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ONH and RNFL Imaging

Interpreting Results
Tanuj Dada
Additional Professor

Dr RP Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi

Q. Why do we need Imaging ?

WGA : New Glaucoma Definition

“Progressive Structural Optic Nerve Damage”
is the NEW “Gold Standard”.

138:458-467.Undetectable Disease May Progress to Functional Impairment RNFL change (detectable) RNFL change (undetectable) SWAP VF changes SAP VF change Ganglion cell death/axon loss Acceleration of apoptosis Normal VF change (moderate) VF change (severe) Blindness VF=visual field. Adapted from Weinreb et al. Am J Ophthalmol. . 2004.

Baseline documentation of the disc changes 2. 2003. Hemorrhage . Mangione CM. 1. Patterns of care for open-angle glaucoma in managed care. Early diagnosis 5. Documentation of progression x Pallor. Lee PP. Arch Ophthalmol. Risk Assessment (OHTS CSLO study) 4. et al.121:777–83. Evaluation of the disc size 3.Does imaging add to clinical care ? Nearly 50% of glaucoma patients did not have a disc drawing or photograph taken at the time of initial examination Fremont AM.

WGA Recommendation The World Glaucoma Association & American Academy of Ophthalmology recommend Imaging as part of routine clinical care .

With so many high tech. machines why is there a problem in diagnosing glaucoma with imaging ? .Q.

7 – 1.Normal Biological Variability ? • Large variability in optic nerve head • 0.5 million optic nerve axons This huge “Normal Variability” Limits ability to differentiate between healthy eyes and glaucoma at one point in time .

Early Diagnosis : A myth Patient A presents with 1 million nerve fibers Q1. Did he start of with 1 million (within normal range) Q2. Did he start of with 1.4 million (within normal range) People in the statistically “normal range”may undergo optic disc and RNFL changes over time and yet still remain within the normal range on the basis of any single exam alone. .

Glaucoma Diagnosis We need to document progressive structural loss over time The patient is his own best “normal” and to diagnose glaucoma you need to monitor change over time Normative Databases are indicators and not specific enough for definitive diagnosis .

Q. Test Re-Test Variability .

00 pm .51 pm Scan done on 4rth march 2006 3.Variability Scan done on 4rth march 2006 2.

0 .Triple Scan GDx Version 6.

Image Quality: Standard Deviation < 10 µm 10 .20 µm 20 .30 µm 30 .40 µm 40 .50 µm > 50 µm Excellent Very Good Good Acceptable Try to improve Poor quality documentation only .

e. higher Standard Deviations (30-50+ µm) mean there is more noise and thus changes need to be much bigger before we can detect them.Image Quality – Standard Deviation High quality images with low Standard Deviations (7-30 µm) allow us to detect small changes. Lower quality images i. .

Image Quality We want to compare similiar quality images to be more assured that change is real and not due to fluctuations in image quality SD 10 SD 11 SD 12 SD 9 SD 10 .

Image Quality
We want to compare similiar quality images to be more assured that change is real and not due to fluctuations in image quality

Review Image Quality
• Standard Deviations should ideally be within 5µm of each other • Exclude outliers from the Progression Series

Astigmatism introduces an optical rotation into the image, affecting image quality. This rotation must be corrected for using astigmatic corrective lenses if the cylinder is more than 1D

Q. Impact of signal strength ? .

scan quality can adversely effect the ability to detect change over time • Therefore.148(2):249-255 . Medeiros FA.Impact of Signal Strength on RNFL • Differences in signal strength were associated with differences in average RNFL thickness • Even under optimal testing conditions. 2009 Aug. Zangwill LM. caution is warranted when detecting glaucomatous progression using scan series of different quality • Signal strength of > 7 is mandatory Vizzeri G. Weinreb RN. Am J Ophthalmol. Bowd C.

Signal Strength Factors influencing Lenticular opacification Posterior capsule opacification Ocular surface disease – dry eye .


patient underwent cataract surgery OCT 4 weeks later Post operative SD-OCT SIGNAL STRENGTH 8/10 .

8 0.3 0.3 0.2 59.6 0.3 ± 15.2 ± 13.004 Inferior average 50.1 56.5 ± 10.58(5):389-94 ) RNFL Parameters Pre operative Post operative P value TSNIT average 49.7 61. Indian J Ophthalmol.6 ± 11. 2010 Sep-Oct.001 .3 21.6 ± 12.2 ± 14.8 ± 7.5 ± 7.001 NFI 41.001 Superior average 51.GDxVCC parameters pre and post cataract surgery (Dada T et al.


