HHS Public Access

Author manuscript
Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
Author Manuscript

Published in final edited form as:

Prog Retin Eye Res. 2017 September ; 60: 66–100. doi:10.1016/j.preteyeres.2017.07.002.

Optical Coherence Tomography Angiography: A Comprehensive

Review of Current Methods and Clinical Applications
Amir H Kashani1,*, Chieh-Li Chen2, Jin K Gahm3, Fang Zheng4, Grace M Richter1, Philip J
Rosenfeld4, Yonggang Shi3, and Ruikang K Wang2
1USC Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine of University of
Southern California; Los Angeles, CA 90033
Author Manuscript

2Department of Biomedical Engineering, University of Washington Seattle, Seattle, WA 98195

3Laboratoryof Neuro Imaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck
School of Medicine of University of Southern California, Los Angeles, CA 90033
4Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of
Medicine, Miami, FL 33136

Abstract
OCT has revolutionized the practice of ophthalmology over the past 10 to 20 years. Advances in
OCT technology have allowed for the creation of novel OCT-based methods. OCT-Angiography
(OCTA) is one such method that has rapidly gained clinical acceptance since it was approved by
the FDA in late 2016. OCTA images are based on the variable backscattering of light from the
Author Manuscript

vascular and neurosensory tissue in the retina. Since the intensity and phase of backscattered light
from retinal tissue varies based on the intrinsic movement of the tissue (e.g. red blood cells are
moving, but neurosensory tissue is static), OCTA images are essentially motion-contrast images.
This motion-contrast imaging provides reliable, high resolution, and non-invasive images of the
retinal vasculature in an efficient manner. In many cases, these images are approaching histology
level resolution. This unprecedented resolution coupled with the simple, fast and non-invasive
imaging platform have allowed a host of basic and clinical research applications. OCTA has been
shown to demonstrate many important clinical findings including areas of macular telangiectasia,
impaired perfusion, microaneurysms, capillary remodeling, some types of intraretinal fluid, and
neovascularization among many others. More importantly, OCTA provides depth-resolved
Author Manuscript

*
Communicating Author: Amir H Kashani, MD, PhD, Assistant Professor, USC Roski Eye Institute, Keck School of Medicine of
USC, 1450 San Pablo St., Suite 4700, Los Angeles, CA 90033, [email protected].
Financial Disclosures:
AHK: NIH K08EY027006, Carl Zeiss Meditec, RPB
CLC: None
JKG: None
GMR: Carl Zeiss Meditec
RKW: NIH, Carl Zeiss Meditec
YS: NIH R21EY027879
PJR: Carl Zeiss Meditec
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
the resulting proof before it is published in its final citable form. Please note that during the production process errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
 Kashani et al. Page 2

information that has never before been available. Correspondingly, OCTA has been used to
Author Manuscript

evaluate a spectrum of retinal vascular diseases including diabetic retinopathy (DR), retinal venous
occlusion (RVO), uveitis, retinal arterial occlusion, and age-related macular degeneration among
others. In this review, we will discuss the methods used to create OCTA images, the practical
applications of OCTA in light of invasive dye-imaging studies (e.g. fluorescein angiography) and
review clinical studies demonstrating the utility of OCTA for research and clinical practice.

Keywords
Optical coherence tomography angiography; retina; glaucoma; physiology; vascular disease;
macular degeneration

1. Introduction
Author Manuscript

Optical Coherence Tomography (OCT) is a non-invasive, interferometric imaging modality

that enables in vivo imaging of the retina in cross-section (Drexler and Fujimoto 2008).
Since its original introduction in 1991 (Huang, Swanson et al. 1991), OCT has been used to
quantitatively evaluate retinal thickness and assess qualitative anatomic changes such as the
presence or absence of many pathologic features, including intraretinal and subretinal fluid.
The original implementation of OCT used time-domain technology (TD-OCT) that required
a moving reference mirror. Therefore, TD-OCT only allowed ~400 A-scans per second and
was commonly used to evaluate only 6 evenly spaced radial line scans that intersected at the
fovea. The resolution of TD-OCT was also limited to 10–15 microns under the most ideal
circumstances. The overall acceptance and clinical utility of TD-OCT was limited until the
implementation of broad-band spectral domain technology (SD-OCT), a Fourier domain
(FD-OCT) methodology, allowed 20,000–40,000 A-scans per second. This significantly
Author Manuscript

improved the field-of-view and image resolution (~3–5 microns) and decreased motion
artifact. Subsequent advances such as swept-source OCT (SS-OCT) incorporate a long
wavelength and narrow-bandwidth source that is swept through a broad range of optical
frequencies allowing very high spatial resolution and improved tissue penetration. The high
cost of SS-OCT technology has limited wide-spread commercial and clinical acceptance of
this method to date. Many additional improvements in OCT methods such as phase-sensitive
OCT (Schwartz, Fingler et al. 2014, Wang, Kirkpatrick et al. April 2007, Wang, Ma et al.
October 2006), polarization-sensitive OCT (Pircher, Hitzenberger et al. 2011), spectroscopic
OCT (Kim, Brown et al. 2015), and OCT Angiography (OCTA) (Ferrara, Waheed et al.
2016) have been developed in recent years. These methods hold the promise of combining
structural information with information about the function of the retinal tissue, and possibly
of assessing tissue metabolism as well. A detailed review of each of the many OCT methods
Author Manuscript

is beyond the scope of this review article, but the brief history of OCT provided above
describes the overall context in which OCT angiographic methods have been developed.

