Ocular Immunology and Inflammation

ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20

Enhanced Vitreous Imaging in Uveitis

Padmamalini Mahendradas, Sumukh Madhu, Ankush Kawali, Abhijit Sinha

Roy, Ruchi Vala, Anand Vinekar & Rohit Shetty

To cite this article: Padmamalini Mahendradas, Sumukh Madhu, Ankush Kawali, Abhijit Sinha
Roy, Ruchi Vala, Anand Vinekar & Rohit Shetty (2017): Enhanced Vitreous Imaging in Uveitis,
Ocular Immunology and Inflammation, DOI: 10.1080/09273948.2017.1360501

To link to this article: http://dx.doi.org/10.1080/09273948.2017.1360501

Published online: 16 Oct 2017.

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 Ocular Immunology & Inflammation, 2017; 00(00): 1–7
© Taylor & Francis Group, LLC
ISSN: 0927-3948 print / 1744-5078 online
DOI: 10.1080/09273948.2017.1360501

ORIGINAL ARTICLE

Enhanced Vitreous Imaging in Uveitis

Padmamalini Mahendradas, DO, DNB, Sumukh Madhu, DNB, Ankush Kawali, DNB,
Abhijit Sinha Roy, PhD, Ruchi Vala, MS, Anand Vinekar, FRCS, PhD, and Rohit Shetty, FRCS, PhD

Narayana Nethralaya, Bangalore, India

ABSTRACT
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Purpose: To study the structural visibility of the posterior vitreous cavity and vitreoretinal interface using Spectral
Domain–Optical Coherence Tomography in patients with uveitis using conventional, Enhanced Depth Imaging
(EDI), Combined Depth Imaging (CDI), and Enhanced Vitreous Imaging (EVI) techniques.
Methods: It was an observational cross-sectional study of 59 eyes of 33 patients between age group 12–72 years
(Median 43) diagnosed as uveitis with posterior segment manifestations underwent OCT using conventional,
EDI, CDI, and EVI techniques. The visibility of posterior vitreous was graded in all the techniques.
Results: A statistically significant difference was seen in posterior vitreous visibility on comparing all four
techniques. EVI showed better visibility of posterior vitreous cavity compared to all other techniques (P < 0.001).
Conclusions: EVI technique provides better structural visibility of posterior vitreous compared to conventional,
EDI, and CDI techniques.
Keywords: Enhanced Vitreous Imaging, EVI, OCT, Optical Coherence Tomography, Uveitis

Spectral domain optical coherence tomography is an
effective method in detecting pathologic features in
uveitis and has rapidly gained popularity for the
same.1 The ease with which it may be repeated safely
during follow up for monitoring the response to inter-
vention has made it the gold standard non-invasive
technique to visualize structural changes in the retina
and evaluate fine retinal details. Commercially avail-
able SD OCT devices have an axial resolution of 5–7
microns with axial scanning speeds of 20,000 to 52,000
A-scans per second.2,3 This makes histologic-like cross-
sectional images of the vitreoretinal interface and the
retinal structures possible. Also the image averaging
system helps in achieving a superior image quality.
The commercially available software averages around
8 to 100 images and increases signal-to-noise ratio in
proportion to the square root of the number of images
averaged.4 Some of the devices also have automated
eye tracking to ensure that the images are obtained
from the same area of interest during each retinal scan.
Present-day SD OCT instruments use near-infrared
wavelengths of approximately 850 nm for ophthalmic
evaluation.5 Firstly, the reason is that it penetrates well
into the retina and the sub-retinal space. Secondly, it
offers better axial resolution and better contrast of
retinal layers. However, deeper penetration is limited
because of the presence of pigments in the retinal
pigment epithelium (RPE) that causes scattering and
choroidal vascularity. Moreover, the zero delay line,
defined as the point of maximum sensitivity on SD
OCT, is located in the vitreous.6,7 As a result, with
increasing depth into the tissue, the sensitivity of
OCT decreases and choroidal details are obscured.
More recently, the enhanced depth imaging (EDI)
was introduced that enabled visualization of choroidal
anatomic features as well on SD OCT.5,8,9 The EDI
acquisition software automatically captures cross-sec-
tional images and causes image inversion so that the
choroid becomes closer to the zero delay line and sensi-
tivity on the outer limit of the choroid is maximum. The
EDI technique thus allows a great detection of the chor-
oidal borders and fine detail. The role of EDI was
demonstrated in one of our previous study where this
technique was used to detect a choroidal mass lesion
that turned out to be a fungal granuloma.10 However,
since the zero delay line is away from vitreous, the
detection of inner retinal surface is reduced and the
posterior vitreous is not visible.

