REVIEW ARTICLE
Past, Present, and Future Concepts of the Choroidal Scleral
Interface Morphology on Optical Coherence Tomography
Emily Huynh, MEng,*† Erandi Chandrasekera, MBBS,*‡§ Danuta Bukowska, PhD,*†
Samuel McLenachan, PhD,*† David A. Mackey, MBBS, MD, FRANZCO,*† and
Fred K. Chen, MBBS (Hons), PhD, FRANZCO*†¶
Abstract: The choroid is the most vascular tissue in the eye and it has
been implicated in the pathophysiology of a variety of ocular diseases. A
new era of research in the choroid began with the improved ability to vi-
sualize this layer and its inner and outer boundaries using spectral domain
optical coherence tomography (OCT) with enhanced depth imaging and
swept source OCT. The accuracy and precision of qualitative and quan-
titative assessments of the choroidal layer support the potential use of
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OCT-derived choroidal parameters for diagnosis, monitoring of disease
progression, planning surgical access, and evaluating treatment response.
Although there is increasing interest in measuring choroidal thickness,
there is currently no consensus nomenclature to classify choroidal lay-
ers and boundaries. Furthermore, the definition and description of the
choroidal scleral interface is inconsistent in the literature, contributing to
interstudy variation in choroidal thickness measurements. The purpose of
this review is to provide an overview of the literature on the definition
of choroidal layers and choroidal scleral boundary, review the discrepan-
cies, and harmonize the terminology so that a consensus nomenclature
can be proposed.
Key Words: choroidoscleral boundary, choroidal thickness,
sclerochoroidal boundary, suprachoroidal space, suprachoroidal layer
(Asia-Pac J Ophthalmol 2017;1:94–103)
T he posterior coat of the eye comprises the retina, the cho-
roid, and the sclera. Before the 1990s, ophthalmic ultraso-
nography was the only method to visualize and measure the
thickness of these structures in vivo. High-resolution, cross-
sectional imaging of the choroid only became possible after
the development of optical coherence tomography (OCT).1
Although initially neglected, imaging of the choroid is now
gaining interest because of the enhanced depth imaging (EDI)
technique in spectral domain (SD) OCT and the more recent
commercialization of swept source (SS) OCT devices.2 These
recent advances enable the visualization of not only the ret-
ina but also the layers of the choroid, the choroidal scleral
From the *Centre for Ophthalmology and Visual Science, The University of
Western Australia, Perth; †Lions Eye Institute, Perth; ‡Save Sight Institute,
University of Sydney, Sydney; §Sir Charles Gairdner Hospital, Perth; and
¶Royal Perth Hospital, Perth, Australia.
Received for publication May 3, 2016; accepted July 23, 2016.
E.H. and E.C. contributed equally to this work.
Supported in part by the National Health and Medical Research Council Early
Career Fellowship (F.K.C.) and the Ophthalmic Research Institute of Australia
(S.M., D.B., F.K.C.).
The authors have no conflicts of interest to declare.
Reprints: Dr Fred K Chen, MBBS (Hons), PhD, FRANZCO, Lions Eye Institute, 2
Verdun Street, Nedlands, WA 6009 Australia. E-mail: fredchen@lei.org.au.
Copyright © 2017 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.22608/APO.201698
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interface (CSI) and, occasionally, the entire thickness of the
sclera through to the orbital fat.3
The choroid is a vascular layer within the posterior coat
of the eye and it is implicated in the pathophysiology of many
posterior segment diseases. The ability to visualize the inter-
face between the choroid and the sclera with SS-OCT and EDI
SD-OCT has enabled measurement of choroidal thickness.
This parameter is now routinely used clinically to assist di-
agnosis and monitor treatment response in a variety of cho-
rioretinal diseases.2 Advances in OCT technology have also
led to the discovery of the suprachoroidal layer (SCL), a tran-
sitional zone between the choroid and sclera. In some cases,
the suprachoroidal space (SCS) has been visualized within the
SCL.4 Previously, the SCS could only be seen in vivo by ul-
trasonography in pathologic conditions such as suprachoroidal
effusion and suprachoroidal hemorrhage.2,4 The ability to vi-
sualize SCS in high resolution in both normal and pathologic
conditions has allowed researchers to reveal new insights in
its role in health and disease. Studies have suggested that the
SCS may be useful for diagnosing and monitoring disease.2
Furthermore, it has been shown to be a potential route for both
medical and surgical treatment.2,5 The administration of be-
vacizumab and triamcinolone into the SCS using a mirocath-
eter in eyes with age-related macular degeneration (AMD)
has been reported to have been performed without any seri-
ous complications.6–8 The possibility of retinal surgery in the
SCS has been investigated as a potential treatment for glau-
coma with the advent of silicone drainage devices, gold micro
shunt implants, and supraciliary microstents.2 More recently,
the “bionic eye,” a retinal visual prosthesis prototype, has also
been implanted into the SCS, demonstrating the suprachoroi-
dal anatomical position as a feasible location for placement
of electrode array through minimally invasive and relatively
uncomplicated surgery. This technique has been shown to be
safe in 3 patients with end-stage retinitis pigmentosa.9
Choroidal thickness is traditionally measured from the
outer limit of the Bruch membrane to the posterior boundary
of the choroid. Although the concept is straightforward, iden-
tifying this boundary in practice is not clear-cut. The presence
of the suprachoroid between the choroidal vessels and sclera
has been reported by several studies; however, there is a lack
of consensus in classifying it as choroidal or scleral in origin.
In contrast, layers in the retina as visualized on SD-OCT have
been well-defined and a consensus nomenclature for the clas-
sification of these layers has been developed to facilitate har-
monization of OCT structure terminology.5 However, a univer-
sal nomenclature has not been extended to the choroidal and
scleral layers, making it difficult to compare the descriptions
of this interface across various research groups. Furthermore,
the term CSI is often used to describe the posterior boundary
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
in studies reporting choroidal thickness. However, some stud-
ies have defined the CSI as a line delineating the inner border
of the sclera, whereas others have defined it as a distinct band
between the choroidal vessels and sclera. The lack of clarity
in the definition of the CSI has led to variation in choroidal
thickness measurements, which reduces the precision of this
measure.
Therefore, the purpose of this review is to provide an
overview of how the choroidal and scleral layers have been
visualized and reported in the literature, highlight the discrep-
ancies, and propose a harmonized nomenclature for the ana-
tomic correlates of the zones and layers of the choroid and its
outer boundary or interface as seen on OCT.
MATERIALS AND METHODS
References for this review were identified through a
comprehensive literature search of MEDLINE and PubMed.
In addition, articles and theses thought to be relevant were also
selected from the references of the articles generated from the
above search. The following key words and combinations of
these words were used in compiling the search: “optical co-
herence tomography,” “choroidal thickness,” “suprachoroid,”
“choroidal scleral interface,” “choroidal scleral junction,”
“choroidal scleral boundary,” “suprachoroidal space,” “swept
source,” and “spectral domain.” Articles were included in the
review if they provided a detailed definition and description
of the choroidal scleral interface and/or suprachoroidal space
with images acquired using EDI SD-OCT or SS-OCT to show
where it was located.
HISTOLOGY OF THE CHOROID
The choroid is most commonly described as a 5-layered
structure (Fig. 1) consisting of the Bruch membrane, the cho-
riocapillaris, the Sattler small and medium vessels, the Haller
large vessels, and the suprachoroid (or suprachoroidal layer).10
The Bruch membrane is an acellular, 5-layered extracellular
matrix with a thickness of 2–4 µm.11 The choriocapillaris is
a highly anastomosed network of capillaries that is approxi-
mately 10 µm thick at the fovea, thinning to about 7 µm in the
periphery.10 Below the choriocapillaris is the Sattler medium
vessel layer, consisting of arterioles and venules. Underneath
this layer is the Haller large vessel layer where choroidal veins
and arteries are found. The border between the Sattler and
Haller layers is indistinct, as there is no established defini-
tion of what is meant by large or medium.12 The extravascular
tissue of the vessels, termed the choroidal stroma, consists of
collagen and elastic fibers, fibroblasts, nonvascular smooth
muscle cells, and numerous giant melanocytes.10 Posterior
to the choroidal vessels/stroma is the SCL, which is approxi-
mately 30 µm thick and extends from the choroidal stroma to
the sclera where the fibers become more compact. It is a tran-
sitional zone between the choroid and the sclera,10,13 consisting
