10

Interpreting OCT scans

Top tips show you how to extract the wealth of valuable
information in retinal OCT scans

Dr Simon Chen
MBBS BSc FRCOphth
FRANZCO Retinal Specialist
Vision Eye Institute, Sydney
Optical coherence tomography (OCT)
is a safe, non-invasive, fast, reliable
test that provides high resolution,
cross-sectional images of the retina and
vitreoretinal interface. It is an increasingly important tool for the diagnosis
and monitoring of a wide range of
vitreoretinal conditions.
Current commercial OCT machines use a
near infrared broadband light source (not
a laser) to illuminate the retina. Differences
in echo time and intensity between the reected light and that from a reference path
are measured and converted into three to
10 micron resolution retinal images. This
is analogous to the use of sonar waves to
image the ocean oor. The resulting image
can be considered to be like an optical
biopsy of the retinal layers. The layers that
appear in an OCT image represent changes
in optical reectance within the retina, which
do not necessarily correlate with familiar
histological layers.
The latest spectral domain OCT (SD-OCT)
machines use complex Fourier analysis
techniques to increase signal processing
speed, resulting in faster scan acquisition
and higher image resolution than is possible
with older, time-domain OCT (TD-OCT) systems such as the Zeiss Stratus OCT.

ILM: Inner limiting membrane

IPL: Inner plexiform layer
INL: Inner nuclear layer
OPL: Outer plexiform layer
ONL: Outer nuclear layer

Colour or greyscale
Colour images
Changes in optical reectance are illustrated in a colour-coded fashion in which warm
colours (red, yellow, white) indicate high
reectivity and cold colours (green, blue)
indicate low reectivity.

condently identify pathological changes.

Features to note (from anterior to posterior)
include:
The anterior signal originates from the
inner limiting membrane (ILM) and retinal
nerve bre layer (RNFL). This has a smooth,
relatively at outline peripherally and a

Greyscale images
Brighter shades are used
instead of warm colours
to indicate high reectivity. Absence of reection
appears black.
Greyscale images are
better than colour images
Figure 2. Macular thickness map showing macular
for visualising epiretinal
oedema due to wet AMD
membranes (ERM), photoreceptor (PR) and retinal
pigment epithelium (RPE)
morphology. Colour images can be mischaracteristic central dip at the fovea (releading as the displayed colours are false
ferred to as the foveal pit).
colours and dramatic changes in colour
 Posterior to the ILM/RNFL, subtle
can be misinterpreted as large changes in
changes in reectance are seen as alOCT reectivity.
ternating bands of hyper- (lighter) and
hypo- (darker) reectance representing
Normal macula OCT scan
the ganglion cell bodies, the inner plexiFamiliarity with the appearance of a normal
form, inner nuclear, outer plexiform and
macular OCT scan (Figure 1) is important to
outer nuclear layers.
Posterior to the outer nuclear layer, a
series of three adjacent and increasingly
hyper-reective lines may be visible, representing the external limiting membrane
(ELM), photoreceptor inner segment/outer
segment junction (IS/OS junction), and
RPE. A focal elevation of the ELM and IS/
OS junction lines beneath the foveal pit
is normally present. The ELM and IS/OS
junction lines are often absent in SD-OCT
scans of suboptimal image quality and in
older TD-OCT scans.
The signal posterior to the RPE arises
ELM: External limiting membrane
NFL: Nerve bre layer
from the choroid as patchy areas of high
IS: Photo receptor inner segment
GCL: Ganglion cell layer
reectivity.
OS: Photo receptor outer
RPE: Retinal pigment epithelium &
segment
OPR: Outer PR/RPE complex

Figure 1. Greyscale SD-OCT scan of a normal macula

OPTOMETRY PHARMA SEPTEMBER 2011

Bruchs membrane

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Protocols for assessment

Top interpreting tips

The most useful scanning protocols for

assessing vitreoretinal disease are:

Be systematic in your approach to reviewing

OCT scans. I typically start by reviewing the
macular thickness map to gain a quick overall view of the macular topography. Look for
areas of retinal thinning (often associated
with atrophic AMD, high myopia or chorioretinal scarring) or thickening (commonly
associated with epiretinal membranes, wet
AMD or macula oedema due to retinovascular disease) (Figure 2).
Next, I look at the high resolution line
scans in greyscale, specically reviewing
each anatomical layer from anterior to
posterior looking for the following:

High-resolution line scan

This is a single high-resolution cross sectional
scan, typically passing through the foveal
centre, although the position of the scan can
be changed to image areas of focal pathology outside of the fovea. This type of scan is
good for making a diagnosis and assessing
the retinal layers in detail (Figure 1).
Composite thickness map
This is a topographical display providing
quantitative information about the thickness of the retina in a colour-coded map
(Figure 2). Warm colours (red, yellow,
white) indicate areas of thicker retina and
cold colours (green, blue) indicate areas
of thinner retina. The normal macula thick-

