Optical coherence tomography

IN GLAUCOMA
How to interpretation?

PRIMA MAYA SARI

MOHAMMAD HOESIN HOSPITAL/FACULTY OF

MEDICINE SRIWIJAYA UNIVERSITY
 Introduction
• Optical Coherence Tomography (OCT) is an
imaging technology that employs low-
coherence interferometry to obtain cross
sectional images of the ocular tissues
 introduction
• Glaucoma is an optic neuropathy with
characteristic optic nerve appearance and
visual field loss for which elevated intraocular
pressure (IOP) is one of the main risk factors

• The optic disc and the RNFL are the principal

sites of apparent glaucomatous damage
 Optic Coherence Tomography (OCT)

Non-invasive examination that can image Optic Nerve Head (ONH)

such as neuroretinal rim area, disc area, cup area, cup volume, cup
disc ratio, horizontal cup disc ratio and vertical cup disc ratio.
Optical Coherence Tomography (OCT) is an imaging technology that displays an
image of micron resolution of invivo tissues, including oculi microstructure.

OCT can be analogous to ultrasonography, but instead of using sound waves, OCT
using near infrared light to obtain a cross sectional image

OCT can be used as a supporting examination to confirm the diagnosis because of its
ease of eye examination both the anterior segment and the posterior segment.
 Optical Coherence Tomography
Basic Principle of OCT

The basic principle of OCT is based on reflected

light imaging. The resolution of OCT depth is very
high, reaching 0.01 mm or 0.4 thousandth of an
inch. So that it can produce cross sectional views
(tomography) of the same internal tissue structures
as tissue pieces under a microscope. The light
entering the eye will be reflected by various layers
of the retina. Light beams on OCT are refracted
briefly in tissue samples. The OCT system then
collects reflected light and measures the difference
in launch time.
Optical Coherence Tomography
Low Coherence Interferometry

Michelson Interferometer
Moveable
Reference Mirror
OCT works based on the principle of Michelson
interferometry by using low coherence infrared light
800-830 nm. The beam is emitted through optical
fibers to the beam splitter and then directed to the S ource Eye under Test
retina and reference mirror. The light that entering
the eye will be reflected by various layers of the
retina.
Beamsplitter

Detector Output Signal

12/20/2008 33
 PERKEMBANGAN OCT

• OCT technology was developed at Dep. Electrical Engineering and Computer Science at the

198 Massachusetts Institute of Technology, United States. In the James G. Fujimoto, PhD laboratory,
the first retinal imaging was carried out by David Huang, MD, PhD, and Joel S. Schuman, MD and

9 data was eported in 1991

• Eric Swanson designed the first clinical OCT prototype of the eye which was built in an
199 engineering laboratory and installed at the New England Eye Center, Tufts-New England Medical

3 Center, FK Tufts in Boston, United States

• Swanson, Puliafito, Schuman, Huang and Fujimoto created a new company in 1994 known as
Advanced Ophthalmic Diagnostics (AOD) to transfer technology to industry. In 1994 this
199 technology was patented and then transferred to industry to Carl ZeissMeditec, Inc. (Dublin,
California). Clinical studies were carried out between 1994 and 1995, and the first commercially
4 available OCT, called OCT 1000, from Zeiss, was marketed in 1996
Optical Coherence Tomography

OCT Scan Pattern

Fast Macular Thickness Map or Macular Thickness Map, both of

1 which use six radial scan lines above the macula

2
Fast RNFL Thickness, is a scan circle around the optical disc.

3 Fast RNFL Thickness, is a scan circle (circle) around the

optical disc.
 APPLICATION OF OCT IN GLAUCOMA

• Anterior Segment-OCT
– Anterior segment OCT (AS-OCT) uses light of
longer wavelength (1310 nm) to obtain images of
the anterior segment
• Posterior Segment-OCT
– Posterior segment OCT uses light of 830 nm to
obtain images of the posterior segment
structures, such as ONH, retinal nerve fiber layer
and macula
 Applications of AS-OCT
• Evaluation of angle structures
• provides detailed calculations of parameters,
such as angle opening distance, angle recess
area, and the trabecular—iris space area
• To evaluate the effect of laser peripheral
iridotomy and other interventions on the angle
anatomy
• Assessment of bleb morphology and patency of
ostium post-filtering surgery
 Posterior Segment-OCT
• to obtain images of the posterior segment
structures, such as ONH, retinal nerve fiber layer
and macula.

