Imaging

Ophthalmol Clin N Am 17 (2004) ix x
Preface
Imaging
Joel S. Schuman, MD
Guest Editor
This issue of the Ophthalmology Clinics of North

America focuses on ophthalmic diagnostics, primarily
imaging, but including advanced functional measures
as well. The articles contained herein represent the
state-of-the-art in ophthalmic diagnostics and are
written by the leaders in the field. This issue has
been endorsed by the International Society for Imaging in the Eye, an organization devoted to the
advancement of the science of ophthalmic imaging.
In Optical Coherence Tomography of the Anterior Segment of the Eye, David Huang, MD, PhD,
Yan Li, MS, and Sunita Radhakrishnan, MD, explore
the usefulness of OCT in anterior segment evaluation. The technology reveals in great detail the
structure of the cornea and anterior segment structures. This technology offers the advantage of noncontact, noninvasive assessment of the anterior eye,
including anterior chamber angle evaluation and high
resolution measurement of corneal thickness. Refractive surgery planning and results can be investigated
as well, including LASIK flap and bed thickness
and morphology.
Somewhat more conventional high resolution anterior segment imaging is discussed in, Anterior
Segment Imaging: Ultrasound Biomicroscopy, by
Hiroshi Ishikawa, MD, and me. We review the
myriad clinical applications of ultrasound biomicroscopy, a technology that is currently available to
clinicians, unlike anterior segment OCT. Ultrasound
biomicroscopy has particular use in anterior segment
tumor evaluation, especially tumors of the ciliary

body, and in angle closure glaucoma, where a rapid
ultrasound biomicroscopy dark room test can measure whether or not an angle is actually occludable.
This is especially helpful in patient education, and
this application should not be underestimated.
The wide spectrum of macular diseases is explored in Clinical Applications of Optical Coherence Tomography for the Diagnosis and Management
of Macular Diseases by Irene Voo, MD, Elias C.
Mavrofrides, MD, and Carmen A. Puliafito, MD,
MBA. The cross-sectional visualization of the retina
made possible by OCT is used to full advantage in
this article. OCT enables near-histologic evaluation of
the macula, revealing the nature and location of
pathophysiology for the clinician.
In Imaging in Glaucoma, Daniel M. Stein,
BA, Gadi Wollstein, MD, and I review the various
imaging technologies used to evaluate glaucoma. The
devices themselves are described in addition to their
clinical applications. Comparisons are given so that
the clinician can visualize the unique information
provided by each device. The clinical studies are
summarized comparing these devices as well.
Moving to functional measures, Electrophysiologic Imaging of Retinal and Optic Nerve Damage:
The Multifocal Technique by Donald Hood, PhD,
is an in-depth review of multifocal electrophysiologic evaluation. The promise of these new methods
is tremendous, with the potential of objective, quanti-
0896-1549/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ohc.2004.02.001
J.S. Schuman / Ophthalmol Clin N Am 17 (2004) ixx
tative measurement of functional abnormalities. This

is in stark contrast to perimetry, which involves the
subjective interpretation of a subjective test.
Continuing in the objective, quantitative electrophysiologic vein, but expanding to include structural
assessment as well, Thomas R. Hedges III, MD, and
Maria-Luz Amaro Quereza, OD, investigate the use
of state-of-the-art technologies in neuro-ophthalmic
disease in Multifocal Visual Evoked Potential, Multifocal Electroretinography, and Optical Coherence
Tomography in the Diagnosis of Subclinical Loss of
Vision. This article discusses a variety of pathologies and portrays the clinical value of these currently
available methods.
Perhaps the most cutting-edge article in this
issue, High-Resolution Functional Optical Imaging:
From the Neocortex to the Eye, by Amiram Grinvald, PhD, Tobias Bonhoeffer, PhD, Ivo Vanzetta,
PhD, Ayala Pollack, MD, Eyal Aloni, MD, Ron Ofri,
MD, and Darin Nelson, PhD, reviews emerging technology for measurement of ocular blood flow and
oximetry. The potential of the technology described
is enormous, and this section promises to translate
what was once science fiction to science.
Joel S. Schuman, MD
University of Pittsburgh School of Medicine
UPMC Eye Center
203 Lothrop Street
Eye and Ear Institute, Suite 816
Pittsburgh, PA 15213, USA
E-mail address: schumanjs@upmc.edu
Ophthalmol Clin N Am 17 (2004) 1 6
Optical coherence tomography of the anterior segment of

the eye
David Huang, MD, PhD*, Yan Li, MS, Sunita Radhakrishnan, MD
Cole Eye Institute, The Cleveland Clinic, Department of Neurosciences NC3, 9500 Euclid Avenue, I20,
Cleveland, OH 44195, USA
Optical coherence tomography (OCT) [1] is a

novel cross-sectional and three-dimensional imaging
modality that uses low-coherence interferometry to
achieve axial (depth) resolutions in the range of 3 to
20 mm. OCT has several theoretical advantages
when compared with current imaging modalities for
imaging the anterior segment of the eye. Unlike
ultrasound, OCT employs light; therefore, it does
not require fluid immersion or probe contact. Furthermore, OCT has a spatial resolution that easily surpasses that of even ultrahigh-frequency ultrasound
[2 9]. Although confocal scanning microscopy
[10 15] can obtain even higher resolution than
OCT, it requires short focal distances and can image
only a small area of the eye at a time. OCT uses
interferometry for depth resolution; therefore, it can
have a long working distance and a wide field of
transverse scanning. Slit illumination imaging, such
as Scheimpflug photography [16] or the Orbscan
system [17 21] (Bausch & Lomb, Rochester, New
York), can also provide cross-sectional images, but
accurate biometry is difficult. The angles between the
slit illumination, subject anatomic surfaces, and imaging axis require complex computations for anatomic reconstruction and measurements. OCT detects
retroreflected light and is more amenable to simple
interpretation and accurate measurements.
The primary limitations of OCT imaging of the
anterior segment are speed and penetration. Commercial retinal scanners (Carl Zeiss Meditec, Dublin,
California) have a scanning speed of 100 to 400 axial
scans per second. Each axial scan contributes a ver-
* Corresponding author.
E-mail address: huangd@ccf.org (D. Huang).
tical line to the OCT image. A corneal image produced by the Zeiss OCT 1 system (Fig. 1) has visible
motion artifacts because the image is acquired over
1 second. It also has coarse pixel grain because it
contains only 100 vertical lines. The 0.8-mm wavelength employed for retinal scanning is close to
visible wavelengths and cannot directly visualize
angle structures owing to scattering loss through the
limbus [22]. A widely useful anterior segment OCT
system would need to overcome both limitations.
This article presents the results using a high-speed
OCT prototype developed collaboratively between
Professor Joseph Izatt (Duke University), Professor
Andrew Rollins (Case University), and the authors at
the Cleveland Clinic Foundation. The system has a
scan rate of 4000 lines per second, which is fast
enough for biometric applications. It uses a longer
wavelength of 1.3 mm, which decreases scattering
through turbid tissues and allows visualization of
angle structures [23]. The system is useful in a range
of clinical applications from laser-assisted in situ
keratomileusis (LASIK) surgery to narrow angle
glaucoma. OCT of the anterior segment is still in its
infancy; therefore, it is discussed at the end of this
article in a section on future prospects.
Background
The precursor technology of OCT [1], optical
coherence domain reflectometry (OCDR), had its
earliest demonstration in biomedical applications
with the measurement of corneal thickness [24].
OCDR is an optical ranging technique, or a method
for measuring the distance between the measurement
doi:10.1016/S0896-1549(03)00103-2
D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16
used safely at the longer wavelength to achieve a

high acquisition rate of 4000 axial scans per second.
This high-speed OCT engine has been used in several
anterior segment OCT scanners to generate the clinical results discussed herein.
High-speed corneal and anterior segment optical

coherence tomography at 1.3-Mm wavelength
Fig. 1. OCT of the cornea with 6.5-mm scan width
performed with the Zeiss OCT 1 system. The image has
not been corrected for aspect ratio and the divergent beam
scan path; therefore, the thickness and corneal curvature
are exaggerated.
system and a target. In OCDR, an optical probe beam

is directed toward a target sample, and the reflected
light is recombined with a reference reflection in an
interferometer. Interference occurs when the two
reflections are mutually coherent. Because OCDR
uses light with a short coherence length, coherence
occurs only when the reference and sample reflections
are closely matched in propagation delay. By scanning the delay of the reference reflection and recording the resulting fluctuation in interference signal, the
OCDR system resolves the amplitudes of sample
reflections as a function of depth (axial delay). OCT
is based on OCDR, with the addition of transverse
scanning of the probe beam to provide at least another spatial dimension for imaging.
Izatt et al published the first report of OCT for
corneal and anterior segment imaging in 1994 [22].
After that report, little attention was paid to anterior segment applications until the Lubeck group
described OCT imaging of laser thermokeratoplasty
lesions in 1997 [25,26], and Maldonado et al [27 29]
reported imaging of the LASIK flap in 1998. Since
then, the rapid popularization of corneal refractive
surgery has spurred investigators to apply OCT to
corneal imaging and to refine the instrumentation
for anterior segment OCT.
In most published reports of anterior segment
OCT applications, the commercial retinal OCT scanner has been used [27 44]. Although visualization of
corneal surgical anatomy and thickness measurements
are possible, the imaging speed, penetration, and field
of view are very limited with the retinal scanner.
Ocular imaging with the 1.3-mm wavelength was
first reported by Radhakrishnan et al using a system
developed by Izatts group [23]. The Izatt system
takes full advantage of the higher power that can be
Using a longer wavelength of 1.3 mm for corneal

and anterior segment (CAS) OCT provides important
advantages when compared with the 0.8-mm wavelength commonly used for retinal imaging. Because
scattering loss is much lower at the longer wavelength, 1.3-mm OCT can penetrate the limbus and
sclera to provide a view of the angle. The absorption
by water is also much stronger at 1.3 mm (9.3-mm
absorption length) [45]. For an eye of average length,
91% of 1.3-mm light that falls on the cornea will be
absorbed by the ocular media, leaving only 9% to
reach the retina. This absorption allows the use of
much higher optical power without damaging the
retina. The permissible exposure level at the 1.3-mm
wavelength is 15 mW according to the current standard set by the American Laser Institute and the
American National Standards Institute (ANSI 2000)
[46]. This level is 20 times higher than the 0.7-mW
limit at the 0.8-mm wavelength [46]. As a result,
CAS OCT can use much higher power and achieve
much higher scan rates. The authors developed several CAS OCT systems using a high-speed OCT engine (4000 A-scans per second) with a 1.3-mm super
luminescent diode (SLD) light source.
The final version of the CAS OCT scanner was
mounted on a slit lamp base and used a charge couple
device (CCD) camera to visualize the scan area in real
time. The scan geometry was telecentric (rectangular),
with adjustable scan widths of 4 to 15 mm and scan
depths of 3.25 or 6 mm. Eight image frames were
acquired and displayed per second in real time, each
with 500 axial scans. The axial resolution was 14 mm
full-width-half-maximum in cornea. The main advantage of the telecentric system was its wide field
capability, which was essential for corneal and anterior chamber studies. This system was used for all of
the studies described herein except for the initial angle
assessment study.
Laser-assisted in situ keratomileusis anatomy
The 1.3-mm wide-field CAS OCT system was
used to examine post-LASIK eyes (Fig. 2). The scan
dimensions are 12 mm wide and 3.25 mm deep
Fig. 2. OCT of an eye 1 day after LASIK surgery.
(in air). When compared with the corneal image

(see Fig. 1) obtained with a 0.8-mm wavelength retinal
scanner, there are several improvements. There is no
apparent motion artifact at the higher image acquisition rate of eight frames per second. The image detail
is much finer with 500 axial scans per frame compared with 100 axial scans per frame. The telecentric
design allows the capture of corneal details over a
much wider scan width.
Many useful anatomic features relevant to LASIK
surgery can be identified in the image (Fig. 2). The
anterior surface reflection is strong at the perpendicular incidence and produces a vertical flare that
defines the corneal apex. Finer features, such as the
epithelial Bowman and the flap lamellar boundaries,
are best visualized with a slight off-normal beam
incidence angle in the midperiphery. The flap internal
reflectivity is stronger than that of the posterior
stroma. The thickness of the cornea, flap, and posterior stromal bed can be measured accurately from
the tomograph.
Angle assessment
Gonioscopy is the gold standard for evaluating the
anterior chamber angle; however, it is highly subjective and requires specialized training. Cross-sectional
imaging of the anterior chamber angle with ultrasound biomicroscopy or OCT is easier to interpret.
Furthermore, objective quantification of the angle can
be obtained from a cross section. Ultrasound biomicroscopy [47] and Scheimpflug photography [48]
have been used for quantitative angle evaluation.
OCT can provide the same detailed angle anatomy
with the added advantage of being noncontact and
easy to perform.
A 1.3-mm high-speed CAS OCT system was used
to assess the angle width. Computer image processing
was performed to obtain correctly dimensioned
images, with adjustments for the scan geometry and
refraction of the OCT beam at the anterior eye surface. Images of an open angle and an occludable angle are shown in Figs. 3 and 4, respectively. Corneal,
scleral, and iris anatomy are visualized in detail.
Features in the limbus and angle are clearly shown,
including the scleral spur, ciliary body band, angle

recess, and iris root. For angle measurements, it is
particularly useful that the scleral spur is highly
reflective and easily identified on OCT.
A clinical study was performed to compare OCT
and ultrasound biomicroscopy angle parameters with
gonioscopic grading by glaucoma specialists. A total
of 31 eyes in 28 subjects were examined. Eight eyes
were judged to be occludable on gonioscopy. Subjects underwent OCT and ultrasound biomicroscopy
imaging of the nasal and temporal anterior chamber
angles. OCT and ultrasound biomicroscopy had excellent correlation with gonioscopy in terms of the
identification of occludable angles. The best OCT
parameters were slightly better than ultrasound biomicroscopy parameters, with 100% sensitivity and
95.7% specificity for detecting gonioscopically occludable angles.
Anterior chamber width and other biometric
parameters
Optical coherence tomography is well suited for
ocular biometry owing to its high image resolution.
When compared with ultrasound, the noncontact
nature of OCT eliminates discomfort and distortion
from probe contact or immersion. The authors highspeed wide-field OCT prototype was able to produce
detailed images of the entire anterior chamber without
any visible motion artifact (Fig. 5). This characteristic
Fig. 3. High-speed 1.3-mm wavelength OCT of an open angle.
Fig. 4. High-speed 1.3-mm wavelength OCT of an occludable angle.
makes the accurate measurement of anterior chamber width and other biometric parameters possible.
Anterior chamber width measurement is clinically important for sizing angle-supported anterior
chamber intraocular lenses. With the increasing use
of refractive phakic intraocular lenses, accurate sizing
becomes an important issue. An intraocular lens that
is too large can press on the iris root and produce pupil
ovalization; an intraocular lens that is too small can
lead to lens movement, decentration, corneal endothelial damage, and iritis [49]. The traditional method
for sizing uses the external corneal diameter, which
is assumed to correspond to the internal anterior
chamber width. Typically, the intraocular lens length
is chosen to be the corneal diameter plus a constant
such as 1 mm.
When the wide-field CAS OCT system was used,
it was possible to measure the internal width of the
anterior chamber directly (Fig. 5). Anterior chamber
width as measured by OCT was compared with
corneal diameter measured by a Holladay cornea
gauge in 20 normal subjects. The anterior chamber
width was 12.53 F 0.47 mm (mean F SD). The
difference of the anterior chamber width from the
corneal diameter was 0.75 F 0.44 mm with a range
of 1.84 mm. The improvement of the SD from 0.47

to 0.44 mm was minimal and showed that intraocular
lens sizing using the corneal diameter would be only
marginally better than using the same size for all eyes.
OCT can improve the accuracy of intraocular lens
sizing several fold. The reproducibility of anterior
chamber width measurements from OCT images was
assessed by an analysis of variance. The variation of
anterior chamber width between images was small
(SD = 0.10 mm), but disagreement between the three
human graders was larger (SD = 0.29 mm). The
authors are developing an automated anterior chamber width measurement software that will remove
the need for a human grader to place cursors at the
angle recesses. Anterior chamber depth and the crystalline lens vault were also measured from the OCT
images with high reproducibility.
Optical coherence tomography appears to be a
reproducible, convenient, and noncontact technique
to perform biometry of anterior chamber dimensions. Further studies are needed to determine whether
it can contribute to a reduction of complications
through better fitting of intraocular lenses for the
anterior chamber.
Future developments
Optical coherence topography is a versatile tool
for visualization and measurement of corneal and anterior segment anatomy. It has the potential for improving the functions currently served by Placido-ring
corneal topography, slit-scanning corneal topography,
ultrasound imaging, and ultrasound pachymetry.
Keratorefractive surgery, anterior chamber biometry, and angle assessment are some of the applications that should benefit from CAS OCT. The
commercialization and general availability of this
technology should increase applications through the
ingenuity of many practitioners.
Fig. 5. Anterior chamber (AC) imaged with the wide-field (15-mm) setting on the slit lamp mounted high-speed CAS OCT
system. The AC width is measured between angle recesses; its depth is measured from the corneal apex to lens apex.
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Anterior segment imaging: ultrasound biomicroscopy

Hiroshi Ishikawa, MD*, Joel S. Schuman, MD
UPMC Eye Center and Department of Ophthalmology, University of Pittsburgh School of Medicine, The Eye and Ear Institute,
Suite 816, 203 Lothrop Street, Pittsburgh, PA 15213, USA
High-frequency ultrasound biomicroscopy (UBM)

(Paradigm Medical Industries, Salt Lake City, Utah)
provides high-resolution in vivo imaging of the anterior segment in a noninvasive fashion. In addition
to the tissues easily seen using conventional methods
(ie, slit lamp), such as the cornea, iris, and sclera,
structures including the ciliary body and zonules,
previously hidden from clinical observation, can be
imaged and their morphology assessed. Pathophysiologic changes involving anterior segment architecture can be evaluated qualitatively and quantitatively.
This article discusses the role of UBM in imaging
of the anterior segment of the eye from the qualitative
and quantitative analysis point of view.
Equipment and technique

The technology for UBM, originally developed
by Pavlin, Sherar, and Foster, is based on 50- to
100-MHz transducers incorporated into a B-mode
clinical scanner [1 3]. Higher frequency transducers
provide finer resolution of more superficial structures,
whereas lower frequency transducers provide greater
depth of penetration with less resolution. The commercially available units operate at 50 MHz and
provide lateral and axial physical resolutions of approximately 50 mm and 25 mm, respectively. Tissue
penetration is approximately 4 to 5 mm. The scanner produces a 5 5 mm field with 256 vertical
image lines (or A-scans) at a scan rate of 8 frames

per second.
Each A-scan is mapped into oversampled 1024
points, with 256 gray-scale levels representing the
logged amplitude of reflection, and then the number
of points is downsized to 432 pixels to fit on the UBM
monitor. The real-time image is displayed on a video
monitor and can be recorded on videotape for later
analysis. Room illumination, fixation, and accommodative effort affect anterior segment anatomy and
should be held constant, particularly when quantitative information is being gathered.
The image acquisition technique has been described elsewhere and is similar to traditional immersion B-scan ultrasonography [3 5]. In the Paradigm
Instruments UBM, the probe is suspended from a
gantry arm to minimize motion artifacts, and lateral
distortion is minimized by a linear scan format. In
the OTI (Ophthalmic Technologies, Toronto, Canada)
device, the probe is small and light enough not to
require a suspension arm, and a sector scanning
method is used. Scanning is performed with the
patient in the supine position. A plastic eyecup of
the appropriate size is inserted between the lids,
holding methylcellulose or normal saline coupling
medium. To maximize the detection of the reflected
signal, the transducer should be oriented so that
the scanning ultrasound beam strikes the target
surface perpendicularly.
Qualitative ultrasound biomicroscopy

This article was supported in part by NIH contracts
RO1-EY13178 and RO1-EY11289.
E-mail address: ishikawah@upmc.edu (H. Ishikawa).
The normal eye

In the normal eye, the cornea, anterior chamber,
posterior chamber, iris, ciliary body, and anterior lens
doi:10.1016/j.ohc.2003.12.001
H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720
logic stimuli (ie, accommodative targets and light);

therefore, maintaining a constant testing environment is critical for cross-sectional and longitudinal comparison.
Glaucoma
Fig. 1. Ultrasound biomicroscopic appearance of a normal

eye. The cornea (C), sclera (S), anterior chamber (AC), posterior chamber (PC), iris (I), ciliary body (CB), lens capsule
(LC), and lens (L) can be identified. The scleral spur (black
arrow) is an important landmark to assess the morphologic
relationships among the anterior segment structures.
surface can be recognized easily (Fig. 1). The scleral

spur is the only constant landmark allowing one to
interpret UBM images in terms of the morphologic
status of the anterior chamber angle and is the key for
analyzing angle pathology. The scleral spur is located
where the trabecular meshwork meets the interface
line between the sclera and ciliary body.
Generally, in the normal eye, the iris has a roughly
planar configuration with slight anterior bowing, and
the anterior chamber angle is wide and clear. Morphologic relationships among the anterior segment
structures alter in response to a variety of physio-
Angle-closure glaucoma
Iris apposition to the trabecular meshwork is the
final common pathway of angle-closure glaucoma,
which represents a group of disorders. This condition
can be caused by one or more abnormalities in the
relative or absolute sizes or positions of anterior segment structures, or by abnormal forces in the posterior
segment that alter the anatomy of the anterior segment. Forces are generated to cause angle closure
in four anatomic sites: the iris (pupillary block), the
ciliary body (plateau iris), the lens (phacomorphic
glaucoma), and behind the iris by a combination of
various forces (malignant glaucoma and other posterior pushing glaucoma types). Differentiating these
affected sites is the key to provide effective treatment.
UBM is extremely useful for achieving this goal.
Angle occludability. Examining eyes with narrow
angles requires careful attention to the occludability
of the angle. Although provocative testing, such as
dark room gonioscopy, is useful for detecting the
angle occludability, it is now rarely used, because it
is subjective, time consuming, and prone to falsenegative results owing to the difficulty of standardizing the slit-lamp light intensity. With UBM, dark room
provocative testing can be performed in a standardized environment generating objective results by providing information on the state of the angle under
normal light conditions and its tendency to occlude
spontaneously under dark conditions (Fig. 2).
Fig. 2. Occludable angle with dark room provocative test. (A) The anterior chamber angle is slit-like opened (arrows) under
a lighted condition. (B) The angle is completely occluded (arrows) under a dark condition.
Pupillary block. Pupillary block is the most common type of angle-closure glaucoma. At the iridolenticular contact, resistance to aqueous flow from the
posterior to the anterior chamber creates an unbalanced relative pressure gradient between the two
chambers, pushing the iris up toward the cornea
(Fig. 3A). This abnormal resistance causes anterior
iris bowing, angle narrowing, and acute or chronic
angle-closure glaucoma. The other anterior segment structures and their anatomic relationships remain normal.
Laser iridectomy equalizes the pressure gradient
between the anterior and posterior chambers and
flattens the iris. The result is a widened anterior
chamber angle (Fig. 3B).
Plateau iris. A plateau iris configuration occurs
owing to a large or anteriorly positioned ciliary
body (pars plicata), which pushes the iris root mechanically up against the trabecular meshwork
(Fig. 4). The iris root may be short and inserted
anteriorly on the ciliary face, creating a narrow and
crowded angle. The anterior chamber is usually of
medium depth, and the iris surface looks flat or
slightly convex, just like in a normal eye. With indentation gonioscopy, the double-hump sign is observed. The peripheral hump results from the rigid
presence of the ciliary body holding the iris root; the
central hump represents the center part of the iris
resting over the anterior lens surface. The space between the two humps represents the area between
the ciliary processes and the endpoint of iridolenticular contact. These findings can be confirmed by
performing indentation UBM (Fig. 5), a special technique that imposes mild pressure on the peripheral
cornea with the skirt of a plastic eyecup so that one
can simulate indentation gonioscopy [6].
Phacomorphic glaucoma. Anterior subluxation of
the lens may lead to angle-closure glaucoma because
Fig. 3. Pupillary block. (A) The angle shows appositional

closure owing to anterior bowing (arrows) of the iris. (B)
The angle is open with a flattened iris after laser peripheral
iridotomy. The patent hole on the iris (arrow) equalizes the
pressure between the anterior and posterior chambers.
Fig. 4. Plateau iris. A large and anteriorly positioned ciliary

body holds the iris root up against the cornea, leading to a
partially occluded angle. The arrow represents the location
of the scleral spur.
of the lens pushing the iris and ciliary body toward the
trabecular meshwork.
Malignant glaucoma. Malignant glaucoma, also
known as ciliary block or aqueous misdirection,
presents the greatest diagnostic and treatment challenge. Forces posterior to the lens push the lens iris
diaphragm forward, causing angle closure. UBM
clearly shows that all anterior segment structures are
displaced and pressed tightly against the cornea with
or without fluid in the supraciliary space (Fig. 6).
Other causes of angle closure. Iridociliary body
cysts can produce angle-closure glaucoma. The anterior chamber angle is occluded partially or intermittently owing to singular or multiple cysts (Fig. 7).
UBM is extremely useful in making the diagnosis
in these cases. Other entities, such as iridociliary tumor, enlargement of the ciliary body owing to inflammation or tumor infiltration, or air or gas bubbles after
intraocular surgery, may also present angle closure.
Open-angle glaucoma
The only type of open-angle glaucoma that shows
characteristic findings on UBM is the pigment dispersion syndrome. In this familial autosomal dominant
disease, mechanical friction between the posterior
iris surface and anterior zonular bundles releases iris
pigment particles into aqueous flow. These particles
are deposited on structures throughout the anterior
10
Fig. 6. Malignant glaucoma (composite image). The lens,

iris, and ciliary process are all pushed forward, resulting in
an extremely shallow anterior chamber and totally occluded
angle. The ciliary process (asterisk) is completely anteriorly
rotated (white arrow), probably pulled by zonules. The
scleral spur is located at the black arrow.
Fig. 5. Indentation UBM on an eye with a plateau iris. The
angle is slit-like opened (the arrow represents the scleral
spur location). The double-hump sign, one hump owing
to the ciliary process (black arrow head) and the other
owing to the lens (white arrow head), is demonstrated.
(Adapted from Ishikawa H, Inazumi K, Liebmann JM, Ritch
R. Inadvertant corneal indentation can cause artifactitious
widening of the iridocorneal angle on ultrasound biomicroscopy. Ophthalmic Surg Lasers 2000;31(4):342 5;
with permission.)
from dehiscence ciliary body detachment, which requires a different management approach [9].
Ocular trauma
Ocular trauma often limits the visibility of the
ocular structure owing to the presence of hyphema.
Accurate assessment of the structural damage and
locating small foreign bodies can be a challenging
task when clear direct visualization is not achieved.
UBM can be performed over a plano soft contact lens
to minimize the risk of further injury with eyecups
segment. The diagnostic triad consists of a Krukenberg spindle, radial transillumination defects of the
midperipheral iris, and pigment deposition on the
trabecular meshwork.
Typical UBM findings associated with this condition include a widely opened angle, an iris with
slight concavity (bowing posteriorly), and increased
iridolenticular contact (Fig. 8). As is true in pupillary
block, there is a relative pressure gradient between
the anterior and posterior chamber; however, because
the anterior chamber is the one that holds higher
pressure, this condition is called reverse pupillary
block [7]. Laser iridotomy eliminates this pressure
gradient, resulting in a flattened iris [8].
Abnormalities of the iris and ciliary body
Ultrasound biomicroscopy is helpful in differentiating solid from cystic lesions of the iris and ciliary
body (see Fig. 7 and Fig. 9). The size of these lesions can be measured, and the extent to which they
invade the iris root and ciliary face can be evaluated.
In hypotony cases, UBM can distinguish tractional
Fig. 7. Angle closure owing to an iridociliary cyst. An

iridociliary cyst (asterisk) pushes the iris root toward the
cornea, resulting in total occlusion of the angle (arrows).
11
appearance with no disruption of the interface in

between the sclera and ciliary body (Fig. 10). In
contrast, in cyclodialysis, the ciliary body is detached
from its normal location at the scleral spur, creating
a direct pathway from the anterior chamber to the
supraciliary space (Fig. 11).
Foreign bodies generate various artifacts based
on their acoustic characteristics [12]. In general, materials that contain air (ie, wood and concrete) create
shadowing artifact by absorbing most of the incoming
ultrasound at their sites, whereas hard and dense
materials (ie, metal and glass) generate comet tail
artifacts by reflecting ultrasound back and forth within
the materials (Fig. 12). Scleral sutures after intraocular surgery can be identified by searching for this
shadowing artifact (by refraction) (Fig. 13).
Intraocular lens position
Fig. 8. Pigment dispersion syndrome. The angle is wide
with a concave iris (arrow). Note the extremely wide
iridolenticular contact. (Adapted from Breingan PJ, Esaki K,
Ishikawa H, et al. Iridolenticular contact decreases following laser iridotomy for pigment dispersion syndrome. Arch
Ophthalmol 1999;117(3):325 8; with permission.)
or with infection in a micro open wound. With the

help of UBM, angle recession can be differentiated
plainly from cyclodialysis [10,11].
In eyes with angle recession, the ciliary body face
is torn at the iris insertion, resulting in a wide-angle
Fig. 9. Iridociliary tumor. Abnormally large ciliary process

