrust us with protected medical information, and as eyecare providers, we need to do everything in our power to follow HIPAA guidelines and keep that data secure.”
By implementing robust security measures, adhering to regulatory requirements, and fostering a culture of cybersecurity awareness, healthcare providers can protect patient data, ensure the accuracy and reliability of diagnoses, and maintain the overall integrity of medical services.
Optimizing patient care
Current research consistently shows that early diagnosis and intervention lead to better patient outcomes, preventing vision loss and improving quality of life.10 Advances in diagnostic tools, particularly OCT and AI, are enhancing the ability of clinicians to detect eye diseases at their earliest stages.
“OCT is a critical part of management for so many of the ocular conditions we see in clinical practice,” says Dr. Kruthoff. “Advancements in image acquisition and quality as well as the power of the validated reference database at our disposal is only going to enhance our ability to accurately diagnose and help guide the treatment for these patients".
"This is beneficial not only for our patients but also us as doctors in our efforts to provide the best possible care and outcomes,” he notes. “I am excited about the direction that this technology is headed and I am very happy to have these improvements on board to help me confidently manage the care for my patients.”
As technology continues to evolve, the potential for even earlier and more accurate detection of eye conditions will further improve patient care and outcomes. By integrating these advanced diagnostic techniques into routine eyecare, healthcare providers can ensure that eye diseases are identified and treated promptly, safeguarding the vision and overall health of their patients.
OCT at work: Patient case examples
An 83-year-old Caucasian female presented to the clinic for regular follow-up of her primary open-angle glaucoma, severe stage in the right eye and moderate stage in the left eye. She reported excellent compliance with all her medications. She reported no changes to her vision or ocular status since her last visit three months prior. She was scheduled for optical coherence tomography (OCT) testing at this visit to monitor progression of her glaucoma.
Detailed patient history
Her surgical history was remarkable for cataract surgery in both eyes roughly 18 years prior, three separate rounds of selective laser trabeculoplasty (SLT) in each eye, and XEN Gel Stent (AbbVie) in the right eye two years prior for uncontrolled intraocular pressure (IOP). Despite her surgical interventions, IOP control required medication to reach her target pressure of mid-teens. Her drop regimen included brimonidine twice daily, dorzolamide-timolol twice daily, and latanoprostene bunod nightly, for both eyes.
Pertinent clinical findings
- Uncorrected visual acuity was stable at 20/150 OD (patient was corrected for monovision at the time of her cataract surgery with the right eye corrected for near vision) and 20/25 OS.
- Pupil testing showed a previously documented relative afferent pupillary defect OD, attributable to the advanced nature of her glaucoma.
- Extraocular motilities were full, and confrontation visual fields showed constriction of her superior visual field OD, again attributable to her glaucoma.
- Intraocular pressure (IOP) measurement by Goldmann tonometry was 25 mmHg OD and 15 mmHg OS.
- Slit lamp examination was remarkable for a flat bleb over her previous gel stent OD indicating no aqueous outflow, moderate corneal staining OU from her significant medication use, and well-centered posterior chamber intraocular lenses OU.
- Dilated fundoscopy illustrated the following:
- 0.9 cup to disc (C/D) ratio with diffuse optic nerve thinning more advanced in the inferior quadrant OD, with a 0.7 C/D with thinning more notable in the superior aspect OS
- All other posterior segment findings were unremarkable.
OCT imaging pertaining to her glaucoma is seen below:
Figure 1. Retinal nerve fiber layer (RNFL) analysis shows diffuse thinning of the right optic nerve, more advanced inferior. The left optic nerve is also remarkable for an early wedge defect at the superotemporal aspect of the disc.
Figure 2. Ganglion cell analysis shows diffuse thinning of the ganglion cell layer/inner plexiform layer complex in the right eye. The left eye shows a classic inferior temporal raphe sign, indicating damage to the inferior nerve fibers that respects the horizontal raphe. This is in contrast to the superior thinning on the RNFL scan, but did correlate to a superior arcuate defect noted on visual field testing.
Figure 3. Guided Progression Analysis (GPA) of the right eye shows advanced nerve tissue loss and progression compared to baseline scans from ten years prior. While the progression has slowed in recent years, there is still concern for further nerve tissue loss, especially with the noted spike in IOP.
