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CHAPTER 5

PARAMETERS

5.1 The Contour Line and the Reference Plane.

Although we have finished the study of the contour line and the reference plane in
chapter 3, we will again refer to them since they are two fundamental elements for the
definition of parameters.
One of the main applications of the HRT is the acquisition of three-dimensional
images of the optic nerve head and the peripapillary retinal surface and their analysis.
Therefore it enables the evaluation of the topography of the optic nerve head, and upon a
patients follow up, it is possible to detect the presence of topographical changes. The
stereometric analysis of the optic disc is one of the most valuable menus of the HRT,
since it provides the complete quantitative analysis of the optic disc. This, added to the
qualitative data, allows us to make a complete evaluation of the optic nerve. The data are
given in µm (micrometers, that is thousandths of a millimeter). For this reason, the
changes (for example, in a longitudinal study) must be significant in order to have real
value and clinical correlation. Therefore, a change in the neuroretinal rim volume of 8 µm
is difficult to verify, whereas a 30 to 40 µm decrease is significant, and depending on the
case, it can be correlated with a decrease of the visual field in a stage of evolution.
As previously stated, most of the parameters are related to the contour line, since it
encloses the area to be studied quantitatively, and to the reference plane, that signals a
level to which volumes and surfaces refer, in an anteroposterior direction. Figure 5.1 is a
diagram of the position of the contour line and the reference plane on the optic disc, and
the structures they enclose.
The parameters are named in two ways. For example the clinical name for the vol-
ume of the neuroretinal rim is rim volume, and its technical name is volume above ref-
erence.

5.2 Surfaces and Volumes

In addition to the contour line and the reference plane, there is another plane referred
to as curved surface. The curved surface is bound by the contour line and it follows the
surface height all along the contour line. This plane is curved because it increases in
height at the superior and inferior poles due to the greater number of fibers in the normal
optic nerve. (This is correlated to the peripapillary retina, where the height from the ref-
erence plane to the contour line is not homogenous.) These variations in the retinal thick-
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Fig. 5.1.

ness make the curved surface irregular. The height in the center of the curved surface
equals to the average height along the contour line.
All the structures (volumes) below the reference plane appear in red.
All the structures (volumes) above the reference plane and below the curved sur-
face appear in blue.
All of the structures (volumes) above the reference plane and above the curved
surface appear in green.
Now, we must correlate the technical and clinical names of volumes and surfaces.
The volume below the reference plane is the cup volume, and the area below the
reference plane is the cup surface or cup area (in red).
The volume above the reference plane and below the curved surface, is the tilted
rim volume, and the area above the reference plane and below the curved surface is re-
ferred to as tilted rim surface or tilted rim area (in blue).
The volume above the reference plane and the curved surface is the flat rim vol-
ume, and the subtraction of the surfaces of the cup and tilted rim from the total disc area
is the flat rim surface or flat rim area (in green).
The surface inside the contour line, is the total disc area.
Figures 5.2, 5.3 and 5.4 show the three surfaces, the three volumes, and their corre-
lation to each other.
In some cases the presence of white regions can be observed. They appear when in
some sector of the optic disc, the height of the curved surface is below the height of the
reference plane. This is the only case where the green area can be found below the blue
area. That is, the white surfaces appear when severe damage to the neuroretinal rim has
occurred, where the decrease of its thickness causes its surface to be below the surface of
the reference plane or when the contour line draw fall inside the cup. In these cases, in
the contour line height variation diagram, the line that represents the contour line itself
(in green), falls below the line representing the reference plane (in red).
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Fig. 5.2

Fig. 5.3

Fig. 5.4
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Fig. 5.5

In the example shown in figure 5.5, the contour line (in green), falls below the refer-
ence plane (in red) in one sector, because the contour line was drawn incorrectly. The
topographical image and the contour line graph with the alterations described can be ob-
served.
Whenever white surfaces appear, the good quality of the image obtained must be
verified, if a mean topography is being studied its standard deviation must be lower than
30 µm, and the reference plane as well as the contour line drawing must be properly lo-
cated [Burk: personal communication].
The differences between the analysis of a normal optic disc and a pathological one
can be observed in figures 5.6 and 5.7.
In the normal optic disc there is a small red surface that corresponds to the cup, it is
surrounded by a blue surface that represents the tilted rim. The green surface that corre-
sponds to the flat rim is around and outside this blue surface. In this case the green and
blue surfaces that make up the neuroretinal rim cover the greatest part of the optic disc
surface, while the red surface represents the physiological cup.
The contour line graph shows both humps, which correspond with the normal fiber
accumulation of both poles.
In the pathological optic disc, a very large red surface that corresponds to the glau-
comatous cup surface can be seen. It is surrounded by two thin rings, that represent the
tilted neuroretinal rim surface (in blue), and the flat neuroretinal rim surface (in green).
Both of them have suffered a great decrease in volume, at the expense of an increase in
the cup surface. In the contour line graph both camel humps are not present and the dis-
tance between the contour line and the reference plane has decreased in relation to the
normal optic disc. Note the decrease in the mean height of the contour line.
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Fig. 5.6

