Quantification of nerve fiber layer thickness in normal and glaucomatous eyes using optical coherence tomography

Topography of diabetic macular edema with optical coherence tomography

OBJECTIVE

This study aimed to develop a protocol to screen and monitor patients with diabetic macular thickening using optical coherence tomography (OCT), a technique for high-resolution cross-sectional imaging of the retina.

DESIGN

A cross-sectional pilot study was conducted.

PARTICIPANTS

A total of 182 eyes of 107 patients with diabetic retinopathy, 55 eyes from 31 patients with diabetes but no ophthalmoscopic evidence of retinopathy, and 73 eyes from 41 healthy volunteers were studied.

INTERVENTION

Six optical coherence tomograms were obtained in a radial spoke pattern centered on the fovea. Retinal thickness was computed automatically from each tomogram at a total of 600 locations throughout the macula. Macular thickness was displayed geographically as a false-color topographic map and was reported numerically as averages in each of nine regions.

MAIN OUTCOME MEASURES

Correlation of OCT with slit-lamp biomicroscopy, fluorescein angiography, and visual acuity was measured.

RESULTS

Optical coherence tomography was able to quantify the development and resolution of both foveal and extrafoveal macular thickening. The mean +/- standard deviation foveal thickness was 174 +/- 18 microns in normal eyes, 179 +/- 17 microns in diabetic eyes without retinopathy, and 256 +/- 114 microns in eyes with nonproliferative diabetic retinopathy. Foveal thickness was highly correlated among left and right eyes of normal eyes (mean +/- standard deviation difference of 6 +/- 9 microns). Foveal thickness measured by OCT correlated with visual acuity (r2 = 0.79). A single diabetic eye with no slit-lamp evidence of retinopathy showed abnormal foveal thickening on OCT.

CONCLUSIONS

Optical coherence tomography was a useful technique for quantifying macular thickness in patients with diabetic macular edema. The topographic mapping protocol provided geographic information on macular thickness that was intuitive and objective.

Investigation of dispersion effects in ocular media by multiple wavelength partial coherence interferometry

We report on quantitative measurements of group refractive indices and group dispersion in water and in human ocular media such as the cornea, the aqueous humor, the lens, artificial intraocular lenses, as well as a total value averaged over the media along the axial eye length of normal subjects and pseudophakic patients in vivo using dual beam partial coherence interferometry. Different optical thickness values due to the dispersion of the cornea are demonstrated using two spectrally displaced light sources. The displacement can be used to indirectly calculate the group dispersion of the human cornea in the spectral region between 810 nm and 860 nm. If the object under investigation is dispersive, resolution is limited due to a broadening of the detected signals. This broadening increases with group dispersion, i.e., the extent to which the group refractive index of the medium varies with wavelength and thickness of the tissue under investigation as well as with the spectral bandwidth of the light source. Measurements of the group dispersion in the cornea, lens and vitreous of pseudophakic and normal human eyes, show that the cornea and the lens are more dispersive than water-by a factor of about 5 and 2, respectively-in the investigated spectral region. The cornea is approximately threefold more dispersive than the human crystalline lens, the aqueous humor is less dispersive than water and the group dispersion of all ocular components together, averaged over the axial length of normal and pseudophakic eyes, was only slightly higher compared to that of water. Since the highly dispersive cornea and lens together have only a thickness of about one sixth of that of the axial eye length, it seems that their contribution to the group dispersive effect along the whole axial eye length is only small.

The associations of optic disc hemorrhage with retinal nerve fiber layer defect and peripapillary atrophy in normal-tension glaucoma

OBJECTIVE

The purpose of the study is to elucidate a topographic correlation between optic disc hemorrhages and retinal nerve fiber layer defects as well as peripapillary atrophy in normal-tension glaucoma (NTG).

DESIGN

The authors prospectively studied the relation between the precise locations of disc hemorrhages and retinal nerve fiber layer defects in the first part of the study. The authors also compared morphometrically the peripapillary atrophy and the optic disc in eyes with disc hemorrhage with eyes without a history of disc hemorrhage in age-matched patients in the second part of the study.

PARTICIPANTS

In part 1, 42 patients with NTG (male/female = 11/31; age, 56.8 +/- 14.2 years) in whom new disc hemorrhages developed were enrolled. In part 2, 51 randomly selected age-matched patients with NTG without a history of disc hemorrhage (male/female = 16/35; age, 55.7 +/- 12.5) were examined.

