OCT reveals true diagnosis

“Case Scenario,” illustrates how a specific device’s image(s) aided in patient management.

PATIENT

A 53-year-old white female with Type 2 diabetes diagnosed two years prior; most recent HbA1c of 8.0%.

EXAM FINDINGS

Best-corrected distance vision: OD: 20/70, OS: 20/30 through a compound hyperopic astigmatic refraction with a +1.00 DS shift in OD.

OU: pigmented changes in macula with feeder vessel to macula from arcade. OD: amsler: + metamorphopsia. OS: focal edema pockets inferior and temporal to fovea.

APPROACH

Zeiss OCT Macular Cube 512 x 128 and angiography 6x6 mm en face analysis, revealing significantly thinned central macular thickness with adjacent focal intraretinal pockets of edema and leakage in the avascular zone. Referral for retinal consult.

DIAGNOSIS

Macular Telangiectasia Type 2

MANAGEMENT

One round of anti-VEGF injections OU, followed by intravitreal steroid-implant OS.

PATIENT CARE TIP

Use imaging to obtain data

CODING

92014, 92015, 92134 OM

CASE STUDY

See the disruption of the intraretinal and RPE layers noted on OCT analysis.

 

 

SUBMIT YOUR CASE STUDIES AT bit.ly/CASESCENARIO

We want to hear how a specific technology aided in the management of a patient.

DR. BARCLAY practices at Ginter Eyecare Center in Lubbock, Texas. He specializes in dry eye disease and among other areas of optometry.

DR. CAMACHO practices at Ginter Eyecare Center in Lubbock, Texas. He specializes in dry eye disease, specialty contact lenses and vision therapy.