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 Edited by

David Huang, MD, PhD

Casey Eye Institute
Oregon Health & Science University
Portland, Oregon

Bruno Lumbroso, MD
Centro Italiano Macula
Rome, Italy

Yali Jia, PhD

Casey Eye Institute
Oregon Health & Science University
Portland, Oregon

Nadia K. Waheed, MD, MPH

 New England Eye Center
Tufts University School of Medicine
Boston, Massachusetts
www.Healio.com/books
ISBN: 978-1-63091-283-3
Copyright © 2018 by SLACK Incorporated
All rights reserved. No part of this book may be reproduced, stored in a
retrieval system or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without written
permission from the publisher, except for brief quotations embodied in
critical articles and reviews.
The procedures and practices described in this publication should be
implemented in a manner consistent with the professional standards set for
the circumstances that apply in each specific situation. Every effort has been
made to confirm the accuracy of the information presented and to correctly
relate generally accepted practices. The authors, editors, and publisher
cannot accept responsibility for errors or exclusions or for the outcome of
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Library of Congress Cataloging-in-Publication Data

Names: Huang, David, editor. | Lumbroso, Bruno, editor. | Jia, Yali, editor. |
Waheed, Nadia K., editor.
Title: Optical coherence tomography angiography of the eye / [edited by]
David Huang, Bruno Lumbroso, Yali Jia, Nadia K. Waheed.
Description: Thorofare, NJ : SLACK Incorporated, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2017012144 (print) | LCCN 2017013148 (ebook) | ISBN
9781630912833 (Epub) | ISBN 9781630912840 (Web) | ISBN
9781630912826 (alk. paper)
Subjects: | MESH: Retinal Diseases--diagnosis | Tomography, Optical
Coherence--methods | Angiography
Classification: LCC RE79.A5 (ebook) | LCC RE79.A5 (print) | NLM WW
270 | DDC 617.7/350754--dc23
LC record available at https://lccn.loc.gov/2017012144
For permission to reprint material in another publication, contact SLACK
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 DEDICATION
We dedicate this book to the pioneers of optical coherence tomography
angiography who first showed that it is possible to acquire and display 3-
dimensional images of capillary networks in the eye and the brain 10 years
ago: Yoshiaki Yasuno, PhD and Ruikang Wang, PhD.
 CONTENTS
Copyright
Dedication
Acknowledgments
About the Editors
Contributing Authors
Introduction

Part I: Principles and Methods

Chapter 1 Optical Coherence Tomography Systems for Angiography
Gangjun Liu, PhD; Alex D. Pechauer, BS; David Huang, MD, PhD;
and James G. Fujimoto, PhD
Chapter 2 Optical Coherence Tomography Angiography Algorithms
Yali Jia, PhD; Simon S. Gao, PhD; and David Huang, MD, PhD
Chapter 3 Cross-Sectional and En Face Visualization of Posterior Eye
Circulations
Yali Jia, PhD; Bruno Lumbroso, MD; Simon S. Gao, PhD; David
Huang, MD, PhD; and David J. Wilson, MD
Chapter 4 Cross-Sectional and En Face Visualization of Normal Anterior
Eye Circulations
Yan Li, PhD; Yali Jia, PhD; David Huang, MD, PhD; and Alison H.
Skalet, MD, PhD
Chapter 5 Artifacts in Optical Coherence Tomography Angiography
Simon S. Gao, PhD; Yali Jia, PhD; and David Huang, MD, PhD
Chapter 6 Quantification
Yali Jia, PhD; Acner Camino, PhD; Miao Zhang, PhD; Simon S.
Gao, PhD; and David Huang, MD, PhD
Chapter 7 Optical Coherence Tomography Angiography: Terminology
David Huang, MD, PhD and Simon S. Gao, PhD
Chapter 8 Optical Coherence Tomography Angiography on the Optovue
AngioVue With Split-Spectrum Amplitude-Decorrelation
Angiography and DualTrac Motion Correction
Tony Ko, PhD and Jay Wei, MS
Chapter 9 Optical Coherence Tomography Angiography: Optical
Microangiography
Ruikang K. Wang, PhD; Qinqin Zhang, PhD; Giovanni Gregori,
PhD; and Philip J. Rosenfeld, MD, PhD
Chapter 10 Optical Coherence Tomography Angiography Imaging With
Topcon’s One-Micrometer Wavelength Swept Source Optical
Coherence Tomography
Charles Reisman, MS; Atsushi Kubota, MS; Masahiro Akiba, PhD;
Catharine Chisholm, PhD; and Michael J. Sinai, PhD
Chapter 11 Spectral Domain Optical Coherence Tomography
Angiography Using NIDEK RS-3000 Advance
Mayss Al-Sheikh, MD and SriniVas R. Sadda, MD

Part II: Retinal Diseases

Chapter 12 Exudative Neovascular Age-Related Macular Degeneration
Type 1, 2, and Mixed Choroidal Neovascularization
Bruno Lumbroso, MD; Steven T. Bailey, MD; Yali Jia, PhD; Marco
Rispoli, MD; and Maria Cristina Savastano, MD
Chapter 13 Short- and Long-Term Response of Choroidal
Neovascularization to Anti-Angiogenic Treatment
Bruno Lumbroso, MD; Steven T. Bailey, MD; Yali Jia, PhD; Marco
Rispoli, MD; and Maria Cristina Savastano, MD
Chapter 14 Nonexudative Neovascular Age-Related Macular Degeneration
Steven T. Bailey, MD; Ching J. Chen, MD; and Yali Jia, PhD
Chapter 15 Type 3 Neovascularization—Retinal Angiomatous
Proliferation
Anna C.S. Tan, MBBS, FRCSED; Kunal K. Dansingani, MA,
FRCOphth; and K. Bailey Freund, MD
Chapter 16 Non-Neovascular Age-Related Macular Degeneration
Ricardo N. Louzada, MD; Nadia K. Waheed, MD, MPH; Jay S.
Duker, MD; and Mark Lane, MBBS Honors
Chapter 17 Polypoidal Choroidal Vasculopathy
Min Wang, MD, PhD; Simon S. Gao, PhD; and Yali Jia, PhD
Chapter 18 Optical Coherence Tomography Angiography of Macular
Telangiectasia Type 2
Ching J. Chen, MD; Brian Tieu, MD, PhD; and Matthew Olson,
CRA
Chapter 19 Central Serous Chorioretinopathy
Eduardo A. Novais, MD; Mark Lane, MBBS Honors; Nadia K.
Waheed, MD, MPH; and Jay S. Duker, MD
Chapter 20 Choroidal Neovascularization of Other Causes
Brian K. Do, MD; Richard I. Kaplan, MD; Patricia Garcia, MD;
Andre Romano, MD; and Richard Rosen, MD;
Chapter 21 Nonproliferative Diabetic Retinopathy
Thomas Hwang, MD; Yali Jia, PhD; Miao Zhang, PhD; and David
J. Wilson, MD
Chapter 22 Proliferative Diabetic Retinopathy
Emily D. Cole, BS; Nadia K. Waheed, MD, MPH; and Jay S. Duker,
MD
Chapter 23 Retinal Venous Occlusion
Marco Rispoli, MD and Bruno Lumbroso, MD
Chapter 24 Retinal Arterial Occlusion
Xiaogang Wang, MD, PhD; Jing Dong, MS; and Yading Jia, BS
Chapter 25 Inherited Retinal Degenerations
Rachel Patel, MD; Simon S. Gao, PhD; Paul Yang, MD, PhD;
Richard G. Weleber, MD; David J. Wilson, MD; and Mark Pennesi,
MD, PhD
Chapter 26 Pathological Myopia
Leonardo Mastropasqua, MD and Luca Di Antonio, MD, PhD
Chapter 27 Flow Characteristics in Retinal Vasculitis Using Optical
Coherence Tomography Angiography
Phoebe Lin, MD, PhD; Miao Zhang, PhD; and Liang Liu, MD
Chapter 28 White Dot Syndromes
Philipp K. Roberts, MD; Lee Jampol, MD; and Amani A. Fawzi,
MD
Chapter 29 Optical Coherence Tomography Angiography in Choroiditis,
Retinitis, and Vasculitis
Andre Romano, MD; Rubens Belfort Jr, MD, PhD; and Daniela
Ferrara, MD, PhD
Chapter 30 Melanocytic Tumors
Alison H. Skalet, MD, PhD; David Huang, MD, PhD; Yali Jia,
PhD; and Yan Li, PhD
Chapter 31 Radiation Maculopathy
Alexandre Matet, MD; Aude Ambresin, MD; Gilda Cennamo, MD;
and Leonidas Zografos, MD

Part III: Optic Nerve Diseases

Chapter 32 Optical Coherence Tomography Angiography in Primary
Open-Angle Glaucoma
David Huang, MD, PhD; Liang Liu, MD; and Michel Puech, MD,
MSC
Chapter 33 Primary Angle-Closure Glaucoma
Chunhui Jiang, MD, PhD and Xinghuai Sun, MD, PhD
Chapter 34 Neurodegenerative Diseases
Albert J. Augustin, MD and Christian Dempe

