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Ideal Imaging Modality Color Fundus Photography Confocal Scanning

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Ideal Imaging Modality Color Fundus Photography Confocal Scanning Disclosures I have no financial disclosures to make. Imaging & Glaucoma: The New and The Next Leonard Seibold, M.D. Instructor/Fellow of Ophthalmology Glaucoma & Cataract Service University of Colorado Denver, CO Ideal Imaging Modality Color Fundus Photography z Historic gold standard z 1. Differentiate between normal and z But is it the current gold standard??? glaucomatous eyes z Advantages z 2. Detect glaucomatous changes before z Reliable method for documenting disc cupping – (stereophotographs) functional vision loss (Pre-perimetric) z Ability to accurately measure cup/rim distances z No new equipment to buy - Most office settings already have camera z 3. Reliably detect progression of disease z Red-free photos can aid in RNFL loss detection z Useful for detection of change over long follow-up z Disadvantages z Other beneficial features z Subjective and variable interpretation z Difficulty delineating nerve rim on 2-D photos z Fast, Easy, Applicable to all patients z Cannot quantify RNFL thickness z No reliable normative database to compare to z Not as helpful early on in disease detection Confocal Scanning Laser Tomography - HRT HRT z 670 nm diode laser beam scans fundus z Intensity of light reflection is a function of z Reflected light from each scan point is measured depth z A pinhole or confocal aperture in front of the detector eliminates scattered light z Retina is dark – prominent z Raster scans of the fundus are built into a 2-D image z Cup is bright - depressed z A series of images are obtained at successive planes of depth z A layered 3-D image is then constructed HRT HRT z 384 x 384 pixel image generated z Several topographic parameters are calculated z 15 x 15 degrees z Compared to normative z Outer disk margin is manually placed database for detection z Reference plane placed at 50 μm below z Followed over time for retinal surface progression z Mean height contour and z Structures above – cup rim area were consistent z Structures below – rim predictors of glaucoma in OHTS Confocal Scanning Laser HRT Polarimetry - GDx z Advantages z CSLO + Polarimetry z Rapid, simple z No dilation z Based on birefringence of RNFL z 3D ONH images and contour parameters from parallel oriented z Proven detection of disease microtubules z Compared to established normative database z 780 nm polarized laser scans z Disadvantages z Manual tracing of ONH margins concentric circles around the disk z Arbitrary reference plane (changes with IOP, edema, z Retardation of polarized light is cardiac cycle) z Difficulty with tilted/myopic/hyperopic discs proportional to RNFL thickness z Poor RNFL analysis z Cornea and lens contribution must be cancelled out – VCC or ECC GDx z Advantages z Fast, simple z No dilation z No reference plane – not affected by IOP z Better measure of RNFL z No manual disc tracing z Large normative database z Disadvantages z VCC requires normal macula z Only useful in peripapillary region z “Odd Scans” without appropriate compensation Optical Coherence Tomography (OCT) Schematic z Introduced 1996 z 850nm diode laser z FDA approved cross-sectional ocular imaging z Beam split to reference mirror and eye modality z Interference pattern correspond to thickness and z Used for: depth of reflecting tissues z Evaluation of retinal/macular pathology z Monitoring RNFL thickness in Glaucoma z Corneal/Anterior segment imaging z Time Domain z Three generations z Spectral Domain (Fourier Domain) z Approved 2006 OCT Technology Comparison Time Domain Spectral Domain z Cross-sectional images allow visualization of Speed 400 A‐scans/sec 29‐55,000 A‐scans/sec each retinal layer Resolution 10‐15 µm 2‐7 µm z Computer segmentation software delineates Image tracking No Yes layer boundaries to calculate thickness Motion Artifact Yes Minimized Ability to detect disease Proven Potentially better z Glaucoma: RNFL and GCC thickness 3D Data sets/modeling No Yes Variability Very good Excellent/? Time Domain Spectral Domain z Stratus – Zeiss Meditec, Dublin, CA z Cirrus (Zeiss Meditec, Dublin, CA) z Spectralis (Heidelberg Engineering, Heidelberg, Germany) z RTVue (Optovue, Fremont , CA) Study Purpose Methods z 1. Compare agreement of RNFL thickness z 40 normal subjects measurements from Time-Domain OCT z Baseline exam: Va, IOP, ONH exam, HVF 24- (Stratus) and