A JOURNAL REVIEW

ON
ROLE OF OPTICAL
COHERENCE TOMOGRAPHY
IN MANAGEMENT OF
MACULAR DISEASES.
What is Optical coherence
tomography ?
 Devised by Tanno et al in 1990 & Introduced by
Huang et al 1991, Optical coherence tomography
(OCT) is a new, non-contact, non-invasive,
transpupillary technique for high resolution, cross-
sectional imaging of tissue.
 It is analogous to :
 computed tomography - which uses X rays,
 magnetic resonance - which uses spin resonance,
and,
 ultrasound B scan - which uses sound waves.
 The operation of OCT is similar to that of
ultrasound B-scan imaging except it utilizes near
infra-red light (830nm) waves rather than acoustic
sound waves. Because of this difference, the axial
resolution of OCT is as high as 10 μm, compared
with 150 μm of that of a conventional 10-MHz B-
scan ultrasound.
 Techniques of oct :
 TIME DOMAIN OCT (STRATUS OCT) has an
axial resolution of 10 microns and a
transverse resolution of 20 microns.
 SPECTRAL/FOURIER DOMAIN OCT is
capable of higher resolutions of 5-
7microns(axial) & 10-20
microns(transverse) and acquires 512 vertical
scans. An experimental ultra high resolution OCT
system has been developed using Ti-laser that
provides an improved axial resolution of 2 to
3microns.
Scanning Tips
1. Have a clear idea regarding the size and location
of the pathology of interest.
2. Refer to other images of the pathology, e.g. color
photos and FA.
3. Review past OCT exams and repeat scan types
used before.
4. Dilate the eye well.
5. 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
6.Use the two buttons near the joystick for
freezing and saving scans.  This saves you from
having to juggle the joystick and the mouse.

7.Minimize patient fatigue by keeping scan

time to a minimum.  Never scan an eye
for more than 10 minutes (FDA
regulation).
8.Keep the cornea lubricated.  Use artificial
tears and have the patient blink when you
are not saving a scan pass.
9.Move the instrument on the x and y axis
Principle :
low coherence interferometry.

MICHELSON
INTERFEROMETER
OCT Image of Normal Fovea

The OCT image above can be compared to what we

know about retinal anatomy from conventional
microscopic sections.  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. 
These layers 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 .  The
Applications

 (a) Follow up of the clinical

course, understanding the
pathogenesis of the disease,
 (b) For assessing the response to
medical/surgical/ laser therapy,
 (c) For documentation and
explaining the prognosis of a
particular disease.
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
 and the sub-retina
Profiles

OCT retinal morphology (form and

structure) can be subdivided into four
"profiles":  Each profile has it's own
set of deformations and anomalous
structures.

 1. pre-retinal profile
 2. overall retinal profile
 3. foveal profile
 4. macular profile
The pre-retinal profile
 A normal pre-retinal profile is black space, as
pictured below, because the normal vitreous space
is translucent, meaning it has minimal reflective
properties.  The small, faint, bluish dots in the pre-
retinal space is "noise".  This is an electronic
aberration created by increasing the sensitivity of
the instrument to better visualize low reflective
structures.
Anomalous structures that have been observed in the pre-
retinal profile include the following: 
1. pre-retinal membrane
2. epi-retinal membrane
3. vitreo-retinal strands
4. vitreo-retinal traction
5. pre-retinal neovascular membrane
6. pre-papillary neovascular membrane
A pre-retinal membrane with traction on the
fovea is pictured below.
The over-all retinal profile
The normal over-all retinal profile has a slightly concave
curvature that you would expect from observing the
surface of a globe.  Abnormal profiles would include
exaggerated concavity and convexity.  Retinal folds would
also result in an abnormal over-all profile.
The following OCT image demonstrates an
abnormal convexity in the over-all retinal
profile.  In this case, a pigment epithelial
detachment is causing the convexity.
The image below demonstrates an abnormal
concavity to the over-all retinal profile.  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, as pictured below.
Deformations that have been observed
in the foveal profile include the
following:
 
1. macular pucker
2. macular pseudo-hole
3. macular lamellar hole
4. macular cyst
5. macular hole, stage 1 (no
depression, cyst present)
6. macular hole, stage 2 (partial
rupture of retina, increased thickness)
7. macular hole, stage 3 (hole extends
to RPE, increased thickness, some
fluid)
8. macular hole, stage 4 (complete
macular cyst
 The macular profile
The macular profile can, and often does,  include the
fovea as it's center.  Therefore, a common OCT scan
length of 6 mm would include
  3 mm of the macula on
each side of the fovea. 

