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Things that Go Bump in the OCT Evaluation

Written by Larry J Alexander OD FAAO, Dr. Arash Sadeghian Thursday, 21 November 2013

When an OCT B-Scan shows an elevation…a bump if you will…what considerations should you have? First and foremost decide the anatomical location of the bump. Is it in front of or behind the retinal pigment epithelium? An elevation of the retinal pigment epithelium is at almost ninety(90) degrees while a neurosensory elevation is typically very shallow. Is the bump in the outer retinal layer? Once that determination is made the differential diagnosis is facilitated.

 

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However, the most significant fact is that a diagnosis and management plan cannot be made solely “in the vacuum of one or two SDOCT scans”.  The clinician must coordinate all clinical modalities available to arrive at a plan.  The clinical observations are very critical.

Caveat: When using any guidelines one must consider correlation with other patient characteristics and other clinical tests such as but not limited to: chief complaint, age, gender, ethnicity, refractive status, family history, associated medical conditions, current medications, pachymetry, visual field testing, angle assessment.

Having said that, appropriate follow-up on all patients is necessary.

Following are several examples of Bumps that present on B-Scan OCTs with the associated potential considerations.

BUMPS UNDER THE RETINAL PIGMENT EPITHELIUM

CASE

In this case we have a patient with a convex presentation of the B Scan of the left eye compared to the right eye.  The OS is hyperopic and is a long-standing amblyopic eye while the OD is emmetropic.  Note also that the convexity is generalized.  Concerns would include something in the orbit pushing the sclera forward but with that there would be a refractive change and other signs and symptoms.  Additionally the appearance of the fundus must be taken into account in the differential diagnosis.  Appropriate follow-up on all patients is necessary.

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 CASE

Contrast with this case where we have a patient with a convex presentation of the B Scan of the left eye compared to the right eye but it is more localized. This bump is underneath the retinal pigment epithelium and appears to be in the choroid.  Concerns would include something in the choroid pushing the retina forward.  Additionally the appearance of the fundus must be taken into account in the differential diagnosis.  The view of the fundus revealed a large choroidal melanoma.  Appropriate follow-up on all patients is necessary.

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CASE

In this case the elevation or “bump” likewise is under the retinal pigment epithelium and appears to be in the temporal retinal area.  This area needs further investigation with other testing protocol and must be related to case history and associated fundus appearance. Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located superior to the macula and temporal to the fovea underneath the retinal pigment epithelium.  Because of the isolated location this area needs to be further investigated with other testing protocol and must be related to the associated fundus appearance.  Also note some very dominant “bumps” in the outer retinal layer with the hint of exudates.  Coordination with the fundus appearance and other testing is critical.  This is a very suspicious scan. Appropriate follow-up on all patients is necessary.

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CASE

In this case the “bump” emanates from the choroid elevating everything above.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  This is a “mass of some variation”.  Appropriate follow-up on all patients is necessary.

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 CASE

These “bumps” are located in the macula and underneath the retinal pigment epithelium.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  These bumps represent depositions on Bruch’s membrane and are fairly symmetrical implicating a dystrophic condition.  Appropriate follow-up on all patients is necessary.

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CASE

These “bumps” are located in the macula and underneath the retinal pigment epithelium.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  These bumps represent elevations on the top of Bruch’s membrane and are fairly symmetrical implicating a dystrophic condition.  Appropriate follow-up on all patients is necessary.

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CASE

These “bumps” are located underneath the retinal pigment epithelium.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  These areas represent drusen and/or retinal pigment epithelial disease. Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located underneath the retinal pigment epithelium and Bruch’s membrane penetrating upward.  This area need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  This is retinal pigment epithelial disease with associated choroidal changes. Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located underneath the retinal pigment epithelium and penetrating upward through Bruch’s membrane.  This area need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  This is retinal pigment epithelial disease with associated choroidal changes that may represent choroidal neovascularization. Appropriate follow-up on all patients is necessary.

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CASE

There is a “bump” located underneath the retinal pigment epithelium and also the neurosensory retina.  The neurosensory retina also has a suspicious bump that is associated with potential neovascularization.  This area need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  Appropriate follow-up on all patients is necessary.

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CASE

An example of the coordination of “testing” showing the Bump in OD with the associated fundus photograph.  In this case there is a suspicious benign choroidal melanoma with overlying Retinal Pigment Epithelial changes. Appropriate follow-up on all patients is necessary.

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CASE

Another example of the coordination of “testing” showing the Bump in OS with the associated fundus photograph.  In this case there is a benign choroidal melanoma with overlying Retinal Pigment Epithelial changes. Appropriate follow-up on all patients is necessary.

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BUMPS ABOVE THE RETINAL PIGMENT EPITHELIUM

CASE

In this case the “bumps” are between the choroid and the neurosensory retina.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  Appropriate follow-up on all patients is necessary.

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CASE

In this case the “bump” is between the choroid and the neurosensory retina.  These areas need to be further investigated with other testing protocol and must be related to the associated fundus appearance.  This appears to be scarring. Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located superior to and including the macula.   It is above the retinal pigment epithelium.  This bump represents a neurosensory separation from the underlying structure. Coordination with the fundus appearance and other testing is critical.  Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located in the macula.   It is above the retinal pigment epithelium.  This bump represents a neurosensory separation from the underlying structure. Coordination with the fundus appearance and other testing is critical.  Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located in the macula.   It is above the retinal pigment epithelium.  This bump represents a cystic leaking issue involving the sensory retina. Coordination with the fundus appearance and other testing is critical.  Appropriate follow-up on all patients is necessary.

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CASE

This “bump” is located in the macula on the top of the retina.   At this location a retinal arterial macroaneurysm is suspect. Coordination with the fundus appearance and other testing is critical.  Note Gross elevation on retinal map. Appropriate follow-up on all patients is necessary.

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CONCLUSIONS

Things that go bump in an OCT evaluation are more often than not significant.  The clinician must first determine the anatomical location of the bump, determine if the bump is the same in both eyes (symmetry) and coordinate that bump with other clinical information and observations.  The cause of the bump cannot be determined base on the scan alone.  A diagnosis cannot be determined by one piece of information but must be a coordination of all materials.

 

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About the Author(s)

Larry J Alexander OD FAAO

Larry J Alexander OD FAAO

Dr. Alexander (1948-2016) was a 1971 graduate of Indiana University School of Optometry. He served in the US Navy then served as a Professor at the University of Alabama Birmingham School of Optometry. Larry contributed to a number of chapters in textbooks and has published three editions of Primary Care of the Posterior Segment, as well as contributed to the professional literature. He also lectured extensively in the area of ocular and systemic disease. His areas of special interest included dysfunctional tear syndrome, glaucoma and macular degeneration.  His lessons are the basis for this site and he will be dearly missed. 

Dr. Arash Sadeghian

Dr. Arash Sadeghian

Dr. Arash Sadeghian graduated from the Southern California College of Optometry. He opened his optometric practice in Corona in 2003. His experience, as well as his ongoing training in special aspects of the field, has allowed him to offer his patients the broadest range of vision care options available today. In addition to his extensive work with contact lenses, low vision, occupational vision, laser surgery and cataract co-management, Dr. Sadeghian is also certified in the use of diagnostic pharmaceutical agents (DPA) and therapeutic pharmaceutical agents & Glaucoma (TPG) for the treatment and management of ocular diseases. Dedicated to promoting the highest standards of his profession, Dr. Sadeghian is a member of the Inland Empire Optometric Society and volunteers his time for special projects. Dr. Sadeghian is also a member of the American Optometric Association.

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