of 5 to 10 layers of giant melanocytes (Fig. 1C) interspersed
between flattened processes of fibroblast cells, embedded in
a network of interconnected collagen lamellar fibers.4 When
the lamellae separate, the potential space becomes a physical
space appearing as the SCS.13 In most healthy eyes, the SCS is
a virtual space because the choroid is in close apposition to the
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Choroidal Scleral Interface on OCT
FIGURE 1. A, Five layers of the choroid illustrated in an SD-OCT scan.
Green dotted lines mark the boundaries of the choroid (from the Bruch
membrane to suprachoroidal layer). B, Enlarged image of the OCT scan
(from the red box in A) shows 4 hyperreflective bands of the outer
retina consisting of the internal limiting membrane (ILM), ellipsoid
zone (EZ), inderdigitation zone (IZ), and RPE. Choroidal vessel layers are
designated as Sattler and Haller layers distinguished by size of vessel
lumen and the outermost layer is the SCL, which consists of densely
packed melanocytes and loose connective tissue (C) represented by
hyperreflective and hyporeflective structures on OCT (B). Scale bars
represent 200 µm.
sclera. As fluid accumulates in physiological or pathological
conditions, it separates and the space becomes real. Depend-
ing on whether the Haller and Sattler layers can be delineated
and whether the suprachoroid is considered to be of scleral or
choroidal origin, the number of choroidal layers can vary from
4 to 6 layers.10
TECHNOLOGY USED TO IMAGE THE CHOROID
Ultrasonography was first used to examine the eye in
1956. It had applications in evaluating trauma, monitoring
and characterizing tumors, detecting vitreoretinal disease,
and ocular biometry.14 Pulses of high-frequency acoustic
waves are transmitted through the eye and echoes created
by reflective ocular structures are received by the ultrasound
transducer. The A-mode (amplitude mode) is a 1-dimensional
image display of reflected sound waves in which echo ampli-
tude is shown along the vertical axis and echo delay (depth)
along the horizontal axis. Juxtaposition of consecutive A-
mode scans using brightness to represent the amplitude of
reflected sound waves creates a cross-sectional image, called
the B-mode (brightness mode). The resolution of ultrasound
imaging depends directly on the frequency or wavelength of
the sound waves used. For a typical clinical ultrasound sys-
tem, sound waves are in the 10 MHz region and this achieves
a spatial resolution of 150 µm in biological tissue. High-fre-
quency ultrasound has also been developed using frequencies
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Huynh et al
of approximately 100 MHz to achieve axial resolution of
15–20 µm. However, high frequencies are strongly attenuated
in biological tissues, leading to decreased depth of penetra-
tion and failure to image the posterior coat of the eye. As a
result, ultrasound for imaging the posterior coat is typically
centered at 10–20 MHz, providing an axial resolution of ap-
proximately 150–200 µm, which is only useful for visualizing
gross changes in the posterior coat.12,14
Optical coherence tomography can be viewed as an opti-
cal analog of ultrasound.15 The principal difference between
OCT and ultrasound is that light travels faster and its wave-
length is much shorter than sound waves, allowing OCT to
achieve higher image resolution. However, due to the high
velocity of light, it is not possible to measure optical echo
amplitude. Instead, OCT uses low coherence interferometry
in which the light beam is split into an object arm (which
enters the eye) and a reference arm. Analysis of the time de-
lay and amplitude of the interference pattern generated by the
backscatter of both beams are used to construct the OCT im-
age. The first OCT device was a time domain system (TD-
OCT) that was able to acquire 400 A-scans per second with
an axial resolution of 8 to 10 µm.16 A broadband light source
at 842 nm was used and the mirror in the reference arm was
mechanically moved to image at different depths.15 Howev-
er, the choroid is poorly visualized using a TD-OCT device
due to the light scattering from the retinal pigment epithe-
lium (RPE), relatively low signal-to-noise ratio, and limited
number of axial scans per B-scan causing lower pixel den-
sity.16 The next generation of OCT devices termed SD-OCT
incorporated a spectrometer with the interferometer to simul-
taneously analyze the interference pattern using the Fourier
transform.16,17 This technique allows the reference mirror to
remain stationary as depth information is frequency encoded.
As a result, scan rates of 20,000 to 52,000 A-scans per second
and axial resolution of 5 to 7 µm, along with better signal-
to-noise ratio, can be achieved.16 However, the outer limit of
the choroid and sclera cannot be reliably identified, as echoes
originating from deeper tissues are more difficult to discern
by spectrometer because they have higher frequency modula-
tion than echoes closer to the zero-phase delay line.16 Most
SD-OCT devices operate with the inner retina closest to the
zero-phase delay line to maximize the sensitivity of the retina
and vitreoretinal interface. As a result, the outer choroid is
further from the zero-phase delay line with subsequent di-
minished signal (Fig. 2A). To improve the definition of cho-
roidal structures, Spaide et al developed a technique called
EDI using SD-OCT. This is achieved simply by moving the
SD-OCT device closer to the eye to invert the image, such
that the zero-phase delay line is positioned at the choroidal
side of the image frame.18 Although EDI techniques improved
the visualization of the choroid and sclera, these structures
were not always clearly seen because the central wavelength
of the light sources used in SD-OCT devices (ranging from
800–870 nm) is not optimal for deep choroidal tissue penetra-
tion (Fig. 2B).19–21 The optimal centered wavelength to image
the choroid is 1050–1060, as longer wavelengths exhibit less
scatter and can penetrate deeper in the tissue because they are
not absorbed by water. These wavelengths are generated by
rapidly tuneable laser sources that are employed in SS-OCT
systems. In addition, SS-OCT utilizes a single photodiode
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Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
FIGURE 2. A comparison of OCT sections through the fovea using
standard SD-OCT (A), EDI SD-OCT (B), and SS-OCT (C) shows similar
clarity in choroidal structures and boundaries between B and C. Note
the greater axial scan depth of 2.6 mm (vertical arrow in C) offered by
the SS-OCT device as compared with 1.8 mm (vertical arrows in A and
B) for SD-OCT. The reduced visibility of the outer choroidal boundary
in A is due to the signal-to-noise ratio drop off as a function of distance
from zero-phase delay (located at the top of the image). The EDI mode
inverses the gradient of the signal-to-noise ratio drop off so that the
outer choroidal boundary clarity can be enhanced by placing the zero-
phase delay at the bottom of the image in B.
for the detection of the interferometry signals,21–23 allowing
acquisition speeds of 100,000 A-scans per second and axial
resolution of approximately 5.3 µm.21 These features of the
SS-OCT system improve visualization of the entire thickness
of the 3 posterior coats of the eye (Fig. 2C).
Vascular choroidal imaging is best achieved with in-
docyanine green angiography and fundus fluorescein angio-
graph.24 They are the gold standard for visualizing choroidal
blood flow.24 However, they do not provide cross-sectional
anatomical information and are unable to accurately identify
the depth of vascular pathology.16 These methods are also in-
vasive because of the need for contrast dye, which has the
potential to induce anaphylactic reaction.24 Several nonin-
vasive methods to visualize choroidal blood flow have been
developed. Doppler OCT measures the Doppler frequency
shift, which is proportional to velocity, in each voxel of an
OCT image. The combined Doppler shift and reflectivity data
from each voxel allows simultaneous visualization of retinal
architecture and blood flow. The so-called OCT angiogra-
phy (OCTA) can also create an image of vascular anatomy
by extracting backscatter light intensity fluctuation data. The
variations in the backscattered light generated by moving ob-
jects within the blood vessels (eg, red blood cells) provide
the contrast for visualizing blood vessels. However, unlike
Doppler OCT, which can only measure flow that is oriented
transversely to the imaging direction, OCTA can be used to
visualize blood vessels irrespective of flow rate (in principle)
and orientation.25 Laser Doppler flowmetry can also be useful
for subfoveal choroidal circulation.16 However, these modali-
ties can only provide qualitative assessment of the choroidal
blood flow but not the extravascular structures.26 Magnetic
resonance imaging (MRI) is another noninvasive imaging
modality that can provide structural, physiological, and func-
tional information on the choroid.27 However, it is more ex-
pensive and lacks in spatial resolution, allowing only 3 layers
of the retina/choroid complex to be discriminated.27,28 Its role
is limited to imaging of medium and large uveal tumors.
© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017 Choroidal Scleral Interface on OCT