Figure 4. GPA of the left eye shows concern for progressive nerve fiber layer loss in the superior quadrant. Even with IOP at target, the patient may benefit from tighter control of her IOP. Fluctuations in out-of-office IOP should be taken into consideration.
Discussion
Glaucoma is a progressive condition that can lead to irreversible loss of vision without proper intervention.11 While several factors may influence the progression of glaucomatous damage, high IOP remains the main risk factor for development of glaucoma and is the only modifiable factor that is proven to slow the progression of the disease.12,13 As severity of glaucoma increases, lower target IOPs are often needed to prevent further damage and potential loss of vision.14
Initial interventions to lower IOP include topical medications, often used in tandem as seen in this patient, and SLT, which is emerging as a first line treatment option based on results of the recent LiGHT study.15 In cases where IOP remains above the desired levels, as seen in the right eye for our patient, or where progression continues despite seemingly good IOP control, as seen in the left eye for our patient, surgical intervention may be warranted.
Microinvasive glaucoma surgeries (MIGS) are a growing array of surgical options for patients who need only mild reduction in their IOP or need a reduction in their medication load. These options often provide faster recovery, less impact on visual acuity, and fewer adverse effects than traditional glaucoma surgeries.16,17 For those with more advanced disease requiring low IOP, more robust surgical options such as trabeculectomy and glaucoma drainage devices are indicated. While the recovery time and adverse effect profile may be higher in these surgeries, the ability to drive IOP into the low teens or even single digits make these viable and necessary options in the patient with severe and progressive glaucoma.18-21
Treatment plan
Given the severity of her glaucoma, the poor IOP control, and the concern for progression in each eye, along with the secondary concern for ocular surface breakdown from her significant medication load, the patient was referred for surgical consult to prevent further optic nerve tissue loss. A tube shunt was recommended for the right eye to give a better chance at achieving consistently low intraocular pressure. The surgical decision for the left eye is pending and determinant on the outcome of her right eye’s procedure. Given the more stable IOP control and less advanced glaucoma, microinvasive glaucoma surgical options may be considered for faster recovery and improved side effect profile.15
A 33-year-old Hispanic female with unremarkable ocular and medical history presented with severe central vision loss in one eye secondary to a referral for evaluation of a “macular hemorrhage”. Upon examination and ancillary testing, the cause was determined to be the presence of a choroidal neovascular membrane (CNVM). This case aims to present the investigation that took place with this non-traditional presentation of CNV, its differential diagnoses, optical coherence tomography (OCT) and OCT-Angiography (OCTA) findings, and management. A thorough evaluation of the fundus and the patient’s ocular and medical history ultimately led to the conclusion that the CNV was idiopathic, though possibly exacerbated by head trauma.
Detailed patient history
The patient described reduced central vision in her left eye (OS) with flashes of light lasting a few seconds with the onset of symptoms occurring two weeks ago. Within that time, the patient subsequently reported being in a close-call car accident, hitting her head on the window one week prior. She was a spectacle wearer without remarkable personal medical or ocular history. Family history was unknown since she was adopted. The patient denied any medications or allergies and was not pregnant.
Pertinent clinical findings
- Best corrected VA of 20/30 OD and 20/300 OS with improvement to 20/250 with eccentric viewing in the left eye.
- Confrontation fields, motility, and cover test were within normal limits.
- Trace APD OS was evident.
- IOP measurements were 18 mmHg OD and 20 mmHg OS.
- Slit lamp examination of the anterior segment was unremarkable
- Dilated fundoscopy illustrated the following:
- Operculated hole OD with signs of chronicity, not active.
- Grey-green elevated lesion approximately 1 disc diameter (DD) in the area superior to and involving the fovea with an adjacent intraretinal hemorrhage measuring 0.5 DD that was overlying the thickened retinal area.
With the examination findings pointing to the presence of CNV and high likelihood of subretinal fluid involvement, macular OCT was performed. As seen in Figure 5, the macular OCT scan reveals a disruption at the level of the RPE as it loses integrity and the presence of hyper-reflective material consistent with a CNV.
Figure 5. Note RPE-Bruch/choroid disruption with overlying hyper-reflective material and a small area of adjacent subretinal fluid.
