AOA 2026: Identifying retinal OCT imaging biomarkers

Raman Bhakhri, OD, FAAO, a professor at the Illinois College of Optometry, detailed a 2-hour lecture he delivered at AOA Optometry’s Meeting 2026 in Phoenix, Arizona on retinal optical coherence tomography (OCT) imaging biomarkers. He defines biomarkers as OCT-only findings that function as clinical guides: they assist clinicians in diagnosis, monitoring disease progression, and predicting outcomes across a range of conditions, including diabetes, age-related macular degeneration (AMD), inflammatory, infectious, and rare inherited diseases. Early identification of these OCT biomarkers supports better therapeutic decisions, such as when to initiate or adjust topical treatments or anti-VEGF therapy.

In diabetes, Bhakhri highlighted disorganization of the inner retinal layers (DRIL) and hyperreflective foci (HRF) as key biomarkers. DRIL is assessed by examining whether the inner retinal layers remain distinct—“like layers of a cake.” When the layers are well organized, visual prognosis and response to therapy in macular edema tend to be better. When the layers become indistinct, outcomes are generally poorer and response to anti-VEGF less robust. HRF, visible only on OCT rather than clinical fundus examination, represent microglial inflammatory activity and often precede more extensive edema or exudation. Their presence signals that the patient is “heading down the wrong road” and may require prompt referral for anti-VEGF injections.

For AMD, Bhakhri again emphasized HRF along with reticular pseudodrusen. HRF in this context often represent RPE cells migrating into more superficial retinal layers and, when perched on drusen, may herald the future development of geographic atrophy. Reticular pseudodrusen, which form above the RPE and can resemble “little hills” or “daggers” extending into the outer retina, are associated with faster progression and higher risk of advanced AMD. Bhakhri suggested that if clinicians can reliably recognize five or six core biomarkers—particularly in diabetes and AMD—they will be well equipped for everyday practice.

He also reviewed advances in OCT technology, from early time-domain systems with crude, low-resolution images to current spectral-domain OCT, now the clinical standard, and higher-resolution swept-source OCT. Importantly, newer platforms incorporate enhanced depth imaging (EDI), allowing visualization not only of the retina but also the choroid, where many pathologic processes begin. Bhakhri regards OCT as indispensable in modern retina care and frames his lecture as highly case-based and imaging rich, focused on practical, clinic-ready takeaways rather than exhaustive pathophysiology.