MORPHOLOGY OF THE RETINA AND CHOROID ON
POSTERIOR SEGMENT IMAGING
Table 1 shows a summary of the structures visualized us-
ing ultrasound and OCT. Advances in choroidal imaging have
allowed more detailed visualization of retinal and choroidal
structures. The posterior coat of the eye was first visualized
through ophthalmic ultrasonography in 1979 by Coleman and
Lizzi.14 The ultrasound image appeared to correspond to what
was visualized histologically, with the exception of the cho-
roid, which was found to be twice as thick. However, this was
hypothesized to be due to the absence of choroidal perfusion
postmortem.14 Although the individual layers of the posterior
coat in a normal eye are often difficult to delineate on ultra-
sound, they can be clearly seen in eyes with retinal detachment,
infiltrative lesion within the choroid (eg, uveal melanoma and
lymphoma), and choroidal detachment. Therefore, the role of
ultrasound in precise measurement of choroidal thickness is
limited in most clinical situations.
The TD-OCT system was introduced by Huang et al29 in
1991. The first highly reflective layer visualized corresponded
to the retinal nerve fiber layer, followed by the inner plexi-
form and outer plexiform layers as distinct bands of moder-
ate reflectivity.30 Directly below was the hyporeflective outer
nuclear layer, followed by a very thin moderate reflective
band representing the inner and outer segments of the photo-
receptors (IS/OS).30 The brightest and thickest reflective band
represents the RPE. Weak reflectivity posterior to the RPE
is considered to represent the choriocapillaris and the inner
choroidal vessels. The external limiting membrane (ELM),
interdigitation zone, Bruch membrane, and choriocapillaris
layers are beyond the limits of resolution on the TD-OCT
system and are thus blended into the IS/OS and RPE bands,
respectively.
The development of SD-OCT in 2002 provided faster
and higher resolution imaging, allowing additional layers
in the retina to be discerned. Anterior to the RPE, the inter-
digitation zone, outer segments of the photoreceptors, ellip-
soid and myoid zones, ELM, Henle fiber layer, ganglion cell
layer, preretinal space, and posterior cortical vitreous were
recognized as separate structures. Posterior to the RPE, the
choriocapillaris, Haller and Sattler layers, and the choroi-
dal scleral juncture were also more easily visible. All these
structures were described by Staurenghi et al, who also pro-
posed a consensus nomenclature and provided descriptions
for the retinal structures visualized on SD-OCT.5 Although
the choroid could now be seen in SD-OCT images, the signal
was weak, making it difficult to reliably visualize its poste-
rior boundary. Hence, the group use a loosely defined term,
“the choroid scleral juncture,” to describe the area beneath
the large vessel layer.5
In 2008, the EDI technique was developed, which led to
the ability to distinguish layers in the outer choroid and sclera.
In good quality images, the sclera could be clearly visualized
as a thick hyperreflective zone, diminishing in reflectivity be-
low the hyporeflective large choroidal vessels. This improved
clarity of the boundary between the choroid and sclera has
enabled quantitative analysis of the choroid. The CSI was
first defined as the inner boundary of the sclera, which is the
most common definition used by studies measuring choroi-
dal thickness. Subsequent studies using EDI techniques noted