(asterisk) involving the iris root and pars plana is visualized.
An intraocular lens is an easy target for UBM

visualization, because it is a type of foreign body.
Optic and haptic locations can be assessed accurately
by looking for a strong echo at their interface plane.
Because the capsular bag cannot always be visualized,
the most peripheral portion of the haptic defines its
position in the capsular bag, ciliary sulcus, or a
dislocated point (Fig. 14). This technique is used in
Fig. 10. Angle recession. Blunt trauma caused a tear into

the ciliary body face (white arrow), but the iris remained
attached to the scleral spur (black arrow). There is no direct
communication between the anterior chamber and the supraciliary space.
12
Fig. 11. Cyclodialysis. The ciliary body is avulsed from the

sclera, resulting in free aqueous flow from the anterior chamber through the cleft into the supraciliary space (asterisk).
various studies related to many different types of

intraocular lenses [13 17].
Quantitative ultrasound biomicroscopy

Physical resolution and measurement precision
Fig. 13. Scleral suture can be identified by looking for its

shadowing artifact (arrow). This artifact is created owing to
refraction of the ultrasound beam at a boundary between
suture thread and the surrounding tissues.
be determined to be distinct. It also specifies the

smallest object detectable. Measurement precision
refers to the width and height of a single pixel on
the screen that can be identified by the operator using
the screen cursor. The UBM measurement software
calculates distance and area by counting the number
of pixels along the measured line or inside the
designated area and multiplies the pixel counts by
Physical resolution is often confused with measurement precision. Physical resolution specifies how
close together two objects can be located yet still
Fig. 12. Intraocular foreign body. (A) Foreign body (arrow head) with a material that consists of multiple cavities
inside (ie, wood and concrete) generates shadowing artifact
(arrow) by absorbing ultrasound power. The iris image is
masked by shadowing. (B) Hard and dense foreign body
(arrow head) (ie, glass and metal) creates comet tail artifact
(arrow) owing to multiple internal reflections. The iris image is disrupted by the comet tail artifact. (Adapted from
Laroche D, Ishikawa H, Greenfield D, et al. Ultrasound biomicroscopic localization and evaluation of intraocular foreign bodies. Acta Ophthalmol Scand 1998;76(4):491 5;
with permission.)
Fig. 14. Posterior chamber intraocular lens haptic. The most

peripheral portion of the haptic is positioned within the capsular bag and is located central to the ciliary process (arrow).
the theoretical size of the pixel. Measurement precision can be better than physical resolution by oversampling the signal.
Commercially available instruments provide lateral and axial physical resolution of approximately
50 and 25 mm, respectively. The resolution of the
Paradigm device is slightly better than that of the
OTI device. The theoretical lateral and axial measurement precision on the standard UBM monitor
(864 432 pixels) is approximately 6 and 12 mm.
Although UBM cannot distinguish two small objects
less than 25 mm apart along the axial scanning line,
it can still measure the distance between two objects
far enough apart ( > 25 mm, such as corneal thickness,
anterior chamber depth) with 12-mm precision.
13
to perform measurements that require multiple steps

(ie, measuring a distance along a line drawn perpendicular to a line between the scleral spur and the
corneal endothelial border that is 500 mm anterior to
the scleral spur).
To minimize the variability of the measurement
process, a fully automated measurement system
would be ideal; however, with current technology,
it would be difficult to develop such a software program. A semi-automated software system that calculates various quantitative parameters after one user
input of the reference point location is a reasonable
Table 1
Parameters proposed by Pavlin et al [1]
Measurement accuracy
Name
Abbreviation
Description
Pavlin et al [2] reported good qualitative agreement of UBM images with histologic sections. Quantitatively, Maberly et al [18] showed good agreement
by measuring the distance from the anterior margin
of peripheral choroidal melanomas to the scleral spur
on UBM images and histologic sections.
Pierro et al [19] compared the corneal thickness
measured by UBM versus ultrasound and optical
pachymetry. The UBM measurement was similar to
the ultrasound pachymetry, whereas optical pachymetry showed a poor correlation with UBM and ultrasound pachymetry. Urbak [20] reported similar
results. Additionally, a specially prepared plastic material was measured with UBM and scanning electron microscopy. The axial and lateral accuracies of
UBM measurements were good and reliable.
Angle opening
distance
AOD
Trabecular iris angle
TIA q 1
Trabecular ciliary
process distance
TCPD
Iris thickness
ID1
Iris thickness
ID2
Measurement reproducibility
Iris thickness
ID3
Iris ciliary process

distance
ICPD
Iris zonule distance
IZD
Iris lens contact

distance
ILCD
Iris lens angle
ILA q 2
Distance between
the trabecular
meshwork and the
iris at 500 mm
anterior to the
scleral spur
Angle of the
angle recess
Distance between
the trabecular
meshwork and the
ciliary process at
500 mm anterior
to the scleral spur
Iris thickness at
500 mm anterior
to the scleral spur
Iris thickness at
2 mm from the
iris root
Maximum iris
thickness near the
pupillary edge
Distance between
the iris and the
ciliary process
along the line
of TCPD
Distance between
the iris and the
zonule along the
line of TCPD
Contact distance
between the iris
and the lens
Angle between
the iris and the
lens near the
pupillary edge
Tello et al [21] reported on the reproducibility of

measuring Pavlins parameters (described in detail
in the next section). Intraobserver reproducibility
was reasonably good, except for the angle opening
distance (AOD), but interobserver reproducibility
was not. Urbak et al [22,23] reported similar results.
Although image acquisition differences were the
major cause of this variability, the variability of the
measurement process cannot be ignored.
All of Pavlins parameters require multiple steps
of measurements of a distance or an angle. The parameters are measured on the UBM monitor, allowing determination of a point-to-point distance or an
angle composed of two straight lines; however, this
method does not keep the previous measurement on
the same screen. It is difficult and not reproducible
14
compromise. The UBM Pro 2000 (Paradigm Medical Industries, Salt Lake City, Utah) can measure
the AOD in a semi-automated fashion. It has dramatically improved overall reproducibility (coefficient of
variation, 7.3 to 2.5; Hiroshi Ishikawa, MD, unpublished data, 1998).
In addition, each observer will set the reference

point on any measurement in an idiosyncratic way.
For example, when measuring corneal thickness, one
observer may tend to select a reference point slightly
more external on the epithelial surface than another
observer. This situation would result in the first
Fig. 15. Pavlins measurement parameters (see Table 1). (A) The angle opening distance (AOD) is defined as the length of the
line drawn from the point on the corneal endothelial surface 500 mm anterior to the scleral spur to the iris surface perpendicular to
the corneal endothelial surface. The trabecular iris angle (TIA, q1) is defined as an angle formed with the apex at the iris recess
and the arms passing through the point on the meshwork 500 mm from the scleral spur and the point on the iris perpendicularly
opposite. (B) The trabecular ciliary distance (TCPD) is defined as the distance between a point 500 mm from the scleral spur
and the ciliary process on the line that is perpendicular through the iris. The iris thickness (ID1) is defined along this line, as is
the iris ciliary process distance (ICPD). Iris thickness also can be measured 2 mm from the iris root (ID2) and at its thickest
point near the margin (ID3). The iris zonule distance (IZD) is defined as a part of theTCPD at a point just clearing the ciliary
process. The length of iris lens contact (ILCD) and the angle at which the iris leaves the lens surface (iris lens angle; ILA, q2) are
easily measured.
15
observer measuring greater corneal thickness, assuming that each observer would choose the same point as
an endothelial border. In general, repeated measurement by the same observer is reasonably reproducible.
Quantitative measurement methods
Methods proposed by Pavlin and colleagues
Pavlin et al [1] established various quantitative
measurement parameters as standards (Table 1,
Fig. 15). The position of the scleral spur is used as a
reference point for most of their parameters, because
this is the only landmark that can be distinguished
consistently in the anterior chamber angle region.
Iris concavity/convexity
Potash et al [24] introduced a parameter to evaluate
the dynamic configurational change of the iris. A line
is created from the most peripheral point to the most
central point of iris pigment epithelium. A perpendicular line is then extended from this line to the iris
pigment epithelium at the point of greatest concavity
or convexity (Fig. 16).
An improved method for assessing the anterior
chamber angle
There is one problem with AOD measurement,
Pavlins classical method of assessing the angle opening, which treats the iris surface as a straight line.
Fig. 17 shows two schematics of the angle, demonstrating exactly the same value for the AOD and the
trabecular iris angle (TIA). Nevertheless, it is obvious that the angle on the right is gonioscopically
narrower and more likely to be occludable than the
angle on the left; therefore, irregularities of iris contour and curvature need to be taken into account.
Ishikawa et al [25] defined the angle recess area
(ARA) as the triangular area bordered by the anterior
iris surface, corneal endothelium, and a line perpendicular to the corneal endothelium drawn to the iris
surface from a point 750 mm anterior to the scleral
spur (Fig. 18). In this way, the iris irregularity is properly accounted for in the measurement.
The semi-automated software in the UBM Pro
2000 also calculates the ARA. After the observer
selects the scleral spur, the program automatically
processes the image, detects a border, and calculates
the ARA. The program plots consecutive AODs from
the base of the angle recess to 750 mm anterior
to the scleral spur and performs linear regression
analysis of consecutive AODs, producing two figuresthe acceleration (or slope) and the y-intercept.
The acceleration describes how rapidly the angle
is getting wider, using the tangent of the angle instead
Fig. 16. Iris concavity/convexity. Iris configuration is

determined first by creating a line from the most peripheral
to the most central points of iris pigment epithelium. A
perpendicular line is then extended from this line to the iris
pigment epithelium at the point of greatest concavity or
convexity. (A) Iris convexity measurement (arrow). (B) Iris
concavity measurement (arrow).
of degrees as the unit. In other words, the acceleration estimates the general shape of the angle, shallow
or wide. The y-intercept refers to the distance between the scleral spur and the iris surface along the
perpendicular to the trabecular meshwork plane. This
generalized value describes the angle opening at the
level of the scleral spur. Although these parameters
may seem similar to the AOD and TIA, there is a
fundamental difference between them. Because the
acceleration and the y-intercept are purely mathematical calculations based on linear regression analysis of the consecutive AODs, they can be negative
numbers, which is impossible for the physically measured AOD and TIA. A negative number for the acceleration means that the angle has an almost normal
configuration at its peripheral part and becomes very
shallow, or is attached to the cornea, at its central part
(ie, appositional angle closure starting at Schwalbes
line with space remaining in the angle recess)
(Fig. 19). A negative y-intercept means that the angle
recess is very shallow or is attached to the cornea at
its periphery, whereas it is relatively wide centrally
16
Fig. 17. Limitation of the conventional angle opening distance (AOD) measurement. (A) and (B) have exactly the same value
for the AOD and trabecular iris angle (TIA, q1). Nevertheless, the angle in (B) is gonioscopically narrower and is more likely
to be occludable than the normal-appearing angle in (A).
(ie, plateau iris and synechial closure) (Fig. 20). By

using three numerical values, the ARA, the acceleration, and the y-intercept, one can describe many types
of angle configuration quantitatively.
Clinical application of quantitative ultrasound
biomicroscopy analysis
Glaucoma
Anterior chamber angle parameters have been
used in various studies, such as the development of
the angle in normal infants and children in relation to
age [26], the difference between angle-closure and
normal eyes [27], and the iris convexity related to age
[28]. Ishikawa et al [25] measured the ARA, acceleration, and y-intercept under standardized dark and
light conditions and reported that the more posterior
the iris insertion on the ciliary face, the less likely the
provocative test would be positive. Esaki et al [29]
found that the anterior chamber angle opening in
normal Japanese eyes narrowed with age in a crosssectional study.
Ultrasound biomicroscopy also provides a powerful tool to evaluate the effect of drug instillation on
the anterior chamber angle, iris, and ciliary body.
Kobayashi et al [30] found that the angle opening
increased after the instillation of pilocarpine in eyes
with narrow angles but decreased in eyes with a wider
17
Fig. 18. Angle recess area (ARA). The ARA is defined as a triangular area bordered by the anterior iris surface, corneal
endothelium, and a line perpendicular to the corneal endothelium drawn from a point 750 mm anterior to the scleral spur to the
iris surface.
or normal angle. Marchini et al [31] reported that the

potent mydriatic effect of 2% ibopamine was greater
than that of 10% phenylephrine or 1% tropicamide.
Several studies have evaluated morphologic
change after surgical procedures. Marraffa et al [32]
found that loss of endothelial cells after laser irido-
tomy was inversely proportional to the distance of the

iridotomy from the endothelium and scleral spur.
Gazzard et al [33] reported that laser peripheral
iridotomy produced changes in iris morphology that
were different from those caused by an increase in
illumination. Chiou et al [34] measured the time
Fig. 19. Negative acceleration in ARA analysis. The linear regression analysis of ARA shows negative acceleration, meaning
that the angle almost has a normal configuration at its peripheral part and becomes very shallow or is apposed to the cornea at its
central part (ie, the appositional angle closure began at the level of Schwalbes line).
18
Fig. 20. Negative y-intercept in ARA analysis. The linear regression analysis shows a negative y-intercept, indicating that the
angle recess is very shallow or is attached to the cornea at its periphery, whereas it has a relatively wide angle recess centrally
(ie, plateau iris and synechial closure).
course of the size of collagen implants after deep

sclerectomy. They quantitatively confirmed that the
collagen implant dissolved slowly within 6 to
9 months, leaving a tunnel in the sclera.
Tumor
Ultrasound biomicroscopy is effective for the diagnosis and management of anterior segment tumors.
Reminick et al [35] measured the size and extent of
anterior segment tumors. Marigo et al [36] described
six eyes with anterior segment implantation cysts in a
comparison of UBM images with size measurement
with histopathologic findings.
Other situations
Other ocular diseases involving the anterior segment can be assessed using UBM. Avitabile et al [37]
investigated the correlation between the thickness
at the corneal apex and disease severity in eyes with
keratoconus. Gentile et al [38] measured the ciliary
body area in uveitic eyes. Maruyama et al [39]
measured the height of ciliary detachment in eyes
with Harada disease. Trindade et al [16] studied the
relative position of the posterior chamber phakic
intraocular lens. Intraocular lens iris touch, intraocular lens crystalline lens touch, and anterior chamber shallowing were observed after implantation.
Summary
Ultrasound biomicroscopy technology has become
an indispensable tool in qualitative and quantitative
assessment of the anterior segment. Advances in software design and algorithms will improve theoretical understanding of the pathophysiology of anterior
segment disorders. Future applications of quantitative techniques will yield important information regarding mechanisms of angle closure, improving
understanding of the dynamic functions of the iris,
accommodation, presbyopia, and other aspects of
anterior segment physiology and pathophysiology.
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Clinical applications of optical coherence tomography for

the diagnosis and management of macular diseases
Irene Voo, MD, Elias C. Mavrofrides, MD, Carmen A. Puliafito, MD, MBA*
Bascom Palmer Eye Institute and Department of Ophthalmology, University of Miami School of Medicine,
900 N.W. 17th Street, Miami, FL 33136, USA
Cross-sectional imaging of the posterior segment

with sufficient resolution to visualize retinal topography and internal tissue structure in vivo has been
possible since the early 1990s owing to the development of optical coherence tomography (OCT) [1].
This noncontact noninvasive technique uses a lowcoherence continuous-wave light source and interferometry for image formation. Differences in time delay
of the reflected light from ocular tissues are detected
by a photodiode followed by signal-processing electronics and computer data acquisition. The tomographs are digitally processed after acquisition to
compensate for micron-scale axial motion artifacts
owing to subject movement or pulsatile blood flow [2].
Optical coherence tomography provides micronscale axial resolution that is not limited by pupil
aperture or ocular aberrations. The temporal coherence properties of the light source determine the
resolution; however, lateral eye movement, which is
not compensated for by the scan registration algorithm, can degrade the image. Standard third-generation OCT systems using a superluminescent diode
light source have an axial resolution of 10 to 15 mm.
Prototype ultrahigh-resolution fourth-generation OCT
uses a femtosecond laser light source and has achieved
an axial resolution of 3 mm [3]. Reflection of light
from different tissue depths and measurement of the
E-mail address: cpuliafito@med.miami.edu
(C.A. Puliafito).
time-of-flight delay and intensity of back-reflected

light allow characterization of anatomic structure.
The inner border of the retina and vitreous is well
defined because of the contrast of the nonreflective
vitreous and highly reflective retina. A red band of
high reflectivity from the nerve fiber layer is generally
seen. The normal fovea is identified by its characteristic depression of the inner retinal border secondary
to the lateral displacement of tissue anterior to Henles
nerve fiber layer. The posterior hyaloid is occasionally
visible as a blue membrane (low reflectivity). The
posterior border of the retina is marked by a highly
reflective red layer and corresponds to the retinal
pigment epithelium (RPE) and choriocapillaris. A
dark layer of minimal reflectivity appears just anterior
to this red layer and corresponds in location and
thickness to the photoreceptors. Another dark layer
of weak reflectivity from the deep choroid and sclera
appears below the red layer of RPE and choriocapillaris. The intermediate layers of retina anterior to the
photoreceptors exhibit moderate reflectivity [4].
Readily available, reproducible, high-resolution
cross-sectional imaging of the retina allows diagnosis,
monitoring, and quantitative assessment of macular
pathology. OCT has become part of the routine
imaging performed at the authors center in patients
who have suspected or known macular diseases.
Viewing the anatomic structure of the vitreoretinal
interface, the macular layers, and the RPE and quantifying these areas in microns has led to improved
clinical decision making and has altered the management of many cases when the biomicroscopic
examination and fluorescein angiogram have been
insufficient for detailed discrimination.
doi:10.1016/j.ohc.2003.12.002
22
I. Voo et al / Ophthalmol Clin N Am 17 (2004) 2131
Selected case reports

Vitreoretinal interface disorders
The interface between the retina and vitreous is
well defined because of the difference in reflectivity of
the relatively acellular vitreous and the parallel-fiber
orientation of the inner retina. Disorders such as vitreomacular traction syndrome, epiretinal membranes,
and macular holes are readily imaged and recognized,
even by persons inexperienced in biomicroscopy.
Macular hole
Diagnosis and staging of macular holes by biomicroscopy can be difficult for even the most experienced examiners owing to simulating conditions, such
as a lamellar hole, vitreomacular traction syndrome,
and cystoid macular edema (CME) with central cyst.
Fluorescein angiography has limited utility for the
diagnosis and monitoring of macular holes. OCT
allows identification of the stage and any persistent
vitreomacular traction not evident on clinical examination, especially in the fellow eye. It is also useful for
monitoring the course of disease, whether spontaneous resolution or progression to a full-thickness macular hole, and the response to surgical intervention.
The likelihood of surgical success from pars plana
vitrectomy and membrane peeling can be predicted by
obtaining quantitative information about the apical
hole diameter, base diameter, and retinal edge thickness by OCT. The preoperative hole diameter has
prognostic significance for postoperative success [5].
Case 1. A 69-year-old ophthalmologist presented
with a 2-month history of a perfect circle covering
and just to the left of the fovea, of which the edge
was becoming more distinct by the week. Past ocular
history was significant for laser retinopexy on the
right eye for a tear in 1999. Best-corrected visual
acuity was 20/20 OU. Confrontation fields were full to
finger-counting OU, and Amsler grid testing revealed
a small central area of metamorphopsia OS. Motility
testing was within normal limits, and there was no
afferent pupillary defect. Anterior segment examina-
Fig. 1. Stage I macular hole OS.
Fig. 2. Resolving stage I macular hole OS.
tion was significant for a 1+ posterior subcapsular

cataract OD and 1+ cortical changes OS not involving
the visual axis. Intraocular pressures were 21 and 19,
respectively. On dilated fundus examination, physiologic optic nerves, a blunted foveal reflex OS, and
laser retinopexy scars OD were noted. OCT imaging
was performed and clarified the diagnosis as an
impending macular hole, stage I OS (Fig. 1). Observation was recommended, and the visual symptoms
were resolved at follow-up examination 6 weeks later.
Repeat OCT showed the resolving macular hole as a
flatter contour of RPE detachment (Fig. 2).
Epiretinal membrane
Given the 6% incidence of epiretinal membranes
in patients aged more than 60 years and the increasing
incidence with age, this coexisting macular pathology
may limit visual outcomes in a significant proportion
of cataract patients. The membrane may have associated macular edema, significant anatomic distortion,
or even a pseudohole appearance. Diagnosis of an
epiretinal membrane through a visually significant
cataract can be difficult, but knowledge of its existence has a tremendous impact on counseling for postoperative expectations. Furthermore, consideration
can be given to combined cataract and vitreoretinal
surgery. In addition, characterization of the epiretinal
membrane with OCT may help in preoperative planning for membrane peeling. A membrane that is
globally attached and associated with extensive retinal
edema must be approached with extreme caution.
Besides its importance in counseling regarding postoperative expectations of visual recovery, OCT can
document the surgical response and the completeness
of epiretinal membrane removal, and can quantify a
decrease in macular thickness.
Case 2. A 67-year-old Hispanic woman presented
with a chief complaint of blurry vision, OS greater
than OD, for 5 months with difficulty reading and
seeing road signs. She had been started on Ocuvite
and dexamethasone/tobramycin (TobraDex) ophthalmic drops three times a day and ointment at bedtime
OU by an ophthalmologist a few days previously.
Best-corrected visual acuity was 20/25 OD and
23
Fig. 3. Epiretinal membrane with associated macular edema.
Fig. 5. Epiretinal membrane with associated CME.
20/60 OS at distance, reading Jaeger -1 OD and -7 OS

at near. Confrontation fields were full to finger-counting, and Amsler grid testing revealed a large area
of central metamorphopsia OS. Ocular motility was
within normal limits, and there was no afferent pupillary defect. Anterior segment examination was significant for a 1+ nuclear sclerotic cataract OU and an
early posterior subcapsular cataract OD. Intraocular
pressures were 18 OU. On dilated fundus examination, a cup to disc ratio of 0.4 OU, an epiretinal
membrane OS, and peripheral cobblestone degeneration OU were noted. There were no drusen, areas of
RPE atrophy, subretinal fluid, or hemorrhage consistent with age-related macular degeneration. OCT imaging of the epiretinal membrane showed associated
macular edema with a central thickness of 468 mm
(Fig. 3). The patient preferred to defer surgery until
the vision worsened and returned for follow-up examination 2 months later. Despite stable Snellen
visual acuity OS, she felt that the vision was much
worse, and repeat OCT showed that the central thickness had increased to 536 mm (Fig. 4). Given the
patients worsening visual function and documented
worsening of edema by OCT, she was scheduled for
vitrectomy with membrane peeling.
2+ afferent pupillary defect was present OD. Anterior