Part IV: Anterior Diseases

Chapter 35 Angiography of the Cornea Using Optical Coherence
Tomography
Winston Chamberlain, MD, PhD; Afshan Nanji, MD, MPH; David
Huang, MD, PhD; and Yan Li, PhD
Financial Disclosures
 ACKNOWLEDGMENTS
The editors would like to thank all of the authors for their high-quality
contributions. Without their enthusiastic energy and support, this book
would not have become a reality. Our heartfelt gratitude goes to all the
authors who contributed their time and expertise to this book.
We thank Kathleen Torok, MS at the Casey Eye Institute for coordinating
the writing assignments and managing the many manuscripts. We thank
Britt Bromberg, PhD at Xenofile Editing for providing professional English
editing that greatly improved the readability of some chapters.
We would like to show our gratitude to SLACK Incorporated and special
thanks to Tony Schiavo for his constant help and encouragement.
 ABOUT THE EDITORS
David Huang, MD, PhD is the Peterson Professor of Ophthalmology and
Professor of Biomedical Engineering at the Oregon Health & Science
University (Portland, Oregon). Dr. Huang received an MD from Harvard
University (Cambridge, Massachusetts) and a PhD from Massachusetts
Institute of Technology (Cambridge, Massachusetts). He completed an
ophthalmology residency at the Doheny Eye Institute/University of
Southern California (Los Angeles, California) and cornea fellowship at
Emory University (Atlanta, Georgia). Dr. Huang is a co-inventor of optical
coherence tomography (OCT), which is the most commonly used
ophthalmic imaging technology at 30 million procedures per year. More
recently he has pioneered anterior segment OCT and OCT angiography. His
seminal article on OCT, published in Science in 1991, has been cited more
than 11,000 times. He has 19 issued patents and 18 pending patents in the
areas of OCT, mobile health testing, tissue engineering and corneal laser
surgery. He has been the principal investigator of 5 NIH research grants
totaling over $20 million. He has published more than 200 peer-reviewed
articles with nearly 40,000 citations. He has edited 8 books. Dr. Huang has
received the Champalimaud Vision Award, the Jonas Friedenwald Award,
the David Epstein Award from the Association for Research in Vision &
Ophthalmology, the Senior Achievement Award from the American
Academy of Ophthalmology, and the Fritz & Dolores Russ Award from the
National Academy of Engineering (USA). He is a fellow of the American
Academy of Inventors and American Ophthalmological Society. Dr. Huang
leads the Center for Ophthalmic Optics and Lasers (www.COOLLab.net).
He is a founder of Gobiquity Mobile Health, Inc. (www.gobiquity.com), a
maker of mobile diagnostic apps.
Bruno Lumbroso, MD has been Director of the Department of
Ophthalmology of the Rome Eye Hospital (Rome, Italy) and Professor LD of
Clinical Ophthalmology at the University of Rome La Sapienza (Rome,
Italy) for more than 35 years. He is now Directorof the private Centro
Italiano Macula in Rome, Italy. He was a pioneer in the development of
clinical applications for en face OCT and OCT angiography. He is co-
founder and General Secretary of the Societa Italiana di Angiografia OCT
and of the Societa Italiana di Laser in Oftalmologia. His main interests are in
logical methods of retinal imaging analysis and interpretation, and in
clinical applications of OCT and OCT angiography technology for retinal
disorders.
Yali Jia, PhD is an Assistant Professor of Ophthalmology and Biomedical
Engineering at the Oregon Health & Science University (OHSU) in
Portland, Oregon. Dr. Jia earned her PhD in Biomedical Engineering from
OHSU in 2010 under the guidance of Dr. Ruikang Wang. Dr. Jia completed
her post-doctoral training with Dr. David Huang at Casey Eye Institute in
2013. She developed split-spectrum amplitude de-correlation angiography
(SSADA), a highly efficient optical coherence tomography angiography
(OCTA) algorithm that made clinical OCTA practical. Her article on
SSADA, published in Optics Express in 2012, has been cited more than 430
times. Dr. Jia was awarded 3 National Institute of Health research project
grants that supported the initial works that demonstrated clinical
applications of OCTA in retinal diseases. She is the technical leader in Casey
Reading Center. Her OCTA reading software (COOL-ART) has been used
by several large clinical studies and many international collaborators. She
has published 75 peer-reviewed journal articles and 25 book chapters; and
co-edited 3 books. Her major contributions to the OCTA community are:
efficient OCTA, quantitative OCTA, projection-resolved OCTA and motion-
free OCTA.
Nadia K. Waheed, MD, MPH is Director of the Boston Image Reading
Center and Associate Professor in Ophthalmology at the Tufts University
School of Medicine (Boston, Massachusetts). She specializes in clinical and
clinical trial applications of optical coherence tomography and optical
coherence tomography angiography.
 CONTRIBUTING AUTHORS
Masahiro Akiba, PhD (Chapter 10)
Topcon Corporation, R & D Division
Tokyo, Japan
Mayss Al-Sheikh, MD (Chapter 11)
Doheny Eye Institute
Doheny Image Reading Center
Los Angeles, California
Department of Ophthalmology
David Geffen School of Medicine
University of California Los Angeles
Los Angeles, California
Aude Ambresin, MD (Chapter 31)
Department of Ophthalmology
University of Lausanne
Jules-Gonin Eye Hospital
Fondation Asile des Aveugles
Lausanne, Switzerland
Albert J. Augustin, MD (Chapter 34)
Professor of Ophthalmology
Department of Ophthalmology
Klinikum Karlsruhe, Germany
Steven T. Bailey, MD (Chapters 12, 13, 14)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Rubens Belfort Jr, MD, PhD (Chapter 29)
Head Professor Ophthalmology
Federal University of São Paulo
São Paulo, Brazil
Acner Camino, PhD (Chapter 6)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Gilda Cennamo, MD (Chapter 31)
Department of Ophthalmology
Università di Napoli “Federico II”
Napoli, Italy
Winston Chamberlain, MD, PhD (Chapter 35)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Ching J. Chen, MD (Chapters 14, 18)
University of Mississippi Medical Center
Jackson, Mississippi
Catharine Chisholm, PhD (Chapter 10)
Topcon Corporation, Eye Care Company
Tokyo, Japan
Emily D. Cole, BS (Chapter 22)
New England Eye Center
Tufts University School of Medicine
Boston, Massachusetts
Department of Electrical Engineering and Computer
Science, and Research Laboratory of Electronics
Massachusetts Institute of Technology
Cambridge, Massachusetts
Kunal K. Dansingani, MA, FRCOphth (Chapter 15)
Vitreous, Retina Macula, Consultants of New York
LuEsther T Mertz Retinal Research Center
Manhattan, Eye, Ear and Throat Hospital
New York, New York
Moorfield Eye Hospital
London, United Kingdom
Truhlsen Eye Institute
University of Nebraska Medical Center
Omaha, Nebraska
Christian Dempe (Chapter 34)
Department of Ophthalmology
Staedtisches Klinikum Karlsruhe
Karlsruhe, Germany
Luca Di Antonio, MD, PhD (Chapter 26)
Retina Consultant of the Ophthalmology
Department Center of Excellence
National High-Tech Center (CNAT) and
Italian School of Robotic Surgery in Ophthalmology
University “G. d’Annunzio”
Chieti-Pescara, Italy
Certified member of EVICR.net.
Brian K. Do, MD (Chapter 20)
University of Southern California Roski Eye Institute
Los Angeles, California
Jing Dong, MS (Chapter 24)
The First Hospital of Shanxi Medical University
Shanxi, P.R. China
Jay S. Duker, MD (Chapters 16, 19, 22)
Director of the New England Eye Center
Professor and Chair
Department of Ophthalmology
New England Eye Center
Tufts Medical Center
Tufts University School of Medicine
Boston, Massachusetts
Amani A. Fawzi, MD (Chapter 28)
Department of Ophthalmology
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Daniela Ferrara, MD, PhD (Chapter 29)
Department of Ophthalmology
Tufts University School of Medicine
Boston, Massachusetts
K. Bailey Freund, MD (Chapter 15)
Vitreous, Retina Macula, Consultants of New York
New York, New York
Clinical Professor of Ophthalmology
Department of Ophthalmology
New York University
New York, New York
James G. Fujimoto, PhD (Chapter 1)
Department of Electrical Engineering and
Computer Science, and Research Laboratory of Electronics
Massachusetts Institute of Technology
Cambridge, Massachusetts
Simon S. Gao, PhD (Chapters 2, 3, 5, 6, 7, 17, 25)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Genentech
South San Francisco, California
Patricia Garcia, MD (Chapter 20)
The New York Eye and Ear Infirmary of Mount Sinai
New York, New York
Giovanni Gregori, PhD (Chapter 9)
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Department of Ophthalmology
Miami, Florida
Thomas Hwang, MD (Chapter 21)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Lee Jampol, MD (Chapter 28)
Louis Feinberg Professor of Ophthalmology
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Yading Jia, BS (Chapter 24)
Department of Vitreous and Retina
Shanxi Eye Hospital
Shanxi, P.R. China
Chunhui Jiang, MD, PhD (Chapter 33)
Eye and ENT Hospital
Shanghai Medical College
Fudan University
Shanghai, P.R. China
Richard I. Kaplan, MD (Chapter 20)
New York Eye & Ear Infirmary of Mount Sinai
New York, New York
Tony Ko, PhD (Chapter 8)
Optovue Inc
Fremont, California
Atsushi Kubota, MS (Chapter 10)
Topcon Corporation, R & D Division
Tokyo, Japan
Mark Lane, MBBS Honors (Chapters 16, 19)
Queen Elizabeth Hospital Birmingham
University Hospitals Birmingham
NHS Foundation Trust
Birmingham, United Kingdom
New England Eye Center
Tufts University School of Medicine
Boston, Massachusetts
Yan Li, PhD (Chapters 4, 30, 35)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Phoebe Lin, MD, PhD (Chapter 27)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Gangjun Liu, PhD (Chapter 1)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Liang Liu, MD (Chapters 27, 32)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Ricardo N. Louzada, MD (Chapter 16)
