IMAGING TECHNIQUES IN

GLAUCOMA
Presenter: Dr. Rujuta
Moderator: Dr. Rita Dhamankar

Various imaging techniques

Anterior Segment:
AS-OCT
UBM

Posterior Segment:
OCT
HRT
GDx

Stereoscopic Optic Disc Photography

Used to document structural abnormalities and

longitudinal changes in glaucomatous eyes

Highly reproducible and records a natural color image of
the retina
Conventional ONH evaluation includes estimation of the
ONH dimensions by observing the image pair with a
stereo viewer
In the stereo image pair, depth is inversely proportional to
the disparity between the two matching points from the
left and right images

Quantitative Imaging
Principles

Clinical Parameters
Measured

OCT

Interferometry

Retinal Nerve Fiber Layer

Thickness

HRT

Confocal Scanning Laser

Ophthalmoscopy

Optic Disc Tomography

GDx

Scanning Laser
Polarimetry

Retinal Nerve Fiber Layer

Thickness

Optical Coherence Tomography (OCT)

Optical Coherence Tomography (OCT)

Non-invasive, real-time, high-resolution imaging

Transverse resolution -20 m

Axial resolution - 810 m
Software uses interpolation to fill in the gaps

Optical Coherence Tomography (OCT)

OCT uses a principle called low coherence interferometry

to derive depth information of various retinal structures

This is performed by comparing the time difference in

reflected light from the retina at various depths with a

reference standard
Differences between the reflected light and the reference

standard provide structural information in the form of an

A scan

Time Domain OCT

Lens

Broadband
Light Source

Distance determines
depth in A scan

SLD
Interferometer
Detector
Creates
A-scan 1
pixel at a
time

Reference mirror
moves back and forth

Combines light
from reference
with reflected
light from retina
Scanning mirror
directs SLD
beam on retina

Process
repeated many
times to create
B-scan

Data Acquisition
Processing

Final A-scan

Fourier Domain OCT

Reference mirror
stationary
Broadband
Light Source

SLD
Interferometer

Grating splits
signal by
wavelength

Spectrometer
analyzes signal
by wavelength

Combines light
from reference
with reflected
light from retina

Process
repeated many
times to create
B-scan

FFT
Spectral
Fourier transform
interferogram converts signal to
typical A-scan

Entire A-scan
created at a
single time

Principles of OCT Technology

An A-scan is the intensity of reflected light at various
retinal depths at a single retinal location
Combining many A-scans produces a B-scan

Retinal Depth

+ ... =

Reflectance Intensity

A-scan

A-scan

A-scans

B-scan

RNFL Analysis
Analysis of RNFL aids in identification of early

glaucomatous loss
Circular scans of 3.4 mm diameter in the peripapillary
region (cylindrical retinal cross-section)
RNFL thickness measurement is graphed in a TSNIT
orientation
Compared to age-matched normative data

Optic Nerve Head Analysis

Radial line scans through optic disc provide crosssectional

information on cupping and neuroretinal rim area

Disc margins are objectively identified using signal from
end of RPE
Parameters:
Disc
cup and rim area
horizontal and vertical cup-to-disc ratio

vertical integrated rim area

horizontal integrated rim width

Signal Strength

Signal Strength

Effect of Decentration

Heidelberg Retinal Tomogram (HRT)

Heidelberg Retinal Tomogram (HRT)

Confocal scanning laser

ophthalmoscope that is capable

of acquiring and analysing threedimensional images of the optic
nerve head and peripapillary
retina

Confocal Scanning Laser Ophthalmoscopy

Uses laser light instead of a bright flash of white light to

illuminate the retina

Confocal imaging is the process of scanning an object
point by point by a focused laser beam and then capturing
the reflected light through a small aperture (a confocal
pinhole)
The confocal pinhole suppresses light reflected or
scattered from outside of the focal plane, which otherwise
would blur the image. The result is a sharp, high contrast
image of the object layer located at the focal plane

Confocal Scanning Laser Ophthalmoscopy

Advantages over Fundus Photography
Improved image quality
Small depth of focus
Suppression of scattered light
Patient comfort through less bright light
3D imaging capability
Video capability
Effective imaging of patients who do not dilate well

Principle
Rapid scanning 670-nm diode laser

Emitted beam is redirected in the

x and y-axis
Along a plane of focus perpendicular to z-axis using two
oscillating mirrors
Two-dimensional image reflected from the surface of the
retina and optic disc
The confocal aperture limits the depth from which reflected
light reaches the detector
Confocal aperture is shifted to acquire multiple optical
sections through the tissue of interest in order to create a
layered three-dimensional image

What the HRT does

Once the patient is positioned, HRT II automatically performs a

pre-scan through the optic disc to determine the depth of the

individuals optic nerve.
Using information from this pre-scan, the fine focus and scan
depth are automatically adjusted to ensure that the entire optic
disc is included on the imaging cross-sections.
Next, it determines the number of imaging planes to use (range
of scan depth 1-4mm)
Each successive scan plane is set to measure 0.0625 mm deeper
Automatically obtains three scans for analysis.
Aligns and averages the scans to create the mean topography
image

HRT Images
Reflectance Image
False-color image that appears similar
to a photograph of the optic disc
Darker areas are regions of decreased
overall reflectance, whereas lighter
areas, such as the base of the cup, are
areas of the greatest reflectance
Valuable in locating and drawing the
contour line around the disc margin

