Tools
Optical Coherence Tomography
Introduction
Optical coherence tomography (OCT) is a noninvasive imaging technique that uses visible and infrared electromagnetic waves to provide detailed, cross-sectional images of body tissues. OCT has widespread application in ocular imaging to diagnose and monitor various ophthalmic pathologies in both the anterior and posterior segments. OCT is commonly employed in evaluating and managing vitreoretinal and macular diseases in addition to processes affecting the optic nerve head, including glaucoma.[1]
OCT has evolved considerably since its invention in the early 1990s and the introduction of the first commercial ophthalmological device in 1996.[2] The 3 main types of OCT are time-domain, spectral-domain, and swept-source. These types differ in image acquisition, scanning speed, axial and transverse resolution, and range of imaging.
Time-Domain Optical Coherence Tomography
Time-domain OCT (TD-OCT) is a first-generation technology that uses a low-coherence interferometer to measure the time delay and magnitude of backscattered light from different tissue depths, subsequently constructing two-dimensional images in a manner similar to ultrasound technology.[3] However, TD-OCT measures only one point at a time, and the coherence length of the light source limits depth resolution.[3] TD-OCT typically uses a superluminescent diode with a relatively broad spectrum as its light source, resulting in decreased image resolution compared to newer technologies. TD-OCT has largely been replaced by techniques that offer faster acquisition speeds, higher image resolution, and a better range of imaging.
Spectral-Domain Optical Coherence Tomography
Spectral-domain OCT (SD-OCT) is a second-generation technology with significantly faster acquisition speeds, deeper tissue penetration, and higher image resolution.[4] SD-OCT uses a spectrometer to detect the spectrum of backscattered light, allowing simultaneous measurement of multiple tissue points.[4] Higher-speed data acquisition enables three-dimensional tissue imaging and improved resolution.
SD-OCT uses Fourier transformations to generate high-resolution, cross-sectional images of biological tissues.[5] In SD-OCT, a broadband superluminescent diode source is used to illuminate the tissue. Light reflected from the tissue is detected using a spectrometer that separates the reflected light into its constituent wavelengths. Interference patterns between the reflected light and a reference beam are measured for each wavelength and processed using Fourier transformations to generate high-resolution images.[6]
Due to its improved imaging capabilities, SD-OCT has become the standard for clinical use in ophthalmology, enabling earlier diagnosis and management of conditions such as age-related macular degeneration, diabetic retinopathy, and glaucoma. SD-OCT also has clinical applications in dermatology, cardiology, and gastroenterology.[7][8]
Enhanced Depth Imaging
Enhanced depth imaging (EDI) in SD-OCT is an imaging modality that places the objective lens in a closer scanning position to the eye, permitting better depth sensitivity and improved visualization of deeper ocular structures, particularly the choroid.[9][10] EDI-OCT is particularly useful when diagnosing and managing diseases that affect the choroid, such as age-related macular degeneration, choroidal neovascularization, polypoidal choroidal vasculopathy, and central serous chorioretinopathy.[10] EDI-OCT can also provide crucial information about the thickness of the retina and the presence of fluid or swelling in the retina or choroid.[11] Modern SD-OCT and swept-source OCT (SS-OCT) machines are capable of acquiring enhanced depth images.[12]
Swept-Source Optical Coherence Tomography
SS-OCT is an advanced noninvasive medical imaging technique that uses a wavelength-sweeping laser and a single dual-balanced photodetector to capture high-resolution images of the anterior segment, retina, optic nerve, and choroid.[13] The longer wavelength of the light source permits deeper tissue penetration and faster scanning speeds, resulting in excellent widefield visualization of posterior segment eye structures superior to SD-OCT with EDI.[14]
Optical Coherence Tomography Angiography
OCT angiography (OCTA) is a noninvasive imaging method that gives a three-dimensional visualization of blood vessels at different tissue levels within the retina and choroid. The images captured by OCTA provide details far superior to those obtained using conventional fundus fluorescein angiography or indocyanine green angiography; OCTA does not carry the time requirement or risks associated with systemic contrast administration.[15] OCTA has multiple applications in neuro-ophthalmology, including multiple sclerosis, anterior ischemic neuropathy, hereditary optic neuropathy, and glaucoma.[15]
Anatomy and Physiology
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Anatomy and Physiology
Effective use of OCT when diagnosing and managing ophthalmic disorders requires a solid understanding of the retinal anatomy provided by OCT images (see Image. Optical Coherence Tomography). OCT provides a two-dimensional cross-sectional image of all retinal layers from the internal limiting membrane to the retinal pigment epithelium. SS-OCT can deliver high-resolution scans of all retinal layers through the sclera-choroid junction.