segment examination was significant for an early
nuclear sclerotic cataract OU. Intraocular pressures
were 16 OU. On dilated fundus examination, an epiretinal membrane was noted OS. No drusen, RPE atrophy, subretinal fluid, or hemorrhage consistent with
age-related macular degeneration was seen. OCT imaging revealed a central thickness of 410 mm OD, with
an epiretinal membrane and associated CME (Fig. 5).
It was concluded that the decreasing vision OD was
secondary to the macular edema from the development of an epiretinal membrane. The patient elected
observation and returned for follow-up examination
6 months later. Best-corrected visual acuity decreased
to 20/200 OD, and repeat OCT imaging revealed a
central thickness of 466 mm with some worsening of
the CME (Fig. 6). An injection of 0.1 mL of intravitreal triamcinolone, 40 mg/mL, was given, and the
patient returned 6 weeks later. Best-corrected visual
acuity was still 20/200 OD, and OCT imaging
revealed no improvement, with a central thickness
of 465 mm and persistent CME (Fig. 7). Because
medical therapy gave no objective improvement,
surgical intervention was recommended. Quantification of the retinal thickening was helpful in assessing
the lack of treatment response to medical therapy and
directing future therapeutic choices.
Case 3. A 61-year-old Caucasian man with worsening vision OD for 6 months presented for a second
opinion on the diagnosis of age-related macular degeneration. He had a past ocular history of inferotemporal branch retinal artery occlusion OD 5 years
before presentation. Best-corrected visual acuity was
20/100 OD and 20/20 OS. Confrontation fields were
intact OS, with loss of the superior hemifield OD.
Amsler grid testing showed sparing of central fixation
OD. Ocular motility was within normal limits, and a
Fig. 4. Epiretinal membrane with increased macular edema

on follow-up examination.
Alterations of the structural anatomy of the macula

Vitreomacular traction syndrome
Vitreous biomicroscopy is challenging, even for
the most experienced clinician. OCT allows an accurate diagnosis with the ease of vitreomacular traction,
even by the relatively untrained clinician, and allows
monitoring of progression. Spontaneous resolution
Fig. 6. Epiretinal membrane with increased macular edema

on follow-up examination.
24
Fig. 7. Appearance on OCT imaging after intravitreal

triamcinolone for macular edema associated with epiretinal membrane.
with normalization of retinal contour or persistent

traction with progressive edema is easily documented.
OCT has become invaluable in determining the
need for and timing of surgical intervention. The postoperative anatomic response can be correlated with
visual recovery.
Case 4. A 34-year-old black woman referred for
evaluation of panuveitis OD with questionable traction macular detachment had been treated with hourly
topical prednisolone acetate 1% (Pred Forte) for
2 months without resolution. Past ocular history was
negative for previous episodes of inflammation or
eye trauma. There were no associated systemic symptoms. Best-corrected visual acuity was 20/400 OD and
20/20 OS. There was no afferent pupillary defect.
Anterior segment examination was significant for
small nongranulomatous keratic precipitates, 2+ cell,
2+ flare, and pigment on the anterior lens surface OD.
The left eye did not have any signs of current or past
inflammatory episodes. Intraocular pressures were
18 and 20, respectively. On dilated fundus examination, 1+ vitreous cell and a flame hemorrhage near an
inflammatory lesion overlying the fovea with apparent
traction were present OD. Fundus examination OS
was within normal limits. OCT was performed to
better visualize the foveal lesion given the hazy view,
and to differentiate it from a macular hole. The findings included vitreomacular traction with associated
macular edema and significant elevation of the neurosensory retina OD (Fig. 8). OCT of the left eye
revealed a normal foveal contour, with no macular
edema or vitreomacular traction. Because the patient
Fig. 8. Vitreomacular traction syndrome with macular

edema OD.
Fig. 9. Persistent vitreomacular traction syndrome with

macular edema on follow-up examination.
was not responding to topical steroid therapy, oral

prednisone was begun, and the patient returned for reevaluation 3 weeks later. Best-corrected visual acuity
was still 20/400 OD and 20/20 OS. Anterior segment
examination was significant for no cell, trace flare
OD. Intraocular pressures were 23 and 21, respectively. On dilated fundus examination, a dark gray circle
overlying the fovea OD was present, suggesting a
macular hole. OCT revealed persistent vitreomacular
traction but of a more narrow configuration (Fig. 9).
The patient continued every 2-hour topical steroid
therapy and returned in 3 weeks. Best-corrected visual
acuity remained 20/400 OD. Anterior segment examination showed an increase to 1+ cell OD. Dilated
fundus examination revealed a full-thickness macular
hole. OCT showed that it was progressing toward a
full-thickness hole OD with central fibrous membrane
formation (Fig. 10). Because of the documented progression of vitreomacular traction on OCT, surgical
intervention was recommended. The patient underwent pars plana vitrectomy, membrane peeling, and
intraocular gas injection.
Pseudophakic cystoid macular edema
The localized intraretinal fluid accumulation of
Irvine-Gass syndrome appears on imaging as nonreflective cystoid spaces in the outer plexiform and
inner nuclear layers. Although cystoid changes are
visible by slit-lamp biomicroscopy and fluorescein
angiography, only OCT can quantitatively assess retinal thickness and demonstrate any associated RPE
structural anomalies beneath the edematous retina,
which can be obscured by leakage on angiography.
More importantly, measurements of retinal thickness
Fig. 10. Persistent vitreomacular traction syndrome with

macular edema on follow-up examination.
25
by OCT correlate more strongly with visual acuity than

the presence of leakage on angiography [6].
Case 5. A 71-year-old Caucasian woman presented with a chief complaint of a central gray
spot and wavy lines for the past 2 months OS.
Past ocular history was significant for uncomplicated
phacoemulsification and intraocular lens placement
OS 2.5 months previously and known idiopathic
central serous chorioretinopathy. The referring ophthalmologist had started the patient on prednisolone
acetate 1% (Pred Forte), six times a day, and diclofenac (Voltaren), four times a day. Best-corrected visual
acuity was 20/20 OD and 20/30 OS. Amsler grid
testing showed a moderate area of central metamorphopsia OS. Intraocular pressures were 13 and 14,
respectively. Anterior segment examination was significant for well-centered posterior chamber intraocular lenses (PCIOL) OU without posterior capsular
opacification. The corneas were clear. There was no
anterior chamber cell, flare, or vitreous. Dilated fundus examination revealed CME OS, peripapillary
mottling OD, and temporal macular RPE mottling
OS. Fluorescein angiography demonstrated CME in
the late frames OS (Fig. 11). OCT imaging was
performed to exclude an RPE detachment consistent
with the recurrence of idiopathic central serous
chorioretinopathy, and showed a central thickness of
505 mm, CME, and no RPE detachment (Fig. 12). The
patient was diagnosed with postcataract CME and
given an intravitreal triamcinolone injection. On fol-
Fig. 12. Cystoid macular edema after cataract extraction in

a patient with idiopathic central serous chorioretinopathy
without associated RPE detachment characteristic of idiopathic central serous chorioretinopathy.
low-up examination 2 weeks later, the best-corrected

visual acuity was 20/25 OS, with subjective improvement in near-reading ability. Repeat OCT imaging
showed a central thickness of 258 mm, a return of
normal foveal contour, and no evidence of idiopathic
central serous chorioretinopathy (Fig. 13).
Diabetic retinopathy
Diabetic macular edema is a principal cause of
visual loss in diabetic patients [7]. OCT may be more
sensitive than biomicroscopy in detecting macular
edema, and can be especially useful for confirmation
in cases that are difficult to examine at the slit lamp
secondary to media opacity or cooperation [8,9].
Central macular thickness has also been shown to
correlate better with visual acuity than the presence of
leakage on fluorescein angiography [10]. The presence of persistent edema unresponsive to initial
therapy (ie, laser photocoagulation) can establish
the need for more invasive intervention (ie, intravitreal triamcinolone or vitrectomy). The efficacy of
intravitreal triamcinolone for diffuse diabetic macular
edema versus traditional focal laser treatment has
been demonstrated by Martidis and associates [11].
The finding of a taut posterior hyaloid or vitreomacular traction can help in selecting the therapeutic
modality and monitoring the response [12,13].
Case 6. A 69-year-old Hispanic woman presented
with a chief complaint of worsening near-vision for
Fig. 11. Late phase of fluorescein angiogram demonstrating CME.
Fig. 13. Resolved CME after intravitreal triamcinolone injection.
26
Fig. 14. Diabetic macular edema with cysts involving the

fovea OS.
Fig. 16. Diffuse diabetic macular edema OS.
the past year to the point at which she could no longer

read books. Past ocular history was significant for a
cataract extraction/PCIOL implantation OS 1.5 years
previously. A diagnosis of type II diabetes was made
1 year previously. Presenting vision was 20/400 OU
without correction, and best-corrected visual acuity
was 20/50 OU. Confrontation fields were full to
finger-counting OU, and motility was within normal limits. There was no afferent pupillary defect.
Anterior segment examination was significant for a
1+ nuclear sclerotic cataract, 3+ posterior subcapsular cataract, and 2+ cortical changes OD, and a
well-centered PCIOL OS without posterior capsular
opacification. Dilated fundus examination showed
moderate background diabetic retinopathy OU, no
clinically significant macular edema OD, and diffuse
macular edema OS. OCT imaging revealed a central
retinal thickness of 558 mm OS with CME involving the fovea (Fig. 14). Focal macular laser therapy
was performed, and the patient was lost to follow-up
for 1 year, after which she returned with a bestcorrected visual acuity of 20/400 OU. OCT imaging
confirmed the presence of diffuse macular edema
with a central retinal thickness of 405 mm OD and
459 mm OS (Figs. 15, 16). Intravitreal triamcinolone injection was performed OU, and the patient
returned for re-evaluation 6 weeks later. Best-corrected visual acuity was still 20/400 OU, and repeat
OCT imaging showed the central retinal thickness to
be 215 mm OD and 266 mm OS, with improved but
persistent CME OU (Figs. 17, 18). The right eye now
had developed a visually significant cataract, making
examination for clinically significant macular edema
difficult. Because OCT imaging revealed that the
macular edema had improved OD, the patient was

thought to be stable from a retinal standpoint for
cataract extraction with PCIOL implantation.
Fig. 15. Diffuse diabetic macular edema OD.
Vein occlusion
Macular edema is a common complication of vein
occlusion. Although it can be detected by biomicroscopy or fluorescein angiography, blocking defects
by hemorrhage or media opacity may obscure detection of this vision-threatening complication. OCT has
the advantage of imaging macular edema and quantifying the increase in retinal thickness despite these
limiting factors. In addition to macular edema, subretinal fluid accumulation and neurosensory retinal
detachment can be detected. The presence of persistent edema unresponsive to initial therapy (ie, laser
photocoagulation) can establish the need for more
invasive intervention (ie, intravitreal triamcinolone).
OCT has a pivotal role in providing objective quantitative information to detect the presence of macular
edema that may be contributing to vision loss and to
monitor the effect of therapeutic interventions, such
as focal laser photocoagulation, intravitreal triamcinolone injection, adventitial sheathotomy, and pars
plana vitrectomy. It also can be helpful in differentiating patients whose vision is limited by photoreceptor damage/retinal atrophy and not macular edema.
Case 7. An 83-year-old Caucasian woman presented with worsening vision OD for 2 weeks. Ocular
history was significant for a central retinal vein occlusion OD diagnosed 2 months previously and presumed secondary to lymphoma. Best-corrected visual
Fig. 17. Improved but persistent CME OD after intravitreal

triamcinolone injection.
27
Fig. 18. Improved but persistent CME OS after intravitreal

triamcinolone injection.
Fig. 20. Resolved CME OD after intravitreal triamcinolone injection.
acuity was 20/200 OD and 20/20 OS. Confrontation

fields were full to finger-counting OU, and ocular
motility was within normal limits OU. No afferent
pupillary defect was present. Anterior segment examination showed a well-centered anterior chamber
intraocular lens OD, with a patent peripheral iridectomy, PCIOL OS. No iris or angle neovascularization
was seen. Dilated fundus examination did not show
neovascularization of the disk or elsewhere. Moderate
vascular tortuosity and four quadrants of intraretinal hemorrhage were present OD. OCT imaging
revealed a central thickness of 740 mm with CME
OD (Fig. 19). The patient elected to undergo intravitreal triamcinolone injection, and on follow-up examination 1 month later, best-corrected visual acuity
had improved to 20/60 OD. A 2+ afferent pupillary
defect was now present, and repeat OCT testing
revealed a central thickness of 246 mm with recovery
of the normal foveal contour (Fig. 20). Three months
later, the patient returned with worsening of the bestcorrected visual acuity, again to 20/200 OD. OCT
imaging revealed a recurrence of CME, with a central
thickness of 623 mm (Fig. 21). A second intravitreal
triamcinolone injection was given. On follow-up examination 3 months later, the best-corrected visual
acuity remained 20/200 OD. Despite resolution of the
macular edema a second time, the patients vision
was no better, and it was concluded that retinal atrophy (as demonstrated by a central thickness of
179 mm and increased reflectivity of the deeper
choroidal layers) was now the limiting factor in visual
recovery (Fig. 22).
Age-related macular degeneration

The structural information provided by OCT is
becoming a valuable diagnostic adjunct to fluorescein
angiography and indocyanine green angiography for
age-related macular degeneration. Identification and
characterization of choroidal neovascular membranes
as above or below the RPE, even when poorly
visualized on fluorescein angiography, is possible.
OCT allows the detection, localization, and quantitative evaluation of subretinal fluid and associated
CME. Anatomic alteration from drusenoid pigment
epithelial detachments, RPE tears, and stages of
retinal angiomatous proliferative lesions are also effectively identified with OCT. The goal of OCT is to
correlate the observed structural changes to changes
in visual acuity, not only to better understand the
mechanism of visual loss but also to predict the
benefit of various treatments. At the authors center,
OCT has been most useful as an adjunct to fluorescein angiography for monitoring the response to
treatment and for differentiating persistent edema or
subretinal fluid from fibrosis when questionable leakage is seen on fluorescein angiography after multiple
photodynamic therapy treatments. Subretinal fibrosis
is highly reflective on OCT and is frequently associated with overlying retinal atrophy, whereas an early
accumulation of subretinal fluid or CME associated
with the recurrence of choroidal neovascular membranes appears differently on imaging.
Retinal angiomatous proliferative lesions appear
early as small intraretinal hemorrhages, often overlying a serous pigment epithelial detachment (stage I).
Fig. 19. Central retinal vein occlusion with associated

CME OD.
Fig. 21. Central retinal vein occlusion with recurrence of

CME 4 months after previously successful intravitreal triamcinolone injection.
28
Fig. 22. Central retinal vein occlusion with resolution of

CME after second intravitreal triamcinolone injection but
retinal atrophy. Note increased reflectivity of deeper choroidal layers.
As retinal angiomatous proliferative lesions evolve

into stage II, macular edema and the formation of an
intraretinal or subretinal neovascular complex arises.
Thermal laser and verteporfin therapy alone have not
been particularly useful for stage II lesions; however,
encouraging results have been observed by combining verteporfin therapy with a postlaser intravitreal
triamcinolone injection. OCT leads the clinician to
suspect and more accurately diagnose a retinal angiomatous proliferative lesion, because extensive CME
and RPE detachments are characteristic of a stage III
lesion. The clinician can then choose to perform a
combined verteporfin/triamcinolone treatment for
better efficacy.
Case 8. An 82-year-old Caucasian man with history
of wet age-related macular degeneration OU presented with a chief complaint of a decrease in contrast
Fig. 23. Late phase fluorescein angiogram demonstrating

leakage secondary to choroidal neovascular membrane and
associated large serous pigment epithelial detachment OS.
Fig. 24. Cystoid macular edema and serous pigment epithelial detachment associated with choroidal neovascular
membrane OS.
while reading with his better right eye. Past ocular

history was significant for thermal laser treatment
to both eyes and photodynamic therapy to the left
eye six times previously, with the most recent treatment 3 months ago. Best-corrected visual acuity was
20/40 OD and 3/200 OS. Intraocular pressures were
25 OU. Anterior segment examination showed a
2+ nuclear sclerotic cataract OU. Dilated fundus examination showed subretinal fluid of the central
macula OU and a large pigment epithelial detachment
OS. Fluorescein angiography confirmed leakage secondary to choroidal neovasulcar membranes in both
eyes and a serous pigment epithelial detachment OS
(Fig. 23). OCT imaging revealed a central thickness of
355 mm OD and 320 mm OS, and CME OS much
greater than OD with an associated pigment epithelial
detachment (Fig. 24). The patient underwent photodynamic therapy on both eyes and an intravitreal
Kenalog injection in the left eye only. On follow-up
examination 1 month later, best-corrected visual
Fig. 25. Late phase fluorescein angiogram with appearance

of persistent large serous pigment epithelial detachment OS.
Fig. 26. Resolution of CME and serous pigment epithelial

detachment 1 month after photodynamic therapy with intravitreal triamcinolone injection. Note the retinal atrophy
and increased reflectivity of deeper choroidal layers.
acuity was 20/50 OD and 20/400 OS. Fluorescein

angiography was repeated, and it was difficult to interpret whether the serous pigment epithelial detachment had resolved (Fig. 25). OCT imaging confirmed
resolution of the pigment epithelial detachment, CME,
and retinal atrophy, as demonstrated by the increased
reflectivity of the deeper choroidal layers (Fig. 26).
Case 9. A 79-year-old Caucasian woman presented
for a second opinion on the treatment for a new retinal
hemorrhage discovered on routine follow-up examination for wet age-related macular degeneration. Past
ocular history was significant for wet age-related
macular degeneration OS, with a stable pigment epithelial detachment for the past 3 years. Best-corrected
visual acuity was 20/50 OD and 20/80 OS. Confrontation fields were full to finger-counting OU, and
Amsler grid testing showed a moderate central area
of metamorphopsia OS. Ocular motility was within
normal limits, and there was no afferent pupillary
defect. Anterior segment examination showed a 3+
brunescent nuclear sclerotic cataract OD and a wellcentered PCIOL OS without posterior capsular opacity. Intraocular pressures were 19 and 16, respectively.
Dilated fundus examination showed soft drusen OD, a
small intraretinal hemorrhage with underlying subretinal fluid, and pigment epithelial detachment OS.
Fluorescein angiography demonstrated leakage in a
pattern interpreted as a classic subfoveal choroidal
neovascular membrane OS (Fig. 27). OCT imaging
clarified the diagnosis as a stage II retinal angiomatous proliferative lesion given the reflective tissue
Fig. 27. Midphase fluorescein angiogram with appearance of

classic subfoveal choroidal neovascular membrane OS.
29
Fig. 28. Stage II retinal angiomatous proliferative lesion.

Note the reflective tissue above the RPE growing intraretinally and associated pigment epithelial detachment.
above the RPE growing intraretinally and associated

pigment epithelial detachment (Fig. 28). The patient
underwent photodynamic therapy with intravitreal
triamcinolone injection. At 2-month follow-up examination, the best-corrected visual acuity was 20/80 OD
and 20/200 OS. Fluorescein angiography was not
easily interpreted as showing persistent or regressed
choroidal neovascular membrane (Fig. 29), and OCT
imaging was performed to clarify that the intraretinal
neovascular component had apparently regressed,
whereas the serous pigment epithelial detachment persisted (Fig. 30).
Retinal detachment
Optical coherence tomography is extremely sensitive in identifying neurosensory retinal elevation
because of the distinct difference in optical reflectivity between the photoreceptors and underlying RPE/
choriocapillaris. In patients with retinal detachment,
OCT can detect the presence of shallow subretinal
Fig. 29. Midphase fluorescein angiogram with appearance

of persistent classic subfoveal choroidal neovascular membrane OS.
30
Fig. 30. Regressed intraretinal component of stage II retinal

angiomatous proliferative lesion but persistent serous pigment epithelial detachment.
Fig. 32. Cystoid macular edema after successful retinal

detachment surgery by scleral buckle placement, cryotherapy, and perfluoropropane gas injection.
fluid or CME that may be difficult to identify on

biomicroscopy, confirming a macula-involving retinal detachment. OCT can also be used to distinguish
true retinal detachment from retinoschisis. Following
the repair of retinal detachment, OCT can be used to
identify the presence of shallow subretinal fluid under
the fovea or CME in patients who have delayed visual recovery despite seemingly successful surgery.
cessful repair. OCT imaging revealed the presence of

CME and a central thickness of 399 mm (Fig. 32), and
the patient was started on a course of topical therapy
with prednisolone acetate 1% (Pred Forte) and ketorolac (Acular).
Case 10. A 34-year-old Hispanic woman was referred for surgical treatment of a macula-involving
retinal detachment. Past ocular history was significant
for high myopia (-10 OU). At presentation, bestcorrected visual acuity was 20/60 OD and 20/20 OS.
Confrontation fields showed loss of the superonasal
field OD. Ocular motility was within normal limits,
and there was no afferent pupillary defect. Anterior
segment examination showed clear lenses OU. Intraocular pressures were 15 and 14, respectively. Dilated
fundus examination showed an inferotemporal retinal
detachment that extended into the macula OD. OCT
imaging to evaluate the cause of decreased vision to
the 20/60 level OD revealed a central thickness of
396 mm and CME despite foveal attachment (Fig. 31).
The patient was diagnosed as having a maculainvolving retinal detachment and underwent a scleral
buckle placement, cryotherapy, and perfluoropropane
gas injection. At the 3-month follow-up examination,
best-corrected visual acuity remained at 20/70 OD,
although the retina seemed to have undergone suc-
Optical coherence tomography provides high-resolution cross-sectional images of macular pathology

in vivo. Owing to its noninvasive noncontact nature
and use of near-infrared illumination of the fundus, it
is well tolerated by patients. The images can be
obtained without dilation and are highly reproducible,
quantifying retinal thickness with an axial resolution
of 10 mm. These qualities make OCT a powerful
diagnostic tool complementary to fluorescein angiography, photography, and biomicroscopy.
Optical coherence tomography has proved to be
particularly useful for the clinical evaluation of vitreoretinal interface disorders and alterations of the
structural anatomy of the macula, such as from
edema, choroidal neovascularization, and detachment
of the neurosensory retina or RPE. The information
obtained from high-resolution evaluation of retinal
anatomy allows the diagnosis of conditions that are
difficult to establish with biomicroscopy or angiography and improves the clinicians ability to make the
optimal treatment decision. The quantitative assessment of OCT allows an objective means to monitor
disease progression and therapeutic response.
A logical application of this technology is the
evaluation of underlying macular pathology in patients considering cataract extraction. Uncovering
vitreomacular traction, epiretinal membranes, occult
choroidal neovascular membranes with minimal
CME, subretinal fluid accumulation, and RPE detachments greatly impacts the clinical management of
cataract patients and the weighing of surgical risks
and benefits. OCT is a uniquely powerful means of
Fig. 31. Macula-involving retinal detachment with CME.
Summary
visualizing retinal morphology and pathology that

may not be revealed using current techniques of
biomicroscopy, fluorescein angiography, or B-scan
ultrasonography, and serves as the newest adjunct in
diagnostic technology.
[7]
[8]
References
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[1] Huang D, Swanson EA, Lin CP, Schuman JS, Stinson
WG, Chang W, et al. Optical coherence tomography.
Science 1991;254(5035):1178 81.
[2] Hee MR, Izatt JA, Swanson EA, Huang D, Schuman
JS, Lin CP, et al. Optical coherence tomography of the
human retina. Arch Ophthalmol 1995;113(3):325 32.
[3] Drexler W, Sattmann H, Hermann B, Ko TH, Stur M,
Unterhuber A, et al. Enhanced visualization of macular
pathology with the use of ultrahigh-resolution optical
coherence tomography. Arch Ophthalmol 2003;121:
695 706.
[4] Puliafito CA, Hee MR, Lin CP, Reichel E, Schuman
JS, Duker JS, et al. Imaging of macular diseases with
optical coherence tomography. Ophthalmology 1995;
102(2):217 29.
[5] Ip MS, Baker BJ, Duker JS, Reichel E, Baumal CR,
Gangnon R, et al. Anatomical outcomes of surgery for
idiopathic macular hole as determined by optical coherence tomography. Arch Ophthalmol 2002;120:29 35.
[6] Shahidi M, Ogura Y, Blair NP, et al. Retinal thickness
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analysis for quantitative assessment of diabetic macular edema. Arch Ophthalmol 1991;109:1115 9.
Moss SE, Klein R, Klein BE. The 14-year incidence
of visual loss in a diabetic population. Ophthalmology
1998;105(6):998 1003.
Hee MR, Puliafito CA, Wong C, Duker JS, Reichel E,
Rutledge B, et al. Quantitative assessment of macular
edema with optical coherence tomography. Arch Ophthalmol 1995;113(8):1019 29.
Yang CS, Cheng CY, Lee FL, Hsu WM, Liu JH. Quantitative assessment of retinal thickness in diabetic
patients with and without clinically significant macular
edema using optical coherence tomography. Acta Ophthalmol Scand 2001;79(3):266 70.
Hee MR, Puliafito CA, Duker JS, Reichel E, Coker JG,
Wilkins JR, et al. Topography of diabetic macular
edema with optical coherence tomography. Ophthalmology 1998;105(2):360 70.
Martidis A, Duker JS, Greenberg PB, Rogers AH,
Puliafito CA, Reichel E, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology 2002;109(5):920 6.
Rivellese M, George A, Sulkes D, Reichel E, Puliafito
CA. Optical coherence tomography after laser photocoagulation for clinically significant macular edema.
Ophthalmic Surg Lasers 2000;31(3):192 7.
Lattanzio R, Brancato R, Pierro L, Bandello F, Laccher
B, Fiore T, et al. Macular thickness measured by optical coherence tomography (OCT) in diabetic patients.
Eur J Ophthalmol 2002;12(6):482 7.
Imaging in glaucoma
Daniel M. Stein, BA, Gadi Wollstein, MD, Joel S. Schuman, MD*
UPMC Eye Center, Department of Ophthalmology, University of Pittsburgh School of Medicine, The Eye and Ear Institute,
Suite 816, 203 Lothrop Street, Pittsburgh, PA 15213, USA
The detection and monitoring of glaucoma are

multifactorial processes traditionally involving several diagnostic modalities, including intraocular pressure measurements, subjective evaluation of the
optic nerve head (ONH), and visual field testing.
These traditional methods of assessing glaucoma have
several key limitations that dictate the need for supplementary approaches. Intraocular pressure is the
major identified risk factor for the development of
glaucomatous damage, and lowering intraocular pressure serves to impede the progression of retinal
degenerative change [1 3]. Nevertheless, the high
interindividual variability and the diurnal variation
in the intraocular pressure have limited the use of this
parameter for the detection of the disease. Moreover,
intraocular pressure values do not indicate whether
damage has occurred, or to what extent. Visualization of the ONH in glaucoma by ophthalmoscopic
examination or serial stereoscopic photographs is
highly dependent on observer skills, inducing high
interobserver and intraobserver variation that affects
the utility of this diagnostic modality [4,5]. Visual
field analysis through automated perimetry is a widely
used technique that is arguably the gold standard to
evaluate glaucomatous neuropathy and to monitor
disease progression. Although it is sensitive and
specific for detecting functional visual field loss,
automated perimetry has several significant limitations [6 9]. The test requires the subjective input of
the tested individual; therefore, it is prone to high
short- and long-term fluctuation. This unavoidable
source of error necessitates multiple retesting to improve the reliability of the technique, delaying the
recognition of glaucomatous damage [10]. Further-
more, numerous studies have shown that glaucomatous field abnormalities may be preceded by structural
changes of the ONH [11 13] and nerve fiber layer
[14 17].
Because glaucomatous damage is largely irreversible, it is imperative to identify accurately eyes
with early structural changes, because they are at risk
for continued injury. It has been suggested that the
earlier glaucoma is detected and treated, the greater
the likelihood that medical or surgical intervention
will delay or prevent the progression of glaucomatous
neuropathy and subsequent functional impairment
[18 20]. This assumption underscores the need for
accurate and reproducible quantitative evaluation of
the eye. Beyond early detection, quantitative imaging
devices might be a more sensitive way to detect glaucomatous progression when compared with clinical
qualitative assessments.
Work during the past two decades has resulted
in the development and implementation of several
imaging technologies designed to detect glaucomatous neuropathy at early stages of disease. This review outlines several of the most current imaging
technologies, including confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry
(SLP), optical coherence tomography (OCT), and
the retinal thickness analyzer (RTA). The technologic
underpinnings, sensitivity and specificity, and clinical
studies of each method are discussed.
E-mail address: schumanjs@upmc.edu (J.S. Schuman).
Confocal scanning laser ophthalmoscopy is a realtime imaging technique that is used to produce three-
Confocal scanning laser ophthalmoscopy