MAIN OUTCOME MEASURE

In part 1, retinal nerve fiber layer defects were observed by scanning laser ophthalmoscopy using an argon-blue laser. In part 2, the area, angular extent, and radial extent of zone beta of peripapillary atrophy and the structural parameters of optic disc were measured by scanning laser tomography using a diode laser.

RESULTS

In part 1, the authors detected 64 disc hemorrhages in 48 eyes of 42 patients; retinal nerve fiber layer defects were shown in 47 (97.9%) of 48 eyes by scanning laser ophthalmoscopy. Of 64 disc hemorrhages, 51 (79.7%) coincided with retinal nerve fiber layer defects in location. These 51 hemorrhages were present on the border (41.2%) or adjacent to the border (58.8%) between the retinal nerve fiber layer defect and the apparently healthy-looking retinal nerve fiber layer. In part 2, the prevalence, area, angular extent of zone beta, and ratio of zone beta area to disc area were significantly greater in the disc hemorrhage group than in the nonhemorrhage group, even though there were no significant differences in disc parameters between the two groups.

CONCLUSIONS

Disc hemorrhage is associated closely with retinal nerve fiber layer defect in location and the size of peripapillary atrophy in NTG.

Biometric investigation of changes in the anterior eye segment during accommodation

Non-invasive biometry of the anterior structures of the human eye can be performed with unprecedented precision of 8-10 microns and a resolution of approximately 9 microns by partial coherence interferometry, which has the potential to assess the effect of cycloplegia on the ocular components of the anterior eye segment, to further improve the precision to 1-2 microns by the use of these agents and to quantify the amount of residual accommodations in different states of cycloplegia. In addition, the anterior chamber depth, the thickness of the crystalline lens, their changes during accommodation, as well as the movement of the anterior and posterior lens pole during accommodation can be quantified objectively and accurately to investigate the mechanism of accommodation.

Evaluation of coexisting optic nerve head drusen and glaucoma with optical coherence tomography

OBJECTIVE

Optic nerve head drusen often make evaluation of the nerve head difficult to interpret. In addition, visual field defects are known to occur in patients with optic disk drusen, resembling glaucomatous damage. The authors report two cases of coincident optic nerve head drusen and glaucoma, in which the use of optical coherence tomography (OCT) in evaluating the nerve fiber layer was beneficial.

PARTICIPANTS

Two patients with both optic nerve head drusen and glaucoma, one with primary open angle glaucoma, the other with pseudoexfoliation glaucoma were evaluated. Both patients had asymmetric optic disk drusen, with clinically visible drusen only in one eye.

INTERVENTION

Ophthalmologic examination, color and red-free photography, automated Humphrey visual field testing and OCT were performed.

RESULTS

Nerve fiber layer loss as measured by OCT was found to be greater than expected by the appearance of the optic nerve head and red-free photography, with visual fields consistent with findings in case 1. In case 2, visual fields were full, despite nerve fiber layer thinning seen by OCT and red-free photography.

CONCLUSIONS

There can be significant nerve fiber layer thinning in patients with both glaucoma and optic disk drusen, despite the appearance of the optic nerve head in these patients. The cup margin may be obscured by the drusen, giving rise to a falsely full-appearing disk. In such cases, OCT may provide a useful means to quantitatively measure the nerve fiber layer thickness and to aid in the management of these patients by detecting nerve fiber layer thinning earlier than would otherwise be possible.

The scanning laser ophthalmoscope

The imaging of the fundus of the eye poses two major technical challenges. First, it is necessary for both the illuminating and reflected beams to pass through the same aperture, the iris. In some commonly used instruments this leads to the use of levels of illumination close to the maximum tolerable by a patient. Second, in order to visualize the different structures present in the various layers of the fundus it is necessary to perform tomographic imaging. The scanning laser ophthalmoscope provides an answer to these particular problems. By scanning the fundus with a narrow laser beam most of the area of the iris is then available for the reflected light and so the intensity of the illuminating beam can be kept low, making it more acceptable for patients. The use of confocal imaging allows 3D images to be produced. In this short review the performance of the instrument will be discussed and its application to a number of clinical problems in ophthalmology considered. Finally there will be a brief description of other instrumentation currently under development.