Adjacent to the choroid is the hyperreflective retinal pigment epithelium/Bruch membrane complex. The interdigitation zone is also hyperreflective and represents the retinal pigment epithelium-photoreceptor junction. The hyperreflective ellipsoid zone is the junction of the inner and outer photoreceptor segments (IS-OS junction); these segments are hyporeflective. The IS-OS junction abuts the hyperreflective external limiting membrane. The hyporeflective outer nuclear layer is adjacent to the hyperreflective outer plexiform layer. Other retinal layers include the inner nuclear layer, the hyperreflective inner plexiform layer, the hyporeflective ganglion cell layer, and the retinal nerve fiber layer.[16] The normal macula is slightly depressed at the fovea due to the migration of the inner retinal layers towards the periphery, exposing the densely packed photoreceptors in the outer retina.[17]
Changes in the normal reflectance of OCT images can indicate underlying ocular pathology. Fluid collections, such as intraretinal, subretinal, or sub-retinal pigment epithelium collections, appear hyporeflective and dark. Hyperreflective substances include but are not limited to exudates, blood, fibrosis, choroidal neovascular membranes, and epiretinal membranes.
Various parameters can be assessed with OCT. Macular thickness is the distance in microns between the internal limiting membrane and retinal pigment epithelium.[18] The central retinal thickness, which includes the central 1-mm diameter retinal thickness, is widely used in clinical practice for diagnosis, treatment protocols, and follow-up.
The normal ranges of common anatomic measurements vary between OCT devices based on the manufacturer, model, and reference population used for calibration. However, typical ranges of normal values are generally reported as follows:
- Central macular thickness: 200 to 250 μm
- Retinal nerve fiber layer: 90 to 110 μm
- Ganglion cell layer: 70 to 90 μm
- Inner plexiform layer: 50 to 70 μm
- Choroidal thickness: 200 to 400 μm; varies significantly with the technique and location of measurement.
Indications
OCT may be indicated for any patient with otherwise unexplained vision loss. Although OCT is a useful clinical tool, it does not replace the need to obtain a comprehensive medical history or perform a thorough ophthalmoscopic examination.
Retinal Disease
OCT has become essential in diagnosing and managing many macular diseases. The macula is the central part of the retina responsible for sharp, detailed vision. Patients with macular disease commonly present with central scotoma, metamorphopsia, or blurred central vision. OCT is recommended even if ophthalmoscopy reveals macular or foveal abnormalities; OCT typically yields results that better correlate with clinical findings. Examples of macular diseases that benefit from OCT include but are not limited to:
- Macular edema, which may be secondary to diabetic retinopathy, intraocular infections, systemic conditions with ocular manifestations, retinal vein occlusion, medications, or postoperative complications including Irvine-Gass syndrome [19]
- Maculopathies, such as wet age-related macular degeneration or choroidal neovascular membrane
- Macular holes [20]
- Vitreomacular traction
- Cellophane maculopathy and macular pucker from epiretinal membranes
- Genetic maculopathies and macular dystrophies such as Stargardt or Best disease.
When monitoring the progression of macular diseases and responses to therapeutic intervention, OCT is indicated for evaluating changes in retinal anatomy and retinal thickness to facilitate the timing of surgical intervention, visualizing and monitoring changes in fluid accumulation over time, and assessing the integrity of the photoreceptor layer.[21]
EDI-OCT, SS-OCT, and OCTA are frequently indicated in the evaluation and management of various choroidopathies, particularly those involving the vasculature, including central serous chorioretinopathy, choroidal neovascularization, and polypoidal choroidal vasculopathy. OCTA is frequently used for imaging patients with diabetic retinopathy, age-related macular degeneration, retinal vein occlusion, and macular telangiectasia.