The purpose of this article will be to review the recent developments in the use of OCT
technology for non-invasive assessment of the retinal vasculature in health and disease with
a particular emphasis on OCTA, whose role in the field of ophthalmology is only beginning
to be defined. We will begin with a technical discussion of the various methods employed

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 3

for OCTA, in order to lay the foundation for understanding its strengths and limitations. To
Author Manuscript

understand the best applications of this method, we further compare and contrast it with
current standard-of-care methods, including fluorescein angiography (FA) and indocyanine
green angiography (ICG). The review concludes with a discussion of published articles in
disease-specific categories that illustrate the strengths and limitations of OCTA, as well as
highlight some of the novel findings OCTA has enabled.

2. Principles of Optical Coherence Tomography Angiography

Since OCTA is a technique that is based on OCT, a brief review of current OCT
methodology is necessary as a prelude to the discussion of OCTA methods. OCT obtains
depth-resolved tissue reflectivity characteristics by detecting the interference signal formed
between the light reflected from the reference mirror and light backscattered from the
biological sample. By changing the position of the reference mirror, the intensity of
Author Manuscript

backscattered light from tissue can be detected from different depths in the tissue sample. A
sequence of echoes originated from various depths form an intensity profile in the axial
direction (A-scan), and optical cross-sections (B-scans) are assembled by scanning the OCT
beam in the transverse direction. Since time-encoded signals are obtained in this manner,
this approach is referred to as time-domain OCT (TD-OCT) (Marschall, Sander et al. 2011).

With hardware advancements and technical developments, later OCT devices detect the
backscattered signals from biological tissues in the frequency domain with either a broad-
bandwidth light source, a charge-coupled device (CCD) camera, and a spectrometer
(spectral-domain OCT or SD-OCT), or by sweeping through a range of optical frequencies
(swept-source OCT or SS-OCT) (Wojtkowski, Leitgeb et al. 2002, Choma, Sarunic et al.
2003, de Boer, Cense et al. 2003, Leitgeb, Hitzenberger et al. 2003, Cense, Nassif et al.
Author Manuscript

2004, Nassif, Cense et al. 2004, Wojtkowski, Srinivasan et al. 2004). SD-OCT typically uses
an 800 to 900-nm wavelength source, and its scan speed ranges from 40 to 100-kHz. SD-
OCT has increased sensitivity roll-off with depth as compared to SS-OCT (Miller, Roisman
et al. 2017, Zhang, Chen et al. 2017). Also, shorter wavelengths are more prone to scattering
and attenuation; thus, they penetrate into tissue less than the longer wavelengths used in the
SS-OCT devices. SS-OCT devices typically use wavelengths above 1000-nm and operate at
speeds equal to or greater than 100-kHz (Drexler and Fujimoto 2008, Ploner, Moult et al.
2016).

For both SD- and SS-OCT enabled devices, frequency information of interference signal
from all depths at a given spatial position in the tissue can be acquired without a need for
physically moving the reference mirror. This information can then be converted into an
intensity profile by Fourier-transform, which represents the tissue depth reflectivity profile.
Author Manuscript

Fourier-domain algorithms are applicable to both SD- and SS-OCT enabled devices. The
implementation of a light source with a broader bandwidth enhances the axial resolution
from 10μm to 2μm, and the introduction of the spectrometer or sweeping frequencies
improves the image acquisition speed (from 400 A-scans/s to between 26,000 and 100,000
A-scans/s) (Drexler and Fujimoto 2008, Gabriele, Wollstein et al. 2010, Grulkowski, Liu et
al. 2012, Leung 2014). With the improvements of scanning speed and resolution in FD-OCT,
collecting 3D scans of biological tissues has become more feasible. More information from

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 4

biological tissues can be acquired in a relatively shorter amount of time, allowing for more
Author Manuscript

detailed visualization of biological structures. With all of its advantages, OCT has emerged
as an important tool in both the quantitative and qualitative assessment of tissue structure.
Clinically, it has become indispensable in the routine diagnosis and management of disease,
especially as it pertains to ophthalmology (Drexler and Fujimoto 2008).

