Fourier Domain OCT:

The RTVue

Michael J. Sinai, PhD

Director of Clinical Affairs
Optovue, Inc.
 Rise of Structural Assessment with
Scanning Lasers
• Scanning lasers provide objective and quantitative
information for numerous ocular pathologies

• First appeared over 20 years ago as a research tool

• Today, structural assessment with retinal imaging

devices has become an indispensable tool for
clinicians
 Role of imaging in clinical practice
• AAO preferred practice patterns recommends using scanning
laser imaging in routine clinical exams
• In glaucoma, studies show imaging results can be as good as
expert grading of high quality stereo-photographs1
• Pre-perimetric glaucoma is now commonly accepted
• In OHTS, most converted based on structural assessment
only (not fields) 2
• OHTS has shown that imaging results have a high positive and
negative predictive power for detecting glaucoma 3

1. Wollstein et al. Ophthalmology 2000

2. Kass et al. Arch Ophthalmol 2001
3. Zangwill LM, Weinreb RN, et al. Archives of Ophthalmol. 2005.
 3 Imaging technologies have been
shown to be effective in detecting and
managing ocular pathologies
Light
Polarizer

• Scanning Laser Polarimetry (SLP) Two polarized components

Birefringent structure
(RNFL)
Retardation

• Confocal Scanning Laser

Ophthalmoscopy (CSLO)

• Optical Coherence Tomography

(OCT)
 SLP – GDx VCC
Strengths
• Provides RNFL thickness
• Large database
• Easy to use/interpret (deviation map/automated classifier)
• Progression

Weaknesses
• Atypical Pattern Birefringence (RNFL artifact)1
• Converts retardation to thickness assuming uniform birefringence (not true) 2
• Only RNFL information (No Optic Disc info and no Retina info)
• Data not backwards compatible

Normal Glaucoma Atypical

1. Bagga, Greenfield, Feuer. AJO, 2005: 139: 437.
2. Huang, Bagga, Greenfield, Knighton IOVS, 2004: 45: 3037.
 CSLO – HRT 3
Strengths
• Provides Optic Disc morphology
• Sophisticated Progression Analysis
• Large ethnic Specific Database comparisons
• Automated classifier
• Data backwards compatible
• Some retinal capabilities
• Cornea microscope attachment

Weaknesses
• Only Optic Disc assessment (poor RNFL)
• Manual Contour Line drawing
• Reference plane based on surface height (can change)
• Retina analysis confined to edema detection and sensitive to image quality
• Cornea scans very difficult and impractical
 OCT – Time Domain
(Stratus from CZM and SLO/OCT from OTI)

Strengths
• Provides Cross Sectional images
• Useful to calculate RNFL thickness
• Cross section scans useful for retinal pathologies
• Database comparisons

Weaknesses
• Slow scan speed (400 A scans / second)
• Limited data for glaucoma, 768 pixel (A-scan) ring for RNFL
• Limited data for retina, 6 radial lines with 128 A scans (pixels) each
• Macula maps 97% interpolated
• No progression analysis
• Location of scan ring affects RNFL results
• Prone to motion artifacts because of slow scan speed
• Poor optic disc measurements
 Time Domain OCT susceptible to
eye movements
• 768 pixels (A-scans)
captured in 1.92 seconds is
slower than eye movements

• Stabilizing the retina

reveals true scan path (white
circles)1

1. Koozekanani, Boyer and Roberts. “Tracking the Optic Nervehead in OCT Video Using Dual Eigenspaces
and an Adaptive Vascular Distribution Model”; IEEE Transactions on Medical Imaging, Vol. 22, No. 12, 2003
Scan location and eye movements
affects results

Properly centered Poorly centered: too inferior Poorly centered: too superior

T S N I T T S N I T T S N I T
Normal Double Hump Inferior RNFL “Loss” Superior RNFL “Loss”
Time Domain OCT artifacts can be
common

1. Sadda, Wu, et al. Ophthalmology 2006;113:285-293

2. Ray, Stinnett, Jaffe . Am J Ophth 2005; 139:18-29
3. Bartsch, Gong, et al. Proc. of SPIE Vol. 5370; 2140-2151
 The Future of OCT
• RTVue Fourier Domain OCT overcomes limitations of
Time Domain OCT Devices
– Better resolution (5 micron VS 10 micron)
– Faster scan speeds (26,000 A scans / sec VS 400)
– 3-D data sets (won’t miss pathology)
– Large data maps (less interpolation)
– Progression capabilities
– Layer by layer assessment
– Versatility (Anterior Chamber Imaging)