Received 23 January 2016; revised 13 July 2017; accepted 24 July 2017

Correspondence: Padmamalini Mahendradas, Narayana Nethralaya, 121/C, Chord Road, Rajajinagar,1 st R block, Bangalore -560010, India.
E.mail: m.padmamalini@gmail.com

1
 2 P. Mahendradas et al.
To overcome this imaging limitation and to obtain a
single comprehensive image of both the vitreoretinal
interface and choroid, the combined depth imaging
(CDI) technique was introduced by Barteselli et al. in
2013.11,12 The CDI technique is an image process mod-
ification that combines conventional SD-OCT scans
with EDI OCT scans into a single image. In this tech-
nique, the vitreoretinal interface is enhanced in the first
half of the scanning process. The operator then selects
the EDI software, and subsequently in the next half,
the choroid becomes highly enhanced. The device later
merges conventional scans with EDI OCT scans into a
single comprehensive image with good sensitivity
throughout the process. The role of CDI imaging tech-
nique in patients with uveitis has already been estab-
lished in our previous study.13
Assessment of the posterior vitreous cavity is impor-
tant in uveitis. The NIH grading system used for grad-
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ing of vitreous haze plays an important role in
prognostication of uveitis.14 Though the available tech-
niques help in a detailed assessment of vitreoretinal
interface, visualization of the posterior vitreous cavity
has been an issue of concern with the available techni-
ques. However, the enhanced vitreous imaging15 (EVI)
now offers a novel technique of visualization of poster-
ior vitreous cavity. In the EVI technique, infrared image
obtained by OCT is focused, and +2 diopters are added.
Changing the focus by +2 diopters allows good visua-
lization of structures in the vitreous and better analysis
of vitreoretinal interface.
Liu et al demonstrated the EVI technique in healthy
eyes using swept source optical coherence tomography.16
A similar technique was used to visualize the intravitreal
cysticercosis in a case of intraocular cysticercosis.17 We
aim to study the structural visibility of posterior vitreous
cavity and vitreoretinal interface using Spectral Domain–
Optical Coherence Tomography in patients with uveitis
using Enhanced Vitreous Imaging (EVI), Normal,
Enhanced Depth Imaging (EDI), and Combined Depth
Imaging (CDI) techniques.
METHODS
Institutional ethics committee approval was obtained
to conduct this cross-sectional observational case ser-
ies. The study was conducted at the Department of
Uveitis and Ocular Immunology, Narayana
Nethralaya, Bangalore, in adherence to the tenets of
the Declaration of Helsinki. Fifty nine eyes of 33
patients (11 males, 22 females) between age group
12–72 years (Median 43) diagnosed as uveitis with
presence of vitreous cells were included in the study.
In patients having bilateral disease, both the eyes were
included. Patients with very dense vitritis or any ante-
rior segment or media opacity due to which it will be
difficult to obtain a clear OCT scan were excluded
from the study.
A written informed consent was obtained to partici-
pate in this research, followed by initial slit lamp exam-
ination and then dilatation with tropicamide eye drops.
Patients clinically diagnosed as having uveitis with pre-
sence of vitreous cells and haze were then subjected to
color fundus photography and OCT scans (high-defini-
tion SD-OCT) with Spectralis™ (Heidelberg
Engineering GmbH, Heidelberg, Germany) using con-
ventional, EDI, CDI, and EVI techniques.
Optical Coherence Tomography Scanning
Protocol
All images for the study were acquired by a single
experienced technician. The Spectralis HRA was set
to perform a 9-mm high-resolution horizontal B-scan,
centered on the area of interest. Use of an internal
fixation light helped to center the scanning line on
the area of interest. Depending upon the area of inter-
est, either a horizontal or a vertical linear scan was
obtained along with the raster scan for each patient.
The averaging system was set to 100 OCT scans. A
sequence of four different images was performed for
each eye of the patients. Presence of artifacts was ruled
out by taking all the linear scans into consideration.
Presence of vitreous cells throughout the linear scan
ensured that they were not artifacts. However, for
comparative purpose, only the vertical and horizontal
linear scans were taken into consideration. Care was
taken to ensure that the same area was imaged in all
four techniques. Proper positioning and comfort of the
patient was ensured prior to scanning process.
Conventional Scan
The upper half of the screen was scanned followed by
activation of the averaging system. After reaching at
least half of the averaging, the image was captured,
and thus the conventional OCT image was obtained.
EDI Scan
The position of the OCT scan was shifted to the lower
half of the screen, and the EDI software was activated
using the EDI button. After reaching at least half of the
averaging, the image was captured, and thus the EDI
OCT image was obtained.
CDI Scan
The position of the scan was shifted to the middle of the
screen. The operator activated the averaging system of the
device, and the image was captured. After reaching half of
the averaging, the operator switched to EDI software. As
Ocular Immunology & Inflammation
 EVI in Uveitis 3