Light scattering and form birefringence of parallel cylindrical arrays that represent cellular organelles of the retinal nerve fiber layer

The retinal nerve fiber layer (RNFL) comprises bundles of unmyelinated axons that run across the surface of the retina. The cylindrical organelles of the RNFL (axonal membranes, microtubules, neurofilaments, and mitochondria) as seen by electron microscopy were modeled as parallel cylindrical arrays in order to gain insight into their optical properties. Arrays of thin fibrils were used to represent organelles that are thin relative to wavelength, and the model took into account interference effects that may arise from spatial order. Angular and spectral light-scattering functions were calculated for the backscattering hemisphere. Scattering was much larger from axonal membranes than from microtubules or neurofilaments. Spectra from 400 to 700 nm show that scattering increases at shorter wavelengths for both axonal membranes and microtubules. At 560 nm, scattering from mitochondria modeled as thick cylinders was approximately the same as that from microtubules but showed little wavelength dependence. The model reveals differences in backscattered polarization ratios that may permit experimental discrimination between microtubule and membrane mechanisms for the RNFL reflectance. Calculated backscattering exceeds measured values by at least 1 order of magnitude, but calculated form birefringence for microtubule arrays is approximately the same as measured birefringence.

Argon laser retinal lesions evaluated in vivo by optical coherence tomography

PURPOSE

To assess the in vivo evolution of argon laser retinal lesions by correlating the cross-sectional structure from sequential optical coherence tomography with histopathologic sectioning.

METHODS

Argon laser lesions were created in the retinas of Macaca mulatta and evaluated by cross-section optical coherence tomography, which was compared at selected time points with corresponding histopathology.

RESULTS

Argon laser lesions induced an optical coherence tomography pattern of early outer retinal relative high reflectivity with subsequent surrounding relative low reflectivity that correlated well with histopathologic findings. The in vivo optical coherence tomography images of macular laser lesions clearly demonstrated differences in pathologic response by retinal layer over time.

CONCLUSION

The novel sequential imaging of rapidly evolving macular lesions with optical coherence tomography provides new insight into the patterns of acute tissue response by cross-sectional layer. This sequential imaging technique will aid in our understanding of the rapid evolution of retinal pathology and response to treatment in the research and clinical setting.

Retinal nerve fiber layer thickness in normal human eyes

PURPOSE

To measure the histologic thickness of the retinal nerve fiber layer (RNFL) in normal human eyes.

METHODS

Human eyes were obtained at autopsy within 6 hours postmortem. The retina was dissected into four quadrants and serially sectioned in historesin. The RNFL thickness was measured histologically in all four quadrants at the disc margin and at regular intervals from the disc margin. Measurements of the RNFL thickness also were obtained at the fovea and in the retinal periphery.

RESULTS

Ten eyes of ten white individuals were studied. Age (mean +/- standard deviation) was 53.1 +/- 19.6 years (range, 18-76 years). For the eyes studied, the disc area (mean +/- standard deviation) and cup:disc ratio (mean +/- standard deviation) were 1.92 +/- 0.1 mm2 and 0.3 +/- 0.08, respectively. Mean superior, inferior, nasal, and temporal RNFL thickness at the disc margin was 405, 376, 372, and 316 microns, respectively. In all four quadrants, the RNFL thickness decreased with increasing distance from the disc margin. The average superior and inferior RNFL thickness was inversely related to age (P = 0.033, P = 0.097, respectively). The average RNFL thickness was not related to disc area. The average RNFL thickness just superior, inferior, nasal, and temporal to the foveola was 27, 34, 26, and 12 microns, respectively. The average RNFL thickness just posterior to the ora serrata in the superior, inferior, nasal, and temporal retinal periphery was 8 to 11 microns.

CONCLUSION

The peripapillary RNFL thickness in humans is thicker than that seen in nonhuman primates. The thinnest peripapillary RNFL is in the region of the papillomacular bundle. These data can be used to determine the accuracy of NFL analyzers in obtaining in vivo RNFL thickness measurements.

Characterization of epiretinal membranes using optical coherence tomography

OBJECTIVE

To evaluate optical coherence tomography (OCT), a novel noncontact and noninvasive imaging technique, for the diagnosis and quantitative characterization of epiretinal membranes.