Device fundamentals
doi:10.1016/S0896-1549(03)00102-0
34
D.M. Stein et al / Ophthalmol Clin N Am 17 (2004) 3352
dimensional images of the ONH. It is based on

the principle of spot illumination and spot detection
[22,23]. A spot of laser light is projected onto the
tissue, and the reflected light is detected by a sensor.
The system uses a pair of conjugated pinholes located
in front of the light source and the light detector
components. This pair ensures that only light
reflected from a defined focal plane will reach the
light detector. Light reflected from layers above or
below the focal plane is not focused to the pinhole,
leaving only a small fraction that can pass and be
detected. Out-of-focus light is highly suppressed, and
the suppression increases rapidly with increasing
distance from the focal plane. The device moves the
focal plane to acquire sequential images. Reconstructing the series of scans at the various focal planes
creates a three-dimensional topographic representation of the surface that is scanned.
The Heidelberg Retina Tomograph (HRT; Heidelberg Engineering, Heidelberg, Germany) is a CSLO
device. The HRT uses a diode laser beam (wavelength, 670 nm) and captures a series of 32 sequential two-dimensional scans in a total acquisition
time of 1.6 seconds. The optical transverse resolution
of the HRT is 10 mm and the axial resolution 300 mm.
The initial scans are focused anterior to the retina;
the last scans are posterior to the bottom of the optic
cup. The system allows three options for the field of
view: 10 10 degrees, 15 15 degrees, or 20 20
degrees. For each focal plane, the HRT acquires
256 256 measuring points, recording a reflection
intensity value at each of the particular (x, y) coordinates of the focal plane. The HRT registers and
aligns the 32 consecutive scans to correct for eye
movements that may occur during image acquisition.
For each (x, y) point, the machine determines the
surface location in the z-axis derived from the center
of gravity of the reflected light along the 32 scans. To
calculate absolute z-axis measurements, a zeroplane is defined, which is determined by calculating
the mean height of the peripapillary retinal surface as
measured by a reference ring that is automatically
defined at the periphery of the scan. The data from
these measurements are color coded and presented as
a topographic and reflective map (Figs. 1 3).
The operator is required to trace the ONH margin.
Based on this contour line, the HRT operation software automatically defines the reference plane. This
plane is located 50 mm posterior to the mean surface
height along a 6-degree arc at the inferotemporal
region of the contour line. The reference plane is
then used as a topographic cutoff. Structures below
the plane are defined as optic cup and structures
above the plane as neuroretinal rim.
Fig. 1. Visual field test of patient with glaucoma (OD).

Visual field shows a superior nasal defect and questionable
superior arcuate defect. This field corresponds to the later
figures showing HRT and OCT scans of this patient.
Heidelberg Engineering has recently developed

a second-generation HRT machine (HRT II). This
device is essentially a small, lightweight, portable,
and automated version of the original HRT. The
transverse field of view is fixed to 15 15 degrees
with a 384 384 measuring point grid in each of
the scanned planes. The number of scanned planes
ranges from 16 to 64 depending on the optic disk
depth. This version uses an internal fixation target and
automatically acquires three consecutive series of
scans, shortening the duration of the image acquisition.
Reproducibility
Measurements with the HRT have been found to
be highly reproducible in numerous studies [24 29].
Rohrschneider et al reported a standard deviation for
each measuring point of 30 F 6 mm in glaucoma
patients and 22 F 6 mm in normal subjects [26].
The coefficient of variation (COV) of the various
HRT measurements in this study ranged from 2.9%
to 5.2% in glaucomatous eyes to 3.3% to 4.6% in
normal eyes.
Weinreb et al [30] showed that reproducibility
was improved when multiple scans were averaged
into a single data set, recommending what is now
35
Fig. 2. HRT scan of normal subject (OD). On the upper left image, the topographic ONH map is shown. The red area marks the
cup, and the green and blue areas mark the neuroretinal rim. The upper right image, the reflectance image, is shown with the
tracing (green) of the optic disk margin and the outline (red) of the optic cup. All of the ONH sectors are marked with the green
checkmark, signifying that they are within the normal limits based on Moorfields regression analysis. At the bottom of the
figure, a graph depicts the surface height along the contour line on the ONH margin. Note the normal double-hump
appearance, with higher thickness in the superior and inferior regions.
the clinical practice of averaging three scans. The

average standard deviation of all image elements was
35.5 mm in healthy subjects, and averaging three scans
reduced this measure to 25.7 mm. In patients with
glaucoma, the standard deviation was 40.2 mm with
one scan, 28.5 mm with three scans, and 24.1 mm
with five scans.
Measurements with the HRT in healthy volunteers
and a model eye had less variability when compared
with ONH analyzer measurements [29]. Another
study showed a significant reduction in the interobserver and intraobserver variability using the HRT
when compared with computer-assisted analysis of
stereoscopic photographs of the optic disk [31].
Sihota et al [32] studied test retest variability
using the HRT II versus the first-generation HRT.
Although they found similar values, eyes with uncorrected astigmatism of more than 1 diopter and
poor visual acuity were suggested to have higher
variability with the HRT II.
Sources of error or variability

Pupil dilation
Mikelberg et al [33] reported higher reproducibility for undilated pupils when compared with dilated
pupils. Contradictory findings were reported by
Zangwill et al [34]. In their study, dilation of the
pupil did not change most HRT parameters; however, for images of poorer quality, the differences
were more pronounced.
Contour line
The operator of the HRT must trace the margin
of the ONH to obtain the stereometric analysis.
Hatch et al [35] assessed the interobserver agreement
of HRT parameters reflecting the variation in contour
line placement. The interobserver agreement ranged
from substantial (intraclass correlation coefficient
[ICC], 0.67 0.73) for rim volume and disk area to
near perfect (ICC, 0.83 0.94) for the mean height
36
Fig. 3. HRT scan of subject with glaucoma (OD). On the upper left image, note the extensive cupping of the ONH and the
thinnest area of neuroretinal rim in the inferotemporal region. Moorfields regression analysis marked the inferotemporal and the
nasal inferior sectors as abnormal and the temporal and the superior sectors as borderline. The typical double-hump
configuration in the lower graph was eliminated mainly owing to tissue loss at the ONH poles. These findings correspond with
the superior nasal visual field defect shown in Fig. 1 and show additional superior ONH damage that might precede the
perimetric appearance.
of contour and cup shape, suggesting that these

parameters are less dependent on the contour line
placement. Iester et al [36] devised a method using a
computer program to create the topographic map,
thereby avoiding the subjective observers input by
drawing the optic disk contour, and showed an increased capacity to differentiate normal from glaucomatous optic disks.
Reference plane
Many of the stereoscopic HRT measurements
are strongly related to the location of the reference
plane. Tan et al [37] showed that the positioning of
the reference plane was the most significant contributor to the variability of measurements (95%
of cases). In an effort to reduce the variation, Burk
et al [38] suggested a method of creating a flexible
reference plane accounting for the subjects particular
optic disk shape when calculating the reference plane.
Park and Caprioli [39] located the reference plane
posterior to the contour line based on nerve fiber layer
measurements as determined by OCT, and showed

an improved diagnostic capability mainly in abnormal
ONH configurations.
Blood vessels
In many cases, the HRT analyses incorporate
blood vessels into the neuroretinal rim. This inclusion
has been suggested as the reason for the higher
HRT rim measurements when compared with the
findings of optic disk photograph planimetric evaluation [40,41]. Moreover, the pulsations of the retinal
arteries also cause variability in HRT measurements.
Chauhan and McCormic [42] showed that pulse
synchronization scanning resulted in a mean 13.6%
decrease in image variability.
Ability to distinguish normal from glaucomatous eyes
A high correlation has been reported between
HRT measurements and visual field global indexes
[43 45]. Numerous studies have examined the capa-
bilities of HRT in differentiating normal and glaucomatous eyes. Cup shape measure, rim area, and cup
volume seem to be the best HRT parameters in
discriminating between eyes, although considerable
overlap exist between groups [46,47]. Improved discrimination between groups has been found by combining several parameters and ONH segmentation
[48 53]. Two of these methods have been incorporated into the HRT II: Mikelbergs discriminating
analysis and Moorfields regression analysis [50,51].
When these methods are used, the specificity and
sensitivity to differentiate between normal subjects
and patients with early glaucoma reach 78% and
89%, respectively, with Mikelbergs discriminating
analysis and 96.3% and 84.3%, respectively, with
Moorfields regression analysis [50,51]. Implementing more sophisticated mathematical approaches
such as neural networks might provide further improvement [54].
The capability of the HRT to detect ONH glaucomatous changes before the appearance of a visual
field defect was evaluated by Kamal et al [55] who
examined a small group of ocular hypertensive individuals in whom reproducible visual field changes
subsequently developed. Various parameters were
found to be significantly different from those of normal subjects.
Chauhan et al [56] have described a new statistical technique for detecting changes in topography
over time with HRT using an analysis of variance
technique. When this technique is used, a higher
frequency of progression is detected by the HRT
when compared with visual field progression, which
might suggest higher sensitivity of this method for
longitudinal evaluation; however, the specificity remains uncertain [57].
Strengths and limitations
Strengths
Rapid simple operation of the device (HRT II)
Three-dimensional, topographic representation
of the ONH
No pupil dilation necessary
Advanced data analysis capability built-in to
machine
Limitations
The use of a reference plane is required.
Manual tracing of the ONH margin must be
performed by the operator.

Measurements may be affected by blood vessels.
37
The CSLO method is appropriate for scanning
the ONH only and may be affected by anatomic

variation or pathologic processes. Although software exists for nerve fiber layer and macular
analysis, the physical limitations of axial resolution for CSLO for these purposes preclude
useful quantitative thickness measurements with
this device in these areas.
Scanning laser polarimetry

Device fundamentals
Scanning laser polarimetry is an imaging technology optimized for quantitative measurements of the
nerve fiber layer for the detection and evaluation of
glaucoma. It uses the birefringent properties of the
retinal nerve fiber layer to quantify its thickness. The
parallel arrangement of the microtubules within
the retinal ganglion cell axons causes a quantifiable
change in the polarization of light that passes through
them. This change is called retardation, and its
numerical value is proportionate to the thickness of
the nerve fiber layer [58].
Currently, SLP is in its fourth commercial generation (Nerve Fiber Analyzer [NFA], NFA II, GDx,
GDx VCC; Laser Diagnostic Technologies, San
Diego, California). The GDx device uses a diode
laser (wavelength, 780 nm) for the illumination and
measurement of a 15 15 degree area of retina
with an acquisition time of 0.7 seconds. Pupil dilation
is not necessary, because studies have shown that
changing the pupil size does not significantly affect
SLP measurements [59,60]. Data from the scanned
area are displayed as a 256 256 pixel color-coded
grid signifying different levels of retardation and
nerve fiber layer thickness. The GDx provides numerous quantitative parameters, all of which are
calculated from a band 10 pixels wide in an ellipse
concentric to the ONH (Figs. 4 6).
In an early validation study, Weinreb et al [61]
correlated the histopathologic findings in fixed monkey eyes with retardation measurements and demonstrated a good correlation (r = 0.83) between
retardation and retinal nerve fiber layer thickness.
Because mainly the cornea and, to a lesser degree,
the lens and the vitreous have birefringent properties
in addition to those of the nerve fiber layer, a compensator accounting for these components has been
incorporated into the GDx. Before the development
of the current version of the GDx variable corneal
compensator (VCC), the SLP device used a fixed
compensator, assuming that all eyes had a slow axis
38
Fig. 4. GDx VCC scan of normal subject (OD). This figure shows the fundus image (top left), a pseudocolor representation of the
nerve fiber layer thickness (middle left), and a map of areas that deviate from normal thickness values (bottom left). The nerve
fiber layer graph shows measured thickness values (green line) superimposed on the normative range (green band).
of corneal birefringence of 15 degrees in the nasal and

downward direction with a magnitude of 60 nm.
Studies by Greenfield et al [62] and Knighton et al
[63] revealed a large variation in polarization properties of the cornea in different subjects. This variation should be compensated properly to obtain
accurate nerve fiber layer measurements. This observation led to the development of the GDx VCC,
which allows for customized compensation based
on the individual corneal properties. The VCC uses
the radial birefringence of Henles fiber layer in the
macula as a control for measurement of corneal
birefringence. Based on these measurements, the
VCC is adjusted for each eye.
Many of the studies conducted with the GDx must

be re-evaluated using the GDx VCC before the utility
of this technology can be evaluated in the diagnosis
and management of glaucoma. The information
presented in following section is discussed mainly
in terms of its applicability to the GDx VCC system.
Reproducibility
Reproducibility data are sparse for the GDx
VCC; however, it can be assumed that this device
will demonstrate improved reproducibility when compared with the original GDx. Weinreb et al calculated
the reproducibility of their early SLP system as the
39
Vitreous opacities
Pons et al [69] studied the effect of vitreous
opacities on retardation measurements and showed
that artifacts produced by these irregularities could
falsely increase the value obtained for mean retinal
nerve fiber layer thickness.
Motion artifacts
The possibility that motion of the eye during
scanning could interfere with measurements was
investigated by Colen and Lemij [70]. Motion artifacts led to an increase in retardation and affected
several GDx parameters. This increase was shown to
be highly variable, and caution was recommended
when interpreting images with such artifacts.
Fig. 5. Visual field test of subject with glaucoma (OD).
Visual field shows an inferior hemifield defect. This field
corresponds to the following figure showing a GDx VCC
scan of a glaucomatous subject.
mean standard deviation of each pixel in the mean

images. They found that the overall mean standard
deviation was 1.0 degree [58]. Hoh et al [64] found
an intraoperator COV for the NFA II device for nerve
fiber layer thickness measurements of 4.5% and 4.9%
for two operators, with decreased reproducibility
between operators. Zangwill et al [65] reported a
mean COV for interoperator reproducibility for the
NFA II of 4.2%. Hollo et al found the reproducibility
to be comparable in normal and glaucoma groups,
with a COV between 3% and 8.9% for the different
sectors investigated [60]. Waldock et al [66] also
reported high interoperator reproducibility of SLP
retardation values and demonstrated improvement
of reproducibility with the use of a blood vessel
removal algorithm.
Ethnicity and age
Ethnicity and age have an effect on retinal nerve
fiber layer thickness measurements by SLP, and these
population factors must be taken into consideration
when interpreting results [67,68].
Corneal surgeries
Owing to the corneal birefringence properties,
surgical procedures in the cornea (eg, laser-assisted
in situ keratomileusis [LASIK], corneal transplantation) can induce erroneous measurements. The introduction of subject-specific corneal compensation is
likely to resolve this source of variability.
Split nerve fiber layer bundles

The GDx images of the peripapillary nerve fiber
layer allow the visualization of nerve fiber bundles.
A study by Colen and Lemij showed that split
nerve fiber layer bundlesareas in the GDx image
where higher retardation is clearly divided into two
symmetric-appearing partsare a common SLP finding in healthy eyes, especially in the superior region [71]. It is likely that these areas will continue
to be seen with the use of GDx VCC. This finding
can be considered normal in patients who have glaucoma even though it can influence some of the builtin GDx parameters, such as the superior maximum
or symmetry.
Macular pathologies
Bagga et al [72] noted that anterior chamber birefringence compensation in GDx VCC is based on
measurements of the macula as an intraocular polarimeter and is highly dependent on an intact Henles
layer. This dependence might induce a source of error in measurement, especially in instances of macular structural disease.
Numerous studies have assessed the ability of the
GDx to distinguish normal from glaucomatous eyes
[73 86]. Nevertheless, because of the inappropriate
fixed corneal compensation in many cases using
previous GDx versions, the estimates of the sensitivity and specificity of this diagnostic modality are of
questionable utility.
In a study that compared the older fixed corneal
compensator GDx system with the modified GDx
VCC system, Weinreb et al [87] showed that the
VCC device had an increased sensitivity and increased areas under the receiver operator characteris-
40
Fig. 6. GDx VCC scan of subject with glaucoma (OD). Note the blue shaded area in the superior region of the thickness map
that signifies a relatively thin nerve fiber layer. This thinning of the superior region is highlighted in the deviation map and
the nerve fiber layer graph showing thickness values outside of the norm in the superior region. This defect corresponds well
with this subjects visual field as shown in Fig. 5.
tic (ROC) curve, a measure of the overall discriminating ability of a test that incorporates sensitivity and specificity. The areas under the ROC for
the various GDx VCC parameters ranged from 0.75
to 0.83 versus 0.62 to 0.68 without the corneal
compensation. Similar findings in other studies confirm that the GDx VCC device has a better correlation
with visual function than the original GDx with fixed
compensation [88,89]. Another study showed that
adding individualized compensation to GDx scans
allowed the investigators to obtain retardation maps
that demonstrated defects that matched those ob-
served in red-free fundus photographs, whereas scans

with fixed compensation did not correlate [90].
One of the most promising GDx parameters in
terms of identifying glaucomatous changes is a neural
network product called the number [91 93]. Because this neural network was developed using
GDx data, it cannot be applied to GDx VCC data.
Studies are underway to determine the new number
using GDx VCC data.
Medeiros et al [94] applied Fourier analysis to the
retinal nerve fiber layer thickness GDx VCC measurements to improve the ability of this device to
distinguish normal versus glaucomatous eyes. Applying the Fourier-based linear discriminant function
gave a sensitivity of 84% for a given specificity of
92%. This result was a significant improvement over
the parameters given automatically by the device.
41
The SLP-VCC method requires an internal ref-
erence polarimeter (macula region), which might

be affected by macular pathologies.
The SLP-VCC method can be used to scan the
peripapillary region only and may be affected
by anatomic variations or pathologic processes.

Strengths
Optical coherence tomography
Rapid simple operation of device
No pupil dilation necessary
Limitations
Limited data are available regarding the VCC
system.
Device fundamentals
Optical coherence tomography is a noncontact
noninvasive imaging technology that uses light to
create high-resolution, real-time, cross-sectional tomographic images [95]. OCT is the optical equivalent
Fig. 7. OCT retinal nerve fiber layer thickness of a normal subject. At the top of the figure, a color-coded cross-sectional map
displays 256 adjacent A-scans. The uppermost red layer delineated with the white lines is the nerve fiber layer. Below this image,
a graph shows the patients nerve fiber layer thickness values (black line) in comparison with normative values. The circular
charts show average nerve fiber layer thickness values for the depicted regions, and the colors denote the correspondence with
the normative database.
42
of B-scan ultrasonography wherein light reflection

from the scanned area is detected. The machine can
differentiate layers in the retina owing to differences
in the time delay of reflections from various components of the tissue.
The OCT device uses a light source consisting
of a near-infrared, low-coherence superluminescent
diode laser (wavelength, 850 nm) split at a 50/50
coupler into two arms. One arm sends light to the
actual sample, and the other sends light to a reference
mirror. For the two beams to recombine, their pulses
must arrive at nearly the same time. An interference
signal is created when path lengths of the reference
and measurement arms are closely matched to within
the coherence length of the light. A series of these
scans is created by panning the light source across
the sample, which ultimately results in a two-dimensional, color-coded map based on detection of the
previously described interference signals. The device
can scan the macula, peripapillary, and ONH regions
(see Fig. 1 and Figs. 7 11). The peripapillary scan is
a circular scan optimally taken with a diameter of
3.4 mm centered at the ONH [96]. The macular
and ONH scans are composed from six linear scans
in a spoke pattern configuration equally spaced
30 degrees apart. The machine automatically identifies the ONH margin as the endings of the retinal
pigment epithelium layer, eliminating the need for
subjective definition of the margin by the operator.
Although it has been recommended that the images
be acquired after pupil dilation, satisfactory scans can
be achieved in most cases without dilation.
Fig. 8. OCT retinal nerve fiber layer thickness of a subject with glaucoma. The cross-sectional map shows diminution of the
nerve fiber layer when compared with the normal thickness. The thinning is pronounced for the most part in the inferior sectors
corresponding to the visual field defect shown in Fig. 1. Abnormal thinning is also evident in the upper sectors, possibly
reflecting structural damage not yet evident by perimetry.
43
Fig. 9. OCT macular map of a normal subject (OS). The uppermost image of the figure is a color-coded, cross-sectional map
along the vertical line, one of the six radial scans that compose the macular map. The central thinning corresponds to the foveola,
and the white lines mark the vitreoretinal and the retinal pigment epithelium boundaries of the retina. The lower left map is the
color-coded macular thickness map wherein blue signifies thinner retina and yellow-green thicker retina. The center map gives
the quantitative measurements in nine sectors.
Several generations of the commercial version

of the OCT device (Carl Zeiss Meditec, Dublin,
California) have been developed. The first-generation OCT 1 has transverse and axial resolutions of
approximately 20 mm and 10 to 15 mm, respectively.
The second-generation OCT 2 has similar hardware
with an improved user interface. Both generations
acquire 100 vertical A-scans in a standard OCT scan
in an acquisition time of approximately 1.2 seconds.
The recently released third-generation OCT 3 machine has improved axial resolution of 8 to10 mm.
The sampling densities can be selected by the user as
512, 256, or 128 vertical A-scans.
An experimental ultrahigh-resolution OCT system
has been developed using a Ti:Al2O3 laser that
provides an improved axial resolution of 2 to 3 mm
[97]. This resolution makes it possible to identify
otherwise unseen intermediate retinal layers, such

as the retinal ganglion cell layer.
Reproducibility
Several studies have confirmed the high reproducibility of OCT measurements [96,98 102]. Using
a prototype OCT device, Schuman et al found that the
standard deviation of nerve fiber layer thickness
measurements was 10 to 20 mm for the mean overall
and 15 to 30 mm for clock-hour measurements [96].
Jones et al [103] calculated the mean COVs for retinal nerve fiber layer data for global thickness, quadrant measurements, and 12-segment subdivisions and
found them to be 5%, 8%, and 9%, respectively.
Carpineto et al [104] showed reproducible nerve fiber layer thickness measurements in normal and
44
Fig. 10. OCT macular map of a subject with glaucoma (OD). The uppermost image shows a marked diminution of the upper red
band, signifying damage to the nerve fiber layer. The color-coded map (lower left) demonstrates a thinning of the macula, most
extensively in the inferotemporal region, which corresponds to the visual field defect shown in Fig. 1. This finding also can be
appreciated from the numerical values in the lower center map.
glaucomatous eyes using various circumpapillary

scan radii and attributed the greatest variability to
intersubject differences. Other investigators have
shown that the reproducibility of OCT measurements
is significantly increased with increased sampling
density [105].
Age
From the earliest studies with OCT [106] to
more recent studies [107,108], it has been shown that
nerve fiber layer thickness decreases with age; therefore, it has been suggested that the OCT normative
values should be developed in a manner that is adjusted for this aging effect.
Sampling density
Although OCT offers the highest axial resolution available for ophthalmic imaging, the transverse
sampling density is limited in all three scan regions.