Department of Ophthalmology
Federal University of Goiás
Goiânia, Brazil
New England Eye Center
Tufts University School of Medicine
Boston, Massachusetts
Leonardo Mastropasqua, MD (Chapter 26)
Full Professor in Ophthalmology
Head of the Ophthalmology Department
Head of the Center of Excellence
National High-Tech Center (CNAT) and
Italian School of Robotic Surgery in Ophthalmology
University “G. d’Annunzio”
Chieti-Pescara, Italy
Certified member of EVICR.net
Alexandre Matet, MD (Chapter 31)
Department of Ophthalmology
University of Lausanne
Jules-Gonin Eye Hospital
Fondation Asile des Aveugles
Lausanne, Switzerland
Afshan Nanji, MD, MPH (Chapter 35)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Eduardo A. Novais, MD (Chapter 19)
Department of Ophthalmology
Federal University of São Paulo
School of Medicine
São Paulo, Brazil
New England Eye Center
Tufts University School of Medicine
Boston, Massachusetts
Matthew Olson, CRA (Chapter 18)
Director of Ophthalmic Imaging Services
Department of Ophthalmology
University of Mississippi Medical Center
Jackson, Mississippi
Rachel Patel, MD (Chapter 25)
Oregon Health & Science University
Portland, Oregon
Alex D. Pechauer, BS (Chapter 1)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Mark Pennesi, MD, PhD (Chapter 25)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Michel Puech, MD, MSC (Chapter 32)
Explore Vision Paris
Paris, France
Charles Reisman, MS (Chapter 10)
Topcon Advanced Biomedical Imaging Laboratory
Paramus, New Jersey
Marco Rispoli, MD (Chapters 12, 13, 23)
Staff Ophthalmologist
Medical Retina Unit
Department of Ophthalmic and Emergency Surgery
Rome Eye Hospital
Centro Italiano Macula
Rome, Italy
Philipp K. Roberts, MD (Chapter 28)
Department of Ophthalmology
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Department of Ophthalmology and Optometry
Medical University of Vienna
Vienna, Austria
Andre Romano, MD (Chapters 20, 29)
Neovista Eye Institute
Ophthalmology; Retina, Macula & Vitreous Center
Americana, Brazil
Richard Rosen, MD (Chapter 20)
Vice Chair and Director of Ophthalmology Research
Surgeon Director and Chief of Retinal Services
The New York Eye and Ear Infirmary of Mount Sinai
New York, New York
Professor of Ophthalmology
Icahn School of Medicine at Mount Sinai
New York, New York
Philip J. Rosenfeld, MD, PhD (Chapter 9)
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Department of Ophthalmology
Miami, Florida
SriniVas R. Sadda, MD (Chapter 11)
Doheny Eye Institute
University of California—Los Angeles
Los Angeles, California
Maria Cristina Savastano, MD (Chapters 12, 13)
Centro Italiano Macula
Rome, Italy
Michael J. Sinai, PhD (Chapter 10)
Topcon Corporation, R & D Division
Tokyo, Japan
Alison H. Skalet, MD, PhD (Chapters 4, 30)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Xinghuai Sun, MD, PhD (Chapter 33)
Eye and ENT Hospital
Shanghai Medical College
Fudan University
Shanghai, P.R. China
Anna C.S. Tan, MBBS, FRCSED (Chapter 15)
Vitreous, Retina Macula, Consultants of New York
LuEsther T. Mertz Retinal Research Center
Manhattan Eye, Ear and Throat Hospital
New York, New York
Singapore National Eye Center/Singapore Eye
Research Institute
Singapore, Singapore
Duke-NUS Medical School
Singapore, Singapore
Brian Tieu, MD, PhD (Chapter 18)
University of Mississippi Medical Center
Jackson, Mississippi
Min Wang, MD, PhD (Chapter 17)
Department of Ophthalmology
Eye and ENT Hospital of Fudan University
Shanghai, P.R. China
Ruikang K. Wang, PhD (Chapter 9)
University of Washington
Department of Bioengineering
Seattle, Washington
Xiaogang Wang, MD, PhD (Chapter 24)
Cataract Department
Shanxi Eye Hospital
Shanxi, P.R. China
Jay Wei, MS (Chapter 8)
Optovue Inc
Fremont, California
Richard G. Weleber, MD (Chapter 25)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
David J. Wilson, MD (Chapters 3, 21, 25)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Paul Yang, MD, PhD (Chapter 25)
Casey Eye Institute
Oregon Health & Science University
Portland, Oregon
Miao Zhang, PhD (Chapters 6, 21, 27)
Optovue Inc
Fremont, California
Qinqin Zhang, PhD (Chapter 9)
University of Washington
Department of Bioengineering
Seattle, Washington
Leonidas Zografos, MD (Chapter 31)
Department of Ophthalmology
University of Lausanne
Jules-Gonin Eye Hospital
Fondation Asile des Aveugles
Lausanne, Switzerland
 INTRODUCTION
Optical coherence tomography angiography (OCTA) has undergone
tremendous growth since its first commercial introduction in 2014. Because
it provides injection-free, capillary-resolution, 3-dimensional angiography
of the retina and choroid, OCTA is in the process of overtaking fluorescein
as the most important angiographic imaging technique of the eye. Five
leading manufacturers of ophthalmic OCT now offer OCTA products, with
2 of them Food and Drug Administration approved in the United States. A
MEDLINE search on OCTA and eye now yields more than 3000 articles.
Clinical investigators have already found use for OCTA in almost every
category of retinal and optic nerve diseases. This book is meant to bring
together all this information so clinicians can have one authoritative text to
turn to as we begin to use this brand new imaging modality that was never
taught when we were in formal training.
Many of us have spent countless hours on weekly fluorescein rounds
during our residencies and fellowships to learn the principles of fluorescein
angiography (FA) and the myriad manifestations of retinal diseases.
Unfortunately, OCTA is sufficiently different that we need to start this
educational process all over again. Let’s begin with the bases of OCTA,
which are high-speed OCT systems and efficient computational algorithms.
These are covered in the first 2 chapters, which clinicians should read, but
not worry about understanding or retaining all the technical details. Get the
rough gist so you have some basis for choosing among the available
commercial systems, which are covered in Chapters 8 through 11. It is useful
to read up on the particular OCTA system that you are using, so you can
take advantage of all the available features.
All OCTA algorithms measure changes in the OCT signal over time,
from which flow signal is derived, as well as the attendant bulk motion and
flow projection artifacts. The intrinsic flow contrast comes from the motion
of blood cells and does not require the injection of any dye or contrast agent.
OCTA is 3-dimensional and can resolve up to 4 separate vascular layers
(plexuses) in the retina. Unlike FA, which detects abnormal blood vessels by
dye leakage, OCTA detects neovascularization and other abnormal vessels
by their occurrence in the wrong layer, as well as their characteristic
patterns. To the user, going from the 2-dimensional FA to 3-dimensional
OCTA is like going from driving a car to flying an airplane—a new set of
skills is needed to deal with the extra dimension. The skills needed to
understand en face and cross-sectional visualizations of OCTA and
recognizing true pathologies vs artifacts are taught in Chapters 3 through 5.
Chapters 3 and 5 are must-reads for most clinicians, while the visualization
of anterior eye circulation discussed in Chapter 4 is more geared toward
researchers in this area. Quantification of flow (Chapter 6) is important for
providing endpoints for clinical studies. For example, to measure the
response of choroidal neovascularization to therapy, or to monitor the
progress of glaucoma. Some OCTA systems offer basic quantification tools
now, and these are likely to become common and more sophisticated in the
next few years. Before moving on to the clinical chapters, it is important for
the readers to have a quick look at Chapter 7, which teaches standard OCTA
terminology, some of which uses similar words with new, specific meanings.
The reader is advised to refer to this chapter as a glossary later if there is any
doubt as to misunderstanding any terms in the subsequent clinical chapters.
The clinical chapters (12 through 35) are written by a wide collection of
experts. We apologize that their style may vary and some content may
overlap. It is, of course, impossible to read through all these chapters in one
sitting. The readers are advised to use these chapters as references when they
encounter questions on the interpretation of OCTA in the clinic. The most
important application of OCTA at the current time is probably in the
confirmation of choroidal neovascularization and the differential diagnosis
of its underlying etiology. Thus Chapters 12, 14, 15, and 17 are of particular
importance. Macular telangiectasia (Chapter 18) and central serous
chorioretinopathy (Chapter 19) are less frequently encountered conditions,
but are important to read about because OCTA offers new information that
can improve the staging and management of these diseases. Finally,
glaucoma specialists should become familiar with the reduction in capillary
density in the optic nerve head, peripapillary retina, and macula that occurs
in glaucoma of all varieties. As quantification tools improve, this is likely to
become an important tool for diagnosing and monitoring this leading cause
of blindness worldwide.
 Because OCTA is noninvasive, rapid, low cost, and easily available as a
software add-on to the current generation of high-speed OCT systems, it
can be used at every visit to screen for suspected diseases and every follow-
up visit to monitor treatment efficacy. It is likely to be used far more than FA
ever was. It is worth investing the time to learn about this new imaging
modality now, and to closely follow the rapid expansion of knowledge on
how to interpret and use OCTA in everyday clinical practice.
 Part I

