The SPECTRALIS SD-OCT system (Heidelberg Engineering, Heidelberg, Germany) is highly advanced and is particularly useful for identifying challenging diagnoses. It is also a technology that is valuable in day-to-day management practice, even in our more straightforward cases. This case, a 72-year-old man with neovascular age-related macular degeneration (AMD), illustrates this.

The patient's visual acuity in the right eye was counting fingers at four feet for several years and vision in the left eye was 20/50. The patient had been referred to me for suspected retinal pigment epithelial tear in the left eye. The referring doctor had given 15 bevacizumab injections (Avastin, Genentech, Inc.) since January of 2008 and in August of 2009, the patient underwent triple therapy with verteporfin photodynamic therapy, bevacizumab, and triamcinolone acetonide (Kenalog, Bristol-Myers Squibb). The referring doctor saw a change in the subsequent fundus photo and was concerned.

The photos of the patient's eye (Figures 1A and B) show areas of both hypo- and hyperpigmentation. The fluorescein angiograms (FA; Figures 2A and B) show corresponding areas of hyper- and hypoflorescence. The SPECTRALIS SD-OCT image shows a tremendous disruption of the retina with areas of subretinal fluid. Figure 3 shows a comparison of images taken of the same slice of retina with the Stratus OCT (Carl Zeiss Meditec, Jena, Germany) vs the SPECTRALIS showing areas of subretinal fluid. The SPECTRALIS image shows the areas of photoreceptors and the preservation of the retinal layers and inner segment/outer segment junction, explaining why this patient has 20/50 vision in that eye. The Stratus is not able to provide such definition.

DISCUSSION
One of the advantages of the SPECTRALIS is the definition that it provides of the retinal structures. We know that preservation of these layers is a critical predictor of visual acuity. If these structures are intact over a fairly disrupted subretinal space, we want to treat aggressively with anti-VEGF therapy.

Additionally, the images taken with the SPECTRALIS can be helpful in management of these cases because they can be used in patient education by providing evidence to support continuing therapy after multiple injections.

Karl G. Csaky, MD, PhD, is the Director, Sybil B. Harrington Molecular Ophthalmology Laboratory, at the Retina Foundation of the Southwest, Dallas. Dr. Csaky states that he is a consultant for Heidelberg Engineering. He may be reached via e-mail at kcsaky@retinafoundation.org.