METHODS

Optical coherence tomography is similar to an ultrasound B-scan, except that light rather than sound is used, which enables higher resolution. Over a 2-year period, OCT was used to examine 186 eyes of 160 patients who had a diagnosis of an epiretinal membrane. Optical coherence tomograms were correlated with visual acuity, slit-lamp biomicroscopy, fluorescein angiography, and funds photography.

RESULTS

Based on OCT, the epiretinal membrane was clearly separated from the retina with focal points of attachment in 49 eyes and globally adherent (no observed separation) in 125 eyes. Globally adherent membranes were associated with the following features: macular pseudohole (32 eyes), a difference in optical reflectivity between the membrane and retina (65 eyes), and/or a visible membrane tuft or edge (92 eyes). The membrane was undetectable on OCT in 12 eyes. The membrane thickness (mean +/- standard deviation) was 61 +/- 28 microns in the 169 eyes in which the thickness could be measured with OCT. Mean central macular thickness measured with OCT correlated with visual acuity (R2 = 0.73).

CONCLUSION

Optical coherence tomography was able to provide a structural assessment of the macula that was useful in the preoperative and postoperative evaluation of epiretinal membrane surgery. Quantitative measurements and the assessment of membrane adherence with OCT may be useful in characterizing the surgical prognosis of eyes with an epiretinal membrane.

Reproducibility of nerve fiber layer thickness measurements using optical coherence tomography

PURPOSE

Optical coherence tomography (OCT) is a new technology that uses near-infrared light in an interferometer to produce approximately 10-microns resolution cross-sectional images of the tissue of interest. The authors performed repeated quantitative assessment of nerve fiber layer thickness in individuals with normal and glaucomatous eyes, and they evaluated the reproducibility of these measurements.

METHODS

The authors studied 21 eyes of 21 subjects by OCT. Each subject underwent five repetitions of a series of scans on five separate occasions within a 1-month period. Each series consisted of three circular scans around the optic nerve head (diameters, 2.9, 3.4, and 4.5 mm). Each series was performed separately using internal (fixation with same eye being studied) and external (fixation with contralateral eye) fixation techniques. The eye studied and the sequence of testing were assigned randomly.

RESULTS

Internal fixation (IF), in general, provides a slightly higher degree of reproducibility than external fixation (EF). Reproducibility was better in a given eye on a given visit than from visit to visit. Reproducibility as measured by intraclass correlation coefficients were as follows: circle diameter (CD), 2.9 mm, 0.51/0.57 (normal/glaucoma) (IF), 0.43/0.54 (EF); CD, 3.4 mm, 0.56/0.52 (IF), 0.43/0.61 (EF); CD, 4.5 mm, 0.53/0.43 (IF), 0.42/0.49 (EF).

CONCLUSIONS

Nerve fiber layer thickness can be reproducibly measured using OCT. Internal is superior to external fixation; each circle diameter tested provides adequate reproducibility.

Optical coherence tomography of age-related macular degeneration and choroidal neovascularization

OBJECTIVE

The authors used optical coherence tomography (OCT), a new technique for cross-sectional imaging of the retina, to morphologically study eyes with nonexudative and exudative age-related macular degeneration (AMD). In patients with untreated exudative AMD, OCT was compared with fluorescein angiography in the identification and classification of choroidal neovascularization (CNV).

METHODS

Optical coherence tomography imaging is analogous to ultrasound, except that the use of light rather than sound enables higher longitudinal resolution with a noncontact and noninvasive measurement. Optical coherence tomography was performed on 391 patients with the clinical diagnosis of AMD and was compared with conventional clinical examination to establish the cross-sectional morphology of different lesions and to develop a classification scheme for CNV. Optical coherence tomograms and fluorescein angiograms then were reviewed and correlated independently in 90 eyes of 86 patients who had exudative AMD without previous laser treatment.

RESULTS

Pigmentary changes, soft drusen, and detachments of the neurosensory retina and retinal pigment epithelium all had distinct presentations on OCT. Subretinal and intraretinal fluid caused changes in retinal thickness or elevation that could be quantified directly from the images. Choroidal neovascularization was evident in the tomograms as a thickening and fragmentation of a reflective layer, which corresponded to the retinal pigment epithelium and choriocapillaris. Changes in the reflection from this layer were observed during the progression of neovascularization, and after laser photocoagulation treatment. Classic CNV consistently presented with well-defined boundaries on OCT, whereas occult CNV had a variable cross-sectional appearance.