TABLE 1. Layers Visualized on Ultrasound and Optical Coherence Tomography Devices

US (150–200 µm) TD-OCT (8–10 µm) SD-OCT (5–7 µm) EDI SD-OCT/SS-OCT (~5.3 µm)

Vitreous Vitreous Posterior cortical vitreous Posterior cortical vitreous

Preretinal space Preretinal space
Retina Nerve fiber layer Nerve fiber layer Nerve fiber layer
Inner plexiform layer Ganglion cell layer Ganglion cell layer
Inner plexiform layer Inner plexiform layer
Inner nuclear layer Inner nuclear layer
Outer plexiform layer Outer plexiform layer Outer plexiform layer
Outer nuclear layer Outer nuclear layer Outer nuclear layer
Henle fiber layer Henle fiber layer
Outer and inner segments of External limiting membrane External limiting membrane
photoreceptors Myoid zone Myoid zone
Ellipsoid zone Ellipsoid zone
Outer segments of photoreceptors Outer segments of photoreceptors
Interdigitation zone Interdigitation zone
Retinal pigment epithelium RPE/Bruch complex RPE/Bruch complex
Choroid Choroid Choriocapillaris Choriocapillaris
Sattler layer Sattler layer
Haller layer Haller layer
Suprachoroidal layer
Sclera Not visible Choroid-sclera junction and sclera Sclera
Orbital fat Not visible Not visible Orbital fat, subtenon space, muscle
insertion

US indicates ultrasonography.

