Automated detection of foveal fixation by use of retinal birefringence scanning

Evaluation of the blinq vision scanner for detection of amblyopia and strabismus

PURPOSE

To report the results of a clinical study designed to evaluate the accuracy of the blinq pediatric vision scanner, which detects amblyopia and strabismus directly by means of retinal polarization scanning, unlike other vision screening devices, which infer possible disease based on detection of refractive risk factors.

METHODS

Subjects 1-20 years of age were prospectively enrolled in this cross-sectional diagnostic accuracy study with planned enrollment of 200. All enrolled subjects were tested by individuals masked to the diagnosis, followed by complete ophthalmologic examination by pediatric ophthalmologists masked to the screening result. Patients previously treated for amblyopia or strabismus were analyzed separately.

RESULTS

The study cohort comprised 193 subjects, 53 of whom had been previously treated, leaving 140 treatment-naïve subjects, including 65 (46%) with amblyopia or strabismus, 11 (8%) with risk factors/suspected binocular vision deficit without amblyopia/strabismus, and 64 (46%) controls. Sensitivity was 100%, with all 66 patients with referral-warranted ocular disease referred. Five patients with intermittent strabismus receiving pass results were deemed "acceptable pass" when considering patient risk factors and amblyogenic potential. Specificity was 91%, with 7 incorrect referrals. Subanalysis of children aged 2-8 years (n = 92) provided similar results (sensitivity 100%; specificity 89%).

CONCLUSIONS

In this study cohort, the blinq showed very high sensitivity and specificity for detecting referral-warranted unilateral amblyopia and strabismus. Implementation of the device in vision screening programs could lead to improved rates of disease detection and reduction in false referrals.

Validation of the Pediatric Vision Scanner in a normal preschool population

PURPOSE

To assess the Pediatric Vision Scanner (PVS), a handheld vision screening device designed to test for amblyopia and strabismus, in a general pediatric population.

METHODS

In this prospective study, trained research staff screened 300 eligible children 24-72 months of age with no known eye conditions for amblyopia and strabismus using the PVS. A pediatric ophthalmologist masked to PVS screening results then performed a comprehensive eye examination. Sensitivity and specificity of the PVS was calculated with a 95% confidence interval.

RESULTS

Based on the gold standard eye examination, 6 children (2%) had amblyopia and/or strabismus. The PVS detected all 6 cases, yielding a sensitivity rate of 100% (95% CI, 54%-100%). The PVS referred 45 additional children (15%) who had normal ophthalmic findings, yielding a specificity rate of 85% (95% CI, 80%-89%). The median acquisition time for the PVS was 28 seconds.

CONCLUSIONS

The PVS detected amblyopia with high sensitivity in a nonenriched pediatric population. The device would allow children with amblyopia and/or strabismus to be referred to an eye care specialist as early as 2 years old. Given its short acquisition time, the PVS can be implemented in a pediatric clinic with minimal impact on workflow.

NONCONFOCAL ULTRA-WIDEFIELD SCANNING LASER OPHTHALMOSCOPY: Polarization Artifacts and Diabetic Macular Edema

Nonconfocal ultra-widefield scanning laser ophthalmoscopes produce foveal polarization artifacts that require normal Henle layer structure and are suppressed by center-involving diabetic macular edema. Polarization sensitivity is insufficient for the artifacts to be reliable clinical screening biomarkers.

Purpose:

Bowtie-shaped polarization artifacts are often present in nonconfocal ultra-widefield scanning laser ophthalmoscope (SLO) images. We studied these artifacts and evaluated their potential value as clinical biomarkers in screening for center-involving diabetic macular edema (DME).

Methods:

We performed a retrospective, observational, cohort study on 78 diabetic adult patients (143 eyes) who had spectral domain optical coherence tomography and nonmydriatic nonconfocal ultra-widefield SLO testing on the same day. Scanning laser ophthalmoscope green-only (532 nm), red-only (635 nm), and composite pseudocolor (532 plus 635 nm) images were examined for the presence of a foveal bowtie polarization artifact.

Results:

Polarization artifacts were absent in all but one eye with center-involving DME (32 of 33 eyes). Polarization artifacts were also absent in many eyes without center-involving DME (49 of 110 eyes in pseudocolor images). As clinical biomarkers of center-involving DME, artifact absence has high specificity (99, 100, and 98% for green, red, and pseudocolor images, respectively) but poor sensitivity (49, 31, and 40% for green, red, and pseudocolor images, respectively).