OCT can also evaluate other retinal abnormalities causing vision loss, such as retinal detachment, retinal pigment epithelial detachments, central serous retinopathy, or pathological myopia.
Optic Nerve
OCT is indicated in the evaluation of optic neuritis, an optic nerve inflammation that can cause vision loss and eye pain. OCT is also crucial for evaluating and managing glaucoma, providing valuable details about the retinal nerve fiber layer and ganglion cell layer thickness, both of which are reduced in the glaucomatous eye.[22] OCT is also used as a screening tool in patients at increased risk of developing glaucoma.[23]
Anterior Segment
Anterior segment OCT (AS-OCT) enables visualization of the entire anterior segment structures in a single image and precise quantitative measurements of these structures, including angle opening distance, angle recess area, and trabecular iris space area.[24][25] The trabecular meshwork, canal of Schlemm, angle configuration, and iris configuration can all be visualized using AS-OCT. AS-OCT is particularly useful in identifying patients with shallow angles at risk of acute angle-closure glaucoma and could benefit from preventative iridotomy. AS-OCT can also be used to evaluate and map the cornea, including in cases of corneal opacities, scars, or dystrophies.[24] Intraoperative AS-OCT has been used widely in keratoplasties, refractive surgeries, implantation of intrastromal rings for keratoconus, and trabeculectomy procedures.[26][27] Please see the StatPearls' companion resource, "Acute Angle-Closure Glaucoma," for more information.
Contraindications
There are no absolute contraindications to OCT. However, as OCT uses light waves passing through the pupil and reflecting off the retina, medial opacities can compromise image quality. Therefore, OCT may be of limited utility in patients with congenital or acquired corneal opacities, severe cataracts, or intravitreous hemorrhage.
Equipment
An OCT image is obtained by directing a beam of light, typically in the near-infrared spectrum, onto a tissue of interest; in ophthalmology, this tissue is typically the retina. The light is simultaneously directed onto a reference mirror. The 2 reflected light beams form an interference pattern, generating A-scans. Numerous adjacent A-scans produce a live cross-sectional image of the tissue called a B-scan.[28] TD-OCT has a typical scanning speed of 400 A-scans per second. In contrast, SD-OCT can produce as many as 100,000 A-scans per second, resulting in faster acquisition of higher-resolution images.[28][29][30] SS-OCT uses a tunable laser with a longer wavelength, typically 1050 nm, with a scanning speed of up to 4 million A-scans per second.[31] AS-OCT also uses a longer wavelength to achieve the width and depth required to scan the entire anterior segment.[32]
Equipment
Historically, OCT machines were large, immobile equipment requiring patients to visit a medical facility for testing. However, this is no longer the case with the development of portable OCT devices. Mobile OCT devices are small and lightweight, with a frequently simplified user interface. Many portable OCT devices are handheld and battery-powered, enabling their use in various settings, such as rural or medically underserved areas, emergency departments, or operating rooms.
Intraoperative OCT is an innovative medical imaging technology that provides high-resolution images of the surgical field, offering superior detail compared to traditional one- and two-dimensional images. Technological advancements have integrated the OCT device into the surgical microscope. The benefits of intraoperative OCT include increased precision and safety during surgical procedures, a reduced risk of complications, and improved surgical outcomes. This technology has widespread applications for procedures of both the anterior and posterior segments.
Personnel
OCT can be performed by any eye care professional who has received appropriate training and demonstrated competency.
Preparation
Patient Preparation
OCT is a noninvasive, noncontact, transpupillary imaging technique. Routine preprocedural pharmacologic pupillary dilatation is not typically performed in clinical practice but may be considered in patients with small pupils to improve image capture and quality. Patients should be counseled on the possibility of pupillary dilatation and advised of the risk of temporary light sensitivity and blurred vision; some patients may experience difficulty driving after the procedure due to these transient effects.
Artifacts can be introduced in OCT images due to either the patient or the machine. Patient-related artifacts are primarily due to excessive eye movements and can be controlled by eye-tracking devices. Patients should be advised to try to remain still during the short scanning period.