soon as a good-quality image was seen, the image was TABLE 1. Etiological distribution of study patients.
captured, and thus the CDI OCT image was obtained.
Etiological Diagnosis Number of Cases (33)

Idiopathic Panuveitis 6
EVI Scan Intermediate uveitis 5
Vogt Koyanagi Harada syndrome 5
Enhanced Vitreous Imaging (EVI) was obtained using Tuberculosis 3
Sarcoidosis 3
the following guidelines.15 IR+OCT mode was selected Mutifocal retinitis 3
in the spectralis OCT machine. The IR image was Toxoplasmosis 2
focused, and then +2 diopters were added to the focus. Posterior uveitis 2
The top of retina was placed just below the four blue Serpiginous choroiditis 1
markers visible. This indicated the sweet spot. Following Idiopathic retinal vasculitis 1
Sympathetic Ophthalmia 1
this, the ART mean was activated and image acquired. Dengue retinitis 1
Changing the focus by +2 diopters allowed good visua-
lization of structures in the vitreous and better analysis
of vitreoretinal interface. Selecting ART 100 allowed TABLE 2. Showing Kappa values for the posterior vitreous (PV)
good visualization of the posterior hyaloid. and vitreoretinal interface (VRI).

Area Conventional EDI CDI EVI

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Optical Coherence Tomography Imaging PV 0.771 0.732 0.722 0.743

Analysis VRI 1 1 1 1

The four images for each eye at the same area of interest
were taken. Patient information and the type of scan-
ning technique as well as the images were masked and
mixed randomly. Two independent masked physicians
reviewed each image on the same monitor with same
resolution at different time points and graded the visua-
lization of posterior vitreous cavity and vitreoretinal
interface separately. Grade 0 indicated that the analyzed
area was not visible; grade 1 indicated that the analyzed
area was barely visible, and grade 2 indicated that the
analyzed area was clearly visible.
Statistical Analysis
The interobserver agreement for the grading of the pos-
terior vitreous and vitreoretinal interface was assessed
using the Cohen κ. Kruskal Wallis test was used to com-
pare the grading of the posterior vitreous and vitreoret-
inal interface among the four OCT images for each eye.
RESULTS
Of the patients, 34% (11) were males, and 66% (22) were
females, out of which 85% (28) cases were bilateral and
15% (5) cases were unilateral. Table 1 shows distribution
of cases based on their etiological diagnosis.
Kappa analysis showed most of the values above
0.7 (Table 2) indicating good inter observer agreement.
Table 3 shows percentage distribution of posterior
vitreous (PV) visibility in all four techniques. There was
statistically significant difference (p < 0.001) in posterior
vitreous using all the four techniques. However, there
was no significant difference in vitreoretinal interface
visibility (p > 0.05). Overall, posterior vitreous cavity
TABLE 3. Percentage distribution of posterior vitreous (PV)
visibility in all four techniques.
Grade 0 Grade 1 Grade 2
Conventional 0 10 (16.95%) 49 (83.05%)
EDI 46 (77.97%) 13 (22.03%) 0
CDI 1 (1.7%) 13 (22.03%) 45 (76.28%)
EVI 0 6 (10.17%) 53 (89.83%)
was best visualized in EVI technique. The following
case examples will better establish the role of EVI ima-
ging technique in uveitis patients.
Case 1:First was a clinically diagnosed case of
Posterior uveitis due to toxoplasmosis in the left eye
that underwent treatment for the same. Fundus exam-
ination of the left eye showed presence of a hypo
pigmented lesion at the fovea with well-defined bor-
ders. It was interesting to see whether the lesion was
still active. Fluorescein angiography would have
clearly established it. But prior to FA, patient under-
went OCT using all the four techniques. The conven-
tional technique as seen in (a) of Figure 1 showed
presence of a well-defined hyper-reflective area in the
inner retinal layers just adjacent to fovea. The EDI scan
(b) showed a normal choroid, and CDI scan (c)
showed a good combination of vitreous cells, hyper-
reflective lesion, and a normal choroid. The EVI tech-
nique however stood out in demonstrating good pos-
terior vitreous visibility and also showed presence of
vitreous cells in the posterior vitreous cavity that sug-
gested activity. The patient was diagnosed as a case of
healing toxoplasmosis and continued receiving treat-
ment. In this case, the EVI technique strengthened our
diagnosis and helped us to continue the treatment.