Conclusion:

Foveal bowtie-shaped polarization artifacts occur routinely in nonconfocal ultra-widefield SLO images. Their presence indicates preserved foveal Henle fiber layer structure. Contemporary nonconfocal ultra-widefield SLO images lack the sensitivity for their bowtie artifacts to serve as reliable biomarkers in screening for center-involving DME.

Computer-aided fixation detection using retinal birefringence in multi-modal ophthalmic systems: Computer, electronics, algorithms

Many diagnostic and some therapeutic ophthalmic devices require a reliable complementing method to track the direction of gaze or just to validate fixation of the eye on a presented target. This would allow acquisition of artefact-free robust images of the fovea and the surrounding macula. So far, there have been only few attempts to provide fast and dependable fixation information to an optical imaging system in real time, to guide image acquisition. The author's lab has developed several instruments that detect the location of the fovea using retinal birefringence scanning (RBS), proven to be very effective. Here, an RBS-based fixation detection subsystem is proposed, designed to operate conjointly with a number of ophthalmic imaging technologies. Combining RBS with such technologies is not trivial, because RBS uses polarized light and polarization-sensitive optics, while most other modalities don't. The polarization optics was optimized by means of enhanced computer modeling. Both the electronic hardware and the software were designed for fast and reliable performance. Because many retinal imaging systems are used in pediatric settings, extensive audio-visual circuitry was employed for efficient attention/fixation attraction. The optomechanics has been optimized for robust data acquisition. This computer-aided conjoint system employs true anatomical information from the back of the eye and needs no calibration. The prototype instrument uses a decision-making logic based on four frequencies generated during scanning. The results reveal the applicability of RBS as an adjunct fixation monitoring modality, showing promise to remove the limitation imposed by eye movements upon advanced ophthalmic imaging technologies.

Near-infrared polarimetric imaging and changes associated with normative aging

With aging, the human retina undergoes cell death and additional structural changes that can increase scattered light. We quantified the effect of normative aging on multiply scattered light returning from the human fundus. As expected, there was an increase of multiply scattered light associated with aging, and this is consistent with the histological changes that occur in the fundus of individuals before developing age-related macular degeneration. This increase in scattered light with aging cannot be attributed to retinal reflectivity, anterior segment scatter, or pupil diameter.

Classification and diversity of amblyopia

Amblyopia is a developmental disorder that affects the spatial vision of one or both eyes in the absence of an obvious organic cause; it is associated with a history of abnormal visual experience during childhood. Subtypes have been defined based on the purported etiology, namely, strabismus (misaligned eyes) and/or anisometropia (unequal refractive error). Here we consider the usefulness of these subclassifications.

In Situ Ellipsometric Monitoring of Gold Nanorod Metamaterials Growth

An in situ transmission-based system has been designed to optically monitor the ellipsometry constants of a hyperbolic plasmonic metamaterial during electrochemical growth. The metamaterial, made from an array of vertically aligned gold nanorods, has demonstrated an unprecedented ability to manipulate the polarization of light using subwavelength thickness slabs, making in situ ellipsometric data a powerful tool in the controlled design of such components. In this work, we show practical proof-of-principle of this design method and rationalize the ellipsometric output on the basis of the modal properties of the nanorod metamaterial. The real-time optical monitoring setup provides excellent control and repeatability of nanostructure growth for the design of future ultrathin optical components. The performance of the ellipsometric method was also tested as a refractive index sensor. Monitoring refractive index changes near the metamaterial's epsilon near zero (ENZ) frequency showed a sensitivity on the order of 500°/RIU in the ellipsometric phase for a metamaterial that shows 250 nm/RIU sensitivity in its extinction.

Detecting central fixation by means of artificial neural networks in a pediatric vision screener using retinal birefringence scanning

Background

Reliable detection of central fixation and eye alignment is essential in the diagnosis of amblyopia (“lazy eye”), which can lead to blindness. Our lab has developed and reported earlier a pediatric vision screener that performs scanning of the retina around the fovea and analyzes changes in the polarization state of light as the scan progresses. Depending on the direction of gaze and the instrument design, the screener produces several signal frequencies that can be utilized in the detection of central fixation. The objective of this study was to compare artificial neural networks with classical statistical methods, with respect to their ability to detect central fixation reliably.

