Optical Coherence

Tomography
OCT
Dennis M. West, CRA

What is OCT?
Diagnostic imaging technique that examines
living tissue non-invasively. It is based on
a complex analysis of the reflection of low
coherence radiation from the tissue under
examination.
Real time cross sectional analysis

OCT allows both qualitative and quantitative

analysis of the retina
Qualitative analysis includes description by
location, a description of form and
structure, identification of anomalous
structures, and observation of the
reflective qualities of the retina

Quantitative analysis involves

measurements of the retina, specifically
retinal thickness and volume, and nerve
fiber layer thickness. This is possible
because the OCT software is able to
identify and "trace" two key layers of the
retina, the NFL and RPE

How does it work?

128

to 768 axial samples (A-scans) in a

single "scan pass
Each A-scan has 1024 data points and is
2mm long (deep).

Resolution
When

all of the A-scans are combined into

one image, the image has a resolving
power of about 10 microns vertically and
20 microns horizontally
Compare that to the resolution of a good
ophthalmic ultrasound at 100 microns

OCT

Ultrasound

Protocols
The

Zeiss OCT 3 has several built-in

protocols for scanning the retina and the
optic nerve head.
A protocol is simply a pre-determined
procedure or method

Scan Protocol Types

Line
Circle
Radial

Lines

The "line" scan simply scans in a single,

straight line. The length of the line can
be changed as well as the scan angle.

The "circle" scans in a circle instead of a

line.

The "radial lines" scans 6 consecutive line

scans in a star pattern

Not All OCT Scans Are Created

Equally
The

"fast" scan protocols of the OCT 3 reduce

the time needed for multiple scans
The scan time reduction is intended to minimize
the error created by patient movement
Fast scans grab fewer A-scans in the 6 mm
length of the scan. The normal 6 mm scan
contains 512 A-scans, whereas the fast 6 mm
scan contains only 128 A-scans, resulting in a
lower resolution image

Fast OCT 3 scan

The same eye scanned with maximum resolution

Retinal Anatomy Compared to OCT

The

vitreous is the black space on the top

of the image
We can identify the fovea by the normal
depression
The nerve fiber layer (NFL) and the retinal
pigment epithelium (RPE) are easily
identifiable layers as they are more highly
reflective than the other layers of the
retina

 This

higher reflectivity is represented by

the "hotter" colors (red, yellow, orange,
white) in the false color representation of
the OCT 3.
The middle layers of the retina, between
the NFL and RPE, are much less easily
identifiable in the scan.

Regions
For purposes of analysis, the OCT image of
the retina can be subdivided vertically into
four regions
the pre-retina
the epi-retina
the intra-retina
the sub-retina

The pre-retinal profile

A normal

pre-retinal profile is black space

Normal vitreous space is translucent
The small, faint, bluish dots in the preretinal space is "noise"
This is an electronic aberration created by
increasing the sensitivity of the instrument
to better visualize low reflective structures.

Anomalous structures
pre-retinal

membrane
epi-retinal membrane
vitreo-retinal strands
vitreo-retinal traction
pre-retinal neovascular membrane
pre-papillary neovascular membrane

The over-all retinal profile

A pre-retinal membrane with traction on the fovea

a pigment epithelial detachment is causing the convexity

Aside from the retinal detachment,

notice the underlying concave curvature of the retina,
suggesting the long eye of a significant myope

The foveal profile

The normal foveal profile is a slight
depression in the surface of the retina

Deformations in the foveal profile

macular

pucker
macular pseudo-hole
macular lamellar hole
macular cyst
macular hole, stage 1 (no depression, cyst
present)
macular hole, stage 2 (partial rupture of retina,
increased thickness)
macular hole, stage 3 (hole extends to RPE,
increased thickness, some fluid)
macular hole, stage 4 (complete hole, edema at
margins, complete PVD)

Macular cyst

Macular hole, stage 2

Macular hole, stage 3

Macular hole, stage 4, operculum

suspended by the hyaloid membrane

The macular profile

The macular profile can, and often does,
include the fovea as it's center

Deformations in the macular profile

Serous

retinal detachment (RD)

Serous retinal pigment epithelial
detachment (PED)
Hemorrhagic pigment epithelial
detachment

Serous retinal pigment epithelial

detachment (PED)