                                                                                                                                        
Deformations that have been observed in the macular
profile include the following:
 1. serous retinal detachment (RD)
2. serous retinal pigment epithelial detachment (PED)
3. hemorrhagic pigment epithelial detachment
 A serous PED is pictured below.  We know that it is a
PED because the fluid (black space around the arrow)
is pushing up underneath the retinal pigment
epithelium, identified by the relatively highly reflective
(red and orange) line (arrow).
 
Intra-retinal anomalies that have been
identified in the macular profile
include:
 
1. choroidal neovascular membrane(I
& II)
2. diffuse intra-retinal edema
3. cystoid macular edema
4. drusen
5. hard exudates
6. scar tissue
7. atrophic degeneration
8. sub-retinal fibrosis
 Cystoid Macular Edema

OCT is capable of detecting small,

fluid-filled, cystic spaces within the
macula.
Central Serous
Chorioretinopathy

Central serous chorioretinopathy is

characterized by the presence of fluid
between the RPE and neurosensory retina.
 Diabetic Retinopathy

Exudates appear as accumulation of dense

material within the neurosensory retina.
Artifacts
 Artifacts in the OCT scan are anomalies in the scan that are
not accurate images of actual physical structures, but are
rather the result of an external agent or action.  
 Notice the large gap in the middle of the scan below.  This is
an artifact caused by a blink during scan acquisition.  This
was a high resolution scan, which takes about a second for
the scan pass, which is plenty of time to record a blink.
The scan below has waves in the retinal
contour.  These are not retinal folds, but rather
movement of the eye during the scan pass.
Various studies have been published in different
journals to study ROLE OF OCT IN MANAGEMENT
OF MACULAR DISEASES. A few of them are
mentioned below.

1. The following study was conducted for Alberta

Heritage Foundation for Medical Research (2003)
Canada
To evaluate the evidence on the use of OCT to
diagnose retinal disease
From 1995–July/August 2003
Cystoid macular oedema diagnosis:1 study
compared OCT with FFA in patients with uveitis.
1 study compared OCT with FFA + slit-lamp
biomicroscopy in patients with diabetic
retinopathy.
Likelihood ratios indicate that OCT provided strong to
convincing diagnostic evidence for detecting cystoid
macular oedema and retinal blood vessel leakage.
Resul
ts:
Accuracy for diagnosis of macular oedema
OCT in patients with uveitis (FFA as reference standard) (1 study):
• Sensitivity = 89%; specificity = 100%
OCT in patients with diabetic retinopathy (FFA as reference standard)
(1 study):
• Foveal retinal thickness: Sensitivity = 81.5%; specificity = 94.1%
(FFA as reference standard)
• Average retinal thickness: Sensitivity = 73.1%; specificity = 100%
(FFA as reference standard)
• Foveal retinal thickness: Sensitivity = 88.8%; specificity = 96.0%
(slit-lamp biomicroscopy as reference standard)
• Average retinal thickness: Sensitivity = 80.2%; specificity = 100%
(slit-lamp biomicroscopy as reference standard)
2.Optical coherence tomography to detect
and manage retinal disease and glaucoma.
Jaffe GJ, Caprioli J.2004,USA.
PURPOSE: To review basic principles of optical coherence tomography, and to
describe its use in the diagnosis and management of retinal diseases and
glaucoma. DESIGN: Perspective. METHODS: Literature review.
RESULTS: Optical coherence tomography is a noninvasive imaging technique
that has been used increasingly to diagnose and manage a variety of retinal
diseases and glaucoma. Optical coherence tomography (OCT) is based on the
principal of Michelson interferometry. Interference patterns produced by low
coherence light reflected from retinal tissues and a reference mirror are
processed into an "A-scan" signal. Multiple A-scan signals are aligned to
produce a two-dimensional image that can be thought of as a form of "in vivo
histology." Optical coherence tomography has been used to identify macular
holes, to differentiate macular holes from simulating lesions, to identify
lamellar macular holes, macular cysts, vitreomacular traction, subretinal
fluid, pigment epithelial detachment, and choroidal neovascularization. It can
be used to identify and quantify macular edema, and to measure retinal
thickness changes in response to therapy. Macular thickness measurements
determined by OCT correlate well with visual acuity and with leakage
observed by fluorescein angiography. Optical coherence tomography is an
accurate and reproducible method to measure retinal nerve fiber layer
thickness. Particularly, when used in combination with other optic nerve
Optical coherence tomography equipment is expensive,
and not all insurance companies reimburse this
procedure. Image quality is dependent on operator
technique & degraded in the presence of
media opacity. Change analysis software for
glaucoma applications is not fully developed,
and there is a scarcity of age, gender, and race-
specific normative data upon which to compare
eyes with retinal disease and glaucoma. In the
next few years, it is likely that the role of OCT as
a method to diagnose and manage retinal
disease and glaucoma will be further defined,
and many of the current limitations will be
overcome.
CONCLUSIONS: Optical coherence tomography is
a useful imaging technique to diagnose and
manage a variety of retinal diseases and
Diabetic macular edema assessed with
optical coherence tomography and
stereo fundus photography.
Strøm C, Sander B, Larsen N, Larsen M,
Lund-Andersen H. Department of
Ophthalmology, Herlev Hospital, University
of Copenhagen, Copenhagen, Denmark.
JAN 2002.To compare retinal thickening in
PURPOSE:
diabetic macular edema assessed subjectively by
evaluation of stereo fundus photographs with that
assessed objectively by optical coherence
tomography (OCT).
CONCLUSIONS: The degree of agreement
between subjectively and objectively assessed
retinal thickening was very good, implying that
Optical Coherence Tomography versus
Stereoscopic Fundus Photography or
Biomicroscopy for Diagnosing Diabetic Macular
Edema: A Systematic Review