Methods

A classical feedforward, pattern recognition, two-layer neural network architecture was used, consisting of one hidden layer and one output layer. The network has four inputs, representing normalized spectral powers at four signal frequencies generated during retinal birefringence scanning. The hidden layer contains four neurons. The output suggests presence or absence of central fixation. Backpropagation was used to train the network, using the gradient descent algorithm and the cross-entropy error as the performance function. The network was trained, validated and tested on a set of controlled calibration data obtained from 600 measurements from ten eyes in a previous study, and was additionally tested on a clinical set of 78 eyes, independently diagnosed by an ophthalmologist.

Results

In the first part of this study, a neural network was designed around the calibration set. With a proper architecture and training, the network provided performance that was comparable to classical statistical methods, allowing perfect separation between the central and paracentral fixation data, with both the sensitivity and the specificity of the instrument being 100%. In the second part of the study, the neural network was applied to the clinical data. It allowed reliable separation between normal subjects and affected subjects, its accuracy again matching that of the statistical methods.

Conclusion

With a proper choice of a neural network architecture and a good, uncontaminated training data set, the artificial neural network can be an efficient classification tool for detecting central fixation based on retinal birefringence scanning.

A no-moving-parts sensor for the detection of eye fixation using polarised light and retinal birefringence information

Polarised near-infra-red light is reflected from the foveal area in a detectable bow-tie pattern of polarisation states, offering the opportunity for eye tracking. A coaxial optical transducer was developed, consisting of a laser diode, a polariser, a filter, and a photodetector. Several such transducers may be used to interrogate different spots on the retina, thus eliminating the requirement for scanning systems with moving parts. To test the signal quality obtainable, using just one transducer, a test subject was asked to fixate successively on twelve targets located on a circle around the transducer, to simulate the retina's being interrogated by twelve sensors placed on a 3⁰ diameter circle surrounding the projection of the fovea. The resulting signal is close to the "ideal" sine wave that would have been recorded from a propeller-type birefringence pattern from a human fovea. The transducer can be used in the detection of fixation for medical and other purposes. It does not require calibration, strict restrictions on head position, or head-mounted appliances.

New pediatric vision screener, part II: electronics, software, signal processing and validation

Background

We have developed an improved pediatric vision screener (PVS) that can reliably detect central fixation, eye alignment and focus. The instrument identifies risk factors for amblyopia, namely eye misalignment and defocus.

Methods

The device uses the birefringence of the human fovea (the most sensitive part of the retina). The optics have been reported in more detail previously. The present article focuses on the electronics and the analysis algorithms used. The objective of this study was to optimize the analog design, data acquisition, noise suppression techniques, the classification algorithms and the decision making thresholds, as well as to validate the performance of the research instrument on an initial group of young test subjects—18 patients with known vision abnormalities (eight male and 10 female), ages 4–25 (only one above 18) and 19 controls with proven lack of vision issues. Four statistical methods were used to derive decision making thresholds that would best separate patients with abnormalities from controls. Sensitivity and specificity were calculated for each method, and the most suitable one was selected.

Results

Both the central fixation and the focus detection criteria worked robustly and allowed reliable separation between normal test subjects and symptomatic subjects. The sensitivity of the instrument was 100 % for both central fixation and focus detection. The specificity was 100 % for central fixation and 89.5 % for focus detection. The overall sensitivity was 100 % and the overall specificity was 94.7 %.

Conclusions

Despite the relatively small initial sample size, we believe that the PVS instrument design, the analysis methods employed, and the device as a whole, will prove valuable for mass screening of children.

Detection of central fixation using short-time autoregressive spectral estimation during retinal birefringence scanning

The manuscript reports on the implementation of autoregressive spectral estimation aimed at improving the accuracy of detecting short-lasting events in signals acquired by a retinal birefringence scanning device that was reported earlier. A signal consisting of two frequency components is generated, where each frequency is a multiple of the scanning frequency. One frequency is produced during central fixation, while another one prevails during off-central fixation. These components may be of a very short duration, presenting a challenge for the FFT to identify them with sufficient time- and frequency resolution. Autoregressive spectral estimation using the Burg algorithm provided a satisfactory solution, capable of reliably differentiating between the two frequency components (96 and 192 Hz) on signal segments of duration as short as 5 ms. The device and the signal analysis methods were developed originally with the purpose of checking for eye alignment and strabismus - a major risk factor for amblyopia. The method enables the technology to work with less-cooperative patients, such as young children. Other medical and non-medical applications are possible.