This area of hyper-reflectivity is even better visualized in Figure 6 of the OCTA and is consistent with abnormal vasculature.
Figure 6. OCT-Angiography En face image visualizing CNV OS.
Figure 7. OCT appearance after three anti-VEGF injections.
Discussion
Age-related macular degeneration (AMD) is one of the commonly encountered conditions in the 21st century with secondary CNVMs potentially leading to devastating and lasting vision loss even in the modern retinal practice.22 While there is a classical association between these clinical entities, this finding is also related with various etiologies and varying demographics that do not fit traditional notions of a senescent disease.
Choroidal neovascular membranes can arise from systemic inflammatory conditions, various infectious causes, and trauma.23,24 Traumatic etiologies are not isolated to ruptures to the choroid, rather they may occur even if significant laser scarring can penetrate Bruch’s membrane potentiating the formation of a CNV.25,26 The possibility that the patient experienced ocular trauma at some point of her life without recalling it became a major consideration in this case.
There are two events that may have necessitated CNV formation. The first possibility might be Bruch’s membrane degradation or disruption along with a hypoxic event recruiting vascular endothelial growth factor (VEGF).23 Secondary causes and etiologies outside of the typical association with nAMD including presumed ocular histoplasmosis syndrome (POHS), pathologically degenerative myopia, idiopathic polypoidal choroidal vasculopathy, angioid streaks of collagen-vascular disease, sickle cell anemia, Paget’s disease, choroidal rupture, tumors, retinal scarring after laser photocoagulation, posterior uveitis, and idiopathic pathologies.23-30
Treatment and prognosis
The patient was diagnosed with a unilateral, active CNVM and was co-managed with a local retinal specialist. Patients in this young demographic usually fare better visually than what is expected of our nAMD patients. In traumatic CNV, the formation of the membrane at times can be part of the healing process or develop up to two years later.25,31,32
Impact resistant eyewear and continued close monitoring is paramount, as these lesions are prone to recurrence. The health of the fellow eye certainly requires special attention to safeguard against further injury with a recommendation to receive comprehensive monitoring on a close basis for the first year.25,31,32
Conclusions
When we suspect CNV in an atypical patient, confirming the diagnosis with modern imaging techniques like OCTA is an efficient and non-invasive means of precise evaluation. A review of systems, evaluation of the fellow eye, and additional history can help rule out other potential causes that may need management by other medical specialties such as chronic inflammatory disease.
Special Acknowledgements: Alexander Martinez, OD, Kirsti Ramirez, OD, Richard Trevino, OD
A 57-year-old Hispanic male patient with a history of glaucoma presented with insidious blur OU. Examination revealed high IOPs, significant optic nerve cupping, and bitemporal field loss in each eye. Multimodal imaging reveals the diagnoses.
Detailed patient history
The patient presented with a chief complaint of distance blur in both eyes that gradually worsened within the past two years. His medical history was remarkable for depression, anxiety, obsessive-compulsive disorder (OCD) diagnosed in 2002, and chronic hypertension dating back to 2017. He was currently being treated with an unknown hypertensive medication.
His documented ocular history showed a diagnosis of unspecified glaucoma from 1980 coupled with laser peripheral iridotomies (LPIs) in both eyes performed by a surgeon in 2002. The family medical history was unremarkable whereas his family ocular history was pertinent for his mother’s glaucoma diagnosis.
Of note, the patient had been medically treated for glaucoma, but he ceased to adhere to the drops.
Pertinent clinical findings
- Best corrected VA of 20/40-2 OD and 20/200 OS. PHNI OD/OS.
- Confrontations showed temporal defects OD/OS that appeared to respect the vertical midline.
- Color vision exam revealed dyschromatopsia OS > OD.
- IOPs were 24 mmHg OD and 26 mmHg OS.
- Slit lamp showed patent LPI OD and non-patent LPI OS.
- Dilated fundoscopy illustrated the following:
- C/Ds of 0.80 OD and 0.70 OS.
- 1+ disc pallor of left optic disc was noted.
Ophthalmic imaging studies
Figure 8. Fundus Color Photography demonstrates the significant rim thinning along with an inferonasal notch at approximately 7 o’clock was evident in the right eye and correlated with OCT nerve/RNFL findings.
