In this episode of Inside Intrepid, Caroline Majcher, OD, FAAO, FORS, professor and director of residency programs at the Oklahoma College of Optometry, and Daniel Epshtein, OD, FAAO, associate clinical professor at SUNY College of Optometry, discussed how optical coherence tomography angiography (OCTA) is changing retinal disease detection.
The message throughout the conversation was clear: OCTA is helping clinicians find vascular disease earlier, sometimes before it becomes obvious on examination or structural OCT.1
OCT angiography fast facts
- OCTA visualizes retinal and choroidal vasculature without dye injection.2
- Unlike fluorescein angiography, OCTA is noninvasive and easily repeatable during follow up.2
- OCTA is becoming increasingly valuable in diabetic retinopathy, age-related macular degeneration (AMD), retinal vascular occlusions, and macular ischemia, particularly when subtle vascular changes are suspected.1
- High-resolution 3x3mm scans can improve detection of subtle neovascularization.3
- Widefield and montage OCTA imaging may reveal peripheral pathology missed clinically.2
Earlier detection in AMD
One of the biggest advantages of OCTA is the ability to detect non-exudative neovascularization before fluid or hemorrhage develops.3 Before OCTA, clinicians often suspected these abnormal vascular membranes existed, but there was no reliable way to consistently visualize them during routine care.3
OCTA is changing that. Drs. Majcher and Epshtein discussed using targeted 3x3mm scans over suspicious lesions, particularly shallow irregular PEDs, to identify early vascular changes before exudation occurs. This may be especially valuable in patients with progressing AMD or suspicious PEDs.3
“Sometimes it’s scary the things we could have missed if we don’t use OCT angiography.”
Changing diabetic retinopathy management
The conversation also highlighted how OCTA may change the management of diabetic retinopathy.4,5 Both clinicians described cases where pathology that was initially believed to represent hemorrhage or intraretinal microvascular abnormalities (IRMA) was later identified on OCTA as subtle neovascularization.
That distinction can completely change referral urgency, follow-up intervals, and treatment planning.4,5 Widefield and montage OCTA imaging may also reveal peripheral neovascularization that is difficult to appreciate clinically, particularly in patients with severe diabetic retinopathy.4,5
“Our clinical examination really doesn’t show us as much as we think or as much as we would like to.”
Evaluating macular ischemia
Another major strength of OCTA is its ability to evaluate macular ischemia and retinal non-perfusion.1,4,5 Dr. Epshtein described diabetic patients with relatively stable structural OCT findings but persistent vision loss.
In many of these patients, OCTA revealed significant disruption of the foveal avascular zone and areas of non-perfusion that helped explain poor visual function.4,5 Dr. Majcher also discussed OCTA’s role in retinal vein occlusions, particularly in assessing ischemia and identifying patients at greater risk for future neovascularization.1
Why isn’t OCTA everywhere yet?
The speakers were also honest about OCTA’s current limitations. In real-world practice, scan quality can break down quickly if patients cannot maintain steady fixation, particularly older adults or patients with advanced retinal disease. Even subtle movement can create artifacts, blur fine vascular detail, or make borderline pathology harder to interpret confidently.2
They also noted that earlier OCTA systems were slower and more limited in peripheral imaging, making it harder to efficiently capture pathology during routine clinic flow. But that appears to be changing quickly. Faster scan speeds, wider imaging fields, and improved software are making OCTA more practical, more efficient, and far easier to integrate into everyday patient care.2
OCTA is changing how early retinal vascular disease is detected, and in some cases, what clinicians are able to detect at all.1
This article was written by Dianne Barnard, RN based on the recorded conversation between Drs. Epshtein and Majcher.