Technique or Treatment
Scanning Protocols
Numerous OCT scanning protocols exist. The commonly utilized macular scanning protocols for the widely used SD-OCT are the three-dimensional cube, raster, and radial scans.[28] The cube scan provides a three-dimensional comprehensive macular image and comprises horizontal adjacent line scans over an area measuring 6 × 6, 7 × 7, or 12 × 9 mm. A raster scan is a series of parallel line scans oriented at any angle; raster scans are of higher resolution.[28] A radial scan comprises multiple line scans positioned at equal angles with a common axis; if the axis coincides with the fovea, the position of pathologic lesions can be estimated with respect to that structure.[28]
Measuring Choroidal Thickness Using Spectral-Domain Optical Coherence Tomography
Choroidal thickness measurement with SD-OCT requires specialized training and should only be performed by a qualified eye care professional. Pupillary dilatation can temporarily increase choroidal thickness and negatively affect the accuracy of choroidal thickness measurements; choroidal thickness should be measured before any dilatation is performed. Accurate choroidal thickness measurements require the zero-delay line to be set as close as possible to the choroid without touching it.
Optical Coherence Tomography Angiography
OCTA is a widely used imaging modality for visualizing the vasculature of the retina and the choroid. This technique evaluates signal changes over time caused by moving objects such as intravascular erythrocytes compared to the surrounding static retinal tissue.[33] OCTA allows for visualization of the retinal and choroidal vasculature in a single scan, particularly the superficial vascular complex, deep vascular complex, avascular complex, choriocapillaris, and choroid. OCTA cannot delineate low-flow vascular abnormalities such as choroidal polyps.[34][35] OCTA can assist in distinguishing between type 1 and 2 choroidal neovascular membranes and monitor responses to treatment.[36][37][38] Please see StatPearls' companion resource, "Optical Coherence Tomography Angiography," for more information.
Complications
The main complications of OCT are related to artifacts. The most common software-related artifact is a segmentation error. This error causes the software to incorrectly identify certain layers in the OCT image and most commonly occurs in patients with vitreomacular traction or wet age-related macular degeneration.[39][40]
Artifacts can also affect the accuracy of OCT measurements in patients with glaucoma. Minimizing artifacts requires proper patient positioning and fixation during image capture. The clinician should systematically exclude the presence of artifacts before interpreting OCT results. Typically encountered artifacts include motion or shadow artifacts and segmentation errors, which can induce erroneous measurements of the retinal nerve fiber layer, ganglion cell layer, and inner plexiform layer. The most common etiology of a shadow artifact is a cataract, which blocks or scatters the light beam and produces a shadow or signal dropout in the resulting image. SS-OCT and EDI-OCT are less susceptible to artifacts when evaluating the glaucomatous eye. To minimize artifacts, it is important to ensure proper patient positioning and fixation during the OCT scan and to carefully review the OCT images for any artifacts before interpreting the results.
Clinical Significance
Macular Edema
OCT has revolutionized the diagnosis of macular edema. Macular edema can arise from various conditions, with diabetes mellitus being the most prevalent cause.[41][42] Several OCT-based grading systems for diabetic macular edema have been proposed. OCT is also useful in evaluating uveitic macula edema due to any etiology, including Irvine-Gass syndrome.[43] Please see StatPearls' companion resources, "Diabetic Macular Edema," "Macular Edema," and "Uveitic Macular Edema," for more information.
Age-Related Macular Degeneration
OCT can be used to assess the area and volume of drusen observed in age-related macular degeneration, which can serve as a prognostic marker.[36] OCT can also demonstrate Type 1 and 2 choroidal neovascular membranes.[44][28] OCT and OCTA are also used to evaluate, classify, and monitor disease progression and response to treatment in wet age-related macular degeneration.[45] Please see StatPearls' companion resources, "Macular Degeneration" and "Wet Age-Related Macular Degeneration," for more information.[44]
Vitreoretinal Interface Disorders
The International Vitreomacular Traction Study Group has developed an OCT classification system for vitreomacular interface disorders, including vitreomacular adhesion, vitreomacular traction, and macular holes.[46] OCT has greatly improved our understanding of the pathophysiology of these disorders and allows for objective assessment of the relationship between the posterior vitreous and retina. A posterior vitreous detachment can be readily observed as a hyperreflective band that has separated from the retina (see Image. Optical Coherence Tomography, Full-Thickness Macular Hole). A posterior cortical attachment that is within 3 mm of the fovea and does not cause any foveal distortion or loss of foveal contour is called a vitreomacular adhesion.[47]
Vitreomacular traction occurs when the posterior cortical vitreous is tightly adherent to the fovea and remains so even when the posterior vitreous detaches. This traction on the fovea causes distortion, macular edema, or foveal detachment.[46][48] Idiopathic macular holes are believed to be caused by the same vitreomacular tractional forces, and OCT scanning has revolutionized the understanding of idiopathic macular holes.