CONCLUSIONS

Optical coherence tomography was useful in quantitatively evaluating subretinal and intraretinal fluid, assessing possible subfoveal involvement of neovascularization, and in monitoring CNV before and after laser photocoagulation. Optical coherence tomography was unable to detect CNV beneath serous pigment epithelial detachments. Optical coherence tomography may have potential in accurately defining the boundaries in a subset of angiographically occult CNV.

Measurement by nerve fiber analyzer of retinal nerve fiber layer thickness in normal subjects and patients with ocular hypertension

PURPOSE

To measure retinal nerve fiber layer (NFL) thickness in normal subjects and patients with ocular hypertension and examine the relationship between age and normal NFL thickness.

METHODS

Nerve fiber layer thickness was determined by scanning laser polarimetry in 210 normal subjects and 100 patients with ocular hypertension. Relative ratios for the superior and inferior NFLs were calculated by dividing the NFL values of the respective regions by the nasal value.

RESULTS

Mean superior NFL in normal subjects measured 2.5 (95% confidence interval [CI], 1.3 to 3.7), and mean inferior NFL, 2.4 (95% CI, 1.2 to 3.6). Regression analysis showed a gradual decrease in NFL thickness with increasing age. In the patients with ocular hypertension, mean superior and inferior NFL were significantly lower compared with those of normal subjects: superior, 1.6 (95% CI, 0.4 to 2.8) and inferior, 1.6 (95% CI, 1.0 to 2.2). Of the patients with ocular hypertension, 58 of 100 (58%) had an abnormal NFL parameter.

CONCLUSIONS

Normograms we obtained for NFL as determined by scanning laser polarimetry may serve as reference points for future studies. Patients with ocular hypertension had a significantly lower NFL thickness, although there was some overlap in resulting measurements with those of normal subjects. The Nerve Fiber Analyzer may be useful for individual follow-up of people at risk for glaucoma; however, its role as a screening instrument requires further study.

Evaluation of the peripapillary circulation in healthy and glaucoma eyes with scanning laser Doppler flowmetry

In order to study peripapillary perfusion, one randomly selected eye of 34 of healthy volunteers and 40 glaucoma patients (27 suffering from primary open-angle glaucoma (POAG) 10 from normal pressure glaucoma (NPG) nd three from other types of glaucoma) was studied with a Heidelberg Retina Flowmeter. Temporal flow adjacent to the disc edge was significantly higher than the nasal flow (p < 0.01). It was reduced significantly in myopia both in controls (p < 0.05) and in glaucoma patients (p < 0.001). However, there was no difference between either controls and glaucoma patients or between POAG and NPG patients. It was independent of treatment type in glaucoma. Within the temporal peripapillary area extremely high flow values (values higher than the mean + 2 SD of the corresponding individual retinal flow) seemed to represent deep peripapillary vascular rings. They were significantly more frequent in glaucoma (72%) than in healthy volunteers (44%, p < 0.05). Their frequency was 83% in myopic and 23% in non-myopic eyes in the control group (p < 0.001). However, in glaucoma patients they were common both in myopic eyes (71%) and in non-myopic ones (75%). The results suggest that capillary perfusion adjacent to the temporal edge of the disc is significantly reduced in myopia. Deep peripapillary vascular structures can be measured on images focused on the surface of the retina, especially if the retina is thinner than normal (healthy myopic eyes and glaucomatous eyes independently of the refraction). This may mask a deficient function of the retinal capillary bed.

Lasers in ophthalmology

This article reviews the principle uses of ophthalmic lasers, providing historical background with an emphasis on new applications and areas of investigation. Ophthalmic photocoagulation was the first medical laser application and has restored or maintained vision in millions of people. More recently, photodisruption and, increasingly, ablation have gained prominence for treating a wide range of ocular pathology. The unique properties of lasers have also been harnessed for diagnostic purposes, with optical coherence tomography representing a significant improvement over existing imaging methods. Many ophthalmic applications of lasers have been developed, but the field is a dynamic one which continues to evolve along with laser technology itself.