Using the OCT 1 and 2 devices, nerve fiber layer
measurements are made by scanning a 360-degree
peripapillary region, but the circle is sampled for
only 100 data points (25 points per quadrant) along
this path. Gurses-Ozden et al have shown that
increasing sampling density along this path (to
100 points per quadrant) decreases variability in
nerve fiber layer thickness measurements [105].
Other investigators studying the reproducibility of
OCT measurements have also suggested the limited
number of sampling points as a source of measurement variability [98]. The OCT 3 device allows the
user to select up to 512 sampling points, which is
likely to address this issue. Furthermore, as described
previously, the macular and ONH scans are composed of linear scans in a spoke pattern configuration
with interpolation of the data for the areas between
scans. It is likely that the unscanned areas between
the linear spokes and the unsampled points along
45
Fig. 11. (A) OCT analysis of the ONH of a normal subject (OS). The image on the left is a inferonasal to superotemporal optical
cross-section map, one of the six radial scans that compose the ONH map. The edge of the retinal pigment epithelium/
choriocapillaris layer is marked by the blue cross, and a straight line connects between the margins. A parallel line located
anteriorly to this line separates the rim (above the line) and the cup (below the line). On the right, the contours of the ONH (red
circle) and optic cup (green circle) are displayed as created from the data obtained from all six radial scans (blue lines; yellow
line represents the scan depicted in the image on the left). (B) OCT analysis of the ONH of a subject with glaucoma (OD). Note
the widened optic cup and increased slope of the contour of the rim in the image on the left, representing axonal loss in the optic
cup of a glaucomatous patient. The contour map on the right demonstrates a large cup, with thinning of the neuroretinal rim most
pronounced in the inferotemporal region, which corresponds to the visual field defects in this patient (see Fig. 1).
each spoke also contribute to variation in OCT measurements [109].

Numerous studies have evaluated the capability
of OCT measurements to distinguish between normal
and glaucomatous eyes. Schuman et al showed that
OCT nerve fiber layer measurements were significantly thinner in glaucomatous eyes when compared
with normal eyes [106]. This observation was confirmed by Bowd et al [110] who found that the
mean overall nerve fiber layer and the layer in

quadrants were thinner in glaucomatous versus normal and ocular hypertensive eyes. Soliman et al [111]
showed that retinal nerve fiber layer measurements on
OCT had a higher diagnostic accuracy when compared with standard red-free photographic evaluation
of glaucomatous eyes. Bowd et al found that the
largest area under the ROC curve for distinguishing
between normal and early glaucomatous eyes was for
OCT inferior quadrant thickness (0.91) [78].
Recent studies have investigated the OCT macular and ONH capabilities in differentiating between
46
groups. Greenfield et al [112] found a significant

correlation between macular thickness and global
visual field indexes. Guedes et al reported a significant reduction in macular thickness in glaucomaaffected eyes when compared with normal eyes. The
area under the ROC curve for discriminating between
normal and advanced glaucomatous eyes was 0.80
in this study. A higher area under the ROC curve was
found in the same study for circumpapillary nerve
fiber layer measurements [109]. Lederer et al [113]
used retinal macular volume to demonstrate a significant difference between normal and early glaucomatous eyes. Schuman et al [114] found that OCT
analysis of the ONH provided useful parameters for
differentiating between groups, with an area under
the ROC curve of 0.79.
A recent study by Essock et al [115] showed that
by applying Fourier-based linear discriminant analysis to OCT nerve fiber layer data (OCT 2), an
increased area under the ROC curve could be demonstrated (0.92) when compared with the results
using other parameters such as mean nerve fiber layer
thickness (0.87) or inferior thickness (0.89).
16 optical cross-sections approximately 100 mm apart,

covering a total area of 3 3 mm in 400 msec.
Five of these scans are obtained for coverage of
20 20 degrees (6 6 mm) around the fovea using
internal fixation targets to direct the eye to the proper
position for each scan. Similarly, four scans are
acquired for imaging of the peripapillary region and
four scans for the ONH. The total acquisition time for
the 13 scans is approximately 10 minutes. The axial
length and refractive error of the examined eye are
measured for automatic calibration of the measured
thickness. Because the incoming light is projected at
an angle and the outgoing light is distant from the
incoming light at the pupil level, pupil dilation of
no less than 5 mm is required for obtaining images.
Zeimer et al reported that the depth precision
of the devicethe ability to determine accurately
the location of a single interfacewas 5 to 10 mm.
The depth resolution of the devicethe minimal
distance between two surfaces that can be resolved
by the devicewas 50 mm [117].
Zeimer et al used a prototype instrument and

demonstrated good reproducibility, with a standard
deviation for the measured data of F9 mm for in
vitro measurements [116]. In a later in vivo study,
they showed an intravisit COV of 3.6% (11.5 mm),
a single-scan intervisit reproducibility of 4.1%
(13.1 mm), and a three-scan average intervisit reproducibility of 3.2% (10.2 mm) [117]. Other studies
have found that the RTA reproducibly measures
foveal thickness and demonstrates high interexaminer
reproducibility [100,118,119].
Strengths
Provides a cross-sectional view of examined
tissue
Highest axial resolution
Multiple scanning regions
Automatic definition of ONH margin
Limitations
Limited transverse sampling
Retinal thickness analyzer

Device fundamentals
Use of the RTA is similar to slit lamp biomicroscopy as it projects a thin laser slit obliquely onto the
retina. Owing to the oblique projection, the backreflected light contains two light peaks corresponding to the vitreoretinal interface and the chorioretinal
interface. The distance between these layers reflects
the retinal thickness [116,117]. The commercial
version of this technology (Talia Technology, Neve
Ilan, Israel) uses a green HeNe laser (540 nm) that,
when projected onto the fundus, is 3 mm in length
and approximately 10 mm in width. The RTA acquires
Reproducibility

Media opacities
The RTA is particularly susceptible to media
opacities. In a study by Polito et al [120], a large
number of RTA measurements were unusable secondary to interference from media opacities.
Focusing images
In a study of foveal thickness measurements in
patients with normal and edematous retinas, Neubauer et al compared RTA measurements with OCT
measurements. Although measurements using the
RTA were reproducible, they were relatively higher
when compared with OCT measurements [118].
The investigators suggested that the overestimation
might be related to fuzzy images despite adequate
focusing according to the user manual.

In a pilot study by Zeimer et al [121], quantitative
retinal thickness losses were detected in the posterior pole of patients who had glaucoma.
Strengths
Multiple scanning regions
Limited cross-sectional view
Limitations
Pupil dilation required
Highly affected by media opacities
Studies involving multiple imaging technologies

Confocal scanning laser ophthalmoscopy and optical
coherence tomography
Device agreement
Mistlberger et al [122] compared OCT measurements with HRT topographic parameters and found
a significant correlation between mean OCT nerve
fiber layer thickness measurements and five HRT
parameters: rim area, cup disk ratio, cup shape
measure, nerve fiber layer thickness, and nerve fiber
layer cross-sectional area ( P < 0.02). Schuman et al
looked at the relationship of HRT and OCT with
respect to ONH measurements [114]. HRT and OCT
measurements of disk area, cup disk ratio, cup area,
and cup volume were highly correlated (r = 0.75
0.85, P < 0.0001), whereas the rim volume was moderately correlated (r = 0.54, P < 0.0001).
Sensitivity and specificity comparisons
In a comparative cross-sectional study by Sanchez
Galeana et al, HRT optic disk scans and OCT nerve
fiber layer analysis were compared to determine their
sensitivity and specificity in discriminating normal
versus early to moderate glaucomatous eyes [82].
HRT sensitivity ranged from 64% to 75% for the
various parameters, and specificity ranged from
68% to 80%. OCT achieved a sensitivity between
76% and 79% and a specificity of 68% to 81%. Zangwill et al compared the ability of HRT and OCT to
distinguish normal and glaucomatous eyes using area
under the ROC curves and found no significant differences between the best discriminating parameter from
each instrument [83]. Schuman et al reported areas
47
under the ROC curve for an association with clinical

diagnosis among OCT and HRT measurements of the
ONH [114]. The two devices demonstrated similar
performances, with an area under the ROC ranging
from 0.47 to 0.79 for the various parameters.
Optical coherence tomography and scanning laser
polarimetry
Device agreement
A recent study by Bagga et al demonstrated a
significant correlation between several SLP (GDx
VCC) parameters and OCT-derived nerve fiber layer
thickness measurements [89]. This correspondence
was shown to be stronger with VCC than with the
fixed compensation model.
Optical coherence tomography and retinal thickness
analysis
Device agreement
Polito et al [21] reported excellent agreements
between OCT and RTA measurements of foveal
retinal thickness, although they found that media
opacities created less interference in OCT images
than in RTA. In contrast, another study showed that
RTA measurements of foveal thickness differed
from OCT measurements in that they were consistently higher, a finding attributed to the different
definition of the measured thickness between the two
devices [118].
Summary
Structural assessment using the imaging technologies discussed herein provides reproducible quantitative measurements of posterior segment ocular
structures. These measurements have been found to
provide useful data for glaucoma detection in various
regions of the posterior segment. Further studies are
needed to evaluate the utility of these technologies
for pre-perimetric glaucoma detection and for monitoring glaucoma progression over an extended period.
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High-resolution functional optical imaging: from the

neocortex to the eye
Amiram Grinvald, PhDa,*, Tobias Bonhoeffer, PhDb, Ivo Vanzetta, PhDc,
Ayala Pollack, MDd, Eyal Aloni, MDd, Ron Ofri, MDe, Darin Nelson, PhDc
a
Department of Neurobiology, The Weizmann Institute of Science, The Grodetsky Center for Research of Higher Brain Functions,
Rehovot, 76100, Israel
b
Department of Neurobiology, The Max Plank Institute, Am Klopferspitz 18, 82152 Muenchen-Martinsried, Germany
c
Optical Imaging, 2 Bergman Street, Rehovot, 76705, Israel
d
Department of Ophthalmology, Kaplan Hospital, Rehovot, 76100, Israel
e
Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, PO Box 12, Rehovot, 76100, Israel
Progress in the fight against blindness depends on

the development of new technologies enabling early
detection and accurate monitoring of diseases such as
diabetic retinopathy, age-related macular degeneration, and glaucoma. New technology may also contribute to better understanding of the pathogenesis of
these diseases, leading to the development of new
drugs and the improvement of preventive treatment.
Extensive research has led to the evolution of several
technologies in the last few decades [1 18]. Nevertheless, the technologies currently in use do not offer
comprehensive information. Direct blood flow visualization and quantification remain elusive. To date,
no technology has been able to image retinal blood
flow directly, particularly in the capillaries. Because
many diseases affect small vessels, information regarding blood flow, particularly in the capillaries, is
needed for early diagnosis of retinal diseases. Oximetry measuring the intravascular oxygen content is an
essential parameter when assessing the degree of
tissue vitality. Many retinal diseases involve blood
vessels, resulting in a reduction of the flow of oxygen
and nutrients to the retinal tissue and leading to
Darin Nelson and Ivo Vanzetta are employees of Optical
Imaging. Amiram Grinvald has financial interest in Optical
Imaging Ltd.
* Corresponding author. Department of Neurobiology,
The Weizmann Institute of Science, Rehovot, 76100, Israel.
E-mail address: Amiram.Grinvald@weizmann.
weizmann.ac.il (A. Grinvald).
ischemia. No currently existing technology can directly image oximetric parameters in the retina [1] in
a quantitative rapid manner [19]. There are no means
for the direct assessment of oxygen, the key parameter of tissue viability. No technology has been
able to demonstrate directly the metabolic functional
status of components of the retinal tissue. Once discovered, functional or metabolic signals will provide
necessary information on the viability and vitality of
diseased tissues using direct methods rather than
indirect methods.
Functional optical imaging, a noninvasive technology widely used in brain research, has recently been
adapted for functional retinal imaging. The authors
believe that functional parameters are more promising
for providing the earliest possible diagnostics rather
than anatomic parameters. This article briefly reviews
functional optical imaging in the neocortex and
describes the type of results obtained by applying
this technology to functional imaging of the eye.
Preliminary results have been published in abstract
form [20 24].
Neocortical functional optical imaging

Noninvasive functional optical imaging of the neocortex based on intrinsic signals without the use of a
contrast agent was developed more than a decade ago
[25 27]. This technology has been designed to detect
minute optical differences between cortical images
doi:10.1016/j.ohc.2003.12.003
54
A. Grinvald et al / Ophthalmol Clin N Am 17 (2004) 5367
obtained under different neuronal processing conditions, differences that previously were thought to be
invisible. Unprecedented accurate functional mapping
of the functional architecture of the neocortex can be
performed. Using high-resolution digital imaging of
exposed cortex and removing extensive biologic
noise, it has been possible to create information-rich
images that reveal minute changes in the light intensity
reflected from the cortex, changes indicating intrinsic
metabolic activity of activated cortical domains (eg,
changes in oxygen consumption, blood flow, blood
volume, and light scattering). The imaging setup is
depicted in Fig. 1. Imaging begins with a sequence of
digital images of the target organ, taken with a video or
digital camera, just after the cortex has been activated
with a given sensory input. Subsequently, functional
maps are obtained by analyzing the small differences between the series of images owing to the
increased oxygen consumption, blood flow, and activity-dependent light-scattering signals. This stage is
followed by a biologic system specific noise reduction procedure that enables the extraction of small but
relevant signals from large artifacts (some are irrelevant physiological events that are removed), image
enhancement, and quantification.
Functional optical imaging based on intrinsic signals
Neocortical functional optical imaging based on
intrinsic signals has provided a new level of understanding of the principles underlying cortical development, organization, and function [28]. In the best
cases, it provides a spatial resolution of 20 mm for
mapping the layout of cortical columns in vivo. This
excellent resolution is much better than that required
to resolve cortical columns. The discussion herein
provides a brief overview of the types of applications
that have been pursued, and the general implications
of some findings for other neuroimaging techniques
based on hemodynamic responses, particularly functional magnetic resonance imaging (f-MRI).
In the mammalian brain, cells that perform a given
function or that share common functional properties
are often grouped together in cortical columns running
from pia to white mater [29 31]. Examples include
the orientation and ocular dominance columns of the
primary visual cortex. Without knowing the function
performed by each group of neurons, it is difficult to
discover the principles underlying the neural code and
its implementation. Attaining an understanding of the
functional organization of a given cortical area is a key
step toward revealing the fundamental mechanisms of
information processing therein. Of special importance
are experimental methods that allow visualization of
the functional organization of cortical columns, particularly methods providing high spatial and temporal
resolution. To date, single- or multi-unit extracellular
recording techniques have provided the best tools for
studying the functional response properties of single
cortical neurons and their synaptic interactions. Although multi-electrode techniques are more promising, the size and placement of these electrode arrays
pose severe problems. Several imaging techniques
have been developed that yield information about
the spatial distribution of active neurons in the brain.
Each of these techniques has significant advantages as
well as limitations. Although the 2-deoxyglucose
method permits postmortem visualization of active
brain areas, or even of single cells, it is a one shot
approach. Only a single stimulus condition in a single
animal can be assayed (the two-isotope method permits the mapping of activity resulting from two
stimulus conditions). Positron-emission tomography
and f-MRI offer spectacular three-dimensional localization of active regions in the functioning human
brain, but both methods have low spatial resolution,
two to three orders of magnitude worse than optical
imaging. Other imaging techniques have also been
applied in vivo with success but suffer from a limited
spatial resolution, a limited temporal resolution, or
both. Among these methods are radioactive imaging
of changes in blood flow, electroencephalography,
magnetoencephalography, and thermal imaging.
Overview of functional optical imaging in the
neocortex
Currently, the best method for imaging the functional architecture of the cortex is based on slow
changes in the intrinsic optical properties of active
brain tissue. This method permits visualization of
active cortical regions at a spatial resolution better
than 50 mm and is immune to some of the problems
associated with the use of optical imaging based on
extrinsic probes [32 35]. The sources for these activity-dependent intrinsic signals include changes in
the physical properties of the tissue affecting light
scattering, and changes in the absorption, fluorescence, or other optical properties of intrinsic molecules. The fact that, in many tissues, small intrinsic
optical changes are associated with metabolic activity
has been known since the pioneering experiments of
Kelin [36] and Millikan [37] on the absorption of
cytochromes and hemoglobin, respectively. The first
optical recording of neuronal activity was made almost 50 years ago by Hill and Keynes [38], who
detected light-scattering changes in active nerves.
Changes in the absorption or fluorescence of intrin-
55
Fig. 1. Optical imaging of functional maps in vivo. (A) The setup. Digital CCD images are taken of the exposed cortex of the
animal, which is sealed in an oil-filled chamber. The cortex is illuminated with light of 605 nm wavelength. During image
acquisition, the animal is visually stimulated with moving gratings projected onto a frosted glass screen by a video projector. The
acquired images are digitized in a camera controller, which transfers the data to the computer controlling the entire experiment.
Functional maps are subsequently analyzed and are displayed on a color monitor. To determine the quality of the maps during the
imaging sessions, the data can be sent to a second computer for detailed, quasi on-line analysis. (Data from Tso DY, Frostig RD,
Lieke E, Grinvald A. Functional organization of primate visual cortex revealed by high resolution optical imaging. Science
1990;249:417 20.) (B) Imaging functional architecture. An activity map for one orientation is obtained straightforwardly by
dividing the image captured during presentation of this orientation by the average of the images captured during presentation of
all orientations. The image of the cortical surface illuminated with green light to emphasize the vasculature is shown at the top.
Activity maps evoked by visual stimulation with horizontal and vertical gratings are shown at the bottom. Scale bar: 1mm.
(Data from Bonhoeffer T, Grinvald A. Iso-orientation domains in cat visual cortex are arranged in pinwheel-like patterns. Nature
1991;353:429 31.)
56
sic chromophores were extensively investigated by

Chance and colleagues [39] and Jobsis [40] (for a
review, see the article by Cohen [41]).
The basic experimental setup for optical imaging
experiments is shown in Fig. 1. The anesthetized
animal is held in a stereotaxic frame (not shown).
The exposed brain is illuminated with flexible light
guides, and digital pictures are acquired by the camera, which views the exposed cortex through a cranial
window. The data are analyzed on the computer
controlling the experiment, and the results are displayed on a color monitor (for detailed practical
guidelines, see the article by Grinvald et al [28]).
Sources of intrinsic signals
More than a century ago, Roy and Sherrington
[42] postulated that the brain possesses an intrinsic
mechanism by which its vascular supply can be
varied locally in correspondence with local variations
of functional activity. Contemporary imaging techniques have indeed demonstrated a strong coupling
between neuronal activity and local metabolic activity and blood flow [25,43,44]. More recently, Ogawa
and colleagues [45] have found that the intrinsic
signal is useful for functional brain mapping with
MR imaging. Optical imaging has revealed the exact
spatiotemporal characteristics of this coupling.
Although the intrinsic signal has different components that originate from different sources, the functional maps obtained at different wavelengths are very
similar, and it appears that all of these components can
be used for functional mapping [27]. Malonek and
Grinvald [46] have used optical imaging spectroscopy,
a new technique providing simultaneous spectral
information from many cortical locations in the form
of a spatiospectral image. The images obtained with
imaging spectroscopy show the spectral changes at
many wavelengths for each cortical point (y versus l)
along a selected line. Using this technique, the authors
have measured the spatial, temporal, and spectral
characteristics of light reflected from the surface of
the visual cortex following natural stimulation. The
technical details are published elsewhere [46 48].
The sources of the intrinsic signals in reflection
measurements from the neocortex are the result of the
following cellular or tissue changes:
Activity-dependent oxygen consumption affect-
ing the hemoglobin saturation level

Changes in blood volume affecting tissue light
absorption
Changes in blood volume affecting tissue light
scattering
Changes in blood flow affecting the hemoglobin
saturation level
Activity-dependent changes in tissue light scat-
tering
The first component of the intrinsic signal in the
neocortex originates from activity-dependent changes
in the oxygen saturation level of hemoglobin. This
change in oxygenation contains two different components. The first component is an early eventan
increase in the deoxyhemoglobin concentration resulting from elevated oxygen consumption of the neurons
owing to their metabolic activity. This component
causes a darkening of the cortex owing to increased
absorption by deoxyhemoglobin molecules and is
referred to as the initial dip. The second component
originates from an activity-dependent increase in
cortical blood volume, increasing the amount of light
absorbed by activated cortical regions in a wavelength-dependent fashion following the absorption
spectra of hemoglobin. The level of spatial regulation
of this component has been of great interest, because
most f-MRI studies use this component of the hemodynamic response. In previous studies of optical
imaging and imaging spectroscopy in the visual cortex
of cats and monkeys, the authors reported a much
weaker colocalization of cortical blood volume
changes with the electrically active columns than the
[Hbr] increase during the initial dip [27,46 49]. This
poorer colocalization is revealed by a lower signal-tonoise ratio in spatial maps of activation calculated
from the cortical blood volume component when
compared with those from the initial dip. This observation is especially true for maps in which the response to a single stimulus condition is normalized by
the response to a blank (single-condition maps). For
differential imaging, in which the response to a
stimulus condition is normalized by or subtracted
from the response to an orthogonal stimulus condition, the maps from the cortical blood volume are still
somewhat poorer than from the initial dip; however,
high-quality functional cortical blood volume maps
have been obtained in cat and monkey visual cortex
with differential imaging [27]. Such differential procedure removes much of the cortical blood volume
noise, because it nearly eliminates the contribution of
the nonstimulus-specific part of the vascular response.
These results indicate that part of the cortical blood
volume changes colocalize with areas of increased
neuronal activity.
The third component is a delayed eventan activity-related increase in blood flow causing a decrease in the deoxyhemoglobin concentration. The
blood rushing into the activated tissue contains higher
levels of oxyhemoglobin. Another signal component

originates from changes in blood volume, probably
owing to local capillary recruitment or a rapid filling
of capillaries and dilation of venules in an area containing electrically active neurons. These blood-related
components dominate the signal at wavelengths
between 400 and 630 nm. It has recently been shown
that capillaries blood volume changes co-localize with
electrical activity and can be used to obtain functional
maps [71]. However, blood volumes in larger vessels
do not. Blood volume changes from all the microvascular compartments compress the cortical tissue, giving rise to a change in light scattering that exists at all
wavelengths, and exhibit a time course typical of
blood volume changes rather than light-scattering
changes that originate from electrical activity per se.
The last significant component of the fast and slow
intrinsic signal arises from changes in light scattering
that accompany cortical activation [32,50,51]. These
changes are caused by ion and water movement,
expansion and contraction of extracellular spaces,
capillary expansion, or neurotransmitter release.
Light-scattering components become a significant
source of intrinsic signals above 630 nm and probably dominate the intrinsic signals in the nearinfrared region above 800 nm.
Studies of the cortical functional architecture: proof
of concept
Initial optical imaging studies investigated wellknown structural elements of the functional architec-
57
ture, such as ocular dominance in the primary visual

cortex and the stripes in V2 [26] or the pinwheellike organization of orientation preference [52].
Subsequently, methodologic improvements made it
possible to investigate more subtle features of cortical
organization, such as direction-selective columns or
spatial frequency columns [53 56]. Similar progress
has been obtained in exploring other visual areas. It
has even been possible to demonstrate functional columns in visual areas further up the processing stream,
that is, in areas V4 [57] and MT [53]. Tanaka and
colleagues [58] have used this method to image the
functional organization in the inferotemporal area,
one of the final stages of the visual pathway critical
for object recognition. Extraordinary high-resolution
maps were reported in the tree shrew [59] and ferret
[60]. Although, to date, most optical imaging studies
have been performed in the visual cortex, this is
not the only sensory system that can be studied using
this method. Indeed, functional optical imaging has
proved to be a useful tool for investigating functional
architecture in the somatosensory cortex of the rat
[25,61] and monkey [56] and the auditory cortex of
the guinea pig and gerbil [62 64]. Extraordinary
high-resolution maps have been reported in the olfactory bulb [65]. Functional optical imaging has
also been applied to the human brain noninvasively
[66 68]. Fig. 2 depicts a collection of journal and
book covers illustrating how popular this technique
has become in cortical research.
Optical imaging has resolved an outstanding
question that could not have been answered using
Fig. 2. Functional optical imaging has been applied to multiple cortical and noncortical areas in multiple species and multiple
sensory modalities. Such maps are depicted on the cover of several journals.
58
Fig. 3. Relationships among pinwheels, ocular dominance columns, and blobs in primary visual cortex of the macaque monkey.
(A) The optical map of ocular dominance. The dark bands represent columns dominated by input from the right eye. Scale bar:
500 mm. (B) The borders of the ocular dominance columns (black lines taken from A) were overlaid onto the discrete angle
map for orientation preference. The pinwheel centers were marked with circles. (C) The continuous angle map of orientation
preference. Same unsmoothed digital data shown in B are depicted using the color scale shown above the map. The oriented
color bars at the right indicate the color code. (D) The CO-rich blobs were marked on the histologic photograph. (E) Angle map
from B and two overlays showing the relationships among blobs, iso-orientation domains, and ocular dominance columns.
( F) Two adjacent fundamental modules, magnified from E. (G) The revised ice cube model illustrating the relationships found in
the above maps. Black lines mark the borders between columns of neurons that receive signals from different eyes. White ovals
represent groups of neurons responsible for color perception (blobs). The pinwheels are formed by neurons involved in the
perception of shape, with each color marking a column of neurons responding selectively to a particular orientation in space.
Note that both the blobs and the centers of the pinwheels lie at the center of the R or L columns. The iso-orientation lines
(appearing as a border between two colors) tend to cross borders of ocular dominance columns (black lines) at right angles. The
slice above the ice cube model depicts two adjacent fundamental modules (400 mm 800 mm). Each module contains a complete
set of about 60,000 neurons, processing all three features of orientation, depth, and color. (Data from Bartfeld E, Grinvald A.
Relationships between orientation preference pinwheels, cytochrome oxidase blobs and ocular dominance columns in primate
striate cortex. Proc Natl Acad Sci USA 1992;89:11905 9.)
alternative approaches. After Hubel and Wiesel [31]

and Livingstone and Hubel [69] described three subsystems responsible for the perception of shape,
depth, and color that combine in the macaque primary
visual cortex in what has been referred to as the icecube model, many other groups attempted to explore the geometrical relationships among these three
subsystems, if any. Optical imaging revealed how the
various columnar subsystems were organized with
respect to one another. Fig. 3 shows the experimental
data and revised ice-cube model, depicting in a
schematic fashion the relationships among orientation
columns, ocular dominance columns, and the blobs in
monkey primary visual cortex that have been found
by the authors [70]. The following detailed relationships have been found:
1. Orientation preference is organized radially.
2. Orientation domains are continuous and have
fuzzy boundaries.
3. Iso-orientation lines tend to cross ocular dominance borders at 90 degrees.
4. Orientation pinwheels are centered on ocular
dominance columns.
5. Blobs are centered on ocular dominance
columns.
6. The centers of the blobs and the centers of the
orientation pinwheels are segregated.
7. A regular mosaiclike organization exists for
each type of functional domain, without there
being an overall pattern of repeating hypercolumns. The latter finding is probably related to
the existence of short-range (<1 mm) rather than
long-range interactions during development.
Retinal functional optical imaging

Overview
The retinal functional imager (RFI) (Optical Imaging Ltd., Rehovot, Israel), based on similar approaches used in the brain, is a digital imaging system
designed to capture accurate retinal images via a
standard fundus camera. Four key parameters are
offered by the new imager.
1. Blood flow: The RFI can map blood flow velocity in retinal vessels, including minute capillaries, often only 5 mm in diameter. The system
can accurately measure the blood flow or speed
at any position in the relevant vessel and can
compare this result with the findings in other
59
vessels, other eyes, or the same patient at another point in time.

