1. Outer Retinal Tubulation
Imoro Zeba Braimah, MBChB, FGCS, FWACS
Paper presented at the Medical Knowledge Fiesta, GCPS, 15th September 2016.

2. INTRODUCTION
SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

3. INTRODUCTION
Branching tubular structures- outer nuclear layer of retina
round or ovoid hyporeflective spaces with hyperreflective borders on SD-OCT.
SD-OCT= spectral-domain optical coherence tomography, ORT=outer retinal tubulation, CME= cystoid macular edema
Image courtesy of Sandrine A. Zweifel
1. Zweifel SA, Engelbert M, Laud K, et al: Outer retinal tubulation: a novel optical coherence tomography finding. Arch Ophthalmol 2009; 127: 1596–1602.

4. Case
66 years, Male with Choroidal Neovascular membrane both eyes-5yrs duration.
Came for follow up – April 2016
Had monthly injections of intravitreal anti-vascular endothelial growth factors (anti-VEGF) agents in right eye
bevacizumab-12 injections
Ranibizumab-6 injections.

5. Past History
First seen in KBTH-16/05/2014- sudden painless loss of vision Right eye, micropsia, metamorphopsia and inability to read– 2 days duration.
Had diabetes mellitus and hypertension under control
Examination
Right Eye
Left Eye
Visual acuity
CF at 4 metres
CF at 2 metres
Intraocular pressure
15mmHg
Lens
Nuclear sclerosis grade 1
Dilated fundus examination
Chorioretinal scar, haemorrhagic pigment epithelial detachment in macular
Chorioretinal scar, subretinal fibrosis, involving fovea centre

6. Fundus Photograph and SD-OCT at presentationB C E D F
Fundus Photograph and SD-OCT at presentation

7. Diagnosis and Treatment
Diagnosis- Choroidal neovascular membrane(CNVM) Both eyes. Right active, left eye fibrotic.
Plan of treatment
Intravitreal injection of anti-VEGF right eye
Observe left eye

8. Visual acuity
6/18
CF at 2 m B A C E F D
Images A,B,C- Shows SD OCT Scans of the right eye at presentation and Images D, E, and F- shows the SD OCT scans after 3 injections of intravitreal bevacizumab in same eye

9. 15 Months after Initial Bevacizumab Injection
Acuity right eye 6/18
Intravitreal bevacizumab stopped and Ranibizumab started
September 2015

10. 24 Months after Initial Bevacizumab Injection
Right Eye
Left Eye
Visual acuity
6/18
CF at 4 m
Intraocular pressure
14mmHg
SD-OCT of both eyes with ORT in the left eye

11. 26 Months after Initial Bevacizumab injection
Right Eye
Left Eye
V. acuity
6/60
CF at 4 m

12. 27 Months after Initial Bevacizumab Injection
Right Eye
Left Eye
Visual acuity
6/18
CF at 4 m
SD-OCT Right eye showing new onset PED and Left Eye showing ORT

13. SD-OCT RIGHT EYE WITH HEMORRHAGIC PED AND LEFT EYE WITH ORT
29/08/ months
SD-OCT RIGHT EYE WITH HEMORRHAGIC PED AND LEFT EYE WITH ORT

14. Diagnosis
Right Eye Choroidal neovascular membrane(CNVM)with persistent Intraretinal fluid and pigment epithelial detachment
Left Eye fibrotic CNVM with OUTER RETINAL TUBULATION

15. OUTER RETINAL TUBULATION(ORT)
Occur due to rearrangement of degenerating/surviving photoreceptors
Advanced degenerative retinal disorders.
Image courtesy of Sandrine A. Zweifel
1. Zweifel SA, Engelbert M, Laud K, et al: Outer retinal tubulation: a novel optical coherence tomography finding. Arch Ophthalmol 2009; 127: 1596–1602.

16. DISEASE ASSOCIATIONS Neovascular AMD(nvAMD) Gyrate atrophy
Pseudoxantoma elasticum
Bietti crystalline dystrophy
Pattern dystrophy
Stargardts disease
Retinitis pigmentosa
Best Disease
Adult vitelliform foveomacular dystrophy
Zweifel et al Goldberg et al 2013
Iriyama et al Dolz-Marco et al 2013
Braimah et al 2016

17. Clinical Significance of ORT
May simulate Cystoid macular edema and subtretinal fluid
Associated with poor visual acuity outcome in nvAMD
Indicator of disease severity
Lee et al 2014
Faria- Correia et al 2013
Espina et al 2015
Goldberg et al 2013

18. Composite image of the right eye of a 32-year-old man with Best disease with stable ORT over a follow-up of 3 years

19. CONCLUSION
ORT was identified in the left eye with fibrotic CNVM and worse visual acuity.
It is important to identify ORT in eyes with CNVM to avoid unnecessary treatment