Intra-retinal anomalies in the

macular profile
Choroidal

neovascular membrane
Diffuse intra-retinal edema
Cystoid macular edema
Drusen
Hard exudates
Scar tissue
Atrophic degeneration
Sub-retinal fibrosis
RPE tear

Choroidal neovascular membrane

Cystoid macular edema cause by

diabetic maculopathy

Sub-retinal fibrosis

OCT and Fluorescein

Angiography in retinal diagnosis
FAs provide excellent characterization of
retinal blood flow over time, as well as size
and extent information on the x and y axis
(north-south, east-west)
The OCT gives us information in the z
(depth) axis, telling us what layers of the
retina are affected

OCT scans for qualitative

analysis of the retina
The

Fast Macular Thickness Scan (FMTS,

FMTM, or FMT scan)
The Line Scan
The Cross Hair Scan (3mm and 6mm)

The Fast Macular Thickness

Scan
The Fast Macular Thickness Scan consists
of 6 radial line scans in a spoke pattern. It
is a low resolution scan that was designed
for quantitative analysis (thickness and
volume)

The FMT scan is placed over the area of

interest, which is usually the macula.
When scanning the macula, the patient
simply looks at the fixation target. The
center of the FMT scan lines up with the
fixation target by default
A scan is saved and then reviewed with any
of the retina analysis tools

Each of the 6 scans can be viewed

individually by clicking on the thumbnails
on the left of the scan selection screen

The Line Scan

The line scan is particularly useful because
of it's flexibility. The length of the line can
be changed, the angle of the line can be
changed, and the line can be dragged with
the mouse to any position or angle on the
video screen

The Cross Hair Scan

Cross Hair Scan performs a high resolution
horizontal line scan and then automatically
flips to a vertical line scan without having
to exit the protocol
This is a common technique used in B-scan
ultrasonography

Scan analysis protocols for

qualitative analysis
Line scans can be viewed with a variety of
analysis tools (see the OCT manual). I
have found the "Align process" to be the
most useful, with the "Proportional"
analysis a good choice if the align process
is not needed

The Align Process

This tool "straightens" motions artifacts

Proportional analysis
Proportional analysis produces an image
with its true horizontal and vertical
proportions

Retinal Thickness Analysis

Using the retinal thickness analysis tool, the
software then traces a line along the NFL
layer and a line along the RPE layer.
The software then measures the distance
between the two lines and a graph is
produced which compares the measured
thickness to the thickness of a normal
retina

Each of the six scans can be reviewed by

clicking on the slider bar to the left, and any
or all of them can be printed out for the
patient's record

Retinal thickness analysis does not measure

retinal elevation
for example this eye with a pigment epithelial
detachment (PED) pictured below. The arrow on
the left would represent retinal elevation, from
the choroid, through the fluid space of the PED,
to the nerve fiber level. The arrow on the right
shows what the analysis measures, defined by
the distance from the RPE (which is detached)
to the NFL

Serial FMT scans over time

One of the most useful functions of the OCT
is the ability to take volume measurement
over time. For example, a FMT scan
before treatment for AMD, and FMT scans
at various intervals after treatment.
Successful treatment should be followed
by a decrease in retinal thickness and
volume

Retinal Thickness/Volume
Change Analysis
Two FMT scans on the same eye, but taken on
different dates, can be selected at the same time
while holding down the "ctrl" key. "Retinal
Thickness/Vol Change is chosen from the
analysis tab.

The analysis will give you a "change map",

showing the difference between the two
scans

Glaucoma Scans
When evaluating the glaucoma suspect
or the glaucoma patient, two
parameters that the ophthalmologist is
interested in are the characteristics of
the optic nerve cup and the thickness
of the nerve fiber layer surrounding the
optic nerve head
The

Fast Optic Disc scan

The Fast RNFL Thickness scan

The Fast Optic Disc scan

The optic cup profile can be evaluated by
capturing a "Fast Optic Disc" scan
The patient fixes on the target, which is
automatically placed at the edge of the scan
window so that the optic nerve is viewed toward
the center of the video window. The operator
then moves the scan so that the star pattern is
centered on the optic nerve head. Centering
can be aided by clicking on the scan window to
view the white centering lines.

The optic nerve scan can be analyzed with

the "optic nerve head analysis" protocol

The Fast RNFL Thickness scan

Nerve fiber layer thickness can be evaluated with
the "Fast RNFL Thickness" scan. This is a
circular scan that requires the operator to place
the circle so that the center of the circle is
centered on the optic nerve head.