© 2017 Taylor & Francis Group, LLC

 4 P. Mahendradas et al.

FIGURE 1. A clinically diagnosed case of posterior uveitis due to toxoplasmosis. The conventional technique (a) showed presence of a
well-defined hyper-reflective area in the inner retinal layers just adjacent to fovea. Posterior vitreous cavity showed presence of vitreous
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cells. The EDI scan (b) showed a normal choroid, and CDI scan (c) showed a good combination of vitreous cells, hyper-reflective lesion,
and a normal choroid. The EVI technique showed more number of vitreous cells in the posterior vitreous cavity (d).

Case 2: This was a case of a 43-year-old female
who had bilateral panuveitis with CME in the right
eye with confirmed case of pulmonary sarcoidosis
on treatment with systemic steroid therapy. As seen
in Figure 2, her conventional scan (a) showed
altered foveal contour, hyporeflective cystic spaces
with high reflective intervening septa suggestive of
cystoid macular edema with subfoveal serous ret-
inal detachment. Posterior border of the choroid
could not be made out in this scan. Her EDI (b)
and CDI (c) scans showed changes similar to that of
the conventional scan in terms of the retinal layers.
Posterior border of the choroid could be made out
in these. In all these scans, posterior vitreous cells
could not be identified. However, in the EVI scan
(d), posterior vitreous cells were seen suggestive of
better posterior vitreous visibility (along with CME
and subfoveal serous retinal detachment). Again,
the posterior border of the choroid could not be
made out.
Case 3: Figure 3 shows the SD-OCT scans of a
case of middle-aged female diagnosed as a case of
right eye presumed ocular tuberculosis with healing
multifocal choroiditis. The conventional technique
(a) showed very few vitreous cells with an incom-
plete posterior vitreous detachment and changes in
the EZ (ellipsoid zone) just adjacent to fovea. Both
EDI (b) and CDI (c) showed changes in retinal layers
similar to conventional in addition to presence of
hyper-reflective echoes in the inner choroid. The
EVI technique (d) showed multiple vitreous opacities
that are suggestive of vitreous cells along with
changes seen in retinal layers. More numbers of
cells suggest the presence of activity.

FIGURE 2. A case of bilateral panuveitis due to sarcoidosis. OCT showing the features of cystoids macular edema with subfoveal
seroud detachment in all scans (a) to (d). Posterior vitreous cells could not be identified in figures (a) to (c). However, in the EVI scan (d),
posterior vitreous cells were seen along with CME and subfoveal serous reitnal detachment.

Ocular Immunology & Inflammation

 EVI in Uveitis 5

FIGURE 3. A case of presumed ocular tuberculosis with healing multifocal choroiditis. The conventional technique (a) showed very
few vitreous cells with an incomplete posterior vitreous detachment and changes in the EZ (ellipsoid zone) just adjacent to fovea. Both
EDI (b) and CDI (c) showed changes in retinal layers similar to conventional in addition to presence of hyper-reflective echoes in the
inner choroid. The EVI technique (d) showed multiple vitreous opacities that are suggestive of vitreous cells in addition to changes seen
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in retinal layers.