2. Microvasculature mapping: The RFI can map
otherwise invisible capillaries and highlight
microvasculature pathology, and may prove to
be effective for earlier detection of neovascularization and for follow-up.
3. Oximetry: The RFI can map the oximetric state
of the eye, an important parameter for diagnosis, monitoring, and treatment guidelines.
4. Metabolic function: The RFI can track dysfunction in some elements of the metabolic
machinery of the retina, a parameter that may
lead to improved diagnosis and treatment.
The RFI performs these measurements or any
contrast agent in a noninvasive manner with no need
to inject dye. The RFI can also serve as a digital fundus
camera for standard angiographic techniques requiring
intravenous injection of dye, such as fluorescein and
indocyanine green. Capabilities of the RFI have relevance ranging from the exploration of basic issues in
retinal physiology to clinical issues in diseases such as
diabetic retinopathy, glaucoma, age-related macular
degeneration, and other retinal disorders.
Current technology used for mapping neocortical
function allows unprecedented sensitivity in functional
mapping of the retina with respect to the previously
described parameters. Starting from digital images
of the retina in the form of a short movie, minute
previously undetectable changes in reflected light
intensity are revealed. The series of digital images
captured at 20 to 100 Hz are converted into functional maps for the various parameters by extracting
and amplifying subtle differences between each of
the images. One obvious advantage of this system is
that all of the parameters are derived from measurements with a single system. The versatility of the
RFI enables it to be used as a core piece of equipment, suitable for many different clinical examinations and research projects with human subjects or
animal models.
Technical aspects of the retinal functional imager
The RFI system combines digital fundus imaging
with functional optical imaging, providing a turnkey
system with flexible parameter settings and open
standard data storage.
Hardware modification to a standard fundus camera
To measure the previously described parameters, the following enhancements are used for the
fundus camera:
60

Fast stroboscopic illumination of the retina is
performed rather than a single flash at a time.

The flash power supply delivers trains up to
8 flashes at up to 100 Hz. This capability is
useful for any application in which rapid acquisition of similar retinal images is important.
Rapid switching is performed among up to four
illumination wavelengths, acquiring multiple
wavelength images with little or no global
movement of the retina.
The 1:5 digital port zooming range, performing independently of the fundus cameras internal field of view selector, lets the operator
choose the level of detail required for the protocol
in question.
A high-speed, large dynamic range megapixel
digital camera is incorporated.
Imaging specifications
Imaging specifications are as follows:
Pixel resolution, 1024 1024
Imaged retinal area, 6 60 degrees
Pixel size on retina, 2 20 mm
Frame rate (full), up to 50 Hz
Frame rate (binned), up to 100 Hz
Wavelength range, 450 1100 nm
The RFI permits the operator to define specific
data acquisition protocols for measuring parameters
such as flow or oximetry, for standard protocols such
as fluorescein angiography, or for sessions that combine the RFIs functionalities in novel paradigms
tailored by an individual investigator.
Illumination specifications
Illumination specifications are as follows:
High-intensity flashes, 8 per train
High-intensity flash rate, up to 100 Hz
Filter positions, 4 standard
Filter switching rate, 55 msec
Continuous illumination, 75 W
Imaging and analysis software
The system software contains several components.
An application that supervises image data acquisition
also includes a live view capacity, useful not only for
adjusting alignment and focus during imaging but also
for live viewing of the retina under infrared illumination. A browser is integrated, providing immediate
feedback on newly acquired images. It also performs
operations such as image re-registration (automatic or
manual), image filtering, and creating and playing
back flow movies. An animation component integrated in the browser allows viewing the results of a
given imaging session with an interactive frame rate
and color table control. It also applies low-pass,
high-pass, and clipping operations to each image as
it is read.
Visualizing retinal blood flow
Invisible information is hidden in a red-free series
of images of the retinal vasculature, taken with the
stroboscopic illumination. Information on how blood
is flowing through the retinas veins, arteries, and
capillaries can be displayed as a movie that directly
shows individual clusters of red blood cells in motion. Fig. 4C shows one flow differential image taken
from the eye of a healthy human subject. The movies
can be viewed in a continuous loop by accessing
http://www.weizmann.grinvald.retinalflow. Fig. 4A
shows a red-free (green illuminated) digital image
of normal human macula. This image is one of a
series of six pictures obtained with the RFI over a
period of 100 ms. The overall retinal area imaged was
4.2 mm on a side (about 15 degrees). The yellow
square shows a large area of interest, 1140 mm on a
side (area shown in Figs. 4B and C). The red square
shows a region of interest 264 mm on a side. Fig. 4C
shows part of the corresponding flow image (yellow
in Fig. 4A), extracted using the RFIs analysis software. Interpretation of this flow image is straightforward. A black spot represents a blood cell or cluster
of red blood cells. In white spots, or gaps, red blood
cells are absent. The courses of several in-focus
capillaries are clearly traced out by trains of black
and white spots, which are elongated by constriction.
Larger blood vessels also have clear gaps and clusters, but these areas are more punctate. In the spaces
between in-focus vessels, the grainy texture of the
image reflects the distribution of red blood cells
moving through deeper, out-of-focus blood vessels.
Quantifying retinal blood motion
The ability of the RFI to visualize individual retinal red blood cells or red blood cell clusters directly,
without the injection of dye, opens up many new
possibilities in the investigation of retinal blood flow,
particularly in small arteries and veins and in capillaries. The flow-enhanced movies of the RFI clearly
reveal the motion of individual clusters of red blood
cellsor even single red blood cellsin vessels as
small as capillaries without the confounding consequences of intermediate assumptions and complicated
transformations. These movies provide a tool for the
61
Fig. 4. RFI direct visualization of blood flow in the human retina. (A) Red-free image of the fundus of a normal subject. Yellow
highlight shows the region magnified in panels B and C. (B) Red-free image at higher magnification. (C) Single frame of a flow
movie. Small red square shows region of additional magnification, illustrated in panel D. (D) Top row shows standard and
annotated (bottom row) flow images from the subregion corresponding to the red square in A, B, and C, obtained at 20-ms
intervals. The top row shows extracts from the raw flow image. Dark clusters of red blood cells appear at lower left, move
rightward, around a sharp curve, and then upward, and exit the frame at the right top. Some motion in other capillaries can also
be seen. In the bottom row, the same images have been annotated for emphasis. The main capillary has been traced in black, and
five gaps between red blood cell clusters have been assigned five colors to emphasize the motion of blood from one frame to the
next. Clusters (black) and gaps (white) move through the capillary shown here at an average rate of 1.6 mm/s.
Fig. 5. Direct automatic determination of flow rate map in the cat retina. (A) Flow rate map calculated from 200 frames, such as
the one shown in the right panel (B), were collected at 100 Hz using a continuous stroboscopic illumination. The velocity at each
pixel was calculated directly by the program. See text for more details.
62
Fig. 6. Semi-automatic quantification of flow in human retina. (A) Red-free image of a normal subject. This image shows several
arteries (red set of colors) and veins (violet set) that were selected for quantification. Each shade of color corresponds to a certain
velocity range. (B) Samples of the calculated velocity, as discussed in the text. Scale bar: 1mm.
Fig. 7. Enhanced visualization of hardly visible vessels. (A) Expanded view of the yellowed region shown in Fig. 4B. Some fine
venules and arterioles are visible, but very little of the capillary bed itself. (B) Same region flow enhanced. Regions with the
strongest flow signal are black, whereas weaker flow regions are white. The flow through larger vessels, although distinct, is less
regimented than the constricted flow through capillaries and appears in gray. (C,D) Similar results obtained from a larger area.
Scale bar: 1mm.
qualitative assessment of retinal blood flow rates.

Nevertheless, quantification of the characteristics of
these movies is required to reach the ultimate goal of
creating measures of retinal blood dynamics. Such
measures would be useful for detecting and monitoring clinical diseases, for investigating the effects of
change on physiologic parameters, such as the elevation of intraocular pressure on hemodynamics, and for
following the effects of drugs on retinal ischemia.
The software analysis suite has built-in tools for
flow rate quantification. It supports three methods of
flow rate quantification, fully manual, fully automatic,
and supervised automatic, each appropriate for different circumstances. The program also makes the data
available in an open format, allowing researchers to
develop their own analysis algorithms and techniques.
Manual quantification
Manual measurement of the flow rate of identified
red blood cell clusters, although cumbersome, is the
simplest most assumption-free method of quantifying
the retinal blood flow rate. By drawing a segment
connecting the same cluster or gap as it appears in two
sequential images, the instantaneous velocity between
those two frames can be directly determined. Although this method provides excellent precision in
capillaries, manual quantification in much larger vessels is problematic. Red blood cell clusters are free to
combine, separate, and overlap, making one-to-one
identifications of moving spots among images difficult. Automated correlation analysis can overcome
these problems.
63
lyzed. The program then automatically identifies them

and determines the blood flow rate within, even detecting variations in flow along the vessels length.
Supervised quantification is interactive, enhancing
confidence in the results. The time from initial recording to flow-rate histogram takes a few minutes. Fig. 6
shows an example of such a result.
Visualization of invisible vessels
Many of the capillaries are traced by trains of
clusters and gaps and are nearly invisible in the corresponding region of the original red-free image,
because the spatial resolution of the normal eye is
10 to 15 mm. The RFI can noninvasively document
fine details of vascular anatomy that otherwise may
be invisible, even in the sharpest red-free images.
Figs. 7A and B emphasize this point. Figs. 7C and D
provide another example from a larger retinal area.
Determination of the retinal oximetric state
The difference between the absorption spectra of
oxy- and deoxyhemoglobin can be used to determine
the oxygenation of blood with spectroscopic methods. For a recent review of previous methodologies,
the reader is referred to the article by Harris et al [19].
When the RFI is used in a multi-wavelength mode,
Automatic quantification
In tapetal animals, retinal reflectance is high
enough to permit retinal flow imaging with incandescent light or low-power flashes (continuous trains for
hours), permitting high-speed imaging of hundreds of
images per series or even live viewing of the blood
flow on a computer monitor. One can apply a fully
automatic quantification algorithm to such large frame
numbers. This algorithm looks for correlations among
image pixels at different time offsets. The points with
the closest correlation are matched, and the flow rate
is calculated from this pairing. Fig. 5 shows an
example from the cat retina.
Supervised quantification
By using the constraining paths given by the image
of the blood vessels, one can greatly improve the
signal-to-noise ratio of the time offset correlation
matching technique. Automatic measurement of flow
rates can be based on as few as six images. The user
loosely traces over the extent of vessels to be ana-
Fig. 8. Oximetric image obtained with the RFI in the retina

of a 36-year-old healthy subject. Due to the different oxygen
saturation of arterial, venous, and capillary blood, arteries,
veins, and capillaries appear in different gray levels, with
white coding for highest and black for lowest oxygen
saturation. The grayish elongated patches are probably artifacts from large chroidal vessels and underscore the current
difficulties with the simple spectral analysis presented here.
64
Fig. 9. Qualitative oximetric retinal maps for detection of ischemia in diabetic patients. Each of the three images includes a
comparison of the color image of the retina, the corresponding fluorescein angiogram, and the oximetric maps obtained by the
RFI. (A) In these three panels, it is evident that areas of leakage seen on the fluorescein angiogram are indeed ischemic. (B) The
darker color of the regions near the fovea suggests that the macula is somewhat anoxic. (C) Another example wherein the redfree and fluorescein angiogram clear sign for anoxia are not seen in another diabetic patient. Note that in B and C, some of the
abnormalities detected by the RFI are hardly seen or difficult to note in the corresponding angiographic images. These latter
results remain to be validated by direct oxygen tension measurements.
spectroscopic decomposition can be performed, and

the oximetric state of the retina can be qualitatively
assessed. Nevertheless, qualitative mapping of the
oximetric state of the retina is rather limited, and
the ultimate goal should be quantitative oximetry. In
some cases, even qualitative mapping can be of
clinical value, particularly in diabetic retinopathy,
when the detection of patches of anoxic regions can

guide treatment. Fig. 8 depicts qualitative mapping of
the oximetric state obtained with the RFI in the retina
of a 36-year-old healthy subject. As expected, the
oxygen levels in the three major compartments,
arteries, and veins, and capillaries, are different but
rather uniform. In contrast, Fig. 9 shows the findings
Fig. 10. Time course image series of the functional signal from cat retina. Near-infrared local changes (right) in retinal reflection
were evoked by local photic stimulation in the visible wavelength range. While a 1-s, local, 100-Hz train of green flashes was
delivered to the cats eye, video images of the feline retina were taken in the infrared at 400 ms/frame. Time increases from right
to left, row-wise from top to bottom. Stimulus duration is marked as a black bar. The control time series without phonic
stimulation is shown at the left. The time course of the signal and its wavelength dependency indicate that it is not the wellknown hemodynamic response. The origin of this metabolic signal remained to be explored. Each image width is 8mm.
in patients with diabetic retinopathy. Each of the three

images includes a comparison of the color image of
the retina, the corresponding fluorescein angiogram,
and the oximetric map obtained by the RFI. A clear
correlation is seen with the finding on fluorescein
angiograms. In the bottom panel, regions in which the
fluorescein angiograms appear normal are revealed as
partially ischemic, underscoring the significance of
qualitative oximetric imaging.
The retinal functional signal
The RFI has been used to measure a novel retinal
functional signal originating from reflectance changes
in the cat retina, evoked on visual stimulation. Its
spatiotemporal properties suggest that it can be attributed to metabolic rather than hemodynamic processes or photoreceptor bleaching. In the cat, this signal
tightly colocalizes with the spatial extent of the visual
stimulus. The functional signal depicted in Fig. 10,
obtained in the cat, illustrates the flexibility and power
of the RFI as a tool for making basic research
discoveries in the retina.
Summary
Much work remains to be done to establish the
clinical usefulness of the RFI for early diagnosis and
treatment guidance. The discoveries obtained by functional optical imaging of the neocortex in the last
15 years and the recent RFI studies of the eyes of
normal subjects and patients with diabetic retinopathy, glaucoma, and age-related macular degeneration
suggest that functional optical imaging of the retina
is likely to become a multi-modality powerful clinical tool.
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
Acknowledgments
The authors thank their previous coworkers, R.
Frostig, E. Lieke, C.D. Gilbert, T. Wiesel, D. Tso, R.
Malach, D. Malonek, and A. Shmuel, for their contributions to the functional mapping of the neocortex,
and M. Belkin for his contribution to research with
the RFI.
[15]
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Bartfeld E, Grinvald A. Relationships between orientation preference pinwheels, cytochrome oxidase blobs
and ocular dominance columns in primate striate cortex. Proc Natl Acad Sci USA 1992;89:11905 9.
Vanzetta I, Slovin H, Omer DB, Grinvald A. Columnar
resolution of blood volume and oximetry functional
maps in the behaving monkey; implications for f MRI.
Neuron 2004, in press.
Electrophysiologic imaging of retinal and optic nerve

damage: the multifocal technique
Donald C. Hood, PhD
Department of Psychology, Columbia University, Schermerhorn Hall, Room 416, MC 5501, 1190 Amsterdam Avenue,
New York, NY 10027, USA
Traditional electrophysiologic tests of vision involve stimulation of relatively large areas of the retina [1]. For the standard electroretinogram (ERG)
and flash visual evoked potential (VEP) tests, the
entire retina is illuminated, whereas for the pattern
ERG and VEP tests, the stimulus typically exceeds
15 degrees in diameter. The size of the stimuli used for
these tests presents a problem if the clinician is
interested in the local topography of the damage to
the retina or optic nerve. Although ERG and VEP
responses can be elicited with relatively small stimuli,
each retinal area must be tested separately. The time
required to obtain multiple responses to construct a
topographical map would be prohibitive. The multifocal technique was devised by Sutter to solve this
problem [2]. Using the multifocal ERG (mfERG) and
VEP (mfVEP) techniques, local responses are
recorded simultaneously from many regions of the
visual field. This article provides an introduction to
these techniques.
The multifocal electroretinogram

Although the mfERG is a relatively new technique, it is used widely to diagnose and study retinal diseases [3]. More than 200 articles, most of
them clinical in nature, have been published in the
last 5 years, and hundreds of centers worldwide have
This article was supported by grants EY02115

and EY09706 from the National Eye Institute, Bethesda,
Maryland.
E-mail address: dch3@columbia.edu
multifocal equipment. Before summarizing how

the mfERG is used in the clinic, the basics of the
technique should be reviewed. The following section provides an overview of how the mfERG is recorded. For more details, the reader is referred to the
article by Sutter and Tran [2], the International Society
for Clinical Electrophysiology of Vision (ISCEV)
guidelines [4], the special issue of Documenta Ophthalomologica published in 2000 (volume 100) on the
multifocal technique, and the review by Hood [3].
Method for recording the multifocal

electroretinogram
The display
Typically, the multifocal stimulus is displayed
on a computer monitor, although LED displays have
also been employed. The display contains an array of
hexagons; the most commonly used displays contain
either 61 or 103 hexagons (Fig. 1A). The hexagons
are usually scaled to produce local responses of
approximately equal amplitude in control subjects
[2]. The retinal size of the display varies across
laboratories and clinics but is generally 40 to
50 degrees in diameter. The ISCEV guidelines [4]
recommend that the luminance of the white hexagons be set to 100 to 200 cd/m2 and the luminance of
the black hexagons to the lowest value available.
When the recording starts, the display appears
to flicker owing to the fact that each hexagon goes
through a pseudorandom sequence of black and white
presentations (Fig. 1B,C). In the most commonly used
software (VERIS; EDI, San Mateo, California), this
sequence is called an m-sequence [2].
doi:10.1016/S0896-1549(03)00101-9
70
D.C. Hood / Ophthalmol Clin N Am 17 (2004) 6988
Fig. 1. (A) The mfERG display. (B) The mfERG display as it might appear at any moment in time. (C) Examples of the
sequence of events at two locations. (D) A schematic of the continuous ERG signal. (E) mfERG responses, which are the
first-order correlations between the ERG signal (D) and the light sequence (C) of each hexagon. (Modified from Hood DC.
Assessing retinal function with the multifocal technique. Prog Retin Eye Res 2000;19:607 46; with permission).
The recording
Using the same electrodes and amplifiers employed for standard full-field ERG recording, a single
continuous ERG record is obtained (Fig. 1D), usually with the pupil dilated. The continuous record
is typically 4 to 8 minutes in length and is obtained
in 15- to 30-second segments for the subjects
comfort. The ISCEV guidelines [4] recommend a
low-frequency amplifier cutoff of 300 Hz and a
high-frequency cutoff of 3 or 10 Hz. The 10-Hz setting will produce changes in the waveforms but is
used more typically than the 3-Hz setting, because it
produces more stable recordings.
Deriving and presenting the multifocal
electroretinogram responses
The mfERG responses for stimulation of a control
subjects right eye are shown in Fig. 1E. These
responses are derived from the single continuous
ERG record (Fig. 1D). Technically, the mfERG responses are derived as the first-order kernels of the
cross correlation between the stimulation sequence
and the continuously recorded ERG [2,3,5 7].
The responses in Fig. 1E are positioned so that
they do not overlap; therefore, the scaling is not linear
as the isodegree circles in Figs. 1A and 1E indicate.

Frequently, it is useful to sum or average the responses
within various regions of the display. Fig. 2B shows
the responses from Fig. 1E summed within rings
around fixation (Fig. 2A). The summed responses
become larger with eccentricity, because progressively larger areas of the retina are stimulated. To
take the area of stimulation into consideration, for
each ring, the summed response (Fig. 2B) is scaled by
the total area of the hexagons in that ring. The
resulting response (Fig. 2C) is expressed as the
response amplitude per unit area (nV/deg2) or response density. Response density is largest in the
fovea [2]. The software available to analyze the
mfERG allows the combination of responses from
any arbitrary grouping of hexagons.
Comparison of the multifocal electroretinogram with

the full-field test
As typically recorded, the mfERG is a cone-driven
response from the central 20 to 30 degrees (radius) of
the retina (see Fig. 1A). The temporal rate of stimulation combined with the light levels employed
ensures that the rods do not contribute to the response

except under unusual circumstances [8,9].
The mfERG shows an initial negative component
(N1) followed by a positive component (P1) and
then a second negative component (N2) (Fig. 2C).
Although the N1 and P1 components of the mfERG
resemble the a- and b-waves of the full-field flash
ERG, the waveforms differ [3,10]. The differences
between the waveforms of the mfERG and the full-
71
field ERG have been attributed to differences in the

methods of light stimulation and the methods of
deriving the responses [10]. In fact, unlike the fullfield ERG, the mfERG is not a response at all but a
mathematical extraction; therefore, the components
of the mfERG should never be referred to as a- and
b-waves. Despite these differences, the N1 response
of the human mfERG (Fig. 2C) is composed of
the same components as the a-wave of the full-field
Fig. 2. (A) The rings used for the analysis in panels B and C. (B) The mfERG responses summed by rings and expressed in mV.
(C) The mfERG responses in panel B divided by the area within each ring and expressed in nV/deg2. (Modified from Hood D,
Odel JG, Chen CS, Winn BJ. The multifocal electroretinogram (ERG): applications and limitations in neuro-ophthalmology.
J Neuroophthalmol 2003;23:225 35.).
72
ERG, and the P1 response is composed of the

same components as the positive waves (b-wave and
oscillatory potentials [OPs]) [10]. If the rate of stimulation of the multifocal sequence is slowed by interleaving seven or more blank frames (93 ms or more),
the waveform of the human mfERG closely resembles
the waveform of the full-field ERG [10].
Topographical measure of diseases of the outer retina
The mfERG provides a topographical indicator
of the health of the outer retina. The standard human mfERG is largely shaped by bipolar cell activity, with smaller contributions from the photoreceptor
and inner retinal (eg, amacrine and ganglion) cells
[11,12]. Fig. 3 illustrates how the cells of the retina
contribute to determine the shape of the human
mfERG [11]. A similar analysis of the mfERG can
be elicited by a slower stimulation rate [13]. When the
standard mfERG paradigm is used, the inner retina
makes a relatively small contribution to the waveforms. In fact, removing the activity of the ganglion
cells has a relatively minor effect on the standard
human mfERG [14]. In the extreme, subtle changes
in the waveform can be observed. For a disease to

decrease the amplitude of the mfERG, the cone
photoreceptors or cone-driven bipolar cells must be
abnormal. The mfERG, like the standard full-field
ERG, provides a measure of the health of the outer
retina (ie, cone photoreceptors and bipolar cells).
For diseases of the outer retina, the mfERG provides a topographical picture of retinal damage. Fig. 4
compares the recordings obtained with the standard
(ISCEV), full-field, clinical ERG protocol with the
mfERG for a patient with retinitis pigmentosa. For the
full-field ERG (left column), the 30-Hz flicker stimulus produces a response of less than 300 nV (bottom of
left column), whereas the responses to the other
stimuli are not detectable. The ERG indicates that
the retina is still producing a small cone-driven signal.
The mfERG (Fig. 4, right column) shows that this
signal is coming almost entirely from the central
5 degrees. For this patient, the full-field ERG appears
to be composed of local responses of similar waveforms. In other patients, the waveform of the local
responses can differ markedly, which may result in
a full-field ERG with a waveform that is not representative of any of the local responses [3,15].
Fig. 3. A model illustrating contributions of the different retinal cell types to the mfERG waveform. (Modified from Hood DC,
Frishman LJ, Saszik S, Viswanathan S. Retinal origins of the primate multifocal ERG: implications for the human response.
Invest Ophthalmol Vis Sci 2002;43:1673 85; with permission.)
73
Fig. 4. The full-field ERG records from a standard clinical protocol (left column) and the mfERG records (right column) are
shown for a patient with retinitis pigmentosa. (From Hood DC. Assessing retinal function with the multifocal technique. Prog
Retin Eye Res 2000;19:607 46; with permission).
The second-order kernel