The analysis software places lines on the top and

bottom of the nerve fiber layer and the distance
between the two lines is interpreted to be the
thickness of the nerve fiber layer

Care must be take to make sure that the image is

captured with the circle centered on the optic
nerve
The placement of the circle can make a big
difference in the analysis of the nerve fiber layer
thickness

These two scans (OD) are of a normal eye. The

scan in the first analysis is well centered and the
RNFL thickness falls within the normal range.
The scan in the second analysis is of the same
eye (OD), but the scan is not well centered. The
analysis is abnormal (black arrows).

Is it Perfect?
Scanning with the OCT suffers from a lack
of registration and questionable
repeatability. Until improvements in the
hardware and software improve or
eliminate these problems, operator skill
will play a major roll in the quality of OCT
scanning.

What makes a good OCT scan?

A good

quality OCT scan has good

reflectivity from edge to edge.
The "hotter" colors (orange, red, white,
yellow) are maximized
Generally, the retina should be in the
lower portion of the scan window so that
the vitreous can be images as well.

Scanning Tips
Communicate

with the doctor regarding the size

and location of the pathology of interest.
Refer to other images of the pathology, e.g. color
photos and FA.
Review past OCT exams and repeat scan types
used before.
Dilate the eye well??????
The patient must keep the forehead against the
bar and the chin in the chinrest, with teeth
together. Use the marker on the headrest to
align the patient vertically. The outer canthus
should be even with the line

Scanning Tips

Use the two buttons near the joystick for

freezing and saving scans. This saves you
from having to juggle the joystick and the
mouse.
Minimize patient fatigue by keeping scan time
to a minimum. Never scan an eye for more
than 10 minutes (FDA regulation).
Keep the cornea lubricated. Use artificial tears
and have the patient blink when you are not
saving a scan pass.
Move the instrument on the x and y axis (using
the joystick) to work around opacities

 Reflectivity

may be further enhanced by

moving the focus knob on the side of the
OCT unit.

Alignment and focus

Alignment and focus are used to maximize
the quality of the scan. Alignment begins
with centering and zooming in on the
"football" shaped reflex in the video
image. The initial lens-to-subject distance
is achieved when the retinal image fills the
video screen. This is similar to the image
you see when doing retina photography.
At this point, your attention should shift to
the scan window

 If

an image is not visible in the scan

window, you should click on the "z-offset
optimize" button on the "scan parameter"
tab. Once the scan image is visible, it can
be move with the z-offset arrows.

At this point, the "optimize polarize" button

should be clicked.

This should automatically refine the focus on

the retina, and you should see an increase
in the "hot" colors in the scan, as
illustrated below. The left image is before
optimization, the right is after.

At this point, the "scan mode" button is clicked so that you

have a full resolution image of the scan(s) in the scan
window. From this point on, maintaining a good scan
image is a matter of adjusting the unit with the joystick if
necessary to compensate for movement by the patient
that may degrade alignment. Encourage the patient to
blink until you are ready to freeze the image

Freezing and selecting the scan

The

image can be frozen with a video

image with a flash or without a flash
When ready to freeze the image, tell the
patient not blink and let the scan go
through several passes before freezing the
image
The software saves the last 8 scan passes
for review. Always use the review button
(on the bottom row of buttons).

When you click on the thumbnail at the bottom, the

current set of scans is displayed in the windows
above. The software also tells you what the signal
strength was for that particular scan, on a scale from 1
to 10, with 10 being maximum signal strength. You
can only save one scan from the group

Noise
The OCT scan can sometimes be improved by
changing the "noise" and "range" settings on the
"OCT Image" tab. The default settings are
indicated by blue markers on the scale

Noise
Most instruments produce the best scans when set
with the default values. Increasing the noise
level will produce "hotter' colors in the scan, but
the noise artifacts will also increase. Noise
artifacts are those "snowflakes" that you see in
the dark areas of the scan (e.g. the vitreous)

Whats New
OCT with

SLO
OCT with HRA (FA and ICG)
Increase in resolution to 5 microns
Overlays, 3D imaging

Questions?
References:
Brancato R. and Lumbroso B. Guide to
Optical Coherence Tomography
Interpretation. Rome: Innovation-NewsCommunication, 2004.
Schuman J., Puliafito C., and Fujimoto J.
Ocular Coherence Tomography of Ocular
Diseases. Thorofare NJ: Slack Inc., 2004.