How to increase the signal strength ? .Q.

.Increasing Signal Strength Ensure the Ocular Lens is Clean Adjust Focus Optimize Polarization Instruct the patient not to blink during optimization Ensure the scan is not too low horizontally Stable Tear film – ask patient to blink before scan is acquired In case of media opacity . move the pupil alignment off-center by clicking in a different spot on the pupil in the iris viewer or adjusting the chinrest position.

Effect of Disc Size? .Q.


85: 1 .False Positive HRT Large Disc CD Ratio = 0.

.Disc Size : MRA.Indian J Ophthalmol. Dada T et al . GPS Jindal S. 2010 Nov-Dec.58(6):487-92. Comparison of the diagnostic ability of Moorfield's regression analysis and glaucoma probability score using Heidelberg retinal tomograph III in eyes with primary open angle glaucoma (n =50) • The sensitivity increased with increasing disc size for both MRA and GPS and vice versa • There was a poor agreement between the overall MRA and GPS classifications.


Effect of centration ? .Q.

Before you comment on Progression Check Centration .

Q. Effect of IOP? .

IOP lowering can impact ONH • Check IOP from exam to exam – Changes of 2 or 3 mm Hg not significant – Changes of 10 mm Hg could be significant .

Q. Glaucoma with ARMD ? .

GDx VCC  Scanning Laser Polarimetry (780 nm) with variable corneal compensation Is based on the principle that polarized light is changed as it passes through the Retinal Nerve Fiber Layer Variable Corneal Compensation eliminates the effect of Corneal Polarization   .

GDx VCC • Macular scan is performed • Henle fibers = uniform birefringence • Abnormal Birefringence pattern of Henle „s Layer yields corneal birefringence • Corneal birefringence is then eliminated to give actual RNFL thickness measurement Macular birefringence note bow tie pattern without compensation .

5 22.4 Superior Average 63.02 78.7 25.9 14.7 ± 31.3 Abnormal Macula 53.9 0.9 ±10.9 .8 ± 5.7 19.1 0. b Protocol I (c) Protocol II (d) Normal TSNIT Average 51.1 66.1 59.7 ± 9. Dave V ARVO 2010 Parameter Protocol I (a) Protocol II (b) p value a vs.1 ± 7.0 ±12.7 ±32.1 Inferior Average NFI 58.6 0.1 62.9 ± 6.9 ± 4.Dada T .3 ± 8.6 ± 33.01 77.2 0.003 82.1 ± 6.9 ± 8.8 ± 7.8 ±16.2 ±14.7 52.2 59.

Standard Scan Protocol Irregular Scan Protocol .

Effect of Peripapillary Atrophy? .Q.

Problems with GDxVCC False Negative Supra .Normal Peripapillary Atrophy .

2 .4.4.2 mm 3.0 .0 mm 4.3 scan diameter scans 2.8 mm J Glaucoma (2009) .4 .3.

Q. Correlate fundus examination with imaging and perimetry ? .


Correlation of structure & function .

Does an Abnormal Scan indicates Glaucoma ? .

IOP 20-22 mmHg .44 yr male open angle. CCT 530.




A Word of Caution ! Imaging Does not replace your clinical examination Provides additional clinical information which is useful in the diagnosis and management of your patients .

Take Home Message • Imaging is critical in diagnosis and management of glaucoma • Expert operator and expert interpreter • Use your own eyes and brain in conjunction with machinery • Check image quality at each visit and correlate structural changes with functional deficits .

Thank You Thank You .

How to identify Progression ? .Q.

How to Diagnose : Glaucoma progression Exam 1 : RNFL thickness = 100 microns December 2010 Exam 2 : RNFL thickness = 97 microns July 2011 Logical Conclusion = 3 microns loss of RNFL thickness Patient has progressed : Initiate or escalate treatment .

Glaucoma progression Must know test re-test variability Exam 1 : RNFL thickness = 100 microns Exam 2 : RNFL thickness = 97 microns Exam 3 : RNFL thickness = 103 microns Truth : Normal Test Re-Test Variability is 6 microns so you cannot take 3 micron loss as “progression” .

Baseline Imaging Exam • Must do test re-test variability to establish range of variability • If change during follow up is more than test re-test variability Only then can you call it a progression .