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.

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;138:458-467.

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, Lee PP, Mangione CM, et al. Patterns of care for open-angle glaucoma in managed care. Arch Ophthalmol. 2003;121:77783.

1. Baseline documentation of the disc changes 2. Evaluation of the disc size 3. Risk Assessment (OHTS CSLO study) 4. Early diagnosis 5. Documentation of progression x Pallor, Hemorrhage

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

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

Normal Biological Variability ?

Large variability in optic nerve head
0.7 1.5 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 rangemay 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

Variability
Scan done on 4rth march 2006 2.51 pm Scan done on 4rth march 2006 3.00 pm

Triple Scan GDx Version 6.0

Image Quality: Standard Deviation

< 10 m 10 - 20 m 20 - 30 m 30 - 40 m 40 - 50 m > 50 m Excellent Very Good Good Acceptable Try to improve Poor quality documentation only

Image Quality Standard Deviation

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

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 5m of each other Exclude outliers from the Progression Series

Astigmatism
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 ?

Impact of Signal Strength on RNFL

Differences in signal strength were associated with differences in average RNFL thickness Even under optimal testing conditions, scan quality can adversely effect the ability to detect change over time

Therefore, caution is warranted when detecting glaucomatous progression using scan series of different quality

Signal strength of > 7 is mandatory

Vizzeri G, Bowd C, Medeiros FA, Weinreb RN, Zangwill LM. Am J Ophthalmol. 2009 Aug;148(2):249-255

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

62 F CORTICAL CATARACT OD

SIGNAL STRENGTH 6/10

patient underwent cataract surgery OCT 4 weeks later

Post operative SD-OCT

SIGNAL STRENGTH 8/10

GDxVCC parameters pre and post cataract surgery

(Dada T et al. Indian J Ophthalmol. 2010 Sep-Oct;58(5):389-94 )
RNFL Parameters Pre operative Post operative P value

TSNIT average

49.2 14.1

56.5 7.6

0.001

Superior average

51.6 12.2

59.8 7.3

0.004

Inferior average

50.2 13.7

61.5 10.3

0.001

NFI

41.3 15.3

21.6 11.8

0.001

BEFORE Phaco IOL

AFTER Phaco IOL

Q.

How to increase the

signal strength ?

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.

Q. Effect of Disc Size?

False Positive HRT

Large Disc CD Ratio = 0.85: 1

Disc Size : MRA, GPS

Jindal S, Dada T et al .Indian J Ophthalmol. 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.

Q. Effect of centration ?

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

Dada T , Dave V ARVO 2010

Parameter

Protocol I (a)

Protocol II (b)

p value a vs. b

Protocol I (c)

Protocol II (d)

Normal
TSNIT Average 51.9 4.7 52.8 5.1 0.02 78.6 33.3

Abnormal Macula
53.9 8.4

Superior Average

63.1 7.1

66.1 6.9

0.003

82.7 32.1

62.0 12.1

Inferior Average NFI

58.8 7.5 22.7 9.2

59.9 6.7 19.3 8.6

0.2 0.01

77.7 31.9 14.2 14.1

59.9 10.7 25.8 16.9

Standard Scan Protocol

Irregular Scan Protocol

Q.
Effect of Peripapillary Atrophy?

Problems with GDxVCC

False Negative Supra - Normal

Peripapillary Atrophy

3 scan diameter scans

2.4 - 3.2 mm 3.2 - 4.0 mm 4.0 - 4.8 mm

J Glaucoma (2009)

Q.
Correlate fundus examination with imaging and perimetry ?

Correlation of structure & function

Does an Abnormal Scan indicates Glaucoma ?

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

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

Q. How to identify Progression ?

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