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Optical coherence tomography (OCT) has had a major influence in ophthalmology in the last decade, contributing to a better understanding of pathology in the posterior segment of the eye. It has become an invaluable tool for diagnosing diseases that may be missed during routine clinical examination.
When evaluating the eyes of pediatric patients, routine diagnostic tools like applanation tonometry, ultrasound biometry, and pachymetry can be difficult to use because they come in direct contact with a child’s eyes. OCT, on the other hand, is noninvasive. It produces high-resolution images of biological tissue useful for investigating diseases in children and adolescents. Earlier-generation time-domain OCT devices were widely touted as a means to achieve in vivo histological examinations. This is even more true with the faster scanning speeds inherent to spectraldomain OCT technology (achieved by the use of a fixed, broader-spectrum light source and improved software). In the context of young patients, who often have difficulty with sustained fixation, the speed of image capture becomes increasingly important.
Two of the more common reasons for pediatric office visits in my practice are complaints of poor vision or unexplained headaches. In the past, my examination of these patients would consist of slit-lamp biomicroscopy, motility, and a full dilated and cycloplegic fundus exam. It was not uncommon in many of these cases to find no causative pathology—thus ruling out such things as cataract, glaucoma, retina issues, and neurological problems—but communicating this to families was not always easy.
Now, when I am confronted with the same situation, I have the results of the OCT scan to supplement the conversation. It is comforting for families to clearly see that there is no edema of the optic nerve, for example, or that the macula exhibits no abnormalities. I find that parents are very appreciative of being able to view an objective image rather than just hearing my report.
An additional benefit of OCT in a pediatric practice is that it has reduced the need for outside consulation and referrals. If I am able to verify that a patient does not have a marker of more advanced or subclinical disease, there may be no reason for additional workup of that patient, whether that is in my office or with a specialist.
ENHANCING DIAGNOSTIC ABILITY
In my practice, I am sometimes referred patients from local pediatricians for evaluation of red eye that is suspicious for keratitis or uveitis. Just as using my slit lamp helps me differentiate anterior segment pathology, the OCT adds to my evaluation of posterior segment disorders.
Retinal diseases in adults can be subtle, whereas in pediatric patients, pathology of the retina or vitreous is usually very obvious. There is always a chance, however, for a rare disease with subtle findings. I have used OCT to diagnose a number of uncommon pathologies in children, such as a shallow retinal detachment in an adolescent (in most children, retinal detachments are very bullous).
OCT images are also useful for evaluating optic nerve drusen, which in pediatric patients can mimic true disc edema. I often receive referals for possible papilledema. An examination with indirect ophthalmoscopy and OCT helps to differentiate optic nerve drusen from true disc edema.
EASE OF USE
The examination process can sometimes induce fear in young children. For children three years and older, fixation toys are frequently used to gain confidence and distract young patients during the evaluation. These kinds of strategies can be used with the OCT as well. I use the iVue OCT (Optovue, Inc., Fremont, CA) in my practice. In my experience, the small size of this particular device makes it less intimidating to young patients. I like to tell young children that I want to take a picture of their eyes with something like the slit lamp, which they are already familiar with. Unless they are overly apprehensive, the images are readily obtainable.
The iVue OCT is also portable and can be taken off its stand for scanning in any position. When working with sometimes anxious young patients, the small size and portability of the device are no small consideration.
The OCT has become an essential tool for a thorough examination of adult patients. Because about 20% of my practice is general ophthalmology, I decided to purchase an OCT. As an added benefit, I have found OCT to be useful for evaluating pediatric patients, especially when communicating with parents and family members.
Stephen B. Prepas, MD, is in private practice in Newport Beach, California, and is an assitant clinical professor of ophthalmology at George Washington University School of Medicine. Dr. Prepas has received financial considerations from Optovue. He may be reached at email@example.com.