Retina Glaucoma Anterior Chamber

 The Evolution of OCT Technology
40,000
RTVue
2006
26,000

20,000

Speed Time domain OCT

(A-scans Fourier domain OCT
per sec) • ~ 65 x faster
• ~ 2 x resolution
Zeiss OCT 1
400 and 2, 1996
Zeiss Stratus
100 2002

16 10 7 5
Depth Resolution (mm)
 Comparison of OCT Images
OCT 1 / 2
(Time Domain) 1996

Stratus OCT
(Time Domain)
2002

RTVue
(Fourier Domain) 2006
 Case 1: AMD

Stratus
(Time Domain)

RTVue
(Fourier Domain)

Drusen not visible in Stratus Time Domain OCT

 Case 2: DME

Stratus
(Time Domain)

RTVue
(Fourier Domain)
 Case 3: PED

Stratus
(Time Domain)

RTVue
(Fourier Domain)

Same eye, PED missed by Stratus

 Case 4: Macula Hole
Stratus RTVue
(Time Domain) (Fourier Domain)
 Time Domain OCT vs Fourier Domain OCT
Time Domain Fourier Domain
• Entire A scan generated at once
• A-scan generated sequentially
based on Fourier transform of
one pixel at a time in depth spectrometer analysis
• Moving reference mirror • Stationary reference mirror
• 400 A scans per second • 26,000 A scans per second
• 10 micron depth resolution • 5 micron depth resolution
• B scan (512 A scans) in 1.28 sec •
B scan (1024 A-scans) in 0.04 sec
• Slower than eye movements • Faster than eye movements
Summary of Fourier Domain OCT
Advantages
• High speed reduces eye motion artifacts present
in time domain OCT
• High resolution provides precise detail, allows
more structures to visualized
• Layer by layer assessment
• Larger scanning areas allow data rich maps &
accurate registration for change analysis
• 3-D scanning improves clinical utility
 RTVue Clinical Applications

Retina Anterior
Glaucoma Chamber
Retina Analysis with the RTVue: Line Scans
Line Scan Cross Line Scan
• Data Captured: 1024 A scans • Data Captured: Provides
(pixels) 2048 A scans (pixels) • vertical and
• Time: 39 msec • Time: 78 msec horizontal high
• Area covered: 6 mm line • Area covered: 2 x 6 resolution B scan
(adjustable 2-12 mm) mm lines (adjustable •Image averaging
2-12 mm) increases S/N
Provides
•High resolution B scan
•Image averaging
increases S/N
Line Scan: Cystoid Macula Edema

Courtesy: Michael Turano, CRA

Columbia University.

Courtesy: Michael Turano, CRA

Columbia University.
Retina Analysis with the RTVue: 3-D Scans
Provides
•3 D map • Data Captured: 51,712 A scans (pixels)
• Comprehensive assessment • Time: 2 seconds
• Fly through review • Area covered: 4 x 4 X 2 mm (adjustable)
• C scan view • 101 B scans each 512 A scans
• SLO OCT image simultaneously
captured
 3-D view reveals extent of
damage over large area

Top Image: En face view of retinal surface from 3-D scan

Bottom Image: B scan from corresponding location (green line)
 Retina Analysis with the RTVue: Macula
Maps (MM5)
• Layer specific thickness maps
Provides: • Detailed B scans
• ETDRS thickness grid
• Data Captured: 19,496 A scans (pixels)
• Time: 750 msec
• Area covered: 5 mm x 5 mm (grid pattern)

Full retinal Inner retinal Outer retinal RPE/Choroid Surface

thickness thickness thickness Elevation Topography
ILM to RPE ILM to IPL IPL to RPE RPE height ILM height
 Glaucoma Analysis with the RTVue: Nerve Head
Map
16 sector analysis
compares sector values
Provides to normative database
and color codes result
• Cup Area based on probability
• Rim Area values (p values)

• RNFL Map

Color shaded regions

represent normative
database ranges based
TSNIT graph on p-values
 Glaucoma Analysis with the RTVue:
Nerve Head Map Parameters
RNFL Parameters Optic Disc Parameters