Principles and Methods

 1

Optical Coherence Tomography Systems

for Angiography

Gangjun Liu, PhD; Alex D. Pechauer, BS;

David Huang, MD, PhD; and James G.
Fujimoto, PhD

Optical coherence tomography angiography (OCTA) detects blood flow

by using motion contrast, computing the changes of optical coherence
tomography (OCT) signals introduced by moving blood cells between
repeated cross-sectional images (B-frames) at the same location. Acquisition
of typical volumetric OCTA data requires high-speed OCT technology.
Fourier domain OCT (FD-OCT) systems have inherently higher detection
sensitivity, so they can achieve a much higher speed than time domain OCT
systems (TD-OCT).1-4 The high speed of FD-OCT allows multiple cross-
sectional images to be rapidly acquired at the same location. Therefore, 3-
dimensional volumetric OCTA data can be obtained in several seconds,
making it practical for clinical imaging. Subsequent processing of images
produced by FD-OCT systems allows the visualization of vascular networks
down to the capillary level in both the retinal and choroidal circulations. In
FD-OCT systems, the interferogram can be measured either with a
broadband light source and spectrometer, a technique known as spectral
domain OCT (SD-OCT), or as a function of time with a wavelength
sweeping laser source and a detector, known as swept source OCT (SS-
OCT).

SPECTRAL DOMAIN OPTICAL COHERENCE

TOMOGRAPHY
In SD-OCT, a broadband light source is used, similar to traditional TD-
OCT systems. The OCT signal and reference beams have a relative time
delay determined by the path length difference (Δz) given by the depth of
the tissue structure relative to a “zero delay” set by the fixed reference path
(Figure 1-1). The interference of the signal and reference beams will have a
spectral modulation or oscillation that can be measured using the
spectrometer and high-speed line scan camera. The periodicity of this
oscillation will be inversely proportional to the echo time delay Δz. Larger
echo delays will produce higher frequency spectral oscillations. The echo
delays can be measured by Fourier transforming the interference signal. This
produces an axial scan measurement (A-scan) of the magnitude vs echo
delay of the backreflected/backscattered light from the tissue. SD-OCT can
also be understood by noting that an interferometer acts like a periodic
frequency filter, where the filter period depends on the path difference Δz
between the sample and reference paths. Spatial features are encoded in
frequency, similar to magnetic resonance imaging. Because all the light
echoes are detected simultaneously, sensitivity is dramatically higher than
TD-OCT, in which the light echoes are detected sequentially.
Figure 1-1. Broadband light is split by a beam splitter into reference and sample beams. A fixed
reference mirror establishes a zero delay. Backscattered light from the reference path and sample
interfere at the beam splitter. The interference spectrum is spatially dispersed by a diffraction
grating and detected with a high-speed line scan camera.

SWEPT SOURCE OPTICAL COHERENCE TOMOGRAPHY

SS-OCT is another type of FD detection. SS-OCT uses a narrow
linewidth light source that is swept in time over a broadband wavelength
(Figure 1-2). The OCT signal and reference beams have a relative time delay
determined by the path length difference (Δz) given by the depth of the
tissue structure relative to a “zero delay” set by the fixed reference path. The
interference of the signal and reference beams produces an oscillation or
beat frequency because of the frequency difference between the 2 light
waves. Different echo time delays of light are encoded as different oscillation
frequencies at the output of the interferometer as the laser is frequency
swept. A high-speed photodetector is used, without requiring a
spectrometer or line scan camera. The oscillation frequency is related to the
echo time delay Δz, with larger echo delays producing higher frequency
oscillations. Similar to SD-OCT detection, in SS-OCT the echo magnitude
vs delay, or A-scan, can be measured by Fourier transforming the detector
signal that is acquired over one frequency sweep of the light source. Because
each frequency sweep generates one A-scan, the imaging rate is determined
by the sweep repetition rate of the light source. SS-OCT can also be
understood by noting that the frequency sweep of the light source essentially
labels different times with different frequencies of the light.

Depth Range and Sensitivity Roll-Off

Since increasing imaging speeds reduces OCT signal levels, high
sensitivity is important for achieving the high speeds necessary for OCTA.
FD-OCT using SD-OCT or SS-OCT is 10 to 100 times more sensitive than
TD-OCT. However, FD-OCT systems typically have a sensitivity that
depends on depth Δz. There is a “sensitivity roll-off ” where the sensitivity
decreases for structures that are further away from the zero delay position.
This can be understood by recalling that the echoes that are further from
zero delay correspond to finer oscillations in SD-OCT (see Figure 1-1) or
higher frequency interference in SS-OCT (see Figure 1-2). In SD-OCT, the
spectrometer has limited resolution and is less effective in detecting higher
frequency spectral oscillations that correspond to echoes that are further
from zero delay (see Figure 1-1). In SS-OCT, the spectral purity or linewidth
of the swept light source determines how far from zero delay the
interference between the OCT signal and reference frequency sweeps can be
detected (see Figure 1-2). Figure 1-3 shows the sensitivity roll-off
performance of SD-OCT and SS-OCT by comparing images of the same
retina at different positions relative to zero delay.5 SS-OCT usually has less
sensitivity roll-off than SD-OCT because the spectrometers used in SD-
OCT have limited spectral resolution.
In addition, SS-OCT instruments typically have a longer imaging range
than SD-OCT instruments. This is because detecting light echoes that are
further from zero delay requires high spectral resolution. The example in
Figure 1-3 shows a 2.2 mm imaging range for SD-OCT compared with a 2.9
mm imaging range for SS-OCT. The exact imaging ranges in commercial
OCT instruments depend on details of design. The combination of long
imaging range and reduced sensitivity roll-off within the imaging range
makes SS-OCT suitable for wide-field and long-range imaging.6,7 Recently,
SS-OCT was demonstrated with an extremely long imaging range of 50 mm,
which could be used to span the entire eye length.7
Finally, SS-OCT instruments typically operate with longer wavelengths
of light than SD-OCT. The penetration of 1050 nm wavelength is better than
840 nm because attenuation from ocular opacity and scattering is less.8,9
This improves visibility of large vessels in the choroid as well as the ability to
image below edema, choroidal neovascular membranes, or drusen.
Figure 1-2. Wavelength (frequency) swept light is split by a beam splitter into reference and
sample beams. A fixed reference mirror establishes a zero delay. Backscattered light from the
sample and reference paths interfere at the beam splitter. The interference spectrum is directly
detected by a photodetector.
Figure 1-3. Cross-sectional OCT images of a normal retina acquired using an 840 nm SD-OCT and
a 1050 nm SS-OCT system.5 SS-OCT has less sensitivity roll-off with depth than SD-OCT.
(Reprinted with permission from Potsaid B, Baumann B, Huang D, et al. Ultrahigh speed 1050 nm
swept source/Fourier domain OCT retinal and anterior segment imaging. Optics Express.
2010;18(19):20029-20048.)

TABLE 1-1. AVAILABLE AND PENDING OPTICAL

COHERENCE TOMOGRAPHY ANGIOGRAPHY SYSTEMS
 COMMERCIAL OPTICAL COHERENCE TOMOGRAPHY
ANGIOGRAPHY INSTRUMENTS
Currently, there are several commercial instruments and software that
perform OCTA: the AngioVue on the Avanti RTVue XR (Optovue Inc), the
AngioPlex on the Cirrus 5000 (Carl Zeiss Meditec Inc), and the DRI OCT
Triton (Topcon Medical Systems Inc). The Optovue and Zeiss systems have
been approved by the Food and Drug Administration for use in the United
States; other instruments are approved outside the United States. Table 1-1
lists these OCTA systems.