There are various stages in forming a macular hole, from a pre-macular hole to a full-thickness macular hole with a complete posterior vitreous detachment.[28] Please see StatPearls' companion resources, "Posterior Vitreous Detachment" and "Macular Hole," for more information.
Pachychoroid Spectrum of Diseases
The pachychoroid spectrum of disease includes central serous chorioretinopathy, pachychoroid neovasculopathy, pachychoroid pigment epitheliopathy, and polypoidal choroidal vasculopathy. These pachychoroid disorders share the common feature of thickened choroid and large caliber choroidal vessels visible on OCT and are best evaluated using SS-OCT.[49] The OCT findings typical of central serous chorioretinopathy include a neurosensory detachment, most commonly at the fovea. Chronic central serous chorioretinopathy may demonstrate hyperreflective foci underneath the detachment or cystoid changes within the detached retina.[50] OCT may reveal retinal pigment epithelial detachment in acute or chronic serous chorioretinopathy.[51][52] Doppler OCT permits analysis of choroidal perfusion, optimizing patient compliance by minimizing motion artifacts to improve the accuracy of results.[53]
Glaucoma
OCT is the dominant imaging modality in patients with glaucoma. SD-OCT can detect glaucomatous changes before they become apparent on visual field testing, often many years before the clinical signs of glaucoma are present. OCT also permits the objective assessment of vision parameters and monitors temporal changes over time.[54] OCT can be used to measure the cup-to-disc ratio, rim area, and other parameters of the optic nerve head. OCT effectively evaluates retinal nerve fiber layer thickness; the glaucomatous eye frequently demonstrates thinning of this layer, particularly in the superior and inferior regions. OCT is also used to assess the thickness of the ganglion cell and inner plexiform layers, which typically show thinning in the inferior and temporal regions. Please see the StatPearls' companion resources, "Glaucoma," "Chronic Closed Angle Glaucoma," "Open-Angle Glaucoma," and "Acute Angle-Closure Glaucoma," for more information.
Other Disease Processes
Paracentral acute middle maculopathy: This retinal finding is often observed in individuals with risk factors for vascular or ischemic disease. Fundus visualization reveals a focal paracentral intraretinal pallid sign, and cross-sectional OCT images show hyperreflective band lesions within the inner nuclear layer, which cast hyporeflective shadows onto underlying retinal layers. These findings are believed to represent deep inner retinal capillary plexus vascular insufficiency. Acute superficial retinal vascular pathology due to diabetes mellitus, sickle cell disease, hypertension, or congenital vascular anomalies is common.[55]
Ethambutol toxicity: Ethambutol toxicity is characterized by perimacular thinning of the retinal nerve fiber layer, visible with OCT. Later stages of toxicity may be associated with generalized or diffuse ganglion cell layer loss.[56]
Plaquenil retinopathy: Advanced plaquenil toxicity is characterized by the loss of the subfoveal retinal pigment epithelial layer with diffuse central retinal attenuation of the outer photoreceptor-pigment epithelium complex.[57]
Crystalline retinopathy: In this condition, OCT reveals discrete focal crystalloid deposits in the outer plexiform layer.[58]
Stargardt disease: OCT reveals characteristic crystalline deposits at the retinal pigment epithelium and possibly Bruch membrane. Mild-to-moderate loss of the characteristic macular contour may be observed.[59]
Best disease: OCT demonstrates hyperreflective diffuse subfoveal material around the interdigitation zone or anterior to the retinal pigment epithelium and Bruch membrane.[60]
Retinitis pigmentosa: Cross-sectional OCT images typically demonstrate cystic foveal degeneration, extensive hyporeflective spaces within neuroretinal layers, outer retinal rosettes, and thinning of the ellipsoid layer. These findings correlate with the retinal bone spicules and diffuse retinal vascular attenuation characteristic of the disease.[61]
Subretinal perfluorocarbon liquid: OCT findings of retained subretinal perfluorocarbon liquid typically include a subretinal hyporeflective dome-shaped cyst, compression of overlying adjacent retinal layers, a hyperreflective band around the retinal pigment epithelium layer, and associated hyperreflective shadows over the underlying choroidal section. Stepping of the retinal pigment epithelium has been described as a key differential finding among patients with residual perfluorocarbon liquid versus residual silicon oil; this finding is attributed to the refractive index of the retained subretinal transparent medium.[62]
Solar retinopathy: OCT shows generalized foveal thinning with a hyporeflective area of varying depth that depends on the extent of visual reduction. This OCT finding often accounts for the loss of photoreceptor inner and outer segments and may extend to the retinal pigment epithelial layer.[63]
Foveoschisis: Foveoschisis is frequently associated with vitreomacular traction, and OCT reveals progressive separation within neuroretinal layers around the foveal pit. Please see StatPearls' companion resource, "Myopic Foveoschisis," for more information.