Fig 5.7

Fig. 5.8

5.3 Parameters of the stereometric analysis

In data screen number 1, in the Stereometric Measurement / Measure / Segment
menu, the following parameters appear with their clinical names:
Disc Area: It is the total surface area of the optic disc, i.e., the surface delimited by
the contour line drawing. Its value is given by the sum of the area of the flat neuroretinal
rim, the tilted neuroretinal rim, and the cup area. It is expressed in mm2 (figure 5.8).
Cup Area: It is the total cup surface, shown in red, and it represents the section area
of the optic disc at reference plane level. Its technical name is area below reference and it
is expressed in mm2 (figure 5.8).
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Fig. 5.9

Cup/Disc Area Ratio: It is the cup-disc ratio, obtained from the ratio between cup
area and disc area. Since it is a coefficient of ratio it is not expressed in units (figure 5.8).
Rim Area: It results from the subtraction of the cup area from the total optic disc
area. Therefore it represents both the surface of the flat neuroretinal rim and the surface
of the titled neuroretinal rim (green plus blue). It is the total neuroretinal rim area and it is
expressed in mm2 (figure 5.8).
Cup Volume: The cup volume is the volume of the optic disc below the reference
plane. Its technical name is volume below reference and it is shown in red. The tomo-
graph identifies the volume that is below the reference plane, it measures the volume of
the structures surrounding the cup below this plane, subtracts it from the first and thus
obtains the cup volume (figure 5.9).
Rim Volume: The neuroretinal rim volume is the volume of the structures located
above the reference plane and inside the contour line. It includes the volumes of the flat
neuroretinal rim and the tilted neuroretinal rim (green plus blue). Its technical name is
volume above reference and it is expressed in mm3 (figure 5.3).
Mean Cup Depth: This value represents the mean of all the depth values below the
curved surface and inside the contour line. It is expressed in mm.
Maximum Cup Depth: This value represents the maximum cup depth. It is the
mean of the 5% highest depths values obtained.
Cup Shape Measure or third moment: It is a parameter that gives an idea of the
slope or fall of the fibers in the optic disc. If the optic disc has a slight slope, the cup
shape measure has negative values, if the slope is close to 90 degrees, the value is near or
above zero, and finally in the case of a severely cupped optic disc, the value is positive
(figure 5.10).
Height Variation Contour: As indicated by its name, this value measures the dis-
tance between the highest and the lowest point of the contour line, i.e., the maximum
height variation of the contour line throughout its course. It is expressed in mm (figure
5.11).
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Fig. 5.10

Fig. 5.11

Mean RNFL Thickness: It measures the mean elevation of the retinal surface along
the contour line, above the reference plane. It represents the difference between the refer-
ence height and the mean height of the contour line. (The reference height is the distance
between the reference plane and the peripapillary retinal surface. The mean height of the
contour line is the distance between the peripapillary retinal surface and the neuroretinal
rim surface.) It is expressed in mm (figure 5.12).
RNFL Cross Section Area: It represents the area enclosed by the reference plane
and the contour line. Therefore its value decreases whenever the height of the contour
line decreases locally as well as generally. It is expressed in mm2 (figure 5.13).
In data screen number 2, in the Stereometric Measurement / Measure / Segment
menu the preceding parameters with their technical names as well as other specific pa-
rameters are displayed:
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Fig. 5.12

Fig. 5.13

Effective Area: It refers to the area below the curved surface, that is the cup area
plus the tilted neuroretinal rim area (in red and blue). It is expressed in mm2.
Mean Radius: It refers to the mean radius of the optic disc, that is, the mean radius
of the drawn contour line. It is expressed in mm.
Mean Height of Contour: It refers to the height between the contour line and the
peripapillary retinal plane (z=0).
Volume Below Surface: It refers to the volume of the structures below the curved
surface. It is expressed in mm3.
Volume Above Surface: It is the volume of the structures above the curved surface.
It is expressed in mm3.
In data screen number 3, in the Stereometric Measurement / Measure / Segment
menu, the following appears: REL Z / AREA, which is the relationship between depth in
axis z and the cup area at that depth, in the sections that go down to the bottom of the
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cup, with a distance of 50 µm between each other. This menu is useful in the reconstruc-
tion of the optic disc profile, in the cases where necessary (figure 4.12).
In the Measurement / Measure / Predefined Segments menu, the main parameters are
measured in 360 degrees, and also in octants and quadrants (figure 4.9).
In the graph that represents the optic disc in figure 5.14, the most relevant parame-
ters have been outlined, and are mentioned below:

DISC AREA CUP AREA

CUP / DISC AREA RATIO RIM AREA

HEIGHT VARIATION CONTOUR CUP VOLUME

RIM VOLUME MEAN CUP DEPTH

MAXIMUM CUP DEPTH CUP SHAPE MEASURE

MEAN RNFL THICKNESS RNFL CROSS SECTION AREA

Fig. 5.14

Figure 5.14 is not drawn to a scale, but it contains pathological anatomy data. A cor-
relation between the outline of the optic disc and the structures such as the retina, the
choroid and the sclera was achieved. Only the most relevant parameters appear in the
figure.
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