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Huynh et al
a hyperreflective band between the outermost limit of the
choroidal vessels and the moderately reflective sclera. This
band was hypothesized to be the SCL, although some stud-
ies referred to this band as the CSI.19,31 Other studies using
EDI techniques noted a hyporeflective band adjacent to the
sclera, which they hypothesized to be the SCS. Spaide et al
also reported the presence of a hyporeflective band under
the CSI in some images, which was hypothesized to be the
SCS.18 However, the significance of the SCS was not eluci-
dated. Subsequent studies using EDI techniques described
the SCS as a variable second layer of the SCL and discussed
how its presence would affect choroidal thickness (CT) mea-
surements.32,33
The choroid can also be visualized with the SS-OCT de-
vice, which showed the same structures as seen on EDI with-
out sensitivity roll-off across the depth of the scan, inherent
within an SD-OCT system. The uniform signal-to-noise ra-
tio and greater scan depth axially in SS-OCT devices reduces
image artefact when visualizing SCL in eyes with posterior
staphyloma. Swept source OCT also revealed 2 patterns of the
SCL if this structure was visible: 1) a single hyperreflective
band or 2) a hyperreflective band accompanied by an adjacent
hyporeflective band, which represents the SCS.4 Visualization
of the CSI may be superior with SS-OCT, with one study re-
porting feasibility of CT measurement in 100% of eyes im-
aged with SS-OCT, compared with 73.54% and 68.3% of eyes
imaged with EDI and non-EDI SD-OCT, respectively.21
In 2015, Ruiz-Medrano et al visualized the insertion of
the inferior oblique muscle in the sclera together with a thin,
hyporeflective line parallel to the choroidoscleral boundary,
which was hypothesized to be the intrascleral portion of the
temporal long posterior ciliary artery. They also observed that
vessels in the choroid are hyporeflective due to the higher
velocity of blood flow compared with retinal blood vessels,
which generate hyperreflective signals.34
Traditionally, choroidal thickness is measured manually
as a perpendicular line from the outer boundary of the RPE/
Bruch membrane complex to the inner border of the sclera
defined as the CSI.12 Measurements are often taken directly
underneath the fovea, as the choroid is usually the thickest
here.35 The morphology of this interface can vary across the
length of the scan and between different types of pathology
and different OCT devices.33 Furthermore, the definitions of
the different types of CSI also vary in the literature.36 Although
the standard deviation in retinal thickness measurements using
SD-OCT was reported to be 12.9 µm, it was 77.4 µm in the
choroid.26 Variability in choroidal thickness measurements can
be attributed to poor image quality, spectrum of pathology of
the subject eyes, and inconsistent definition of the outer cho-
roidal boundary.33 The SCL, found between the outer border of
the large vessel layer and inner sclera, has caused ambiguity
regarding the exact location of the boundary.32 Although mul-
tiple algorithms have been proposed for evaluating automated
choroidal thickness measurements, there is no gold standard.
Such measurements typically exclude the SCL. Whether this
layer should be included in choroidal thickness measurements
requires further investigation. However, the nomenclature
used to describe the choroidal layers can be standardized to
avoid confusion for future definitions of the CSI.
Differences in choroidal thickness measurements from
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Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
SS-OCT versus SD-OCT were generally found to be insig-
nificant.22,37–39 In contrast, differences in pathology caused
larger differences in choroidal thickness measurements. In
a study by Tan et al, it was found that subfoveal choroidal
thickness measurements made using SS-OCT and SD-OCT
devices were very similar with mean differences ranging
from 7 to 15 µm between any 2 devices.39 Although the re-
liability was comparable among eyes with retinal diseases
and normal eyes, a higher proportion of eyes with disease
showed a difference between SS-OCT and SD-OCT greater
than or equal to 20 µm.39 A study by Barteselli et al40 that
compared SD-OCT with SS-OCT reported that SS-OCT was
similar to SD-OCT in visualizing the choroidoscleral bound-
ary (CSB) in 90% of eyes. Eyes were given a grade from 0 to
2 indicating the visibility of the CSB. The average (± standard
deviation) grading of 1.81 (± 0.39) was given to SS-OCT and
1.78 (± 0.38) for SD-OCT (P = 0.566). The sharpness of cho-
roidal structures was found to be greater with SS-OCT than
SD-OCT (P < 0.001). Matsuo et al39 postulated that choroi-
dal thickness measurements were thicker using SS-OCT be-
cause the choroid-scleral border seen on SD-OCT scans may
not be the true border. Tan et al22 noticed this phenomenon in
some patients in whom there was a hyperreflective region that
initially appeared to be the choroid-scleral border on the SD-
OCT scans, although on closer examination, the true border
was seen beyond that point.39 Because differences in choroidal
thickness between OCT devices were also found to be smaller
among patients with thinner choroids, Tan et al postulated that
in eyes with thicker choroids, a signal loss and artefacts and
shadows cast by the connective tissues between the vessels
might impair visualization of the choroid-scleral border more
in SD-OCT than in SS-OCT, thus accounting for the greater
variability.22
An important factor in standardizing choroidal thickness
measurements is the definition of the CSI.32 The study by Yiu
et al32 in 2013 reported that participants with a visible SCL
had the greatest differences in choroidal thickness measure-
ments. This suggests that choroidal thickness measurements
can be substantially affected by how the CSI is defined. They
performed choroidal thickness measurements by using 3 dif-
ferent landmarks to define the posterior boundary and found
that choroidal thickness measurements could have a mean
difference of up to 70 µm when 3 different boundaries were
used to define the outermost limit of the choroid. These 3 pos-
terior boundaries were as follows: 1) posterior vessel border
to define vascular CT; 2) outer border of the SCL to define
stromal CT; and 3) inner border of the sclera that includes the
SCL to define total CT. This study highlighted the potential for
systematic error in the reporting of choroidal thickness mea-
surements. Therefore, it is imperative that the CSI be clearly
identified in future choroidal studies and that segmentation al-
gorithms differentiate among the 3 types of morphology. It is
timely to discuss a standardized definition for the CSI.
THE CHOROIDAL SCLERAL INTERFACE
The CSI is a commonly used term in the choroidal thick-
ness literature. Although it appears in various forms such as
the choroidal-scleral junction, sclerochoroidal interface, and
choroidoscleral boundary, they all refer to the zone where the
© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
choroid meets the sclera. To clearly compare the definition of