1. Posterior vitreous face

This is a thin, curved or horizontal line of
hyper-reectivity visible anterior to the retinal
surface. It is often not visible if the vitreous is
still completely attached to the macula or if
it has detached anteriorly
beyond the area visualised
by the OCT scan. When visible, the vitreous face may
be completely detached
from the macula or partially
detached with residual attachment to the central
macula and fovea; this is
a common normal appearFigure 3. Macular thickness map showing partial resoance called a perifoveal
lution of macular oedema following intravitreal antiposterior vitreous detachVEGF treatment for wet AMD (same eye as in Figure 2)
ment and represents the
early stages of a posterior
vitreous detachment (Figure 5).
ness is approximately 150 to 250 microns;
If the attachment between the vitrethis gure varies according to the specic
ous and the fovea is abnormally strong,
machine and manufacturers normative
pathological changes due to vitreomacular
database. Thickness maps are good for
traction may be visible as a change in the
quickly identifying and localising areas
shape of the normal foveal pit (the pit may
of diffuse retinal pathology that may be
be absent, shallower than usual, irregular
missed on individual high resolution line
or have underlying cystic structures visscans. The quantitative data provided by
ible) or splitting/cystic changes within the
serial thickness maps is useful for monitorneurosensory retina (Figure 6). Advanced
ing progress and response to treatment
vitreomacular traction can lead to a fullover time, particularly in conditions such as
thickness defect in the central neurosensory
macular oedema associated with diabetic
retina known as a macular hole (Figure 7).
retinopathy, retinal vein occlusions, ERMs
or choroidal neovascularisation associated
2. Vitreoretinal interface
with wet age-related macular degeneration
Look at the anterior surface of the retina for
(AMD)(Figure 3).
features of an epiretinal membrane (ERM).
These are common and identified as a
En face and 3D scans
distinct hyper-reective line in close contact
These provide impressive-looking images
with the retinal surface. ERMs can cause a
demonstrating the three-dimensional apwrinkling of the retinal surface, which can
pearance of the vitreoretinal interface,
be visible as irregular saw-tooth shaped
which can be useful for educating patients
undulations in the retinal surface. ERMs may
and spicing up lecture presentations. Their
cause a reduction in depth or even complete
clinical usefulness is relatively limited
loss of the normal foveal dip (Figure 8).
(Figure 4).
Continued page 12

Figure 4. Three-dimensional macular

scan showing vitreomacular traction

Figure 5. Perifoveal posterior vitreous detachment

Figure 6. Vitreomacular traction with

secondary foveal cyst

Figure 7. Full thickness macular hole

due to vitreomacular traction. Freeoating operculum visible anterior to
macular hole.

OPTOMETRY PHARMA SEPTEMBER 2011

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From page 11

Figure 8. Epiretinal membrane with

loss of the foveal pit and irregular
retinal contour

Figure 9. Wet AMD with cystic intraretinal uid, subretinal uid and
pigment epithelial detachment

Figure 10. Cystoid macular oedema

due to branch retinal vein occlusion.
Note disruption of the IS/OS junction in
the foveal region associated with poor
visual acuity of counting ngers.

Figure 11. Dry AMD with drusen

visible as irregular protuberances of
the RPE

OPTOMETRY PHARMA SEPTEMBER 2011

3. Neurosensory retinal layers

Qualitatively assess the thickness, regularity and continuity of the retinal layers. Look
specically for hyporeective cystic changes
indicating uid that may be intraretinal,
subretinal (between the neurosensory retina
and the RPE) or sub-RPE (below the RPE).
Common causes of cystic uid accumulation include wet AMD (Figure 9), diabetic
macula oedema and retinal vein occlusions.
Exudates may be seen as focal areas of
hyper-reectivity within the neurosensory
retina in diabetic maculopathy, retinal vein
occlusions and wet AMD.
4. IS/OS junction
Specically assess the visibility and continuity of the IS/OS junction because the
integrity of this structure often correlates
with visual acuity in many retinal conditions.
If the IS/OS junction is clearly visible and
unbroken, the visual acuity is often good
but if the IS/OS junction is disrupted, the
visual acuity is often correspondingly poor
(Figure 10). Thus the IS/OS junction can
be considered to be a surrogate marker for
retinal photoreceptor viability and provides
prognostic information in monitoring or predicting response to treatment of conditions
such as epiretinal membranes or wet AMD.
5. RPE
Look for areas of elevation, variation in
thickness (thickening or thinning), and uid
above or below the RPE or discontinuity.
AMD is associated with a wide variety
of RPE changes on OCT, such as drusen
appearing as small dome-shaped protuberances in the RPE (Figure 11), pigment
epithelial detachments (PED) seen as larger
dome-shaped elevations, brosis (areas of
RPE thickening) atrophy (area of RPE thinning). Central serous retinopathy (CSR) is
often associated with small PEDs, typically

Figure 12. Central serous retinopathy with subretinal uid and a small
underlying RPE detachment

in association with overlying subretinal uid

(Figure 12).
The choroid is poorly visualised with current generation OCTs but future machines
will achieve greater choroidal resolution,
enabling changes in conditions such as
degenerative myopia, CSR, PCV and inammatory choroidopathies to be analysed.
6. Assess quality of scan, look for
common artifacts
Poor-quality scans may appear grainy, irregular in contour, colour and intensity, and
may result from ocular surface disease (dry
eyes, blepharitis, corneal disease), poor
xation, small pupils or extreme refractive
error. Prior to performing an OCT scan, the
ocular surface should be examined, the
patient should be asked to blink, articial
tear-drops may be used in patients with
dry eye, and xation should be monitored
or assisted with the use of an external xation light.
Review scan placement (is the fovea
centred or does the scan include the area
of pathology?) and algorithm performance
(do the computer-generated boundary lines
used to calculated retinal thickness correlate
with ILM/PR location?).
Movement artifacts are common due to
poor xation, poor patient co-operation or
nystagmus, and appear as an undulating
irregular appearance of all retinal layers.
Shadow artifacts posterior to retinal vessels
are a common and unavoidable feature of
many normal scans.

Conclusion
OCT scanning provides detailed qualitative
and quantitative information about the retinal structure in a wide range of retinal conditions. A familiarity with the appearance of
a normal OCT scan and a systematic approach to evaluating retina OCT scans will
enable practitioners to glean the maximum
amount of clinically useful information when
interpreting OCT scans.