A passing glance? Differences in eye tracking and gaze patterns between trainees and experts reading plain film bunion radiographs

Eye tracking and gaze pattern studies have been used to evaluate human behavior for decades. This is because of its ability to reveal conscious and subconscious behaviors when subjects are tasked with observation, decision making, and surgical performance. Many have popularized the use of this technology for radiographic assessment while evaluating radiologist behaviors, but little has been described for surgeon behavior patterns when evaluating preoperative deformities by radiograph. Because the radiographic assessment strongly influences surgical selection, the present study was designed to evaluate the differences between groups of novice and experienced surgeons' gaze patterns when tasked to describe hallux valgus deformities. The subjects were asked to rate the deformity as "none," "mild," "moderate," or "severe." Using an externally mounted eye tracking system, our study assessed saccades, fixations, overall time spent per radiograph, and the subjects' chosen bunion rating. Both the novice and advanced groups of foot and ankle surgeons were tasked to evaluate 25 total anteroposterior radiographs from patients who presented with a primary complaint of bunion pain. These patients were chosen at random, such that all participating surgeons had no previous patient familiarization. Statistically significant differences were observed with regard to the activity and rating of the moderate bunion films. The experience of surgeons does appear to modify gaze behavior with respect to time and attention, such that less overall time spent per image is needed by the advanced group, with improved efficiency. Future academic curriculum and training techniques could be developed to reflect these potential technical differences in search behavior, diagnostic technique, and surgical selection strategy.

Modern technologies for retinal scanning and imaging: an introduction for the biomedical engineer

This review article is meant to help biomedical engineers and nonphysical scientists better understand the principles of, and the main trends in modern scanning and imaging modalities used in ophthalmology. It is intended to ease the communication between physicists, medical doctors and engineers, and hopefully encourage “classical” biomedical engineers to generate new ideas and to initiate projects in an area which has traditionally been dominated by optical physics. Most of the methods involved are applicable to other areas of biomedical optics and optoelectronics, such as microscopic imaging, spectroscopy, spectral imaging, opto-acoustic tomography, fluorescence imaging etc., all of which are with potential biomedical application. Although all described methods are novel and important, the emphasis of this review has been placed on three technologies introduced in the 1990’s and still undergoing vigorous development: Confocal Scanning Laser Ophthalmoscopy, Optical Coherence Tomography, and polarization-sensitive retinal scanning.

Improved eye-fixation detection using polarization-modulated retinal birefringence scanning, immune to corneal birefringence

We present an improved method for remote eye-fixation detection, using a polarization-modulated approach to retinal birefringence scanning (RBS), without the need for individual calibration or separate background measurements and essentially independent of corneal birefringence. Polarization-modulated RBS detects polarization changes generated in modulated polarized light passing through a unique pattern of nerve fibers identifying and defining the retinal region where fixation occurs (the fovea). A proof-of-concept demonstration in human eyes suggests that polarization-modulated RBS has the potential to reliably detect true foveal fixation on a specified point with an accuracy of at least ± 0.75°, and that it can be applied to the general population, including individuals with sub-optimal eyes and young children, where early diagnosis of visual problems can be critical. As could be employed in an eye-controlled display or in other devices, polarization-modulated RBS also enables and paves the way for new and reliable eye-fixation-evoked human-machine interfaces.

Effect of change in macular birefringence imaging protocol on retinal nerve fiber layer thickness parameters using GDx VCC in eyes with macular lesions

This study evaluates the effect of two macular birefringence protocols (bow-tie retardation and irregular macular scan) using GDx VCC on the retinal nerve fiber layer (RNFL) thickness parameters in normal eyes and eyes with macular lesions. In eyes with macular lesions, the standard protocol led to significant overestimation of RNFL thickness which was normalized using the irregular macular pattern protocol. In eyes with normal macula, absolute RNFL thickness values were higher in irregular macular pattern protocols with the difference being statistically significant for all parameters except for inferior average thickness. This has implications for monitoring glaucoma patients who develop macular lesions during the course of their follow-up.

Can eye-tracking technology improve situational awareness in paramedic clinical education?

Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one’s surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.

Detecting fixation on a target using time-frequency distributions of a retinal birefringence scanning signal

Background

The fovea, which is the most sensitive part of the retina, is known to have birefringent properties, i.e. it changes the polarization state of light upon reflection. Existing devices use this property to obtain information on the orientation of the fovea and the direction of gaze. Such devices employ specific frequency components that appear during moments of fixation on a target. To detect them, previous methods have used solely the power spectrum of the Fast Fourier Transform (FFT), which, unfortunately, is an integral method, and does not give information as to where exactly the events of interest occur. With very young patients who are not cooperative enough, this presents a problem, because central fixation may be present only during very short-lasting episodes, and can easily be missed by the FFT.