Optic disc pit maculopathy: OCT shows detachment of the pigment epithelial layer extending from the temporal optic cup margin and affecting the macula; dome-shaped macular distortion is a frequent finding.[64]
Acute idiopathic maculopathy: Outer neuroretinal submacular exudative detachment is a common OCT finding during the acute phase. Following the resolution of exudative detachments, typical OCT findings include hyperreflectivity of the photoreceptor outer segments layer with retinal pigment epithelial thickening.[65]
Acute macular neuroretinopathy: OCTA typically shows mild hypoautofluorescent petaloid patterns around the paramacular area.[66]
Enhancing Healthcare Team Outcomes
OCT imaging is a widely used tool for diagnosing and monitoring various retinal diseases, including glaucoma.[67] OCT provides an excellent two-dimensional cross-sectional image of the tissue and, as previously described, has significantly improved our understanding of many conditions, including vitreoretinal interface disorders. OCT is frequently used as a sole investigative tool to support clinical diagnosis.
In the acute setting, modern OCT, with multimodal imaging and OCTA, can be key for differentiating several ocular ischemic emergencies without systemic injection of dyes. OCTA is gaining popularity and can image several disorders of the anterior segment and retina.[68] OCT mapping of the peripapillary retinal nerve fiber layer also forms a valuable adjunct to standard automated perimetry and neuroimaging for detecting or predicting the localization of defects within the visual pathway.[69][70][71] SS-OCT machines also take advantage of their high resolution and penetration to facilitate preoperative biometry in the presence of dense cataracts.[72]
Amid these advanced practice applications of OCT technology in ophthalmic imaging, available OCT systems still pose some limitations.[73] Although there are pitfalls with OCT imaging, it forms the cornerstone of retinal imaging, and several ongoing advancements are being made to develop this technology further.[74] Further research and practice advancements, with or without the application of machine learning, are bound to promote the significance, precision, and hopefully accessibility of OCT in everyday practice.[75]
Media
(Click Image to Enlarge)
Optical Coherence Tomography, Full-Thickness Macular Hole. This image shows a full-thickness macular hole with an overlying operculum and thickened edges of the surrounding retina.
Contributed by M Musa, OD
(Click Image to Enlarge)
Optical Coherence Tomography. The image shows an optical coherence tomography scan of the macula in a normal eye. ILM, inner limiting membrane; RNFL, retinal nerve fiber layer; GCL, ganglion cell layer; IPL, inner plexiform layer; INL, inner nuclear layer; OPL, outer plexiform layer; ONL, outer nuclear layer; ELM, external limiting membrane; ISOS, inner and outer segment; OPT, outer photoreceptor tip; RPE, retinal pigment epithelium; BM, Bruch membrane; MT, macular thickness; mRNFL, macular retinal nerve fiber layer; GCIPL, combined ganglion cell and plexiform layer; INL, inner nuclear layer.
Motamedi S, Gawlik K, Ayadi N, et al. Normative data and minimally detectable change for inner retinal layer thicknesses using a semi-automated OCT image segmentation pipeline. Front Neurol. 2019;10:1117. doi: 10.3389/fneur.2019.01117.
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