FIGURE 4. OCT images of a case of panuveitis in the right eye, conventional scanning (a) showed epiretinal membrane formation,
foveal distortion, and thickening. Visualization of choroid was obscured but could be well appreciated in EDI (b) and CDI (c), and EVI
(d) showed the presence of vitreous cells.

Case 4: There was also a case of panuveitis
(Figure 4) where conventional scanning (a) showed
minimal vitreous haze, epiretinal membrane forma-
tion, foveal distortion, and thickening. Visualization
of choroid was obscured but could be well appreciated
in EDI (b) and CDI (c) in addition to other findings
and was normal. EVI (d) however showed multiple
opacities suggestive of vitreous cells, and active panu-
veitis was confirmed.
Case 5: Our final example was a case of healing
serpigineous choroiditis (Figure 5). This clearly
demonstrated the presence of vitreous membrane and
posterior vitreous cells (d) that was not seen in any of
the other three techniques [(a), (b), and (c)], which once
again highlights the effectiveness and better visibility
of EVI technique.
Presence of hyper-reflective dot echoes in the pos-
terior vitreous cavity was seen in six cases by EVI
technique that is not present in Normal, EDI, and
CDI scans. Partial posterior hyaloid detachment was
seen in one case in all four techniques, two cases it was
seen in Normal and EVI techniques, and in one case it
was seen in EVI techniqenue. Bursa premacularis was
seen in Normal, CDI, and EVI techniques in five cases,
in one case by Normal and EVI technique, and in three
cases it was picked up EVI only.
DISCUSSION
The vitreoretinal interface (VRI) is a complex composite
structure connecting the vitreous cortex and the inner
retina. The introduction of spectral domain optical coher-
ence tomography (SD-OCT) has enhanced Vitreoretinal
Interface (VRI) imaging considerably and facilitated the
diagnosis, follow-up, prognosis determination, and

© 2017 Taylor & Francis Group, LLC

 6 P. Mahendradas et al.
FIGURE 5. A case of healing serpiginous choroiditis in the left eye clearly demonstrated the presence of vitreous membrane and
posterior vitreous cells that was not seen in any of the other three figures [(a), (b), and (c)].
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management of VRI-associated pathologies. Becerra-
Revollo et al.18 described the use of enhanced vitreous
imaging using conventional SD-OCT. Uji et al.19
reported novel vitreous body micro architecture findings
in their study using the EVI technique in healthy volun-
teers. Barak et al.20 in his study on SD-OCT highlighted
the role of this imaging technique in studying various
VRI-associated disorders. Munk et al.21 also stressed
upon the role of VRI assessment in better prediction of
treatment efficacy in future.
Also the introduction of swept source optical coher-
ence tomography (SS-OCT) has opened a new dimen-
sion in visualization of posterior segment structures
and allows visualization of vitreous, retinal, and chor-
oidal changes in a single scan. Chen et al.22 reported a
case of acute toxoplasma chorioretinitis and found that
SS-OCT can visualize the vitreous and chorioretinal
changes in a single scan, compared with the different
imaging algorithms required with SD-OCT. Adhi et al.23
used the three-dimensional wide-field volumes
acquired using high-speed, long-wavelength swept-
source optical coherence tomography (SSOCT) for ana-
lyzing the VRI in diabetic patients. Nevertheless, the
role of SD-OCT in visibility of posterior vitreous cavity
and VRI cannot be overemphasized. We have studied
the structural visibility of the posterior vitreous cavity
and vitreoretinal interface using the conventional, EDI,
CDI, and EVI techniques in various posterior uveitic
entities. Grading of posterior vitreous visibility helps
in better prognostication of the disease and enhances
decision making in the management. The case examples
discussed earlier show that the EVI technique plays an
important role in better visualization of posterior vitr-
eous cavity. The role of the CDI technique has already
been proven. Together, all four techniques will allow an
in-depth analysis of posterior vitreous cavity, VRI, ret-
inal layers, and the choroid as a whole.
CONCLUSION
EVI technique provides better structural visibility of
posterior vitreous compared to conventional, EDI, and
CDI techniques. Presence of vitreous cells using EVI
technique in SD-OCT helps in the management of
patients with uveitis.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
paper.
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