the CSI in the literature, we will adhere to the guidelines pro-
posed by Staurenghi et al regarding the use of the terminology
“band” or “layer” for describing a discrete and defined lamina
as opposed to “line,” which is a 1-dimensional structure.5 It
is important to clearly define the CSI to enable accurate cho-
roidal thickness measurements that can be compared across
studies. In the literature, these terminologies have been used
interchangeably, making it difficult to determine how each
study has defined the CSI.
The posterior boundary for CT measurements was first
defined as the inner surface of the sclera in the pilot study us-
ing EDI techniques by Margolis and Spaide,35 which we inter-
pret as a line between the choroidal vessel and scleral bands.
Although the SCS was observed in the original description
of EDI techniques by Spaide et al,18 this was not included in
choroidal thickness measurements. Subsequent studies have
adopted this definition for the posterior border of the cho-
roid.22,35,38,41,42 However, some authors have described the CSI
as a hyporeflective zone,1,26 whereas others have described it as
a hyperreflective zone.43,44 By definition, if the CSI is consid-
ered a line, it should not have an intensity descriptive term as-
sociated with it. We believe these authors are still referring to
the same CSI; however, their description should be interpreted
as measuring to the outer border of the hyporeflective choroi-
dal vessels or the inner border of the hyperreflective sclera.
Michalewska et al, who imaged the choroid using SS-OCT,
were able to clearly visualize the SCL below the choroidal
vessels as a hyperreflective band followed by a hyporeflec-
tive band.4 However, they defined the CSI as lying between
the choroidal vessels and the SCL, aligning with the original
definition of the CSI.
Several studies have described the CSI as a hyperreflec-
tive band between the choroidal vessels and sclera.19,31,33,45
Maul et al19 defined the CSI as having a width less than or
equal to the RPE depending on image quality, whereas other
studies described the CSI as a distinct hyperreflective band
below the choroidal vessels and if present, above the hypore-
flective SCS. For measuring choroidal thickness, Ikuno et al31
used the inner boundary of the CSI as the limit of the choroid,
whereas both Maul and Boonarpha33 used the outer bound-
ary of the CSI as the limit of the choroid. In EDI SD-OCT
images, Yiu et al observed a hyperreflective band followed
by a hyporeflective band between the choroidal vessels and
sclera, which they named the choroidal stroma and lamina fus-
ca/SCL, respectively.32 Rather than defining the suprachoroid
as originating from the choroid or sclera, Yiu et al proposed 3
definitions for the CSI which were the boundaries posterior to
the 1) choroidal vessels (vascular thickness), 2) hyperreflec-
tive choroidal stroma (stromal thickness), and 3) hyporeflec-
tive SCL (total thickness or lamina thickness).
A review of the literature shows that the CSI has been de-
scribed as both a boundary and a band. Currently there is no
consensus definition and description for the CSI. However, this
needs to be standardized so that choroidal thickness can be
compared across studies. As the majority of choroidal thick-
ness studies and automatic segmentation algorithms have
defined the CSI as a boundary, we believe that it should be
considered as a boundary between the choroid and the sclera.
Whether this boundary includes or excludes the suprachoroid
© 2017 Asia-Pacific Academy of Ophthalmology
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Choroidal Scleral Interface on OCT
depends on whether this layer is visible and how this layer is
classified by the authors, as there is no universal consensus
for its origin yet. Furthermore, examination of the definition
and description of the CSI in the literature has highlighted the
discordance in the nomenclature for the anatomic correlates
of bands visualized in OCT. Correct band assignment is nec-
essary for proper evaluation of both normal and pathological
states in the retina.46
HARMONIZATION OF THE TERMINOLOGY IN
DESCRIBING THE OUTER CHOROIDAL BOUNDARY
Very few studies are clear about which anatomic corre-
late visualized on OCT they are referring to when discussing
the CSI in text and even fewer studies describe or demonstrate
the appearance of the CSI on an OCT image. Often, authors
use anatomic landmarks to define the CSI and assume that all
readers will interpret these anatomical terms in the same way.
For example, “the outer aspect of the lamina fusca, rather than
the outer limit of the choroidal vessels, was the landmark used
to determine the most distal aspect of the choroid and inner
edge of the sclera.”34 However, a review of the literature, as
outlined in the Methods section, has shown that a universal
naming system for the choroidal and suprachoroidal struc-
tures observed in EDI SD-OCT and SS-OCT has yet to be
established. In this section, we review the nomenclature and
description of the structures visualized in EDI SD-OCT and
SS-OCT. Duplicate or derivative works were not included.
We also propose a nomenclature for the choroidal layers that
is based on histology and harmonizes the terminology used in
our review.
The nomenclature we propose for the anatomic cor-
relates visualized on OCT is in the first column of Table 2.
Table 2 also shows the nomenclature for the choroidal layers
described by the 4 studies included in our review, highlight-
ing the discrepancies in the literature compared with the refer-
ence. Papers included in this table provided both a name and
a description of the structure visualized and/or demonstrated
the structures in figures. All studies to date have defined the
anterior boundary of the choroid as the base of the RPE/Bruch
complex. However, some studies have called this layer either
the RPE18,19 or Bruch membrane.4,33 Nevertheless, all the stud-
ies refer to the same structure visualized on OCT and the cho-
sen nomenclature is merely semantics, as the OCT structure
representing the RPE and Bruch membrane are usually in-
separable under normal conditions.5 The number of choroidal
vessel layers identified by studies varies. In some studies, the
choroidal vessels are separated into 3 distinct layers, whereas
other times they are collectively referred to as the choroidal
vessels. However, the posterior boundary of the choroidal ves-
sels is consistent in the literature.
If the SCL is present in an OCT image, it is situated be-
tween the choroidal vessels and the sclera and visualized as
either a single hyperreflective band or as a double structure con-
sisting of a hyperreflective band followed by a hyporeflective
band, where the darker band is termed the SCS. It was report-
ed that the SCL was visible in both eyes of 41.8% of the par-
ticipants in the study by Yiu et al.32 Studies have found that the
visibility of the SCL depends on the status and type of disease
along with systemic factors such as age.24,33 A number of studies
www.apjo.org | 99
 TABLE 2. Proposed Nomenclature for Anatomic Landmarks Seen on EDI SD-OCT and SS-OCT Images