• Axial resolution of spectral-domain (SD) OCT is

twice higher (5-7 microns) than stratus OCT
(approximately 10 microns). The SD OCT
instruments can acquire B-scans 45 to 130 times
faster than Stratus OCT and multiple B-scans
 Interpretation of OCT
• Quality Assessment
• 1. Appropriate centration of the peripapillary
circular scan is essential for accurate
measurements of RNFL thickness.
• 2. Signal strength value of the scan should be
greater than 5.
• 3. Homogeneity of the RNFL scan is important
since loss of reflectivity can affect the overall
quality.
Figure 10. Missing data represented in black (see
arrow) due to staphyloma
 AXIAL LENGTH
Axial length has been shown to influence SD-OCT measurements of
both RNFL thickness and ONH parameters due to axial-length
induced ocular magnification

The longer the eye, the thinner the RNFL and the smaller the optic
disc area and neuroretinal rim area

However, refractive error independent of axial length has not been found to
affect RNFL thickness measurements as long as well focused fundus image is
obtained during scan acquisition by utilizing the cirrus SD-OCT internal fixation
focus adjusment

This adjustment can account for refractive errors from -20.0 D to

+20.0D
The RNFL profiles (centered and displaced scans) obtained by displacing the scan
circle at an arbitrary distance during OCT imaging using the fast RNFL 3.4 scan
protocol in the same eye are shown in the serial analysis printouts. The RNFL
profile centered at the disk is shown in blue and those with scan circles displaced
superiorly (A) and inferiorly (B) (demonstrated in the corresponding fundus
photographs) are in red
Retinal blood flow measurement with doppler OCT may help us
understand the role of perfusion in the causation and treatment of
glaucoma, other optic neuropathies and retinal disease
SD OCT is a powerful objective structural assessment tool that can
greatly assist clinicians in diagnosing and managing glaucoma
Retinal nerve fiber layer analysis: RNFL thickness measurement is
graphed in a TSNIT orientation and compared to age matched
normative data. Decreased RNFL thickness represents glaucoma.

ONH analysis: Disk margins are objectively identified by

using signal from and of RPE. Key parameters include cup to
disk ratio and horizontal integrated rim volume.

Macular thickness analysis: Thinning of macula may reflect

glaucomatous loss.

A recent software upgrade of Stratus OCT (Stratus OCT Version

5.0) has included the glaucoma progression analysis to evaluate
the association between average RNFL thickness and age.
 Advantages of OCT
Easy to operate.

Has the best resolution among all the imaging devices

Has a rapid image acquistion time.

Being a noncontact technique, images can be obtained without

causing undue discomfort to the patient.

Qualitative and quantitative data can be collected and analyzed in an

objective and reproducible way.

It is the only technology capable of imaging the optic nerve head, retinal
nerve fiber layer and macula.

Can obtain posterior segment images without pupillary dilatation.

 Precision of OCT in Early Diagnosis of
Glaucoma

Various studies on OCT4-8 have shown:

Measurement of RNFL thickness with OCT has

been reliable in discriminating normal from
glaucomatous eyes.

OCT has good sensitivity and specificity for

differentiating normal from glaucomatous
eyes.
 Limitations of OCT
AS-OCT has a poor ability to show the details of ciliary body and the posterior
surface of the iris ( since the posterior pigment epithelium of the iris and the
ciliary epithelium block the passage of infrared light). Therefore AS-OCT can
not detect cyclodialysis clefts and ciliary body tumors.

Image quality of superior and inferior quadrants of the angle with AS-OCT is
suboptimal due to interference from the eyelids.

Automatic demarcation of the optic disk borders

Landmarks, such as scleral spur and Schwalbe’s
line are not always clearly visible as with UBM, so
quantitative measurements of angle width may
not be very accurate.
by the machine may be inaccurate in cases of
parapapillary atrophy, which would confound the
interpretation of optic disk topography. This may
limit the ability of OCT to detect the progression of
glaucomatous optic disk damage.
 Limitations of OCT
It is possible that localized NRR/optic cup changes would be
missed by the interpolation algorithm. It is possible that localized
NRR/optic cup changes would be missed by the interpolation

Depends on the skill of the Poor quality of images in

operator. dense media opacities.

Difficult in uncooperative
Expensive instrumentation
patients.
 CONCLUSION
Medicine and technology are advancing hand in hand to provide
quality health care

Technology innovation and improvement will continue to impact

health services.

The lack of large scale normative database is perhaps the greatest

issue in interpretation of OCT results at this point of time.

These issues must be resolved before OCT can be accepted for

widespread clinical use in glaucoma.
 CONCLUSION
utility of OCT as a glaucoma diagnostic tool is extremely high as, adequate
data exist to evaluate the patients in conjunction with other clinical
parameters

A patient can be followed over time, using his or her own baseline.

The two eyes of the patient can be compared for asymmetry, and a
single eye can be examined for focal or sectoral NFL thinning.

The clinician must correlate clinically with IOP, ONH and NFL appearance,
visual field data, as well as quantitative data contributed by technology, to
detect glaucoma and its progression
• Thank you