Insights into advanced retinopathy of prematurity using handheld spectral domain optical coherence tomography imaging

Abstract

Purpose: To elucidate the subclinical anatomy of retinopathy of prematurity (ROP) using spectral domain optical coherence tomography (SD OCT).

Design: Prospective, observational case series.

Participants: Three low-birth-weight, severely premature infants.

Methods: Clinical examination was performed using a portable slit lamp and indirect ophthalmoscope. Imaging was performed by using a handheld SD OCT device and Retcam (Clarity Medical Systems, Pleasanton, CA) or video-indirect recording. Spectral domain optical coherence tomography imaging was conducted without sedation at the bedside in the neonatal intensive care unit on 1 patient. The other 2 patients had an examination under anesthesia with SD OCT imaging in the operating room.

Main outcome measures: In vivo determination of vitreoretinal morphology, anatomy, and pathology by clinical examination, imaging, and SD OCT.

Results: Linear and volumetric imaging was achieved with the handheld system in infant eyes despite tunica vasculosa lentis and vitreous bands. Imaging was not possible in eyes with notable vitreous hemorrhage. Analysis of SD OCT images revealed preretinal structures (ranging from 409 to 2700 microm in width and 212 to 440 microm in height), retinoschisis, and retinal detachment in the posterior pole of patients with advanced ROP. Both the retinoschisis and the preretinal structures were not identified on conventional examination or imaging by expert pediatric ophthalmologists. The preretinal structures varied in location and size, and may represent preretinal fibrovascular proliferation. Some were found in close proximity to blood vessels, whereas others were near the optic nerve.

Conclusions: Handheld SD OCT imaging can be performed on the sedated or nonsedated neonate and provides valuable subclinical anatomic information. This novel imaging modality can reveal the location and extent of posterior ROP pathology not evident on standard examination. This could affect future clinical decision-making if studies validate a management strategy based on findings from this imaging technique.

Figures

Figure 1

Mobile workstation connected to a handheld probe for spectral domain optical coherence tomography (SD OCT) imaging in the operating room. A neonate is positioned in the supine position with the operator using a wrist rest to stabilize the noncontact hand-held SD OCT probe.

Figure 2

Patient 1’s left eye. A, Video-indirect image of the optic nerve and posterior pole of the retina without evidence of preretinal structures. B, Sum voxel projection image of optic nerve and posterior pole. There is also partial loss of some B-scan images from motion artifact (white arrows). C, Same summed voxel projection image in (B) with preretinal tissue (red areas in D) surrounding and overlying optic nerve. Light blue arrows provide image orientation (B, C). Scale bars are 1000 μm. D, Cropped cross-sectional spectral domain optical coherence tomography (SD OCT) image demonstrates preretinal structures traced in red and corresponds to yellow vertical line in (C). Purple arrows denote shadowing artifact of preretinal structures (D, F), and yellow arrows point to focal shadowing (D, F). E, Three-dimensional SD OCT image depicts preretinal structures in the posterior pole. N = nasal; T = temporal. F, Representative cross-sectional image demonstrates a variety of subclinical pathology. Green arrow indicates retinal detachment, brown arrow denotes retinoschisis, and red arrows point to preretinal structures. G, Retcam fundus photograph demonstrates tractional retinal detachment 1 month after SD OCT imaging.

Figure 3

Patient 1’s right eye. A, Representative video-indirect ophthalmoscopy image without evidence of preretinal tufts and clear optic nerve head margins. B, Sum voxel projection of the preretinal tissue (red areas in C) demonstrates close proximity of preretinal structures to blood vessels. The yellow line corresponds to the location of the cross-sectional spectral domain optical coherence tomography (SD OCT) image in (C). Light blue arrows provide image orientation (B, C). Scale bars are 1000 μm. C, Cross-sectional SD OCT image demonstrates preretinal structures outlined in red. White arrow points to an arcing imaging artifact, dark blue arrows correspond to shadowing from retinal blood vessels, and purple arrows correspond to shadowing from preretinal structures. D, Retcam fundus photograph demonstrates tractional retinal detachment with dense pre-retinal fibrosis over the optic nerve and macula 1 month after SD OCT imaging.

Figure 4

Patient 2’s right eye. A, Retcam fundus photography demonstrates tractional retinal detachment temporal to the fovea and chorioretinal scars from laser retinopexy. B, Cross-sectional spectral domain optical coherence tomography (SD OCT) image shows retinal detachment (green arrow) and subclinical retinoschisis (lamellar schisis) (brown arrow). Light blue arrows provide image orientation (B, C). C, Sum voxel projection image with yellow line corresponding to cross-sectional SD OCT image in (B). Vascular pattern can be correlated with image in (A). D, Three-dimensional SD OCT image from temporal side of retina depicts retinoschisis and retinal detachment.

Figure 5

Patient 3’s right eye before vitrectomy surgery. A, Retcam fundus photography demonstrates tractional retinal detachment, vitreous hemorrhage, thick membrane complex over the macula creating prominent retinal folds, and tractional retinal detachment. B, Sum voxel projection with visible vascular pattern not seen clearly in (A). Yellow line corresponds to exact location of cross-sectional B scan in (C), and dashed blue line corresponds to approximate location of repeated linear scan in (D). Note that dashed blue line is partially displaced to the right of the image based on image alignment of this compared with the B scans comprising summed voxel projection in (B). Light blue arrows provide image orientation (B–D). C, Cross-sectional volumetric spectral domain optical coherence tomography (SD OCT) image shows vitreous attachments (orange arrowsC, D) and retinoschisis (brown arrow). D, Cross-sectional summed linear SD OCT image shows retinal detachment (green arrow), epiretinal membrane with vitreous attachments, and deep intraretinal/subretinal structures (2 of 5 are labeled with tan arrows).

Figure 6

Patient 3’s left eye 4 days after vitrectomy surgery. A, Cross-sectional spectral domain optical coherence tomography (SD OCT) image demonstrates retinal detachment (green arrow) and retinoschisis (brown arrow). There are also subretinal hyperreflective dots present near green arrow. Light blue arrows provide image orientation (A, B). B, Sum voxel projection image with yellow line corresponds to the approximate location of the cross-sectional SD OCT image in (A). C, Retcam fundus photography demonstrates tractional retinal detachment and chorioretinal scars from laser retinopexy.