OPTICAL COHERENCE TOMOGRAPHY IMAGING

WAVELENGTHS
The wavelength of the OCT light source determines type of imaging
application and its performance. In order to achieve improved OCT imaging
depth in a highly scattering tissue, a long wavelength is required. However,
the choice of wavelength is limited by the absorption spectrum of water
(Figure 1-4).10 OCT at 1310 nm wavelength is used for imaging the anterior
eye.11 However, this wavelength is highly absorbed by the vitreous and
cannot be used for retinal imaging.
OCT retinal imaging is performed at wavelengths where the water
absorption is low. Most commercial instruments are SD-OCT systems that
operate at 840 nm wavelengths. This wavelength offers several benefits for
commercial use. Broadband light sources are available that can achieve fine
axial image resolution and are relatively low cost. Line scan cameras, either
charge-coupled devices (CCDs) or complementary metal-oxide
semiconductor (CMOS) cameras using silicon semiconductor technology,
are also relatively low cost and can detect these wavelengths.
OCT retinal imaging can also be performed at 1050 nm wavelengths,
where there is an absorption window in water.9 Early studies demonstrated
that these longer wavelengths were less sensitive to ocular opacities, such as
cataracts, and enabled an improved imaging depth in the choroid. An SD-
OCT system at 1050 nm would require a more expensive line scan InGaAs
camera technology in order to detect this longer wavelength. Therefore,
most 1050 nm OCT instruments are based on SS-OCT. Although swept
lasers are also expensive, SS-OCT enables higher acquisition speeds than
SD-OCT. Table 1-2 shows a comparison between 840 nm and 1050 nm
wavelengths for retinal imaging.

Figure 1-4. Light absorption spectrum of water.10 For retinal imaging, OCT systems operate at
wavelengths in the low-absorption windows around 840 nm or 1050 nm. The 1050 nm
wavelength has reduced attenuation from scattering or ocular opacity. Longer wavelengths at
1300 nm are too strongly absorbed by water to enable retinal imaging but are used in the anterior
eye.

TABLE 1-2. COMPARISON OF 840 AND 1050 NM

WAVELENGTH CHARACTERISTICS
840 NM WAVELENGTH 1050 NM WAVELENGTH
Easily implemented on SD-OCT; low Typically implemented on SS-OCT
cost and good performance make this for improved depth range and
the most commonly used wavelength speed, but SD-OCT also possible
clinically
More attenuation from media opacities Better beam penetration through
opacity
Provides finer axial resolution Axial resolution limited by
absorption window
OCT beam is visible to the patient and OCT beam is not visible to the
can disrupt fixation and cause eye patient
motion

Resolution
The axial image resolution in OCT is governed by the light source and is
independent of the focused beam spot size. The axial resolution is given by
0.44λ02/Δλ, where λ0 is the central wavelength and Δλ is the full width at
half maximum (FHWM) bandwidth or sweep range of the light source.
Figure 1-5 shows the relationship between axial resolution (in air) and the
bandwidth of the light source. The axial resolution in tissue can be obtained
by dividing by the index of refraction (approximately n = 1.3). To achieve a
given axial resolution, broader bandwidths are required if longer
wavelengths are used. Systems operating at 840 nm have a finer axial
resolution compared to 1050 nm systems because the bandwidth at 1050 nm
is limited by the width of the water absorption window (see Figure 1-4).
Transverse image resolution is determined by the spot size of the focused
OCT beam. At the diffraction limit, finer resolution is achieved by using
larger numerical apertures and shorter wavelengths. For retinal imaging, the
OCT beam incident into the eye is collimated and the numerical aperture is
determined by the beam diameter on the cornea. A finer transverse
resolution can be achieved using a large incident OCT beam diameter;
however, a larger beam diameter is more susceptible to vignetting on the
pupil, making nonmydriatic imaging difficult. In addition, aberrations in the
eye limit the focused spot size on the retina for larger OCT beam diameters.
Finally, there is a trade-off between transverse resolution and depth of field,
such that increasing transverse resolution decreases the depth of field. For
OCT, the depth of field must be long enough to span the depth of retinal
pathologies. Therefore, imaging is commonly performed with a low
numerical aperture so that the transverse resolution and depth of field are
balanced. Figures 1-6 and 1-7 demonstrate OCTA from an SD-OCT at 840
nm and an SS-OCT at 1050 nm wavelengths. Both are capable of resolving
capillary networks. The transverse image resolutions are governed by details
of the instrument design. Some manufacturers design a smaller incident
beam diameter to simplify instrument alignment, trading off transverse
resolution on the retina.

Figure 1-5. The relationship between OCT axial imaging resolution and the spectral bandwidth
(full width at half maximum) of the light source or wavelength sweep range.
Figure 1-6. En face OCT angiograms (3 × 3 mm) taken of a healthy fovea using (A) an SD-OCT
system at 840 nm (RTVue XR) and (B) an SS-OCT system at 1050 nm (DRI OCT Triton).

Projection Artifacts and Penetration Depth

OCTA can have imaging artifacts that are important to understand in
order to avoid misinterpretation.12 Since OCTA visualizes vasculature by
detecting fluctuations in successive B-scans, it will visualize any fluctuations
in OCT signal in addition to vasculature. Structures that are located behind
blood vessels will have a fluctuating OCT signal and produce contrast in
OCTA images. This causes superficial vasculature to project onto deeper
structures. Figure 1-8 shows an en face OCTA of the retinal pigment
epithelium (RPE) layer that appears to have a vascular pattern because of the
projection artifact from retinal vasculature. The projection artifact is present
for both 840 nm SD-OCT and 1050 nm SS-OCT.
If the OCT signal is too low, it is not possible to obtain OCTA
information and vasculature may not be visualized, even if it is present.
Compared to 840 nm wavelengths, imaging at 1050 nm has lower light
scattering, which allows a deeper penetration into turbid tissue.8,9,13
Compared to 840 nm, there is higher water absorption at the 1050 nm
wavelength, which causes attenuation when passing through the ocular
media, but this is counterbalanced by the higher power that can be safely
used.14 These features are of particular interest when considering OCTA
applications because the increase in light penetration allows for imaging
below the RPE, drusen, and hemorrhage.

Figure 1-7. En face OCT angiograms (3 × 3 mm) of the choriocapillaris in a healthy eye using (A) an
SD-OCT system at 840 nm (RTVue XR) and (B) an SS-OCT system at 1050 nm (DRI OCT Triton).
Figure 1-8. OCTA projection artifact on retinal pigment epithelium (RPE) layer using (A) an SD-
OCT system at 840 nm (RTVue XR) and (B) an SS-OCT system at 1050 nm (DRI OCT Triton). Retinal
vasculature is visible even though it is anterior to the RPE and there is no vasculature in the RPE.

THE FUTURE: WIDE-FIELD OPTICAL COHERENCE

TOMOGRAPHY ANGIOGRAPHY
High-speed imaging has been demonstrated for both SD-OCT and SS-
OCT systems. The scan rate of SD-OCT is determined by the speed of the
line scan camera that is used. Typical line scan cameras used for 840 nm SD-
OCT system have speeds of 20 to ~70 kHz. Higher speed line scan cameras
are also available and speeds of ~300 kHz have been demonstrated, but
involve trade-offs in axial resolution or imaging range.15
SS-OCT has the benefit of not requiring a spectrometer or line scan
camera. The scan rate in SS-OCT is determined by the sweep repetition rate
of the light source and can be much faster than SD-OCT. The development
of new swept laser technology known as Fourier domain mode locking
enabled dramatic increases in laser sweep rates, and recent demonstrations
of retinal imaging using research SS-OCT systems have achieved an A-scan
rate of several MHz.16,17 This could allow one to image the retina with a
very large field of view (FOV) of 100 degrees.18 More recently, compact and
manufacturable vertical cavity surface-emitting lasers have been developed
that enable both long-range and high-speed SS-OCT.7 High-speed OCT is
important for OCTA because repeated B-scans are required in order to
visualize vasculature using motion contrast. The higher speeds enable wider
FOV OCTA imaging. We have demonstrated a wide-field OCTA FOV of 12
× 12 mm2 in ~4 seconds with a 400 kHz SS-OCT system (Figure 1-9).

Figure 1-9. Wide-field OCTA with 12 × 12 mm field of view acquired using a 400 kHz SS-OCT
(research prototype instrument).