Technically, the responses discussed thus far are
first-order kernels. When commercially available software is used, it is possible to derive higher order
kernels. In general, the only higher order kernel
typically reported is the first slice of the second-order

kernel. Fig. 5 provides a simple way to understand the
meaning of the second-order kernel. The schematic
shows that, for any given hexagon, the presentation
of a flash of light can be preceded in the previous
frame by either a flash or darkness. If the response
74
Fig. 5. A schematic illustrating how the second-order kernel is derived. See text for details. (Modified from Hood D, Odel JG,
Chen CS, Winn BJ. The multifocal electroretinogram (ERG): applications and limitations in neuro-ophthalmology. J Neuroophthalmol 2003;23:225 35.)
after the flash differs from the response after the blank
frame, there is a second-order kernel and this kernel is
equal to the difference between the responses [3,5].
The second-order kernel is a measure of how the
mfERG response is affected by a preceding flash. It
is not a response of a particular subset of retinal cells.
The integrity of the outer and inner retina is important for a normal second-order kernel. In monkeys, blocking action potentials generated by the
ganglion cells and amacrine cells markedly reduce
but do not eliminate the second-order kernels [11,12].
In humans, damage to the ganglion cells does not
necessarily change the second-order kernels [14];
however, outer plexiform damage can eliminate the
second-order kernels in patients with degenerative
diseases of the receptors [3,16]. Consequently, a
diminished second-order kernel does not imply damage to a particular set of cells.
Clinical uses of the multifocal electroretinogram
Although the mfERG is used in clinics worldwide, many patients who could benefit from mfERG
are not tested. Other patients are tested using the
mfERG when full-field ERG tests would be as, if
not more, informative. The mfERG test is best reserved for situations in which the full-field ERG is
normal or is likely to be normal or uninformative. The
examples described in this section and elsewhere [3,7]
illustrate such cases.
Establishing that a disease has an outer retinal origin

Frequently, the clinician must determine whether
a visual field defect is caused by damage to the outer
retina (ie, receptors and bipolar cells) or to the ganglion cells/optic nerve. In most cases, when the site of
damage is the outer retina, the fundus examination,
angiogram, or full-field ERG will be abnormal.
Nevertheless, in some circumstances, damage to the
outer retina can be missed by these tests. Fig. 6B
shows the mfERG responses from a patient with a
defect that would be hard to detect using the traditional full-field ERG or focal ERG. The fundus in this
patient appeared normal, and his visual acuity was
20/20. 24-2 Humphrey visual fields (HVF) (Fig. 6A)
showed paracentral ring scotomas in both eyes. The
records at the bottom of Fig. 6A show the average
response density within the three areas marked. The
amplitudes of the responses are reduced markedly in
the ring with the most severe field damage. The question for the ophthalmologist was whether the field
defect was caused by glaucoma or a retinopathy. The
mfERG confirmed that the problem was in the outer
retina. It would be difficult to detect this defect using
the traditional full-field ERG or focal ERG [1,17].
Comparing the multifocal electroretinogram with
visual field topographies
The clinical utility of the mfERG can be enhanced
greatly by comparing the findings with the visual
fields from static automated perimetry. As is true for
Fig. 6. (A) The OS (left panel) and OD (right panel) 24-2 HVFs of a patient with paracentral scotomas. (B) The OS (left panel)
and OD (right panel) mfERG responses for this patient. The vertical and horizontal calibration bars indicate 100 nV and 60 ms,
respectively. Bold dark gray, thin black, and dashed light gray circles indicate radii of 5, 15, and 25 degrees, respectively. (C) The
OS (left panel) and OD (right panel) mfERG responses, expressed as response density, for the area within 5 degrees (dark gray),
between 5 and 15 degrees (black), and between 15 and 25 degrees (light gray). (Modified from Hood D, Odel JG, Chen CS, Winn
BJ. The multifocal electroretinogram (ERG): applications and limitations in neuro-ophthalmology. J Neuroophthalmol 2003;
23:225 35.)
75
76
all clinical measures, variability can lead to a degree

of uncertainty in the interpretation of mfERG results;
however, much of this uncertainty disappears if the
mfERG and visual field topographies agree. To compare the HVF with the mfERG topographies, isodegree contours can be added as shown by the circles
in Fig. 6. Although more sophisticated procedures exist
for comparing the HVF with the mfERG [18], these
contours are sufficient for most clinical purposes. The
agreement between the mfERG and HVF topogra-
phies in Fig. 6 establishes the retinal origin of the

defect with a degree of certainty not possible with
tests that do not provide topographical information.
Differentiating among different retinal diseases
The specific pattern of amplitude and implicit
time abnormalities can help to distinguish different
retinal diseases. A large delay in the timing of the
mfERG is associated with damage to the receptors/
outer plexiform layer [3,15,16,19,20]. In diseases
Fig. 7. (A) The 30-2 HVF of a patient with retinitis pigmentosa. (B) The mfERG responses for this patient. (C) The mfERG
responses, expressed as response density (C) and as summed responses (D) for the area within 5 degrees (dark gray), between 5
and 15 degrees (black), and between 15 and 25 degrees (light gray).
such as retinitis pigmentosa and cone dystrophies,

the responses in regions of depressed sensitivity
sometimes show marked delays. Fig. 7 shows the
HVF field (panel A) and mfERG responses (panel B)
for a patient with retinitis pigmentosa. The responses
from the central regions have normal timing, whereas
the responses from the peripheral regions, where the
fields are depressed, show large delays. This difference can be seen more easily in panel C, where the
response densities (see Fig. 2) are shown for the three
regions indicated in panels A and B. Because the
central region represents a small proportion of the
total field, the full-field ERG will be dominated in
77
this patient by the peripheral responses (summed

responses in Fig. 7D). In fact, this patient has a large
but delayed 30-Hz full-field flicker response. Interestingly, although retinitis pigmentosa is a disease of
the receptors, the retina can still produce large but
delayed responses in some patients.
Although large delays in timing are a sign of
degenerative photoreceptor disease, local lesions to
all layers and damage to the inner nuclear layer
(eg, bipolars) are usually associated with smaller
responses that have minimal delays in timing. The
patient whose mfERG records appear in Fig. 8B
complained of a C-shaped field problem following
Fig. 8. (A) The 10-2 HVF of a patient after surgery to repair a macular hole. (B) The mfERG responses for this patient. (C) A
three-dimensional representation of the mfERG results. (D) The responses from the affected eye (black) and the other eye (gray)
were averaged for regions within and outside of the defect. The dashed curve is the black curve scaled in amplitude.
78
surgery to repair a macular hole. Her 10-2 HVF

(Fig. 8A) matched the subjective complaints. The
depressed amplitudes in the mfERG responses seen
in Fig. 8B and the three-dimensional representation in
Fig. 8C closely correspond to the field. This finding
suggests that the damage is at or before the bipolar
cells. Damage to the nerve fiber layer would not
produce these local losses in amplitude. Fig. 8D shows
the average responses from the good eye (gray) and the
affected eye (black) for a region within the defect
(upper traces), as well as for a region outside the defect
(lower traces). The amplitude is reduced with little
change in implicit time. The dashed curve represents
the black record scaled in amplitude. In Fig. 8D,
in addition to a reduction in amplitude, there is a subtle
change in waveform, with N2 relatively reduced in
amplitude. The second-order kernel (not shown) is
missing in the affected region, accounting in part for
this change in waveform [3,5]. Local lesions are often
easier to see in the second-order kernel [21,22].
Diabetic retinopathy can affect the inner and outer
retinal layers. Consequently, the mfERG from patients with diabetic retinopathy can show a range of
changes [23,24]. Some patients have normal mfERG
responses in regions of poor sensitivity, consistent
with inner retinal damage. Other patients show large
but delayed responses in such regions, consistent with
damage in the outer retina, probably the outer plexiform layer [3].
Other clinical uses
There are other less common uses of the mfERG
in addition to establishing the retinal locus of a
disease process and differentiating among diseases.
In a review of cases seen by neuro-ophthalmologists,
the author and his colleagues [7] found that the
mfERG could be used to rule out functional (nonorganic) causes, to follow the progression of a disease,
and to distinguish between two pre-existing conditions that could have caused a visual field defect. In
addition, mfERG has been used to examine patients
before and after treatment for retinal detachment [25],
laser treatment for macular edema secondary to diabetic retinopathy [23], and surgery for macular holes
[26]. Other uses of the mfERG technique will most
likely be found as new interventions are developed.
The mfERG should be particularly useful in situations
in which localized changes are expected, such as
experimental retinal transplant procedures and local
drug injections.
The need for normative values
In all types of electrophysiologic testing, each
clinic should establish its own normative values.
For reference purposes, normative values have been

published [27 31].
Detecting ganglion cell damage with the multifocal
electroretinogram
The effectiveness of the mfERG for detecting local
ganglion cell damage in humans is currently under
debate. Although the literature contains various contradictory findings, the evidence is relatively clear on
some points. First, a component generated at the optic
nerve head seems to reflect local ganglion cell activity.
Sutter and Bearse [32] first identified this component
in the human mfERG, calling it the optic nerve head
component (ONHC). Second, a component similar to
the ONHC has been identified in the monkey mfERG
[33]. When action potentials are blocked in the
monkeys eye, this ONHC disappears, as does a
high-frequency component that resembles oscillatory
potentials [33 35]. Because only the ganglion cells
and a few classes of amacrine cells fire action potentials, the ONHC undoubtedly depends on action
potentials produced by the ganglion cells. On the
other hand, it is not clear whether the high-frequency
component depends on ganglion cell or amacrine cell
activity. The ONHC and the high-frequency component are larger in the monkey mfERG than in the
human mfERG [33]. Because these inner retinal
contributions are large in the monkey, it is relatively
easy to see the effects of glaucomatous damage in
monkey models [36,37]. Some patients with glaucoma show changes in the standard mfERG, and these
changes can often be related to measures of the OHNC
or high-frequency component [14,38 42]. Nevertheless, attempts to detect glaucomatous damage with the
standard mfERG recordings show relatively poor
sensitivity and specificity [14,40,41,43]. The relatively small ONHC in humans can be enhanced with
specialized paradigms of mfERG stimulation (eg,
the global flash paradigm [44 46]) or methods of
analysis [32]. Even with these methods for enhancing
the contributions of the inner retina, the results remain
controversial. Although, in a few patients, clear evidence of local damage has been reported [42,45,47],
in general, the results published to date have been
disappointing [47,48]. It remains unclear whether the
mfERG, combined with a global flash paradigm, can
detect early damage. If the results of future studies are
more encouraging, the mfERG technique should be
compared with other objective tests of ganglion cell
function, such as the pattern ERG, the photopic
negative response, and the multifocal VEP [49]. For
now, the mfERG cannot be considered a useful clinical tool for studying ganglion cell damage.
Common mistakes
Two common mistakes are worth mentioning.
First, three-dimensional representations, such as that
shown in Fig. 8C, should never be presented without
the accompanying response array (Fig. 8B). Records
without any signal can produce three-dimensional
plots that have a peak in the center, that is, noise
by itself can appear as if there were a foveal response
present [4,7]. Second, eccentric fixation can mimic a
macular problem [7]. This effect is particularly troublesome in the patient who has a small central loss of
vision that could be caused by optic atrophy or outer
retinal disease. Optic atrophy, coupled with eccentric
fixation, can mimic the mfERG recorded when an
outer retinal defect is present. In cases of central loss,
it is important to have a way of determining where
the patient is looking [7].
Summary
The mfERG is a useful clinical tool [3]. It is particularly valuable for distinguishing damage to the
outer retina (choroidal, receptor, and bipolar damage)
from damage to the ganglion cells and optic nerve
when the full-field ERG is normal. In many cases, the
changes in amplitude and waveform can help identify
the particular level at which the retina is affected.
Technical problems must be overcome to obtain useful mfERG recordings. If the clinician is already
recording high-quality full-field ERGs, recording
high-quality mfERGs should not be difficult. Nevertheless, the difficulties involved in full-field ERG
testing are also encountered in the recording and the
analysis of mfERG, and other difficulties unique to
the multifocal technique arise. In general, mfERG
testing is best done at centers with an electrophysiologist trained in ERG and multifocal technology.
The multifocal visual evoked potential

The VEP is a gross electrical potential generated
by the cells in the occipital cortex. VEP responses can
be recorded simultaneously from many regions of
the visual field using the mfVEP technique introduced
by Baseler and colleagues [50,51].
Method for recording the multifocal visual evoked
potential
The VEP signal is recorded using the same electrodes and amplifiers employed for conventional VEP
recording. There are critical differences in the display,
79
the method of stimulation, and the analysis of the

raw records. This section provides basic information
on how the mfVEP is recorded. For more details, the
reader is referred to the review by Hood and Greenstein [52].
The display
The mfVEP can be recorded with a wide range
of displays and paradigms. Most of the mfVEP work
to date has been done using pattern reversal stimulation and the display in Fig. 9A, which was introduced
by Baseler and colleagues [50,51]. The dartboard display contains 60 sectors, each containing 16 checks,
8 black and 8 white. The sectors and the checks are
scaled based on cortical magnification. The retinal
size of the display varies across laboratories but is
generally between 30 and 60 degrees in diameter. For
the recordings presented herein, the diameter was
44.5 degrees. Although there are no ISCEV guidelines
for mfVEP recording, typically, the luminance of the
white hexagon is set between 50 and 200 cd/m2 and
the black hexagon to the lowest value available.
The recording
A single continuous VEP (EEG) record is obtained with electrodes over the occipital region. In
general, the mfVEP is recorded with two midline
electrodes, which serve as the active and the reference
electrodes. A third electrode, the ground, is placed on
the forehead or the ear (the so-called bipolar recording). Klistorner and Graham [53] suggested recording from four channels with two additional electrodes
placed lateral to the inion. Hood and colleagues
[52,54] use three active electrodes, one placed
4 cm above the inion and two placed 4 cm lateral to
the inion on each side. Each active electrode is
referenced to the inion, providing three channels of
recording. This technique effectively provides six
channels of records, because the recordings that
would result from three additional channels can be
derived with software (Fig. 9B). Fig. 9C shows the
mfVEP responses (midline channel) for a control
subject. The best responses, defined in terms of a
signal-to-noise ratio from all six channels, are shown
in Fig. 9D. For this individual, the additional channels
improved the recordings from the horizontal meridian
(black ellipses) and the fovea (gray ellipses), as
suggested by Klistorner and Graham [53].
Displaying the multifocal visual evoked potential
responses
The mfVEP responses are usually displayed as
an array shown in Figs. 9C and D. The spatial scale
80
Fig. 9. (A) The display employed for the mfVEP recordings. (B) The electrode locations employed for the mfVEP recordings.
(C) Array of mfVEP responses obtained from the midline electrode placements (A D in panel B). (D) Array of mfVEP
responses obtained from the recording channels that produce the best responses, as defined by the highest signal-to-noise ratio.
for this array is not linear as a comparison of the

isodegree circles in Figs. 9C and D indicates. The
responses in the array are positioned arbitrarily so that
they do not overlap. Within the central 2.6 degrees
(5.2 degrees in diameter), there are 12 responses,
whereas a region that is considerably larger than the
entire central 2.6 degrees produces each of the
responses in the outer ring.
As is true for the mfERG, each of the individual mfVEP responses in the array is not, technically,
a response; rather, each response is derived via a
correlation between the stimulation sequence of a
particular sector and the overall single continuous
VEP recording.
Comparison of the multifocal visual evoked potential

responses from two eyes
Considerable intersubject variability occurs in the
amplitudes and waveforms of the mfVEP responses.
This variability occurs owing to individual differences
in the location and folding of the visual cortex [18,52].
Fig. 10 shows the mean responses obtained with
monocular stimulation of the right (black) and left
(grey) eyes of 30 normal control subjects. These
responses are nearly identical because they are generated in the same cortical regions. There are two
exceptions. First, there is a small amplitude asymmetry along the horizontal meridian. Second, there is a
81
Fig. 10. The averaged mfVEP responses for 30 normal control subjects.
small interocular latency difference of about 4 or 5 ms

across the midline. This small difference can be seen
in the insets in Fig. 10. The left eye leads in the left
visual field, and the right eye leads in the right visual
field. The article by Hood and Greenstein [52] provides a discussion of the reasons for these differences.
Comparison of the multifocal visual evoked potential
with the conventional test
The major components of the mfVEP resemble
those of the conventional VEP elicited by pattern
reversal stimuli. In Fig. 11, the conventional pattern
VEPs recorded with stimulation of the upper and
lower hemifields are compared with the summed
mfVEPs (from the midline channel) for the same
hemifields. In the mfVEP, there is an initial negative
component around 65 ms followed by a prominent
positive component (C2) around 95 ms, analogous
to the N75 and P100 of the conventional pattern VEP
[55]. Nevertheless, the mfVEP responses differ from
the pattern VEP. The pattern VEP from the upper
hemifield is often a complex waveform, whereas the
mfVEP responses above and below the midline are
reversed in polarity. As noted by Baseler et al [50],
the reversal in polarity of the mfVEP response suggests that the primary generator of the mfVEP is in the
Fig. 11. A comparison of the conventional pattern VEP

(pVEP) and the mfVEP. Responses from the upper (dashed)
and lower (solid) hemifields are shown. (Modified from
Fortune B, Hood DC. Conventional pattern-reversal VEPs
are not equivalent to summed multifocal VEPs. Invest
Ophthalmol Vis Sci 2003;44:1364 75; with permission.)
82
calcarine fissure. Fortune and Hood [55] speculated

about the causes of the differences between the
mfVEP and pattern VEP. They suggested that the
mfVEP is largely generated in V1 (striate cortex),
whereas the conventional VEP contains a relatively
larger extrastriate contribution. Recently, Zhang and
Hood [56] extracted a large principal component
of the mfVEP that appears to be generated in V1.
Topographical measure of diseases of the ganglion
cells and optic nerve
Local damage to the ganglion cells and optic
nerve can be detected with the mfVEP. To date, two
groups have developed quantitative techniques for
comparing mfVEP abnormalities with visual defects
measured with static automated perimetry [18,52
54,57 62]. These techniques are more elaborate
than those used in mfERG. To illustrate the problem,

consider the patient whose 24-2 HVF (probability
plot) is shown in Fig. 12A. This patient had unilateral glaucomatous damage in the left eye; the HVF
for the right eye was normal. The defects in the left
eye are circled in gray and black. The mfVEP responses obtained from the patients left eye (red)
and right eye (blue) are shown in Fig. 12B. The isodegree contours are shown for the HVF and the
mfVEP responses.
To determine which of the responses from the
left eye (red records in Fig. 12B) were abnormal,
mfVEP probability plots analogous to the HVF probability plot in Fig. 12A were developed. Monocular
mfVEP probability plots (left two panels in Fig. 12C)
were obtained by comparing the patients mfVEPs
with the mfVEPs from the left and right eyes of a
group of control subjects [52]. Each square is the
Fig. 12. (A) The 24-2 HVF total deviation probability plot from the left eye of a patient with glaucoma. (B) The mfVEPs from
the left (red) and right (blue) eyes. The red, blue, and green circles in panels A and B indicate radii of 2.6, 9.8, and 22.2 degrees,
respectively. (C) The probability plots for the mfVEPs in panel B. See text for details. (Modified from Hood DC, Greenstein VC.
The multifocal VEP and ganglion cell damage: applications and limitations for the study of glaucoma. Prog Retin Eye Res
2003;22:201 51; with permission.)
physical center of one of the sectors in the mfVEP

display (see Fig. 9A). For each sector, the amplitude
of the patients mfVEP was determined and compared
with values for a group of control subjects [52,54,
61,62]. A colored square indicates that the mfVEP
was statistically significant at the 5% (desaturated
color) or 1% (saturated color) level. The color indicates whether the left (red) or right (blue) eye was
significantly smaller than normal.
The HVF (Fig. 12A) and mfVEP (Fig. 12C) probability plots are on the same linear scale. A direct
comparison can be made. To aid in this comparison,
the black and gray ellipses from Fig. 12A are overlaid
onto Fig. 12C. The mfVEP confirms the HVF defect
within the black ellipse but not the defect within the
gray ellipse.
In some patients, especially those with unilateral
damage, an interocular comparison of the mfVEPs
is a more sensitive indicator of damage [52,59] than
is monocular comparison with the control group. To
obtain the interocular mfVEP plot in Fig. 12C (right
hand panel), the ratio of the mfVEP amplitudes of
the two eyes was measured for each sector of the
display and compared with the ratios from a group
of controls [18,52,54,57,58]. The result was coded
as in the monocular fields. The defect within the
gray ellipse was still not apparent, but an arcuate
defect was detected in the lower field that was not
present in the HVF. Subsequent tests confirmed that
this defect was real. Hood and Greenstein [52] have
83
provided a review of the derivation and use of

monocular and interocular probability plots.
Clinical uses of the multifocal visual evoked potential
Although the clinical role of mfVEP is still being
defined, five uses can be identified.
Diagnosing and following optic neuritis/multiple
sclerosis
Optic neuritis is a clinical syndrome characterized
by an acute unilateral loss of vision accompanied by
an afferent pupillary defect. It is often one of the first
signs of multiple sclerosis. Typically, the optic neuritis partially or completely resolves within 3 months.
In fact, some patients have reasonably normal visual
fields after recovery. In some of these cases, the patients complain of hazy or fuzzy vision in parts
of the visual field, although the HVF can appear
normal in these regions. After recovery, the mfVEP
shows local delays, presumably in the regions corresponding to the portions of the optic nerve that
were demyelinated.
The mfVEP records in Fig. 13B show the range
of findings that can be observed in a patient sustaining
an attack of optic neuritis [63 65]. In this case, the
HVF probability plot (Fig. 13A) shows a paracentral
defect. The mfVEP (Fig. 13B) shows that, outside the
region of the defect on the HVF (black ellipse), there
are regions with delayed mfVEP responses (asterisks)
Fig. 13. (A) The 24-2 HVF total deviation probability plot from a patient with optic neuritis and multiple sclerosis. (B) The
mfVEPs from the left (gray) and right (black) eyes. (Modified from Hood D, Odel JG, Winn BJ. The multifocal visual evoked
potential (VEP): applications and limitations in neuro-ophthalmology. J Neuroophthalmol 2003;23(3):225 35.)
84
and regions with reasonably normal mfVEP responses

(plus signs). In fact, regions with delays can border
regions that have responses with normal amplitude
and latency; therefore, the mfVEP can detect local
demyelinizaton [63].
The mfVEP is clearly superior to the HVF and
the conventional VEP for following patients with
optic neuritis and multiple sclerosis. Whether the
conventional pattern VEP is abnormal will depend
on the relative contributions of the normal and abnormal regions. The conventional VEP is most likely to
miss problems in the upper field, which typically
contribute less to the overall VEP signal than does
the lower field [55]. Fig. 14 shows the visual field
probability plots (panel A) and mfVEP responses
(panel B) from a 45-year-old man who complained
of blurred vision in the upper field of the left eye. His
conventional pattern VEP and HVFs (panel A) were

normal. The mfVEPs summed within each quadrant
are shown as the insets in panel B. The mfVEPs are
clearly delayed in the upper field. The diagnosis of
multiple sclerosis was confirmed on MRI studies
showing lesions in the left optic nerve.
Ruling out functional (nonorganic) causes
The conventional VEP has traditionally been used
to rule out functional or nonorganic causes of a visual
defect. Because multiple local responses are obtained,
the mfVEP is more effective than the conventional
VEP for this purpose. A local defect can be identified
on the mfVEP but missed totally on the conventional
VEP if the defect involves a small part of the total field
stimulated. In these cases, the diagnosis of a functional cause can be avoided. On the other hand, it is far
Fig. 14. (A) The 24-2 HVF total deviation probability plots from a patient with optic neuritis and multiple sclerosis. (B) The
mfVEPs from the left (gray) and right (black) eyes are shown.
easier to make the diagnosis of a functional cause

when large normal mfVEP responses are present in
regions of the field where the 24-2 HVF shows a profound defect [66].
Identifying unreliable fields
The HVF test provides a measure of fixation errors
as well as false-positive and false-negative errors,
allowing the test to identify unreliable fields. Many
patients cannot produce reliable HVFs. For most of
these patients, the mfVEP provides an alternative.
Identifying questionable fields or fields that need
confirmation
In many cases, the ophthalmologist has insufficient or contradictory evidence, making it difficult to
diagnose the cause of a defect seen on the HVF. In
such cases, the mfVEP provides another topographical map that can help in the diagnosis [52].
Detecting glaucomatous damage
Ophthalmologists rely on visual fields from automatic static perimetry such as the 24-2 HVF to detect
and to follow glaucomatous damage. Because glaucoma can be controlled with medication and surgery,
early detection and therapeutic intervention are critical. Histologic studies on donor eyes have found that
HVF tests may not detect defects until substantial
ganglion cell damage has taken place [67 69]. This
finding has encouraged the search for new techniques
for identifying functional defects. The mfVEP has
been suggested as a test that may be superior to the
HVF [58].
Local ganglion cell damage secondary to glaucoma
can be detected with the mfVEP [18,52 54,57,58,
70 72]. In many cases, the mfVEP objective field loss
resembles the field loss measured with the subjective
HVF technique [52,58]. In other cases, the mfVEP
detects damage missed by the 24-2 HVF. The extent to
which the mfVEP will outperform standard white-onwhite perimetry remains an unanswered question [52].
Hood and Greenstein [52] have provided a theoretical framework for judging when the 24-2 HVF or
the mfVEP will be superior in detecting damage. They
start with the assumption that the mfVEP response is
composed of two componentssignal and noise.
With this assumption, the evidence supports a simple
proportional relationship between the local loss of
ganglion cells and the amplitude of the signal in the
local mfVEP response [52,59], that is, losing one half
of the local sensitivity ( 3 dB loss) results in a
decrease of the mfVEP signal by one half. Hood
85
et al [52,59] suggest that the decreases in local visual

field sensitivity and local mfVEP signal amplitude are
proportional to local ganglion cell loss.
Based on the Hood Greenstein analysis and measures of the variability of the HVF and mfVEP, there
will be circumstances in which the mfVEP will detect
damage missed on the HVF, as well as circumstances
when the reverse will be true. The patient in Fig. 12
provides an example. The mfVEP detects a defect
missed by the 24-2 HVF (purple ellipse) in the lower
field, whereas the reverse is true for the defect in the
upper part of the 24-2 HVF (gray ellipse). The Hood
Greenstein analysis suggests that the two tests will
often, but not always, agree. This theoretical analysis
also helps specify the conditions under which one
test will be better at detecting damage [52]. Recent
evidence supports this analysis [73].
Summary
Multifocal VEP technology is still in its infancy.
Although many aspects of the recording and analysis will be improved with time, the mfVEP can be
used in the clinic today. It can help to identify
functional (nonorganic) problems, demyelinating diseases, glaucomatous damage, and poor field takers.
Given the software and techniques needed to record
and interpret the results, mfVEP testing should be
performed in centers experienced with this technique.
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Multifocal visual evoked potential, multifocal

electroretinography, and optical coherence tomography in
the diagnosis of subclinical loss of vision
Thomas R. Hedges III, MD*, Maria-Luz Amaro Quireza, OD
Tufts University, New England Eye Center, 750 Washington Street, Box 450, Boston, MA 02111, USA
Neuro-ophthalmology has many possible definitions, including the discipline of diagnosing diseases
affecting vision before the development of clearly
identifiable clinical signs. In addition, neuro-ophthalmology includes proving the absence of neurologic
disease, especially in patients with functional loss of
vision. Frequently, it is determined that a patient with
apparent neurogenic loss of vision actually has an
ophthalmic condition, such as occult maculopathy.
Three relatively new modalities are becoming technologically refined enough to be useful in clinical practice. These methods are optical coherence tomography
(OCT), multifocal electroretinography (mfERG),
and multifocal visual evoked potential recording
(mfVEP). Perhaps the most revolutionary modality is
mfVEP, because it has the potential of replacing
conventional visual field testing.
Multifocal visual evoked potential