Gianni Virgili, Francesca Menchini, Andrea F. Dimastrogiovanni, Emilio

Rapizzi, Ugo Menchini, Francesco Bandello, and Raffaella Gortana Chiodini
Rome, Italy in 2000.

PURPOSE. To review systematically the sensitivity and

specificity of optical coherence tomography (OCT) for

diagnosing macular edema attributable to diabetic
retinopathy compared with well-established gold
standard tests such as fundus stereophotography or
RESULTS. Fifteen studies were considered eligible. These studies were
of good quality for most items of the QUADAS checklist, but most
studies did not report masking of examiners and did not describe how
withdrawals and undetermined results were treated. Seven studies
included healthy control subjects, which could have artificially
enhanced OCT diagnostic performance. All but one study included
both eyes of the patients without taking into account the within-
subject correlation in statistical analyses. Sensitivity and specificity
data could be extracted from only 6 of 15 studies, because
appropriate cross tabulations of index and reference tests were not
reported by the others. In five of these studies, central retinal
thickness cutoffs between 230 and 300 µm were adopted to define
abnormal OCT results and considered the central type of CSME only,
whereas in one study a complex algorithm accounting for extrafoveal
CSME was used. The design of one study was case–control and was
excluded from the meta-analysis. The expected operating point on
the summary ROC, a pooled estimate of all studies, corresponded to a
sensitivity of 0.79 (95% CI: 0.71–0.86), a specificity of 0.88 (95% CI:
0.80–0.93), a positive likelihood ratio of 6.5 (95% CI: 4.0–10.7), and a
negative likelihood ratio of 0.24 (95% CI: 0.17–0.32). These values
suggest a good overall performance of OCT for diagnosing CSME.
Purpose: To investigate the quantitative assessment of macular edema
secondary to central or branch retinal vein occlusion with foveal thickness
measurements by optical coherence tomography (OCT).

Material and methods: Thirty eight eyes of 38 cases examined between

October 2000-May 2002, with central or branch retinal vein occlusion were
included in the study. At initial examination and during follow-up
examinations at 3-6 month intervals, complete ophthalmic examination was
done, color fundus photographs were taken and fluorescein angiography was
performed. Foveal thickness measurements were taken in macular cross-
section images obtained with optical coherence tomography. Control group
included thirty-nine eyes of 33 healthy objects without eye pathology. Foveal
thickness measurements were obtained from macular OCT images and
compared with the values of study group.
Results: At initial examination, there was sponge-like retinal swelling in 34
%, cystoid macular edema in 34 %, serous macular edema in 19.2 % and
mixed edema in 12.8 % of 38 cases (11 of them had central, 27 of them had
branch retinal vein occlusion). In the study group, the mean foveal thickness
at initial examination (590.2 ± 45 µm) was significantly higher than the
mean value at last visit (403.1± 53 µm). These values were also
significantly higher than the mean foveal thickness in control group (177.1
± 19.4 µm). There was negative correlation between mean foveal thickness
measurements and visual acuities at initial and final examinations.