To date, OCTA has a limited FOV because of the limited OCT system
speed. High-speed OCT technology is essential for wide-field OCTA
applications. However, the sensitivity of OCT is limited by the maximum
permissible incident power on the eye set by the American National
Standards Institute.19 There is a trade-off between the speed of OCT
systems and sensitivity. Operating at high imaging speeds requires short
exposure times and therefore less light will be collected and sensitivity will
Another random document with
no related content on Scribd:
the weeks consumed by the trip, an existence which must have been
somewhat like that of Noah’s family in the Ark.
There was not, as I have mentioned, any means of keeping foods
fresh, nor was there even ice water to be had on those boats. We
used entirely, even for drinking, the muddy river water, which was
hauled up in buckets on the barber side of the boat, while the
steward was emptying refuse to the fishes on the pantry side. The
passengers became more or less intimate, necessarily, on a trip
such as I am attempting to describe. There was no place to sit but in
the general cabin, the sleeping rooms being so cramped. There was
no library, very little reading, but much fancy work, mostly on canvas,
footstools and bell-pulls. A bell-pull, you may want to know, was a
long band about three inches wide; it was hung from the parlor
cornice and connected with a bell in the servant’s region; it was quite
the style to embroider them in gay vines and flower designs.
The elderly ladies knit fine thread nightcaps, collars and lace.
Really some of the “old lady” work was quite handsome. Thus
fingers were kept busy, while gossip and interchange of bread and
cake recipes entertained the housewives who had never heard of
cooking schools and domestic science. Our trip necessarily
embraced at least one Sunday. I remember my father had a dear old
relative of the deepest dyed Presbyterian type (father of the late Dr.
T. G. Richardson), who always on his river trips landed wherever he
happened to be on Saturday and on Monday boarded another boat
(if one came along), his scruples forbidding Sunday travel.
 American Stagecoach.

(From “Forty Etchings, from Sketches Made with the Camera Lucida in North
America in 1827 and 1828,” by Captain Basil Hall, R. N.)

Arrived at the end of our river journey, father chartered a whole

stage to take his family a two days’ trip into the heart of the blue
grass region. Nine passengers filled the interior of the coach, and
four or five, if need be, could ride on top. The rumble (we always
called it boot) was filled with baggage. The vehicle had no springs,
but was swung on braces, which gave it a kind of swaying motion
that always made me sick. However, we managed to start off in fine
style, but every time there was a stop to change horses all of us
alighted, stiff and tired and hot, to “stretch our legs,” like Squeers in
Dickens’ “Nicholas Nickleby.” At noon we rejoiced to hear our
coachman’s horn, a grand, loud blast, followed by toot, toot!—one
toot for each passenger, so the tavern man would know how many
plates to lay, and his wife how many biscuits and chicken legs to
have ready. We always made out to spend the one night of the
journey at Weissiger’s tavern in Frankfort, the best tavern in all the
land. We had a leisurely breakfast the following morning and were
refreshed in body and soul for the last lap of our journey.
Late afternoon the stage winds up a hill, and in a woods pasture
and surrounded by blue grass meadows the gable end of a red brick
house can be seen. My dear, tired mother puts her head out of the
window, “Driver, blow your horn.” A great blast sounds over the
waving grass and blossoming fields, and we know that they know we
are coming. Tired as the horses are after the long, hard pull; tired as
the coachman must be, he cracks his whip, and we gallop up the
shady lane to the dear old door as briskly as though we were fresh
from the stable. Long before we are fully there, and the steps of the
nine-passenger coach can be lowered; long before the boys can
jump off the top, a host of dear faces, both white and black, is
assembled to greet us. As a little child I always wondered why it was,
when the occasion was so joyful, and all of us tumbled from that
stage so beaming and happy, that as my aunt folded my mother in
her arms, they both wept such copious tears. Now I know.
 XX
HOTEL AT PASS CHRISTIAN IN 1849

If there is a more restful spot on earth than a comfortable rocking-

chair on a deep veranda, with a nearby view of the dancing waters of
the gulf through a grove of tall pines, commend me to it. A whole
month on the west coast of Florida, all sand underfoot, pines and
oaks overhead, is ideal for fagged-out, tired-out, frayed-out humanity
from busy cities. This is not an advertisement, so I do not propose to
tell where six people from six different and widely separated parts of
the country last year dropped down from the skies, as it were, upon
just such a delightful straight mile of gulf coast.
One halts at a “turpentine depot” and takes a queer little tram to
the Gulf, seven miles away. Tram is hauled over wooden rails by two
tired nags whose motions suggest the lazy air of the pines. It is
loaded with the baggage—crates of hunting dogs—(fine hunting
abounds), the mail bag, some miscellaneous freight and finally the
passengers.
The country hotel is pine; ceilings, floors, walls are pine, the home-
made and built-in furniture is pine; a big fire, roaring in the open
fireplace if the day is chilly, is also made of pine—the rich, red
Florida pine, ever so much richer in color and in turpentine than the
boasted Georgia article. With the fish swimming in front of this hotel
and the birds flying behind, and rabbits running in both directions, it
goes without saying the table is above the average.
Here on the broad verandas, as we rock and dream the lazy days
away, visions visit me of the old hotel at Pass Christian in the forties.
The oaks and three China trees in front of the veranda, and the view
of the nearby waters, the whistle of mocking-birds among the china
berries (thank heaven! sparrows have not found this Elysium) lend
additional force to the semblance. One old lady, who hunts not,
neither does she fish, rocks on the sunny veranda and dreams, as is
the wont of those who have lived beyond their day and generation.
She brings forth from a long-forgotten corner of memory’s closet a
picture covered with the dust of years, and lovingly brushes away the
dimness, when behold! old Pass Christian, dear old Pass Christian,
before the day of railroads and summer cottages, before the day of 6
o’clock dinners and trailing skirts, of cotillion favors and abbreviated
bathing suits.
The old hotel was built with a wing or extension at each end, which
formed with the main building three sides of a square. There was no
attempt at landscape gardening; not even a rosebush or an oleander
decorated the little court. No plaster Apollos and Dianas such as
were seen peeping about the shrubbery of the various cottages (like
the De Blancs’ and Ducayets’) that dotted in those days the old
bayou road, and were considered so very decorative, but plain sand
and scrub such as meet my eye to-day on this little frequented part
of the Florida Gulf Coast. There was no beach driving or riding of
gay people then—none here now.
I fly back to the summer of ’49, and live again with the young girls
who made life one long summer’s day. We walked the pier, the
image of one before my eyes now, to the bath-houses in muslin
dresses. Bathing suits were hideous, unsightly garments, high neck,
long sleeves, long skirts, intended for water only! The young girls
returned under parasols and veils. How decorous! No baigneuse
decolletée to be seen on the beach. Our amusements were simple
and distinctly ladylike. There was no golf or tennis, not even the
innocent croquet, to tempt the demoiselles to athletics, so they
drifted more to the “Lydia Languish” style.
There was no lack of beaux who came, more than enough to “go
round,” by the Saturday boats, in time for the weekly hop—danced
all Saturday night and returned to weekly drudge (as they called it) in
the city. The bonbons and flowers they brought vanished and faded
long before the little boat with its freight of waving hats and
handkerchiefs faded in the twilight of a summer Sunday.
 Also there come to my dream two dainty Goodman sisters,
wonderful and most accommodating musicians they were. One was
already affianced to her cousin, George Nathan. He was a
prosperous business man at that time. I doubt if even his name is
known among his thrifty race in New Orleans to-day. He carried off
his accomplished wife to Rio Janeiro, and made his home in that
country, which was as far away to us then, as the North Pole is to-
day. The younger sister met that summer at the Pass and eventually
married E. C. Wharton, an attaché of the Picayune, whose articles
were signed “Easy Doubleyou.” He was soon dancing attendance on
the pretty, curly haired girl. I remember how he wandered around
with pad and pencil, and we girls were horribly afraid of being put in
the Picayune. No reason for fear, as it was before the dawn of the
society page and personal column. The Whartons drifted to Texas
during the war, and at Houston they found already a host of stranded
Louisianians; but “Easy Doubleyou” had a government appointment
of some kind. The rest of us were simply runaways.
There, too, was Dick Taylor, propelled in a wheel chair over that
hotel veranda, an interesting convalescent from severe illness, or
perhaps a wound, I do not recall which, his valet so constant in
attendance that we wondered how the young man ever got an
opportunity to whisper sweet nothings into the ear of lovely Myrtle
Bringier—but he did! And that was the fourth engagement of the
season that culminated in marriage, which signalizes the superior
advantages of a hotel veranda, and most especially that of dear old
Pass Christian. Dick Taylor had a magnetic personality, which
overshadowed the fact (to paraphrase a Bible text) he was the only
son of his father, and he the President.
In New York some years ago “The Little Church Around the
Corner,” still garnished with its wealth of Easter lilies and fragrant
with spring bloom, threw wide its portals for the last obsequies of this
loved and honored Confederate general. In that throng of mourners
was one who had known him in his early manhood on the veranda of
that old Pass Christian hotel, and whose heart had followed his
career with ever-increasing admiration and veneration even unto the
end. I lay aside my old picture forever. Alas! it remains “only a dream
at the best, but so sweet that I ask for no more.”
 XXI
OLD MUSIC BOOKS