Perimetry remains one of the essential tools for
neuro-ophthalmic diagnosis; however, all forms of
visual field testing depend on the active participation
of the patient. The subjectivity of visual field testing
leads to considerable variability and unreliability. This
problem is especially true in automated perimetry in
which the examiner, and the interpreter of the visual
field, has less control over the patients performance
E-mail address: THedges@tufts-nemc.org
(T.R. Hedges III).
of the test. Although manual perimetric skills, once

the pride of the neuro-ophthalmologist, are still necessary, they are also time consuming. mfVEP recording may provide a solution to these problems. If it can
be refined to the point at which small areas of visual
field loss can be detected, the ease of performance of
the test for the patient and the objective data provided
will advance the ability to diagnose conditions that
affect the visual field. Furthermore, the additional
physiologic information of latency and the amplitude
of the multifocal evoked potential waveform will add
more depth to the clinical information one needs to
make timely and accurate diagnoses.
For several decades, standard VEP has been used
to study a variety of ophthalmic problems [1]. This
technique essentially records macular responses. Multifocal technology [2] allows VEP waveforms to be
generated from stimuli to multiple areas of the visual
field [3,4]. This approach has been applied to a variety
of clinical disorders, particularly glaucoma [4,5]. The
authors have used the AccuMap system (ObjectiVision Pty, Sydney, Australia) and the Visual Evoked
Response Image System (VERIS; EDI, San Mateo,
California). This article discusses the authors preliminary experience with both of these devices for neuroophthalmic disorders.
The stimulus used for mfVEP includes families of
pseudorandom binary sequences of groups of 16
alternating checks (Fig. 1). These check patterns are
arranged within multiple segments of the stimulus
field (56 segments within 24 degrees [32 nasally] for
the AccuMap and 60 segments within 44.5 degrees for
the VERIS). Signals are recorded from two to four
electrodes arranged vertically or in a cross over the
occiput using single or multiple channels. The re-
doi:10.1016/S0896-1549(03)00104-4
90
T.R. Hedges III, M.L.A. Quireza / Ophthalmol Clin N Am 17 (2004) 89105
Fig. 1. Multifocal VEP stimulus pattern (AccuMap).
corded signals are amplified 100,000 times and

band pass filtered between 3 and 30 Hz. The signals
may be scaled to the electroencephalogram. Computation of signals occurs by cross-correlation of the
responses evoked by the sequence stimulation with
the sequences themselves. Refractive errors, cataracts,
and eccentric fixation can influence the results and
need to be considered when interpreting mfVEPs [6].
The authors have found that the results from
mfVEP correlate well with the results of automated
perimetry in many situations. Nevertheless, the results
from normal subjects are not entirely free of minor
variations and some variability. Interestingly, some of
the authors best normal recordings have been
obtained from patients who were presumed to have
functional or fictitious visual field defects (Fig. 2). In
fact, one of the best uses of mfVEP has been in
documenting normal visual field function in patients
with suspicious hemianopias and visual field constriction. Identification of bitemporal hemianopia as a
functional problem on mfVEP has been reported by
Merle et al [7]. The authors have documented normal
responses in six patients, one with monocular hemianopia, one with heteronymous quadrantanopias, one
with monocular severe visual field constriction, and
two with tubular visual fields (Massicott and Hedges,
submitted for publication, 2004).
The mfVEP results in patients who have maculopathy show findings that would be expected. The
amplitude and latency are clearly affected within the
area detected by perimetry (Fig. 3). In patients who

have long-standing visual field defects from optic
nerve and chiasmal disease, there seems to be a direct
correlation with automated visual field findings
(Fig. 4). More studies are needed to determine whether these apparent correlations will remain reliable. The
added feature of mfVEP of providing physiologic
data, as opposed to anatomic or simply localizing
information, is illustrated in patients with demyelinating disease. As expected in patients with optic
neuritis, the mfVEP latencies are affected more profoundly than are amplitudes. This effect can be seen in
patients who have recovered from optic neuritis, in
whom the amplitude of the mfVEP may be relatively
normal but in whom latency delays remain (Fig. 5).
Such latency delays may provide a more sensitive
means to follow the course of patients with optic
neuritis, especially when it occurs owing to multiple
sclerosis. Hood et al [8] reported persistent mfVEP
latency delays in three patients in whom loss of visual
acuity, visual field, and mfVEP amplitudes returned to
normal after treatment of optic neuritis. Patients with
ischemic optic neuropathy also have been studied with
mfVEP [9].
Multifocal VEP results from patients with retrochiasmal visual pathway disorders have not correlated
as well as expected with visual field findings. The
authors have found that mfVEP abnormalities do not
respect the vertical meridian as distinctly as visual
field changes (Fig. 6). This observation applies to
91
Fig. 2. Normal mfVEP responses (A) from a 45-year-old woman who had a temporal visual field defect in her left eye (B), which
remained when both eyes were tested simultaneously.
patients with long-standing occipital damage as well

as those with more recent damage to occipital and
visual radiations. Betsuin et al [10] found it necessary
to summate the responses in each quadrant of the
mfVEP to obtain useful data in patients with chiasmal
and retrochiasmal visual field defects. Wall et al [11]
found that 5 of 10 hemianopic visual field defects
were missed using a prototype of the AccuMap.
Multifocal VEP identifies visual field defects relatively accurately and reproducibly. It allows an
analysis of latency and amplitude data at various
points in the visual field. A technician can perform
it rapidly and conveniently. Above all, it is objective.
Ultimately, mfVEP may replace visual field testing, at
least automated testing.
Multifocal electroretinography
Multifocal ERG, like mfVEP, permits an evaluation of local electrophysiologic responses across the
human retina. It provides objective data useful for the
early detection of focal retinal disease and the evaluation of treatment. The technique allows the simultaneous and topographical recording of the ERG
activity of hundreds of retinal locations from the posterior pole, and it can separate true variation among
retinal regions from a variability in the responses over
time in a single recording session of 4 to 8 minutes. It
is especially useful in patients who have localized
damage in the outer retina. Conventional ERG remains useful for detecting disorders that cause diffuse
92
Fig. 3. Multifocal VEP (A) from a patient with a well-circumscribed visual field defect (B) from a macular lesion.
retinal damage, such as retinitis pigmentosa and autoimmune retinopathy.

The authors have been using the VERIS device
developed by Sutter et al [12] to record mfERGs. The
stimulus matrix consists of 103 hexagonal elements
within a 30-degree visual field at a viewing distance
of 27 cm. These elements are scaled in an array with
eccentricity to elicit more equal signal amplitudes at
all locations. The stimulation rate is 75 Hz. Each area
is stimulated with the same pseudorandom sequence
of light and dark, called a maximum length sequence or m-sequence, so that each video frame
has a 50% probability of being light or dark. In this

way, the overall luminance remains constant. Because
of the light levels employed and the repetitive stimulation, cone responses are recorded. Burian-Allen
bipolar contact lens electrodes are used. The subjects
pupils are dilated. The opposite eye is occluded. After
visual acuity is corrected for the viewing distance,
patients are instructed to maintain fixation on a
central spot. This fixation can be monitored with a
camera. The first-order components of the mfERG
cone responses are recorded, and three-dimensional
display plots are obtained in each case. An artifact
Fig. 4. Multifocal VEP (A,B) from a man with bitemporal visual field defects (C,D) from a pituitary adenoma.
93
94
Fig. 5. Multifocal VEPs from a 30 year-old woman who had recovered most of the vision lost from optic neuritis associated with
multiple sclerosis. mfVEP for the left eye is normal (A) but shows increased latencies in the right mfVEP (B). Visual acuities
were 20/15 OD and 20/20 OS, and visual fields were relatively normal OS (C) and showed areas of mild depression OD (D).
elimination technique is used. The first-order kernel

can be considered as the mean response to a local
flash. It consists of a negative deflection followed by
a positive deflection, with a shape similar to that of
conventional ERG a- and b-waves. Whether these
deflections have the same retinal origins as ERG
a- and b-waves remains to be determined [13]. The
authors have found mfERG to be useful in diagnosing
a variety of relatively occult macular disorders, including hydroxychloroquine retinopathy, Stargardts
disease, acute idiopathic blind spot enlargement syndrome, and occult age-related macular degeneration.
Retinopathy from hydroxychloroquine remains a
difficult problem to diagnose early. No broadly accepted screening tests exist. Full-field ERG is incapable of detecting early damage, which appears to be
located in the macular area. Maturi et al [14] described
a case in which a 45-year-old woman was treated

with hydroxychloroquine averaging 400 mg/day
for 6 years. mfERG showed decreased electrical responses in the macular areas with a reduction in
amplitude and latency. Visual symptoms and loss of
visual acuity had already become well established
[14]. Recently, the authors reported a series of cases
in which mfERGs were distinctly abnormal in three
patients in whom visual acuities were still 20/20 to
20/25 (Fig. 7) [15]. These patients were symptomatic
and had detectable perifoveal visual field loss. mfERG
confirmed that the visual symptoms were caused by
hydroxychloroquine. To date, the authors have not
detected mfERG abnormalities in patients taking
hydroxychloroquine who have not become symptomatic. Nevertheless, identifying presymptomatic
mfERG abnormalities in these patients through pro-
95
Fig. 6. Multifocal VEP (A,B) from a 55-year-old woman who had right homonymous hemianopia (C) from apparent perinatal
hypoxic injury to the left occipital cortex since birth associated with hemiband atrophy of the optic nerves.
spective follow-up at various intervals of time might

allow for discontinuation of the drug before visual
morbidity occurs.
The acute idiopathic blind spot enlargement syndrome and the multiple evanescent white dot syndrome, which may be distinctive phenomena, can
usually be diagnosed with confidence by clinical
examination. In some cases, confirmation that blind
spot enlargement is caused by peripapillary retinal
disease may be necessary to avoid more expensive or
invasive testing to rule out other disorders. mfERG
has been reported to show distinctive peripapillary
changes in patients who have acute idiopathic blind
spot enlargement syndrome or the multiple evanescent

white dot syndrome [16 20]. The authors also have
found mfERG to be helpful in such cases (Fig. 8).
Stargardts disease frequently presents as a loss of
visual acuity in children who have minimal findings
on clinical examination. If flecks are not seen in the
retina, one must rely on fluorescein angiographic
absence of normal choroidal fluorescence, the socalled silent choroid. Scanning laser ophthalmoscopy can show macular changes that can identify
subgroups of Stargardts retinopathy [21]. Kretschmann et al [22] found that, in patients with Stargardts
retinopathy, mfERG could detect foveal dysfunction
96
Fig. 7. Multifocal ERG recordings (A) showing generalized depression surrounding a relatively preserved central peak from a
52-year-old woman who had been on hydroxychloroquine for 8 years. She had visual acuities of 20/25 OD and 20/25 OS, normal
screening color plate testing, and pericentral visual field loss on automated perimetry (B) compared with a normal mfERG (C).
97
Fig. 8. Multifocal ERG showing reduced responses in the area corresponding with blind spot enlargement (A) from a 38-year-old
woman. (B) Visual acuity was 20/20 in both eyes, and there was mild haziness around an otherwise normal-appearing optic disk
and retina.
in the early stages of the disease in patients lacking

morphologic fundus changes and with good visual
acuity. The authors also have found mfERG to be
useful in diagnosing Stargardts disease (Fig. 9).
Multifocal ERG is also useful in occult maculopathy from age-related macular degeneration [23],
retinitis pigmentosa [24], and branch retinal artery
occlusion [25]. Piao et al reported eight cases of occult
maculopathy in which the macular ERG amplitudes
and implicit times were decreased and delayed, respectively, when ophthalmoscopic, fluorescein angiographic, and full-field ERG results were normal.
Chappelow and Marmor [26] recorded the mfERG
in six patients who had central serous choroidopathy.
The mfERG was depressed not only in the areas of
detachment but also beyond the detachment in the
acute phase of the disorder. In five patients, after
resolution of clinical signs, mfERG amplitudes improved but remained subnormal throughout the posterior pole, and the latencies improved from prolonged
to midnormal values [26]. Vajaranant et al [27] found
mfERG abnormalities in clinically affected regions

only in six patients. Other conditions in which mfERG
has been employed include areolar choroidal dystrophy [28], Bests macular dystrophy [29], and macular
holes [30]. Although mfERG findings have been
recorded in patients with glaucoma [31,32], the clinical usefulness of these findings in the management of
glaucoma remains to be seen.
Multifocal ERG can be used to rule out retinal
disease. When one wishes to confirm normal central
retinal function to bolster the evidence for the location
of a lesion responsible for visual loss elsewhere in the
visual system, such as a subclinical cataract, a normal
mfERG can be helpful. The mfERG should be normal
in most optic nerve diseases; however, caution must
be maintained in cases in which visual acuity is
reduced to the point where fixation may not be
adequate throughout the mfERG test or, if fixation is
maintained, it is eccentric. The authors have found
that, in patients with acute Leber hereditary optic
neuropathy, initial mfERGs can appear abnormal. In
98
Fig. 9. Multifocal ERGs (A,B) from a 13-year-old boy with visual acuity of 20/60 OD and 20/40 OS. There were no fundus
abnormalities except for a dark choroid on fundus fluorescein angiography (C,D). Full-field ERG was normal.
99
Fig. 10. Optical coherence tomogram (A) and fluorescein angiogram (B) from a 34-year-old man with a history of facial
numbness and blotchy vision in the right eye for 1 week. Visual acuity was 20/15 OD and 20/10 OS, color vision normal, there
was no afferent pupillary defect, and visual field testing was unrevealing. OCT showed a discrete area of subretinal fluid. Review
of the fluorescein angiogram showed a subtle area of leakage in the macula.
100
patients with long-standing visual loss from Lebers

neuropathy, mfERGs are better and practically normal
in some patients. The apparent abnormalities on
mfERG in acutely affected patients most likely represent an artifact of fixation. These abnormalities have
been noted by other investigators (R.H. Karden,
personal communication, 2002).
Multifocal ERG is an efficient clinical technique to
identify and map abnormalities in the outer retina in
the early phases of diseases not detectable with other
methods or in cases in which ophthalmic findings are
sparse or inconclusive. mfERG may help distinguish
different retinal diseases and localize the site of the
dysfunction. Proving the presence of retinal dysfunction by mfERG can allow clinicians to avoid expensive and worrisome neurologic investigations.
menting subtle abnormalities within and under the

retina in patients thought to have possible optic
neuropathy because of a paucity of clinical and
angiographic retinal findings. OCT can identify nerve
fiber layer loss that may be difficult to document
photographically. OCT can be used to identify, document, and measure retinal nerve fiber layer thickening
from papilledema and conditions in which there is
swelling of the optic nerve and the nerve fiber layer.
OCT has been useful in demonstrating secondary
retinal effects from optic neuropathy. It adds to the
repertoire of techniques that provide objective and,
most importantly, quantitative data useful in neuroophthalmic diagnosis and treatment. The technical
aspects of OCT have been well described elsewhere
[33]. The following sections describe some examples
of neuro-ophthalmic uses of OCT.
Optical coherence tomography
Retinopathy suggesting optic neuropathy
Optical coherence tomography is another clinical

tool that can be helpful in neuro-ophthalmic situations. It is very sensitive for identifying and docu-
Frequently, neuro-ophthalmologists are asked to

see patients for whom the clinical retinal findings do
not appear to account for the degree of visual loss
Fig. 11. A 9-year-old boy with neuroblastoma was treated with occipital radiation and cisplatin and lost vision in both eyes
within 1 week. MRI was normal. (A, B) OCT showed subretinal and intraretinal edema. (C, D) Both optic disks showed indistinct margins.
detected by visual acuity or visual field testing. Many

of these patients are referred by retinal surgeons who
have problems dealing with retinal a condition for
which there is no treatment. If they cannot repair the
problem, they have trouble accepting that it accounts
for the patients clinical syndrome. Proving that a
retinal lesion is indeed responsible for a given visual
defect is all too often the duty of the neuro-ophthalmologist. Frequently, this duty leads to making a
diagnosis by exclusion. Such an approach can become
expensive and time consuming.
Some patients with age-related macular degeneration may have minimal abnormalities that can
be visualized ophthalmoscopically or on fluorescein
angiography. OCT has been shown to be helpful in
demonstrating retinal and subretinal abnormalities,
proving that the location of an apparently subclinical
loss of vision is retinal in origin [33]. In almost all
situations, central serous retinopathy can be diagnosed
101
by ophthalmoscopy. Usually, it is easily confirmed by

fluorescein angiography; however, in rare cases, OCT
can show small collections of subretinal fluid that may
not be clearly seen otherwise. OCT can readily show
subretinal fluid even in the most mild cases (Fig. 10).
OCT scans can be performed quickly through an
undilated pupil, which can be important in patients
suspected of having optic neuritis in whom afferent
pupillary function may need to be monitored.
Cisplatin has been reported to cause optic neuropathy, cerebral leukomalacia, and retinopathy [34]. The
authors found that OCT revealed retinal effects of
cisplatin in one patient (Fig. 11).
Nerve fiber layer loss

Most of the work on OCT measurement of nerve
fiber layer changes from optic atrophy has been in the
Fig. 12. A 30-year-old nurse experienced memory loss and fatigue. MRI showed a craniopharyngioma. Postoperatively, visual
acuities were 20/20 in both eyes, but there were persistent left homonymous visual field defects (A). OCT showed diffuse
thinning of the nerve fiber layer in the contralateral right eye and loss temporally (B) and nasally (C) in the ipsilateral left eye.
102
Fig. 13. A 70-year-old woman had anterior ischemic optic neuropathy in her right eye with optic disk swelling and inferior visual
field loss. The left visual field (A) and acuity were normal. OCT showed nerve fiber layer thickening in the left asymptomatic eye
(B), and re-evaluation of the left optic nerve head showed mild swelling and a peripapillary flame hemorrhage (C). Three weeks
later, she had anterior ischemic optic neuropathy in the left eye with inferior visual field loss (D), more severe nerve fiber layer
swelling (E,F).
field of glaucoma [33]. In patients who have neuroophthalmic problems, OCT demonstration of retinal
nerve fiber layer thinning can be used to detect and
monitor optic atrophy from a variety of conditions,
including optic nerve head drusen [35], optic pits [36],
optic nerve trauma [37], and optic hypoplasia [38].
OCT also can be used to help rule out optic neuropathy when nerve fiber layer measurements are normal.
Optical coherence tomography can be used to
measure retinal nerve fiber layer loss in conditions
affecting the pregeniculate visual pathways and in rare
cases when retrogeniculate lesions have been present
long enough to cause transsynaptic degeneration.
The utility of OCT nerve fiber layer analysis for patients with lesions such as pituitary adenoma remains
to be determined. Currently, visual field testing (and
mfVEP) to detect optic nerve dysfunction before
nerve fiber layer loss occurs remains the most effective way to assist endocrinology and neurosurgical
colleagues in following patients with compressive
optic neuropathy (Fig. 12).
103
Retinal nerve fiber layer thickening

Optical coherence tomography can demonstrate
and measure retinal nerve fiber layer thickening. It
may be useful in detecting subclinical anterior ischemic optic neuropathy. The authors have seen OCT
abnormalities in patients who presented with anterior
ischemic optic neuropathy in one eye weeks before
they had clinical signs and symptoms in the opposite
eye, a presentation that has been observed clinically
by others (Fig. 13) [39].
Optical coherence tomography is useful in detecting and following pathologic optic disk swelling in
patients with papilledema. During the course of the
authors investigations regarding the usefulness of
OCT in the diagnosis and management of papilledema, macular scans in some patients revealed subretinal abnormalities. These findings occurred in
patients who had a loss of visual acuity, which can
also occur from intraretinal macular edema (macular
star) and macular hemorrhage. Histopathologic evi-
Fig. 14. Fundus photographs (A,B) and OCT showing submacular fluid (C,D) from a 30-year-old woman with idiopathic
intracranial hypertension. Visual acuities were 20/50 OD and 20/60 OS.
104
dence of subretinal fluid associated with papilledema

has been reported [40], but clinical evidence has been
limited [41]. In a series of 45 patients who had
bilateral optic disk edema from increased intracranial
pressure, the authors detected subretinal fluid on OCT
that resolved after treatment in six cases (Fig. 14) [42].
[10]
[11]
Summary
[12]
Multifocal VEP and mfERG techniques show

promise for routine clinical use in neuro-ophthalmology. OCT is now used in many subspecialty areas of
ophthalmology, especially in studies of the retina and
glaucoma. Although neuro-ophthalmologists must
still rely on time-consuming history taking and careful
clinical examination, the three modalities described
herein can provide objective proof regarding clinical
diagnoses in selected cases, saving time and avoiding
costly neurologic investigations.
[13]
[14]
[15]
[16]
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Ophthalmol Clin N Am 17 (2004) ix x

This issue of the Ophthalmology Clinics of North

tumor evaluation, especially tumors of the ciliary

J.S. Schuman / Ophthalmol Clin N Am 17 (2004) ixx

tative measurement of functional abnormalities. This

Ophthalmol Clin N Am 17 (2004) 1 6

Optical coherence tomography of the anterior segment of

Optical coherence tomography (OCT) [1] is a

D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16

used safely at the longer wavelength to achieve a

High-speed corneal and anterior segment optical

system and a target. In OCDR, an optical probe beam

Using a longer wavelength of 1.3 mm for corneal

D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16

Fig. 2. OCT of an eye 1 day after LASIK surgery.

(in air). When compared with the corneal image

including the scleral spur, ciliary body band, angle

Fig. 3. High-speed 1.3-mm wavelength OCT of an open angle.

D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16

Fig. 4. High-speed 1.3-mm wavelength OCT of an occludable angle.

of 1.84 mm. The improvement of the SD from 0.47

D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16

D. Huang et al / Ophthalmol Clin N Am 17 (2004) 16

[40] Bagayev SN, Gelikonov VM, Gelikonov GV, et al.

Ophthalmol Clin N Am 17 (2004) 7 20

Anterior segment imaging: ultrasound biomicroscopy

High-frequency ultrasound biomicroscopy (UBM)

Equipment and technique

image lines (or A-scans) at a scan rate of 8 frames

Qualitative ultrasound biomicroscopy

The normal eye

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

logic stimuli (ie, accommodative targets and light);

Fig. 1. Ultrasound biomicroscopic appearance of a normal

surface can be recognized easily (Fig. 1). The scleral

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

Fig. 3. Pupillary block. (A) The angle shows appositional

Fig. 4. Plateau iris. A large and anteriorly positioned ciliary

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

Fig. 6. Malignant glaucoma (composite image). The lens,

Fig. 7. Angle closure owing to an iridociliary cyst. An

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

appearance with no disruption of the interface in

or with infection in a micro open wound. With the

Fig. 9. Iridociliary tumor. Abnormally large ciliary process

An intraocular lens is an easy target for UBM

Fig. 10. Angle recession. Blunt trauma caused a tear into

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

Fig. 11. Cyclodialysis. The ciliary body is avulsed from the

various studies related to many different types of

Quantitative ultrasound biomicroscopy

Fig. 13. Scleral suture can be identified by looking for its

be determined to be distinct. It also specifies the

Fig. 14. Posterior chamber intraocular lens haptic. The most

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

to perform measurements that require multiple steps

Trabecular iris angle

Iris ciliary process

Iris zonule distance

Iris lens contact

Iris lens angle

Tello et al [21] reported on the reproducibility of

H. Ishikawa, J.S. Schuman / Ophthalmol Clin N Am 17 (2004) 720

In addition, each observer will set the reference