HRT Images
Topographic Image
Relays information concerning the
height of the surface contour of the
optic disc and retina
False-color coded
Pixels that appear bright in the
topographic image are deeper, and
dark pixels are elevated
Thus, the neuroretinal rim should
appear darker than the surrounding
retina and the base of the cup usually
appears lightest

Analysis
After the contour line is drawn around the border of the optic

disc, the software automatically places a reference plane parallel

to the peripapillary retinal surface located 50 m below the
retinal surface

The reference plane is used to calculate the thickness and cross-

sectional area of the retinal nerve fiber layer

 The parameters of area and volume of the neuroretinal rim and

optic cup are also calculated based on the location of the

reference plane. The cup is considered to be the area of the
image that falls below the reference plane, whereas areas that
are of greater height than the reference plane are considered the
neuroretinal rim

HRT can differentiate between normal & early

glaucomatous eyes with a sensitivity of 79% to 87% &
specificity of 84 to 90%

Moorfields Regression Analysis (MRA)

MRA differentiates between

glaucomatous and healthy ONHs by

detecting diffuse and focal changes of the
neuroretinal rim area
Encorporates ONH size, and the effect of
age
Classifies the eye using normative data,
for both global and sectoral analyses, the
latter using six sectors
Results are indicated as color-coded
symbols: A green checkmark when inside
normal limits; a yellow exclamation mark
when borderline; and a red cross when
outside normal limits.

Glaucoma Probability Score (GPS)

Shows the probability of damage
Fast, simple interpretation
Based on the 3-D shape of the optic

disc and RNFL

Utilizes large, ethnic-selectable
databases
Employs artificial intelligence:
Relevance Vector Machine
No drawing a contour line or
relying on a reference plane
Reduced dependency on operator
skill

Topographic Change Analysis (TCA)

Statistically-based progression algorithm that accurately

detects structural change over time by comparing

variability between examinations and providing a
statistical indicator of change
Aligns subsequent images with the baseline examination,
providing a point-by-point analysis of the optic disc and
peripapillary RNFL

GDx VCC

GDx VCC
Provides highly reproducible, objective measurements of

the RNFL, to detect structural changes early

Compares these measurements to an age-stratified, multiethnic normative database, providing a unique visual
representation

Scanning laser polarimetry

Use of polarised light to measure the thickness of the

retinal nerve fiber layer

Measures the phase shift (retardation) of polarized laser
light passing through the eye
The phase of the light is changed by the arrangement and
density of retinal nerve fiber layer (RNFL)

Scanning laser polarimetry Principle

The polarised laser scans the fundus, building a monochromatic

image
The state of polarisation of the light is changed (retardation) as
it passes through birefringent tissue (cornea and RNFL)
Corneal birefringence is eliminated (in part) by a proprietary
'corneal compensator
The amount of retardation of light reflected from the fundus is
converted to RFNL thickness

GDx VCC
Provides quantitative RNFL evaluation

Key elements:
Thickness Map
Deviation Map
TSNIT graph
Parameter Table

Key Features of the Printout

Fundus Image

Useful for checking image quality

Well focused
Evenly illuminated
Optic disc well centered

Key Features of the Printout

Thickness Map

Shows the RNFL thickness in a color-coded format

Thick RNFL values are coloured yellow, orange, red
Thin RNFL values are coloured dark blue, light blue, green

Key Features of the Printout

Deviation Map

Reveals the location and magnitude of RNFL defects over

the entire thickness map

Analyzes a region 20 x 20 centered on the optic disc
For each scan, the RNFL thickness at each pixel is
compared to the age-matched normative database, and
the pixels that fall below the normal range are flagged by
coloured squares based on the probability

Deviation Map continued

Dark blue squares represent areas

where the RNFL thickness is below

the 5th percentile of the normative
database
Light blue squares represent deviation
below the 2% level
Yellow represents deviation below 1%
Red represents deviation below 0.05%
Uses a grayscale fundus image of the
eye as a background

Deviation Maps for eyes at different stages of disease

Key Features of the Printout

TSNIT Map

Displayed at the bottom of the

printout
In a normal eye the TSNIT plot
follows the typical double hump
pattern
When there is RNFL loss, the TSNIT curve will fall below

this shaded area, especially in the superior and inferior

regions
Also, a dip in the curve of one eye relative to another is
indicative of RNFL loss

Key Features of the Printout

Parameter Table

The TSNIT parameters are summary measures based on

RNFL thickness values within the calculation circle

Parameters continued
Inter-eye Symmetry: Measures the degree of symmetry

between the right and left eyes by correlating the TSNIT

functions from the two eyes
Values range from 1 to 1, where values near one represent
good symmetry

The Nerve Fiber Indicator (NFI)

Global measure based on the entire RNFL thickness map

Calculated using an advanced form of neural network,

called a Support Vector Machine (SVM)

Output values range from 1 100
1-30 -> normal
31-50 -> borderline
51+ -> abnormal

Normal printout

Early Glaucoma Example

Advanced Glaucoma example

Serial Analysis
Detecting RNFL Change Over Time
Serial Analysis can

compare up to four
exams
The Deviation from
Reference Map
displays the RNFL
difference, pixel by
pixel, of the followup
exam compared to
the baseline exam

Summary
The imaging techniques provide comprehensive RNFL

assessment to aid the clinician in the diagnosis of

glaucoma
However, they do not replace a careful clinical
evaluation or visual field testing