Spectral-Domain OCT (Cirrus, 2, Gonioscopy Spectralis, RTVue) z OCT scans: Stratus, Cirrus, Spectralis, RTVue z 2. Analyze and compare intervisit z All performed same day reproducibility of each machine z All done with same technician z All scans repeated 2-8 weeks later by same technician. Agreement with Stratus Agreement with Stratus Mean ± SD STRATU Average 110.10 ± 12.81 Temporal 75.79 ± 13.03 S Superior 133.46 ± 16.71 Nasal 87.57 ± 16.85 Inferior 143.59 ± 19.89 Mean Mean ± SD r difference p‐value CIRRUS Average 98.68 ± 10.89 ‐11.33 0.000 0.911 Temporal 64.88 ± 10.37 ‐10.87 0.000 0.746 Superior 123.52 ± 16.18 ‐10.01 0.000 0.701 Nasal 74.88 ± 10.31 ‐12.48 0.000 0.755 Inferior 132.01 ± 18.91 ‐11.35 0.000 0.861 Mean ± SD SPECTRAL Average 106.59 ± 12.82 ‐3.36 0.001 0.869 IS Temporal 78.54 ± 14.22 3.01 0.034 0.748 Superior 131.4 ± 18.45 ‐2.10 0.222 0.780 Nasal 78.12 ± 13.13 ‐9.35 0.000 0.659 Inferior 137.37 ± 18.95 ‐5.92 0.000 0.854 Mean ± SD RTVUE Average 112.78 ± 13.2 2.81 0.001 0.905 Temporal 88.19 ± 19.35 12.30 0.000 0.490 Superior 135.81 ± 17.51 2.32 0.202 0.752 Nasal 86.81 ± 13.11 ‐0.52 0.768 0.650 Inferior 148.13 ± 20.32 4.82 0.003 0.853 r = Pearson Correlation Cffit Agreement with Stratus Bland-Altman Analysis Reproducibility Reproducibility Mean Mean Reproducibility 95% CI CoV 95% CI ICC 95% CI Intervisit Intervisit 8.83 7.21 to 10.45 2.86 2.17 to 3.42 0.94 0.91 to 0.97 Difference 95% CI p‐value Difference 95% CI p‐value STRATUS 15.96 11.44 to 20.47 7.86 4.35 to 10.23 0.85 0.76 to 0.95 18.05 15.44 to 20.65 4.89 3.84 to 5.75 0.87 0.82 to 0.92 Stratus Average 0.37 ‐0.79 to 1.53 0.536 Spectralis Average ‐0.01 ‐1.36 to 1.33 0.983 23.73 19.31 to 28.15 9.28 7.38 to 10.85 0.78 0.72 to 0.84 Temporal ‐0.27 ‐2.24 to 1.71 0.791 Temporal ‐0.87 ‐3.53 to 1.80 0.528 18.31 12.67 to 23.95 4.52 2.62 to 5.82 0.89 0.82 to 0.95 Superior ‐0.01 ‐2.34 to2.31 0.990 Superior ‐0.43 ‐2.07 to 1.20 0.607 8.89 5.75 to 12.02 3.03 1.47 to 4.03 0.92 0.87 to 0.97 CIRRUS 11.91 7.33 to 16.48 5.79 2.82 to 7.69 0.87 0.77 to 0.96 Nasal 1.09 ‐1.63 to 3.81 0.437 Nasal 0.45 ‐0.59 to 1.48 0.401 24.77 11.55 to 37.99 7.10 0.00* ‐ 10.74 0.74 0.55 to 0.93 Inferior 0.70 ‐1.73 to 3.14 0.576 Inferior 0.36 ‐1.37 to 2.09 0.687 17.29 12.84 to 21.73 7.78 5.24 to 9.68 0.70 0.58 to 0.83 18.63 14.37 to 22.88 5.02 3.57 to 6.13 0.88 0.82 to 0.94 Mean Mean 11.72 9.31 to 14.13 3.91 2.81 to 4.77 0.90 0.85 to 0.95 Intervisit Intervisit SPECTRALIS 21.28 16.50 to 26.05 8.79 6.42 to 10.46 0.74 0.65 to 0.82 Difference 95% CI p‐value Difference 95% CI p‐value 14.14 10.44 to 17.84 3.97 1.91 to 5.28 0.93 0.89 to 0.97 8.39 6.86 to 9.91 3.90 2.98 to 4.64 0.95 0.93 to 0.97 Cirrus Average 0.19 ‐1.14 to 1.53 0.777 RTVue Average ‐0.56 ‐1.42 to 0.30 0.209 14.68 9.80 to 19.57 3.68 1.85 ‐ 4.86 0.93 0.88 to 0.98 Temporal 0.33 ‐1.18 to 1.83 0.672 Temporal 2.84 0.20 to 5.47 0.041 RTVUE 6.59 5.59 to 7.59 2.09 1.71 to 2.41 0.97 0.96 to 0.98 Superior 0.75 ‐3.15 to 4.64 0.710 Superior ‐1.24 ‐2.83 to 0.35 0.134 18.96 13.70 to 24.22 7.56 4.79 to 9.57 0.89 0.82 to 0.96 13.09 11.14 to 15.05 3.51 2.79 to 4.11 0.93 0.91 to 0.96 Nasal ‐1.61 ‐3.92 to 0.69 0.178 Nasal ‐0.16 ‐1.98 to 1.66 0.861 15.31 12.24 to 18.38 6.04 4.51 to 7.25 0.86 0.80 to 0.93 Inferior 0.33 ‐2.29 to 2.94 0.807 Inferior ‐0.60 ‐2.03 to 0.83 0.418 12.02 10.00 to 14.03 2.99 2.31 to 3.54 0.96 0.94 to 0.98 All measurements in Micometers (µm), Reproducibility = 2.77 x intervisit within-eye standard deviation (Sw), CoV = Coefficient of Variation, ICC = Intraclass Correlation Coefficient Scan Quality Spectralis Errors z Reasons for discarding z Poor image quality z Failure to delineate accurate RNFL/ILM boundaries z Total scans discarded: 11 z Spectralis: 10 (10/79 = 12.6%) z Cirrus: 1 z RTVue: 0 Conclusions Follow Up Study z SD-OCT RNFL thicknesses are highly z Can Software upgrades alter RNFL correlated to Stratus measurements? z However, each SD-OCT’s measurements are z Can they improve quality? significantly different than Stratus z Can they reduce segmentation errors? z Physicians should be aware of relationships when following patients z All instruments were highly reproducible between visits z RTVue > Stratus = Cirrus > Spectralis Factors Affecting OCT Measurements Software Improvements Updates z Operator error Minor software revisions z Lens/Cornea pathology Fix minor bugs, maintain the product, insert basic new functions Provided at no additional cost z Image artifacts (PVD, vessels, etc.) Change in version number after decimal point ( e.g.
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