Three 'Red Lines' for Pattern Recognition-Based Differential Diagnosis Using Optical Coherence Tomography in Clinical Practice

Background: Optical coherence tomography (OCT) devices for imaging of the eye are broadly available. The test is noninvasive, rapid, and well-tolerated by patients. This creates a large number of OCT images and patient referrals. Interpretation of OCT findings at the interface between neurological and ophthalmologic conditions has become a key skill in the neuro-ophthalmology service. Similar to the interpretation of visual fields, recogntion of the vertical and horizontal medians are helpful. A third 'red line' is added, which will be reviewed here. Evidence: Levels 1a to 5 evidence. Acquisition: Literature research. Results: There is level 1a evidence that neurodegeneration of the brain is associated with inner retinal layer atrophy. Predominantly, this is driven by retrograde (trans-synaptic) axonal degeneration from the brain to the eye. This process typically stops at the level of the inner nuclear layer (INL). Anterograde (Wallerian) axonal degeneration from the eye to the brain can trespass the INL. The geography of atrophy and swelling of individual macular retinal layers distinguishes prechiasmal from postchiasmal pathology. The emerging patterns are a front-back 'red line' at the INL; a vertical 'red line' through the macula for chiasmal/postchiasmal pathology; and a horizontal 'red line' through the macular for pathology pointing to the optic disc. This is summarized by illustrative case vignettes. Conclusions: The interpretation of patterns of individual retinal layer atrophy (3 'red lines') needs to be combined with recognition of localized layer thickening (edema, structural) at the macula. Certain macular patterns point to p hology at the level of the optic disc. This requires revision of the optic disc OCT and will guide need for further investigations. The 3 'red lines' proposed here may be found useful in clinical practice and the related mnemonics ('half moon,' 'sunset,' 'rainbow') for teaching.