Harmonization of Nomenclature for

Huynh et al

OCT Description Povazay (2009) Yiu (2014) Boonarpha (2015) Michalewska (2015) Histologic Correlates of OCT Layers

Hyperreflective RPE RPE/Bruch membrane RPE/Bruch membrane Bruch membrane RPE/Bruch membrane complex/

100 | www.apjo.org
complex complex lamina vitrea
Moderate reflectivity Choriocapillaris Choroidal vessels Choriocapillaris Choriocapillaries Choroidal vessels*
Choriocapillaris
Round/oval shaped Sattler layer Choroidal stroma Sattler layer Choroidal stroma
hyperreflective profiles Haller layer Haller layer Sattler layer
with hyporeflective cores Haller layer

Hyperreflective N/A N/A Suprachoroid Suprachoroidal layer/ Suprachoroidal layer†/

lamina fusca/lamina suprachoroidal lamina/
suprachoroidea suprachoroid/lamina fusca
Hyperreflective CSI Choroidal stroma Suprachoroidal lamina/CSI N/A Suprachoroidal stroma
Hyporeflective Lamina fusca sclera Suprachoroidal layer/ Suprachoroidal space Suprachoroidal space Suprachoroidal space
lamina fusca
Moderately reflective Sclera Sclera Sclera Sclera Sclera
homogeneous region of
decreasing reflectivity

N/A indicates not applicable.

*The choriocapillaris, Sattler layer, and Haller layer are not always differentiable.
†The suprachoroidal layer is not present in all eyes. If it is present, there are 2 possible configurations: 1) single hyperreflective band (suprachoroidal stroma) or 2) hyperreflective band followed by a hyporeflective
band (suprachoroidal stroma and suprachoroidal space).