Method

This paper presents a method for detecting short-lasting moments of central fixation in existing devices for retinal birefringence scanning, with the goal of a reliable detection of eye alignment. Signal analysis is based on the Continuous Wavelet Transform (CWT), which reliably localizes such events in the time-frequency plane. Even though the characteristic frequencies are not always strongly expressed due to possible artifacts, simple topological analysis of the time-frequency distribution can detect fixation reliably.

Results

In all six subjects tested, the CWT allowed precise identification of both frequency components. Moreover, in four of these subjects, episodes of intermittent but definitely present central fixation were detectable, similar to those in Figure 4. A simple FFT is likely to treat them as borderline cases, or entirely miss them, depending on the thresholds used.

Conclusion

Joint time-frequency analysis is a powerful tool in the detection of eye alignment, even in a noisy environment. The method is applicable to similar situations, where short-lasting diagnostic events need to be detected in time series acquired by means of scanning some substrate along a specific path.

A device for continuous monitoring of true central fixation based on foveal birefringence

A device for continuous monitoring of central fixation utilizes birefringence, the property of the Henle fibers surrounding the human fovea, to change the polarization state of light. A circular scan of retinal birefringence, where the scanning circle encompasses the fovea, allows identification of true central fixation-an assessment much needed in various applications in ophthalmology, psychology, and psychiatry. The device allows continuous monitoring for central fixation over an extended period of time in the presence of fixation targets and distracting stimuli, which may be helpful in detecting attention deficit hyperactivity disorder, autism spectrum disorders, and other disorders characterized by changes in the subject's ability to maintain fixation. A proof-of-concept has been obtained in a small study of ADHD patients and normal control subjects.

Birefringence of the central cornea in children assessed with scanning laser polarimetry

Corneal birefringence is a well-known confounding factor with all polarization-sensitive technology used for retinal scanning and other intraocular assessment. It has been studied extensively in adults, but little is known regarding age-related differences. Specifically, no information is available concerning corneal birefringence in children. For applications that are geared towards children, such as retinal birefringence scanning for strabismus screening purposes, it is important to know the expected range of both corneal retardance and azimuth in pediatric populations. This study investigated central corneal birefringence in children (ages three and above), by means of scanning laser polarimetry (GDx-VCC™, Carl Zeiss Meditec, Inc.). Children's measures of corneal retardance and azimuth were compared with those obtained in adults. As with previous studies in adults, corneal birefringence was found to vary widely in children, with corneal retardance ranging from 10 to 77 nm, and azimuth (slow axis) ranging from -11° to 71° (measured nasally downward). No significant differences in central corneal birefringence were found between children and adults, nor were significant age-related differences found in general. In conclusion, establishing knowledge of the polarization properties of the central cornea in children allows better understanding, exploitation, or bypassing of these effects in new polarization-sensitive pediatric ophthalmic applications.

Modeling and minimizing interference from corneal birefringence in retinal birefringence scanning for foveal fixation detection

Utilizing the measured corneal birefringence from a data set of 150 eyes of 75 human subjects, an algorithm and related computer program, based on Müller-Stokes matrix calculus, were developed in MATLAB for assessing the influence of corneal birefringence on retinal birefringence scanning (RBS) and for converging upon an optical/mechanical design using wave plates ("wave-plate-enhanced RBS") that allows foveal fixation detection essentially independently of corneal birefringence. The RBS computer model, and in particular the optimization algorithm, were verified with experimental human data using an available monocular RBS-based eye fixation monitor. Fixation detection using wave-plate-enhanced RBS is adaptable to less cooperative subjects, including young children at risk for developing amblyopia.

Revealing Henle's fiber layer using spectral domain optical coherence tomography

PURPOSE

Spectral domain optical coherence tomography (SD-OCT) uses infrared light to visualize the reflectivity of structures of differing optical properties within the retina. Despite their presence on histologic studies, traditionally acquired SD-OCT images are unable to delineate the axons of photoreceptor nuclei, Henle's fiber layer (HFL). The authors present a new method to reliably identify HFL by varying the entry position of the SD-OCT beam through the pupil.

METHODS

Fifteen eyes from 11 subjects with normal vision were prospectively imaged using 1 of 2 commercial SD-OCT systems. For each eye, the entry position of the SD-OCT beam through the pupil was varied horizontally and vertically. The reflectivity of outer retinal layers was measured as a function of beam position, and thicknesses were recorded.