I wonder how many old ladies start to go through an unused hall

closet, to make room for an accumulation of pasteboard boxes too
good to throw away, and hampers too strong to discard, and in that
long-closed closet, which a junk man with push-cart is waiting to help
clear out, find a treasure, long since buried under piles of trash,
mourned for, and, as in the case of many departed things, at length
given up for lost—then forgotten. In just such a dark closet, from
beneath a pile of old magazines (what they were kept and stored for
goodness knows) and crazy bits of bric-a-brac, that nobody but a
junk man (not even Salvation Army men, who are getting to be
mighty choosy, by the way) would cart off, I found two bruised music
books.
One dated back to 1847, when I was a schoolgirl in New Haven,
and played with great éclat “La Fête au Couvent” quadrilles,
purchased of Skinner & Co., Chapel Street. Chapel Street still exists,
but Skinner & Co. are buried in the dust of more than sixty years. I
cannot play “La Fête au Couvent” or any other fête now, but I can
close my eyes and see the lovely young girls in the school music
room whirling away to the music of the inspiring cotillion. Alas! Alas!
Time has whirled every one of them away and stiffened the nimble
fingers that danced so merrily over the keys.
In those far away days that are as yesterday to my dreaming there
were “Variations” of every familiar melody. Variations that started with
the simple air and branched off into all sorts of fantastic and involved
and intricate paths. “Oft in the Stilly Night,” “’Tis Midnight Hour,”
“Twilight Dews,” “Low-Back’d Car,” “The Harp That Once Thro’ Tara’s
Halls,” “Oh, Cast That Shadow From Thy Brow,” and so on and on,
whole pages of “Variations,” now dim with age, but every blessed
note brings to me the faces and voices of those long stilled in death.
One sweet young girl played “The Harp That Once Thro’ Tara’s
Halls” and “’Tis Midnight Hour” so charmingly that my eyes were
dimmed when I turned the leaves of the school-day music book, for
her fate was saddest of all—an inmate for years of an insane
asylum. Another who sang as she played the “Low-Back’d Car” so
delightfully (she was half Irish) died suddenly of yellow fever. Still
another associated with “Oh, Cast That Shadow From Thy Brow,”
played the melody on a guitar, accompanied by her sweet young
voice. Alas! She, too, is gone where they play on harps and there are
no shadowed brows. So, on and on to the bitter end, and with a sigh
I close the first chapter of my musical reminiscences that have lain
dormant so many, many years.
The fashion of dedicating bits of music to some well-known person
—need not be a musician, either, but a body of some note—has
passed away with the one-button glove and the green barège veil of
sixty years ago. In the ’50s it was quite common, and my dear music
book of that date holds ever so many dedicated polkas and
mazourkas. The very front leaf has a picture of a wonderfully
crocheted kind of a serpent with a man’s head, rather a shocking
thing, “Sea Serpent Polka,” dedicated to Miss Rose Kennedy, by M.
Strakosch. Dear Rose used to play it for us. It was not an inspiring
bit of music, but her wonderfully deft touch would make melody out
of anything that had crochets and quavers in it.
There is, a few pages further, another dedication to the
incomparable Rose, “Grande Polka de Concert,” by Wallace. Miss
Lou Gross, a most accomplished musician, daughter of the noted
surgeon, Dr. Samuel Gross, was honored by Strakosch in the
“Kossuth Galop,” a galloping thing, much in the Strakosch style,
which predominated in those days. Strakosch believed in a grand
“send off” of his innumerable productions. There’s “Carnival de
Paris,” dedicated to Mme. Caroline Arpin (I did not know of her) and
“Flirtation Polka,” to Mme. Lavillebeuvre, who was a delightful pianist
and merited something more inspiring than that “Flirtation.”
Then Wallace dances on the pages with a “Polka” adorned with
the name of Mlle. Dumilatre, and Ed Armant dedicates “La Rose
Polka” to Miss Augusta Slocomb. I don’t think Armant wrote music;
he “got it done,” as the saying is. That was not an unusual feat; a
valse was dedicated to Miss Philomène Briant, by George
McCausland, and he was ignorant of a note in music—he “got it
done.” P. A. Frigerio honored Miss Sara Byrne by the dedication of
“La Chasse Polka.” Miss Sara was a decided belle in the ’50s, so a
bit of music with her name attached found rapid disposal. Also, a
belle of the ’50s was Miss Estelle Tricou. Lehman, chef d’orchestre
at the opera house, wrote “Souvenir de Paris” in her honor. Miss
Estelle was bright and sparkling and beautiful, so was much in
evidence. George W. Christy wrote more than one of his “starry”
verses to “E. T.,” and they were printed in the Picayune. George was
not noted for self-effacement and modesty. His signature always
appeared in full to his sentimental effusions.
Lehman dedicated his “Clochettes Polka Mazourka,” a fine,
inspiring bit of dance music it was, too, to Mme. Odile Ferrier, and
“La Valentine Polka,” another charming, catchy dance piece, to Miss
Anaïs Boudousquie. There was Mme. Angélina, a new French
importation, whose specialty was the new dances that nobody else
could teach. She was immortalized by “L’Esmeralda Nouvelle Danse
de Salon.” We pupils had to learn some new steps and flourishes to
be able to make successful début, after All Saints’ Day, for it was
decreed “L’Esmeralda” was to be most popular. Everybody, even
some stout old ladies that did not mean to be relegated to back
seats, and passé beaux who were fast becoming clumsy and awfully
hard to dance with, took dancing lessons on the sly of Mme.
Angélina, not to mention the young girls, débutantes and such, that
went in small installments to her tiny room in Royal Street....
After this seeming digression I turn a leaf in the old music book to
dedications to Mme. Boyer, “Mazourka Sentimentale,” by the fertile
Strakosch, and here, too, “La Valse Autrichienne” by a new name—
E. Johns. Mme. Boyer was the fashionable teacher of music. Both
these dedicated pieces we scholars had to learn, and both bits,
besides a dozen other bits a thousand times more difficult and
intricate, like Gottschalk’s “Bamboula,” for instance, are so spotted
with black pencil marks they are a sight! For the madame did not
make a suggestion as to technique or expression or anything else in
the musical mind that was not emphasized by a pencil mark on the
page.
I find that most of this music was published by Mayo, No. 5 Camp
Street; by Lyler & Hewitt, 39 Camp Street. Lehman published his
own work at 194 St. Anne Street.... I am not half through, but I am
weary of looking over these old music books. So many memories
cluster about every page—memories of lovely dances with delightful
partners. Oh! That grand valse à cinq temps, the music of which was
never printed, and no band but Lehman’s band could play it, and
nobody taught the whirling steps but Mme. Angélina. Memories of
sweet girls, now old and faded, or, better than that, listening to the
“Music of the Spheres.” Memories of painstaking professors whose
pencil marks are all that is left to bring forcibly to mind their patient
personality. I turn the last leaf, and lo! here is a unique bit of music
and information—“The Monterey Waltz,” by Eugene Wythe Dawson,
a little Texas boy, who dedicates it to the little musicians of his own
age (eight years) in the sister States! I do not remember anyone who
essayed to render the “Monterey Waltz”—I never did—but Eugene
Dawson was still playing the piano in Texas during the war, proving
possibly our grandfather’s dictum, “A man who plays the piano is
mighty little account for anything else.”
We don’t think so now. I would be glad for a musician, male or
female, in this house to render for me the sweet musical numbers
that once made my young heart bound.
 XXII
THE SONGS OF LONG AGO