All parameters color-coded based on

comparison to normative database
Glaucoma Analysis with the RTVue: Nerve Head Map
Nerve Head Map (NHM) Ganglion Cell Map (MM7) 3-D Optic Disc
• Data Captured: 9,510 A scans
(pixels) • Data Captured: 51,712 A
• Time: 370 msec • Data Captured: 14,810 A
scans (pixels)
• Area covered: 4 mm diameter scans (pixels) • Time: 2 seconds
circle Provides • Time: 570 msec
• Area covered: 4 x 4 X 2 mm
• Area covered: 7 x 7 mm
•Cup Area
• Rim Area
• RNFL Map Provides Provides
• Ganglion cell complex
•3 D map
assessment in macula • Comprehensive
• Inner retina thickness is:
assessment
• NFL
• Ganglion cell body
• Dendrites

TSNIT graph
The ganglion cell complex (ILM – IPL)
Inner retinal layers provide complete Ganglion cell
assessment:
• Nerve fiber layer (g-cell axons)
• Ganglion cell layer (g-cell body)
• Inner plexiform layer (g-cell dendrites)

Images courtesy of Dr. Ou Tan, USC

 Normal vs Glaucoma

Cup
Rim
NHM4 RNFL

Ganglion cell
assessment
GCC with inner
retinal layer
map

Normal Glaucoma
Glaucoma Cases

Optovue, RTVue
 64 year old
Glaucoma Patient Case BK white male

24-2 white on white visual field Nerve Head Map on RTVue

Normal
 Glaucoma Patient Case BK

Macula Inner Retina Map on RTVue

10-2 white on white visual field Normal

RTVue Normative Database
• Age Adjusted comparisons for more
accurate comparisons
• Age and Optic Disc adjusted comparisons
for Nerve Head Map scans
• Over 300 eyes, ethnically mixed, collected
at 8 clinical sites worldwide
• IRB approved study from independent
agency

34
 Nerve Head Map (NHM4)
with Database comparisons
Patient Information

RNFL Thickness Map

RNFL Sector Analysis

Optic Disc Analysis

Parameter Tables

TSNIT graph
Asymmetry Analysis
 Ganglion Cell Complex (GCC)
with Database comparisons
Patient Information

GCC Thickness Map

Deviation Map

Parameter Table

Significance Map
 Early Glaucoma
Borderline
Sector results
in Superior-
temporal region

Abnormal
OS Normal
parameters

TSNIT dips
below normal

TSNIT shows
significant
Asymmetry
GCC Analysis may detect damage
before RNFL

GCC and RNFL analysis will be correlated,

however GCC analysis may be more sensitive
for detecting early damage
 Glaucoma Progression Analysis
(Nerve Head Map of stable eye)

Thickness Maps

Change in
optic disc
parameters

TSNIT graph
comparisons

Change in
RNFL
parameters

RNFL trend
analysis
 Glaucoma Progression Analysis
(GCC of stable glaucomatous eye)

Thickness Maps

Deviation Maps

Significance
Maps

GCC parameter
change analysis
Versatility: Scanning the Anterior Chamber
with the same device

Cornea
Adapter
Module
(CAM)
Higher resolution allows better
visualization of LASIK flap

2 years after LASIK with mechanical microkeratome

Image enhanced by frame averaging
 056-CP
Post-LASIK interface fluid & epithelial
ingrowth

50
Epithelial ingrowth
Fluid
100

150

200

250

300

Fibrosis
350

400
Higher resolution helps visualize
pathogens

Acanthamoeba in 0.25% agar

 Pachymetry Maps

Inferotemporal
thinning

Normal Keratoconus
 Angle Measurements

Normal Narrow
 LD044, OS

Narrow angle after peripheral iridotomy

Limbus
Angle
Opening
Distance
500 m
anterior to
scleral
spur
(AOD 500)
Scleral spur
 MaTa, OD

Normal Angle

Limbus Trabecular
meshwork-
Iris Space
750 m
anterior to
scleral
spur
(TISA750)

Scleral spur
 Advantages of the RTVue
• 5 micron resolution allows more structures and detail
to be visualized
• High speed allows larger areas to be scanned
• Layer by layer assessment
• Data-rich maps
• Volumetric analysis
• Comprehensive glaucoma assessment (Cup, Rim, RNFL,
ganglion cell complex)
• Normative Database
• Progression Analysis
• Anterior Chamber imaging
Thank You!