Figure 9. HVF 24-2 (SITA Standard testing strategy) illustrates significant bitemporal hemianopsia along with a superior arcuate defect OS and subtle centrocecal defects OD. Note the high mean deviation and pattern standard deviation in both eyes.
Figure 10. OCT and RNFL analysis revealed greater thinning in the left eye (left image). The ganglion cell analysis (GCA) in the right image demonstrated significant thinning of the ganglion cell complex (GCC) in both eyes with one small inferotemporal sector spared (red circle).
Laboratory studies
The patient reported that routine blood work results from his last physical were unremarkable.
Radiology studies
Magnetic resonance imaging (MRI) of the brain—with emphasis on the optic chiasm—with and without contrast was ordered. MRI revealed a 2.6 x 3 x 4.4 cm T1 isointense, T2 iso/hyperintense heterogeneously enhancing sellar lesion with suprasellar extension, and mass effect on the chiasm. There was less than 50% encasement of bilateral cavernous internal carotid arteries, consistent with macroadenoma. There was also a mass effect on bilateral anterior communicating arteries and the third ventricle.
Figure 11. MRI illustrates macroadenoma (sagittal section in the left image, axial section of brain and orbits in the right image) highlighted with the yellow circle in each imaging study.
Differential diagnosis
The primary/leading differential diagnosis was compressive optic neuropathy secondary to a chiasmal lesion such as pituitary macroadenoma. Other potential diagnoses may include craniopharyngioma, parasellar internal carotid arterial aneurysm, meningioma, and third ventricle hydrocephalus.34-36
Diagnosis and discussion
Nonfunctioning pituitary adenoma is the second most common type of pituitary adenoma.33 Unlike functioning adenomas, they don’t secrete hormones causing clinical syndromes, and are commonly macroadenomas. If untreated, 50% of macroadenomas will grow within four years33 while those who were treated may have the same 50% risk for residual tumor regrowth within five years after surgery.34-36 Chiasmal lesions may initially affect acuity, then subsequently cause field loss, diplopia, fatigue, seizures, optic atrophy, optic nerve cupping, and ganglion cell death.
Although this patient was also suffering from glaucoma, it is essential to be able to detect non-glaucomatous signs of optic nerve atrophy. Unexplained decreased central vision, nerve pallor, visual field defects respecting the vertical midline, and other neurologic symptoms should alert the clinician. One study also showed that isolated temporal rim thinning is a specific sign of non-glaucomatous cupping, specifically compressive optic neuropathies.37 Typically, glaucomatous nerves will have less rim pallor, more pronounced vertical elongation of the cup, peripapillary atrophy, and disc hemorrhaging.38
Treatment and management
The patient underwent successful transsphenoidal surgery. He was scheduled for an MRI two weeks later to determine if there were any remnants of the adenoma.
Conclusions
Patients frequently have multiple conditions affecting the same tissues. It is important to question and investigate any inconsistent findings. This patient with glaucoma also had a chiasmal lesion. Careful ophthalmic workup revealed bitemporal field defects and optic disc pallor. This prompted further investigation and detection of a pituitary macroadenoma, which was amenable to surgery.
Final thoughts
Advances in diagnostic tools like optical coherence tomography (OCT and OCTA) are transforming the ability to detect eye diseases early, before significant vision loss occurs. The ZEISS CIRRUS 6000 OCT stands at the forefront of this revolution, providing high-resolution widefield imaging, rapid scan speeds, eye tracking, a comprehensive reference database, including integration with multimodal ZEISS FORUM Workplaces for streamlined clinical workflows. Enhanced cybersecurity features, safeguarding patient data, the CIRRUS 6000 represents a powerful all-in-one solution for comprehensive ophthalmic imaging and analysis.
As this technology continues evolving, the potential for earlier and more accurate detection will further elevate patient care and vision preservation. By integrating advanced OCT into routine practice, ECPs can promptly identify and treat blinding eye diseases like glaucoma, macular degeneration, and diabetic retinopathy at their most treatable stages. Coupled with the insights of skilled clinicians and surgeons, this allows for tailored intervention to possibly mitigate irreversible vision loss, improving outcomes and quality of life for patients worldwide. The future of preserving sight lies in fully embracing these innovative diagnostic capabilities.