Conclusion: Optical coherence tomography is a

useful technique for noninvasive, objective and
quantitative assessment of macular edema
secondary to retinal vein occlusions with foveal
Purpose : To evaluate central serous chorioretinopathy (CSCR) with
optical coherence tomography (OCT) during the acute and resolution
phase.

Method : 12 patients (8 men and 4 women) who were examined

between October 2000 and May 2001 and diagnosed as CSCR were
included in the study. Complete ophthalmologic examination was
performed, color fundus photographs were taken and optical coherence
tomography was performed. Fundus fluorescein angiography was
performed in all cases except two pregnant women during initial
examination. FA and OCT were repeated during the control
examinations. The difference between the retinal thickness and serous
Results : 14 eyes of 12 patients had on acute phase of CSCR
according to fundus examination and fluorescein angiography. 2 patients
were pregnant and one of them had bilateral involvement. Fluorescein angiography 
was not performed in these cases. Fluorescein angiograhy revealed one or more
leakage points in 10 eyes, multiple pigment epithelial detachments (FED) in one eye.
OCT scans showed neurosensory retinal detachment and increased retinal thickness 
in 13 eyes, and PED's in one eye. FED in a pregnant woman was detected by OCT.
During follow-up period, in the eyes without active leakage point in fluorescein 
angiography, the neurosensory detachments resolved and retinal thickness decreased 
In  OCT  scans.
 

Conclusion: OCT is a useful and objective diagnostic technique 
in  evaluating  FED,  neurosensory  retinal  detachment  and  retinal 
thickness  in  CSCR.  It  may  be  an  alternative  diagnostic  tool  in 
pregnant women.
Virgili et al. (2007)
Italy : systematically the sensitivity and specificity
To review
of OCT for diagnosing macular oedema attributable to
diabetic retinopathy compared with fundus
stereophotography or contact and non-contact fundus
biomicroscopy.

OCT can be used to diagnose CSME, particularly its

central type or CDME, and decide on laser
photocoagulation in patients with intermediate
suspicion of disease The strength of this conclusion is
limited by the fact that data could be extracted from
only a fraction of the published literature due to
limitations in reporting. The precision of estimates is
inflated by the within-patient correlation between
Results : Sensitivity = 0.79 (95% CI: 0.71–0.86);
specificity = 0.88 (95% CI: 0.80–0.93)
 Comparison between optical coherence tomography
and fundus fluorescein angiography for the detection
of cystoid macular edema in patients with uveitis.
ANTCLIFF R. J. ; STANFORD M. R. ; CHAUHAN D. S. ; GRAHAM E. M. ;
SPALTON D. J. ; SHILLING J. S. ; FFYTCHE T. J. ; MARSHALL J.
Department of Ophthalmology, Rayne Institute, St. Thomas'Hospital, London.

Purpose: To compare optical coherence tomography (OCT) with fundus

fluorescein angiography (FFA) for the detection of cystoid macular edema
(CME) in patients with uveitis.

Main Outcome Measures: Detection and distribution of macular edema.

Results: One hundred eight eyes had similar results on both OCT and FFA in
that 67 eyes had CME and 41 eyes had no CME. In 10 eyes subretinal fluid
was detected on OCT but not FFA. Five of these eyes had CME on FFA but not
OCT. Three other eyes had CME that was detected by FFA but not by OCT.
Compared with FFA, the OCT sensitivity for detecting CME was 96% (including
the eyes with subretinal fluid), and the OCT specificity was 100%.

Conclusions: OCT is as effective at detecting CME

as is FFA but is superior in demonstrating axial
 Conclusion :
1) OCT can detect very early macular disease changes.
2) It can be used to study, diagnose, monitoring & guiding
retreatment decisions.
3) It is reproducible, accurate, sensitive and specific.

Limitations:
1) Clear media needed,
 2) Pupillary dimeter of approx. 4 mm,
 3) Costly.

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