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© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017 Choroidal Scleral Interface on OCT

FIGURE 3. An SS-OCT image and its corresponding A-scan intensity profile at the fovea. A, SS-OCT image with structures demarcated by colored
lines. B, Corresponding intensity profile where the colored lines indicate the beginning of the structures: the retina consists of the neuroretina (NSR)
and the RPE. The peaks within the retina (magenta) indicate the 1) ILM, 2) ELM, 3) ellipsoid zone, and 4) RPE. Choroidal vessels (green), suprachoroidal
stroma (blue), suprachoroidal space (red), and sclera (cyan) are seen below the retina. Colored lines represent the start of each layer where the average
intensity between lines is indicative of the relative reflectivity used to describe OCT images in Table 2.

were able to identify the double bands of the SCL. However,
the anatomic correlates assigned to them differed among the
groups. Povazay et al named the 2 bands the lamina supra-
choroidea and the lamina fusca sclera, respectively.45 Yiu et
al36 termed them the choroidal stroma and the SCL. According
to histology, the choroidal stroma is the extravascular tissue
containing collagen and elastic fibers, fibroblasts, nonvascular
smooth muscle cells, and numerous large melanocytes that are
juxtaposed to the blood vessels.10 Hence, it is considered to
be incorporated with the Sattler and Haller layers. To date, no
other studies have described the SCL as consisting of only a
hyporeflective band. Therefore, we suggest that it is inappro-
priate to assign this nomenclature to 2 bands. Boonarpha et al
called the 2 bands the CSI/SCL and the SCS, respectively.33
According to the reference nomenclature, the SCS is part of
the SCL and hence the hyperreflective portion of the double
band cannot be termed the SCL. The nomenclature for the 2
bands proposed by Michalewska et al4 aligned with the refer-
ence nomenclature.
In general, similar structures are visualized among studies
on OCT images. Although some studies have been able to de-
lineate more than 1 band in the choroidal vessels or have noted
the presence of the SCL and at times the SCS within it, the
choroidal layers visualized among studies are the same. Only
the nomenclature used for the layers differs, causing confusion
in the literature. Studies that have observed the hyporeflective
band within the SCL have agreed that it represents the SCS.
However, a review of the literature has revealed that there is
currently no consensus nomenclature for the hyperreflective
band of the SCL. Some studies have termed the hyperreflec-
tive band the CSI. However, as previously discussed, the term
CSI should be reserved for the boundary between the choroid
and sclera, where the SCL is classified as either of choroidal
or scleral origin, if it exists. Others have incorrectly used
nomenclature that has already been assigned to another layer.
Thus, we propose to refer to this layer as the suprachoroidal
stroma. The demarcation of the layers described in Table 2 are
shown in the EDI-OCT image in Figure 3A and the relative
reflectivity of each structure is shown in the corresponding
intensity profile in Figure 3B.
FUTURE DIRECTIONS
Optical coherence tomography technology will continue
to advance, allowing better visualization of the posterior coat
of the eye and additional published research on the choroid. It
is, therefore, important to establish universal terms for describ-
ing choroidal layers and sclera and to standardize nomencla-
ture used in the definition of the boundary between the choroid
and sclera, to allow easier comparison between future studies
examining choroidal thickness. This would involve defining
whether the SCL and the SCS within it belong to the choroid
or the sclera. Until then, we suggest that the CSI should be de-
fined as the end of the choroidal vessels for choroidal thickness
measurements so that results can be compared with the initial
choroidal thickness studies. This is due to the limited signal
penetration in eyes with thicker choroids or retinal pathologies
that may reduce the likelihood of clearly visualizing the CSI.32
From a functionality perspective, measuring to the posterior
vessel border also makes sense because choroidal thickness is
usually measured as a marker for choroidal vascular perfusion.32
However, we recommend measuring the thickness of the SCL
and SCS separately if observed, as they have potential in the
diagnosis and treatment of various conditions.
CONCLUSIONS
As seen in histology, the suprachoroid is a transitional
zone containing both choroidal and scleral elements. The
border between the choroid and the sclera is, therefore, not
well-defined. The definition of the choroidal scleral interface
has changed with advancing OCT technology. With TD-OCT,
structures beneath the RPE were difficult to discern and thus
were collectively termed the choroid. Spectral domain OCT al-
lowed deeper penetration, facilitating distinction between the
choroidal vessel layers (choriocapillaris, Haller and Sattler
layers) and sometimes the scleral tissue. This expanded the
number of choroidal layers that can be visualized and enabled

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Huynh et al
the most posterior layer, the choroid scleral juncture, to be
identified. Enhanced depth imaging SD-OCT strengthened
the signal deep into the choroid, allowing better delineation
of the transition from choroid to sclera. The variable morphol-
ogy encouraged inconsistency in the naming of the choroidal
and scleral structures with multiple research groups simulta-
neously describing the boundary. Furthermore, the advent of
EDI SD-OCT and SS-OCT allowed the visualization of the
suprachoroidal layer within which there may be a supracho-
roidal space. This imposed a new challenge in the standardiza-
tion of the choroidal scleral interface definition with the use of
inconsistent nomenclature in the literature.
We propose the CSI to be a line representing the poste-
rior boundary of the choroid delineating the choroidal vessel
layers from the sclera, rather than a separate layer, to be con-
sistent with histology. Furthermore, the automated segmenta-
tion algorithm for the choroid has been developed based on
the assumption that the CSI is a line rather than a layer. As
research has not yet been able to classify the SCL as origi-
nating from the choroid or sclera, we recommend the use of
descriptive terms such as hyperreflective and hyporeflective
bands to label the SCL.
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