How the ballads of our youth are, in memory, merged into the
personality of those who sang them! How, as we recall the simple
rhymes, the sweet voices of departed friends clothe them in melody.
The songs of my early years come to me to-day with more freshness
than the songs I heard yesterday, and with them come more vividly
to mind the voices and faces of those long-gone friends than come
the faces of those of to-day.
How many of us can recall “Blue-eyed Mary”? the little ballad with
which my mother always quieted me to rest. The pitiful little song!
And in my childhood days, too, mammy rocked me to sleep with “Ole
Grimes is daid, dat good ole man.” I never hear “Blue-eyed Mary” or
“Old Grimes” now, nor have I for more than threescore years and
ten, they are both so buried in oblivion, though I can repeat every
word of each, they were so nestled and rocked into my baby life.
When my father’s home was on Customhouse Street Duncan
Hennen lived directly opposite. Mrs. Hennen was a dashing beauty.
She had a sister from Tennessee visiting her, who had a powerful
voice, and she sang “Old Rosin the Beau” and “Life on the Ocean
Wave” with all the abandon of a professional. My father admired her
style prodigiously, but my mother thought it too robust. “The Carrier
Dove—fly away to my native land, sweet dove,” and “Twilight Dews,”
she pronounced more ladylike. (How often we used that word
“ladylike.” We rarely hear it now.) I must have been a very small “little
girl” when I heard Wallace, in concert, sing “The Old Arm Chair.” No
one since Wallace ever sung that touching, homely ballad so
beautifully. Once having heard his sympathetic rendering, one
always associates the song with William Wallace.
 I think it has been full sixty years since that song and “Farewell to
Tom Moore,” by Byron, have been heard. And “Twilight Dews,” oh,
my! and “Shells of the Ocean”—“One summer’s day in pensive
thought,” etc. Young girls played their accompaniments and tossed
their ringlets and sang those ditties to enraptured swains, who often
stood back of them, holding the candle at the proper angle and
turning the leaves! How it all comes back to this dreaming old lady,
who never sang, but who dearly loved to listen to her more gifted
friends....
In the Cajin settlement on the border of which I occasionally visited
there was a family of Lafitons—I boldly give the name, for the two
sons, Lafiton fils and Pete, never married, and all the family died
years and years ago, but there was a lovely sprig of a girl,
Amenaide, who possessed a fine voice and no doubt would have
made her mark if she had had the necessary training, but she was
one of the flowers “born to blush unseen.” I don’t think she knew one
note of music. Of course, a guitar, much more a piano, was beyond
her reach. She sang the sweet old French melody, “Fleuve du Tage,”
delightfully. I wonder now where she ever heard it. For years after
when I heard the song Amenaide rose before me, and with her the
impression that she was not equaled.
There was another touching little ballad, in the days that were,
“We Have Been Friends Together,” and that tender “Good-by,” who
ever sings them now? Nobody, unless it be some old lady with
quavering voice, who sings them in her heart while she dreams of
the sweet girls of “Long, long ago” who have vanished.
“I Cannot Sing the Old Songs,” and “When Stars Are in the Quiet
Skies” were two of the songs we loved to hear in the days before
“Dixie” and “The Volunteer” and “The Bonnie Blue Flag” captured the
voices of so many of our sweet singers.
Some of us remember Mollie Haynes, who became the wife of
Col. Charles D. Dreux, and none can recall her charming personality
without a thought of the superb voice she possessed. “Ave Maria,
Ora Pro Nobis”—none that I knew could render that prayerful melody
with the pathos of Mollie Dreux. We all remember that Col. Dreux
was the first Confederate officer from Louisiana who fell in battle,
and no subsequent funeral was more largely attended than was
Charles Dreux’s. “Joys That We’ve Tasted” brings to mind a popular
singer in the “Long Time Ago,” Mrs. George D. Prentice, of Kentucky.
How the names and the very people come thronging my mind as I
recall these old melodies in which they are associated.
A few years since, listening to the well-trained voice of a
professional, as she rendered some intricate, superlative kind of
music, that did not in the least appeal to me, I ventured to ask if she
would favor us with “Ben Bolt.” She graciously consented. And she
rendered that simple old ballad that every child whistled or hummed
when I was a child, with so many trills and bravuras, and I don’t
know what else in the vocal line, that I was lost in amazement.
Svengali himself could not have idealized to the same extent. Poor
“Sweet Alice” was buried under such an avalanche of sound that one
could not recognize the “corner, obscure and alone,” where she was
supposed to rest under a “slab of granite so gray.”
So, perhaps, in the march of improvement, where none sing
unless they possess a voice that would electrify a whole opera
house audience, it is well the dear old songs of long ago are not
resurrected and amplified to suit the tastes and requirements of to-
day. I recall though, with a thrill of tender memory, hearing Jenny
Lind sing “Home, Sweet Home”—just the simple ballad—without a
single flourish when she was in New Orleans in 1851. I was in deep
mourning and did not dream I would have the pleasure of hearing
her, but a friend secured a loge grillée, and insisted upon my going,
accompanied by my brother. It was all arranged so courteously and
so sympathetically and so kindly that I could not refuse, and thus I
heard that incomparable artist sing “Home, Sweet Home.”
No longer can mother sit in her “old arm chair” waving a turkey tail
fan warm summer evenings, and be comforted and soothed by
sweet warblings of her girls at the piano. No longer can the tired
father call for his favorite, “Oh! Would I Were a Boy Again,” or “Rock
Me to Sleep, Mother,” or Mrs. Hemans’ “Bring Flowers, Fresh
Flowers,” the sweet old flowers that all girls were singing sixty years
ago. The old mothers and fathers, the bright young daughters are
scarce buried more deeply or mourned more deeply than are the
songs of long ago.
 XXIII
A RAMBLE THROUGH THE OLD CITY

In the days of which I write New Orleans bore a very different

aspect from the present, and it may be well for me to take my
readers on a gossipy ramble through the thoroughfares which I so
often traverse nowadays in my thoughts.
Canal Street in the early forties was, par excellence, a resident
street. From Camp and Chartres Streets, way back as far as
sidewalks were flagged or bricked, which was only a few blocks,
Canal Street was lined with homes, side by side, often without even
an alley to separate them, as though land was scarce and one need
economize space, whereas just beyond was land in plenty, but no
sidewalks or easy approaches to speak of. From Camp Street to the
levee were, as I remember, large wholesale business houses,
convenient to the shoppers of large supplies, who arrived at regular
intervals from their plantations on Belle Creole, or some other coast
packet, frequently retained their quarters on the boat the short time it
was in port, and so monsieur and madame could accomplish their
necessary shopping, untrammeled by the elegancies and
inconvenient hours of a hotel.
 Things were conducted on a very liberal basis in those days. I
have a liking for that old way—it was so debonair and generous,
putting the captain on the same social standing as his guests.
On the lower side of Canal Street, about where Holmes’ store now
stands, were more homes, in a row, all the houses exactly alike, with
narrow balconies stretching clear across the fronts, in a most
confidentially neighborly way. The lower floors were doctors’ or
lawyers’ offices or exchange brokers’. Fancy goods, dry goods, retail
shops, in fact of every kind, were on Chartres or Royal Street; none
on Canal. R. W. Montgomery had his home also on that fashionable
thoroughfare.
Christ Church was on the corner of Baronne and Canal, and Dr.
Laycock was the pastor at the date of which I write, and, with few
exceptions, all these families were of his flock.
Lower Camp Street was occupied mostly by exchange brokers’
and such offices. The Sun Mutual Insurance Company had a
conspicuous sign on a modest two-story brick building which any
insurance structure to-day would put to shame.
 If it is near Christmas time, when we are taking this gossipy
ramble, we might meet a flock of turkeys marching up Camp Street,
guided by a man and boys with long poles. In those days fowls were
not offered for sale ready dressed or plucked, but sold “on the hoof,”
as we say of cattle. Camp and the adjacent resident streets were, to
use another Westernism, a favorite “turkey trot.” Those turkeys may
have trotted miles. Goodness knows whence they took up the line of
march—presumably at some boat landing—but they were docile as
lambs and in good condition. No roast turkey gobbler, or, better still,
boiled turkey hen with oyster dressing, tastes now like the ones
mother had on her table when I was a child and clamored for the
drum-stick. What does taste as good to us old folks to-day? Nothing!
Absolutely nothing!...
In Exchange Alley (it may have a new name now, since Triton
Walk and Customhouse Street and others of the old days have been
rechristened) my father and a number of other “attorneys at law,” as
their signs indicated, had offices. Mr. Wharton was one, and I also
recall two Hebrew beaux of that date who were neighbors of my
father’s, A. K. Josephs and M. M. Cohen. Nobody knew their given
names. Beyond Camp Street, near Magazine, Mme. Shall kept a
boarding house. It was a popular hostelry for gentlemen. Ladies did
not board, except (to use Susan Nippers’ language) as temporaries.
 Exchange Alley.

Visitors to the city “put up” at the St. Charles Hotel, in the hands of
Colonel Mudge. St. Charles was the best hotel even then, comparing
favorably with the Galt House, in Louisville, under the management
of that prince of hosts, Major Aris Throckmorton—which is saying
volumes for the St. Charles. In the season flocks of Nashville,
Louisville and Cincinnati belles descended upon New Orleans, sat in
gorgeous attire and much chatter of voices on the divans under the
chandelier of the St. Charles parlor, while the kindly fathers and
insinuating brothers, bent on giving the girls a good time, foraged
about the ample rotunda, captured, escorted in and introduced many
eligible beaux found sauntering around that fascinating rendezvous.
Up Carondelet Street—one could not find the location on a city
map now, for, as I remember, the streets were not named—were
suburban homes, all about, quite remote and countrified. Judge John
N. Duncan lived in one of those cottages. There was a grand, big
yard surrounding it, with fig trees, hedges, rosebushes and vines, a
perfect bower of delight to us children. Rose, the only daughter, was
a lifelong friend of mine. She became the first wife of Col. William
Preston Johnston. Nearby lived the Peter Conreys, who gave lovely
lawn parties, that the naughty uninvited dubbed “Feat sham peters.”
Not so very far away, in the neighborhood of Constance and Robin
Streets, there was erected in 1843 Quite a grand residence for the
Slark family. I do not remember much of them in those early days,
though they lived near enough to my father’s to be neighbors. Later
in life my acquaintance with them was more intimate. I recall, though,
quite vividly Mrs. Slark’s visiting card, which I admired prodigiously.
Being a small collector of curios that unique bit of pasteboard was
one of my treasures till I lost it! There seems to have been
considerable latitude in the style of visiting cards about that time—
some were highly glazed and had gilt edges; some were even pink
tinged, but I think Mrs. Slark’s was the ne plus ultra—a bird’s beak
holding a waving pennant, and on its flowing folds was engraved
“Mrs.—Abigail—L.—Slark,” something after the style of the eagle
and E pluribus unum.
I find I am wandering away from that dear old Canal Street of
fragrant memories. Fragrant, though the broad neutral ground was a
wilderness of weeds of dampy growth, and (so our John used to tell
me) snakes! There certainly were frogs after a spring rain. I have
heard their croaks. Further back toward the swamps were deep
ditches, with crawfish sneaking about in them. Fine fishing place for