RESULTS

The reflectivity of HFL was directionally dependent and increased with eccentricity on the side of the fovea opposite the entry position. When HFL was included in the measurement, the thickness of the outer nuclear layer (ONL) of central horizontal B-scans increased by an average of 52% in three subjects quantified. Four cases of pathology, in which alterations to the normal macular geometry affected HFL intensity, were identified.

CONCLUSIONS

The authors demonstrated a novel method to distinguish HFL from true ONL. An accurate measurement of the ONL is critical to clinical studies measuring photoreceptor layer thickness using any SD-OCT system. Recognition of the optical properties of HFL can explain reflectivity changes imaged in this layer in association with macular pathology.

New, simple theory-based, accurate polarization microscope for birefringence imaging of biological cells

We propose a new, simple theory-based, accurate polarization microscope for birefringence imaging of cytoskeletal structures of biological cells. The new theory lets us calculate very easily the phase retardation and the orientation of the principal axis of a particular area of a biological living cell in media by simply measuring the intensity variation of a pixel of a CCD camera while rotating a single polarizer. Just from the measured intensity maxima and minima, the amount of phase retardation delta between the fast and the slow axis of the sample area is obtained with an accuracy of 5.010+/-0.798x10(-3) rad. The orientation of the principal axis is calculated from the angle of the polarizer for the intensity maximum. We have compared our microscopes with two previously reported polarization microscopes for birefringence imaging of cytoskeletal structures and demonstrated the utility of our microscope with the phase retardation and orientation images of weakly invasive MCF7 and highly invasive MDA MB 231 human breast cancer cells as an example.

Mueller matrix retinal imager with optimized polarization conditions

A new Mueller matrix polarimeter was used to image the retinas of normal subjects. Light from a linearly polarized 780 nm laser was passed through a system of variable retarders and scanned across the retina. Light returned from the eye passed through a second system of retarders and a polarizing beamsplitter to two confocal detection channels. Optimization of the polarimetric data reduction matrix was via a condition number metric. The accuracy and repeatability of polarization parameter measurements were within +/- 5%. The magnitudes and orientations of retardance and diattenuation, plus depolarization, were measured over 15 degrees of retina for 15 normal eyes.

Directional eye fixation sensor using birefringence-based foveal detection

We recently developed and reported an eye fixation monitor that detects the fovea by its radial orientation of birefringent nerve fibers. The instrument used a four-quadrant photodetector and a normalized difference function to check for a best match between the detector quadrants and the arms of the bow-tie pattern of polarization states surrounding the fovea. This function had a maximum during central fixation but could not tell where the subject was looking relative to the center. We propose a linear transformation to obtain horizontal and vertical eye position coordinates from the four photodetector signals, followed by correction based on a priori calibration information. The method was verified on both a computer model and on human eyes. The major advantage of this new eye-tracking method is that it uses true information coming from the fovea, rather than reflections from other structures, to identify the direction of foveal gaze.

Birefringence-based eye fixation monitor with no moving parts

For the purpose of vision screening, we develop an eye fixation monitor that detects the fovea by its unique radial orientation of birefringent Henle fibers. Polarized near-infrared light is reflected from the foveal area in a bow-tie pattern of polarization states, similar to the Haidinger brush phenomenon. In contrast to previous devices that used scanning systems, this instrument uses no moving parts. It rather utilizes four spots of linearly polarized light-two aligned with the "bright" arms and two aligned with the "dark" arms-of the bow-tie pattern surrounding the fovea. The light reflected from the fundus is imaged onto a quadrant photodetector, whereby the circular polarization component of the polarization state of each reflected patch of light is measured. The signals from the four photodetectors are amplified, digitized, and analyzed. A normalized differential signal is computed to detect central fixation. The algorithm is tested on a computer model, and the apparatus is tested on human subjects. This work demonstrates the feasibility of a fixation monitor with no moving parts.

Relationship between foveal birefringence and visual acuity in neovascular age-related macular degeneration

PURPOSE

To investigate the relationship between visual acuity and foveal birefringence in patients with neovascular age-related macular degeneration.

METHODS

In total, 40 patients with choroidal neovascularization underwent macular imaging with scanning laser polarimetry. Bowtie patterns, typically seen in birefringence images of the macula, were evaluated and classified into three categories: (1) regular bowtie present; (2) bowtie present, but disrupted; and (3) no bowtie present. The relation of the bowtie appearance to the best-corrected logMAR visual acuities was tested (ANOVA).

RESULTS

Mean visual acuity was best for the group that had regular bowties (mean logMAR=0.34) and differed statistically significantly from the disrupted bowtie group and no bowtie group (P=0.01 and 0.0007). Ages for the three groups did not differ (P=0.31).

CONCLUSIONS

Appearance of a regular bowtie indicates a substantially intact Henle fibre layer with the potential for good visual function, despite the presence of underlying pathology. Conversely, disruption or absence of a bowtie may indicate severe damage to the photoreceptors, consistent with the finding of poorer visual acuity.

Polarimetric high-resolution confocal scanning laser ophthalmoscope

A polarimetric high-resolution confocal scanning laser ophthalmoscope has been developed. The system incorporates a fixed linear polarizer in the illumination path and a rotatory quarter-wave plate and another fixed linear polarizer in the registration path. Retinal areas that are smaller than those provided by commercial instruments can be imaged. Series of four fundus images for independent polarization states in the second pass were recorded for different eyes and retinal locations and the spatially resolved Stokes vectors calculated. From those images, the contrast across retinal blood vessels was maximized and the corresponding image was reconstructed. In terms of polarization, the analysis of small retinal areas might prove to be useful in the improvement of retinal imaging and the enhancement of structural details in the early diagnosis of ocular pathologies.

Pediatric Vision Screener 1: instrument design and operation

We develop the Pediatric Vision Screener (PVS) to automatically detect ocular misalignment (strabismus) and defocus in human subjects. The PVS utilizes binocular retinal birefringence scanning to determine when both eyes are aligned, with a theoretical accuracy of <1 deg. The device employs an autoconjugate, bull's-eye detector-based system to detect focus. The focus and alignment pathways are separated by both wavelength and data acquisition timing. Binocular focus and alignment are detected in rapid alternating sequence, measuring both parameters in both eyes in <0.5 sec. In this work, the theory and design of the PVS are described in detail. With objective, automated measurement of both alignment and focus, the PVS represents a new approach to screening children for treatable eye disease such as amblyopia.

Automated detection of ocular alignment with binocular retinal birefringence scanning

We previously developed a retinal birefingence scanning (RBS) device to detect eye fixation. The purpose of this study was to determine whether a new binocular RBS (BRBS) instrument can detect simultaneous fixation of both eyes. Control (nonmyopic and myopic) and strabismic subjects were studied by use of BRBS at a fixation distance of 45 cm. Binocularity (the percentage of measurements with bilateral fixation) was determined from the BRBS output. All nonstrabismic subjects with good quality signals had binocularity >75%. Binocularity averaged 5% in four subjects with strabismus (range of 0-20%). BRBS may potentially be used to screen individuals for abnormal eye alignment.

Effect of individualized compensation for anterior segment birefringence on retinal nerve fiber layer assessments as determined by scanning laser polarimetry

PURPOSE

Scanning laser polarimetry estimates retinal nerve fiber layer (RNFL) thickness through measurement of retardation of a polarized laser light passing through the naturally birefringent RNFL and cornea. The commercial instrument, the GDx Nerve Fiber Analyzer (Laser Diagnostic Technologies, Inc., San Diego, CA), uses an anterior segment compensator of fixed magnitude and slow polarization axis to eliminate the contribution of the cornea to the total signal. Previous studies have shown up to 30% of patients are not adequately compensated by this method. The aim of this study was to determine the effect of individualized anterior segment compensation using a newly designed variable compensator on estimates of retinal nerve fiber layer thickness compared with those as determined with the fixed compensator in the commercial device.

DESIGN

Comparative, observational case series.

PARTICIPANTS

Twenty-eight eyes from 14 normal participants and 24 eyes from 12 patients with bilateral glaucoma.

METHODS

Using information derived from a scan of the macula, a newly designed variable anterior segment compensator for the GDx was set to neutralize anterior segment birefringence. Normal participants and patients with glaucoma underwent RNFL measurements using the standard (fixed) compensator and the variable compensator. The results were compared using Hotelling's generalized means test and Bonferroni's adjustment for multiple comparisons.

MAIN OUTCOME MEASURES

Standard GDx modulation and thickness parameters as determined with the fixed and variable compensators.

RESULTS

All thickness values were statistically significantly lower as determined with the variable compensator, with no discernible differences in any of the modulation parameters.

CONCLUSIONS

Individualized anterior segment compensation lowers the RNFL thickness values as determined by scanning laser polarimetry compared with those determined with the standard fixed compensator. This may narrow the normal range and increase the discriminating ability of scanning laser polarimetry between normal and disease. However, modulation is less affected, and the modulation parameters may thus prove more useful for distinguishing between normal and glaucoma.

Polarization properties of the in vitro old human crystalline lens

We have studied the spatially resolved polarization properties of the in vitro intact old human crystalline lens (from 56 to 88 years old) by using Mueller-matrix imaging polarimetry. Analysis was performed within an average of 54 h of death. Results show that the overall retardation is small (7 degrees on average) and decreases from the centre of the lens to the periphery. Lenticular birefringence is linear but has a spatial dependence, reducing outwards along the radius. The distribution of azimuthal angle of the birefringent structure of the crystalline lens changes depending on each individual lens. Diattenuation and polarizance were found to be small, however, depolarization was about 35% for the set of lenses studied here.

Measurement of parameters of polarization in the living human eye using imaging polarimetry

An imaging polarimeter using liquid-crystal variable retarders (Bueno, J. M., Artal, P. (1999). Double-pass imaging polarimetry in the human eye. Optics Letters, 24, 64-66) has been used to study the parameters of polarization in the living human eye. Retardation introduced by birefringent structures of the eye has been calculated by using a spatially resolved collection of Mueller matrices obtained from series of 16 double-pass retinal images. Results for images with a 2-mm pupil diameter show that although the retardation introduced by the eye in a double-pass varies among individuals, at the central cornea the slow axis is directed along the upper-temporal to lower-nasal line and the ellipticity is close to zero, which indicates the presence of linear birefringence. As pupil size increased, the measured retardation also increased, while ocular birefringence remained linear and azimuthal angle changed without a clear tendency.

Effect of corneal polarization axis on assessment of retinal nerve fiber layer thickness by scanning laser polarimetry

PURPOSE

Scanning laser polarimetry uses an anterior segment compensating device that assumes a fixed axis of corneal birefringence, which we call the corneal polarization axis. The purpose of this investigation was to establish the distribution of corneal polarization axes among a population of normal eyes and to evaluate the relationship between corneal polarization axis and posterior segment retardation.

METHODS

We constructed a noninvasive slit lamp-mounted device incorporating two crossed linear polarizers and an optical retarder in order to measure the slow axis of corneal birefringence. Normal subjects underwent corneal polarization axis measurement. A subset of eyes underwent scanning laser polarimetry of the peripapillary retinal nerve fiber layer (n = 32) and macula (n = 29), and retardation measurements were evaluated in each group.

RESULTS

One hundred eighteen eyes of 63 normal subjects (35 female, 28 male) underwent corneal polarization axis measurement (mean age, 45.5 +/- 17.1 years). Six eyes (5.1%) demonstrated unmeasurable corneal polarization. In the remaining 112 eyes, the mode of the corneal polarization axis distribution was 10 to 20 degrees nasally downward (range, 90 degrees nasally downward to 54 degrees nasally upward). A significant (P <.0001) correlation was observed between fellow eyes (R(2) =.52), with a mean difference of 11.2 +/- 10.5 degrees (range, 0-52 degrees). Corneal polarization axis was significantly associated (R(2) =.52-.84) with retinal nerve fiber layer and macula summary retardation parameters (average thickness, ellipse average, superior and inferior average, superior and total integral; P <.0001 for all groups).

CONCLUSIONS

The mean corneal polarization axis among normal corneas is nasally downward; however, considerable intraindividual and interindividual variability exists. The linear relationship between corneal polarization axis and posterior segment retardation parameters is responsible, in part, for the wide distribution of retinal nerve fiber layer thickness data generated by scanning laser polarimetry.

Mathematical modeling of retinal birefringence scanning

Retinal birefringence scanning (RBS) is a new technique that is used to detect the fixation of the eye remotely and noninvasively. The method is based on analysis of polarization changes induced by the retina. In this study, the principles of RBS were mathematically modeled to facilitate a better understanding of the origins of the signals obtained. Stokes vector analysis and Mueller matrix multiplication were augmented with Poincaré sphere representation. The cornea was modeled as a linear retarder. The foveal area was modeled as a radially symmetric birefringent medium. The model accurately predicted the frequency and phase of RBS signals obtained during central and paracentral fixation. The signal that indicates central fixation during RBS likely results from a combination of the radial birefringence of the Henle fibers and the overlying corneal birefringence.