OCTA is a new imaging technique based on OCT which allows for the visualization of
functional blood vessels in the eye. The principle of OCTA is to use the variation in OCT
signal caused by moving particles, such as red blood cells (RBC), as the contrast mechanism
for imaging blood flow (Wang, Jacques et al. 2007, Zhang, Zhang et al. 2015, Chen and
Wang 2017). In order to conceptualize this, imagine two OCT signals, one is backscattered
from static structural tissue and the other is backscattered from the moving RBCs in vessels
(Figure 1). The signal from the structural tissue remains steady, while the signal from the
flowing blood changes over time due to the constant motion of the RBCs. To differentiate
Author Manuscript

the moving particles from static tissue, repeated scans are performed at the same location.
Temporal changes of the OCT signal in subsequent scans caused by the moving particles
generate the angiographic contrast, providing the opportunity to visualize the
microvasculature. Notably, any moving particle may generate a motion contrast signal;
however, the predominant movement in retinal tissue is from the RBCs. For example, lipid
particulates in solution generate OCTA signals as a result of Brownian-like motion (Fingler,
Schwartz et al. 2007). After Fourier transform, the OCT signal contains amplitude
(intensity) and phase information, and so several algorithms have been developed for OCTA
technique in order to utilize different components of the OCT signal. They can be separated
into three categories: (1) phase-signal-based OCTA, (2) intensity-signal-based OCTA, and
(3) complex-signal-based OCTA.
Author Manuscript

2.1 Phase-signal-based OCTA Techniques

2.1.1 Doppler OCT—Following the invention of OCT, the notion of utilizing OCT
techniques to measure blood flow velocities noninvasively emerged in the mid-1990s. Based
on TD-OCT, Chen et al. developed an optical technique for noninvasive imaging of in vivo
blood flow dynamics and tissue structures by combining Doppler velocimetry with OCT
(Chen, Milner et al. 1997). In the same year, Izatt et al. demonstrated a bidirectional color
Doppler imaging technique for visualizing flow in biological tissues by employing coherent
signal-acquisition electronics and joint time-frequency analysis algorithms to perform flow
imaging simultaneous with conventional OCT images (Izatt, Kulkarni et al. 1997). The
central hypothesis for Doppler OCT is that if a sample interface moves axially at a constant
speed vs, the backscattered OCT signal experiences a frequency or phase shift, fD, called the
Doppler shift, and that phase shift is additive to the carrier/heterodyne interference
Author Manuscript

frequency associated with the reference arm (Leitgeb, Werkmeister et al. 2014, Zhang,
Zhang et al. 2015).

To detect the Doppler shift in a TD-OCT signal, a short-time Fourier-transform algorithm is

applied to extract the phase information, and a small window sliding across an A-scan is
used to acquire the local frequency shifts at various depths. However, this approach is
computationally expensive and reduces the axial resolution for imaging flow. Therefore, it

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 5

cannot be applied for in vivo real-time flow measurements (Proskurin, He et al. 2003,
Author Manuscript

Leitgeb, Werkmeister et al. 2014).

The introduction of Fourier-domain based OCT systems brought a dramatic change in

Doppler OCT development. The significantly increased scanning speed of FD-OCT enables
higher in vivo flow detection sensitivity, without compromising image quality (Leitgeb,
Schmetterer et al. 2003). In 2002, Leitgeb et al. demonstrated the first functional extension
of FD-OCT for measuring blood flow and showed the high phase sensitivity of the method
(Leitgeb, Schmetterer et al. 2002). With FD-OCT, the blood flow information can be easily
acquired by calculating the changes in the phase signals between adjacent A-scans.

Although Fourier-domain based Doppler OCT significantly improved the sensitivity, image
quality, and scanning speed, there were still some drawbacks associated with it. First, it
cannot detect flow if the vessels are perpendicular to the incident OCT beam. Second, the
Author Manuscript

Doppler shift is vulnerable to the movement of the sample. In order to obtain precise phase
differences for accurate measurements of blood flow velocity, it is important to minimize the
phase differences caused by the bulk motion of the sample. Oftentimes, this is difficult to
achieve because unavoidable sample movements occur during in vivo imaging (Makita,
Hong et al. 2006).

Despite this limitation, in 2006, Makita et al. reported a noninvasive retinal angiography
imaging technique based on Doppler OCT, called optical coherence angiography. Two
mechanisms were proposed to minimize the sample movement in the axial direction: (1)
compensation of the axial shift between adjacent A-scans within one B-scan using
histogram-based bulk motion Doppler shift compensation, and (2) compensation of the
motion between adjacent B-scans using the cross-correlation of particular A-scans of
Author Manuscript

interest. After tissue motion compensation, the angiography was obtained as the average of
Doppler OCT and power Doppler, which was defined as the power of the phase difference
between adjacent A-scans (Makita, Hong et al. 2006). Their approach is regarded as the first
phase-signal-based OCTA technique.

Doppler OCT is insensitive to microcirculation, and visualization has typically been limited
to major veins and arteries (Leitgeb, Schmetterer et al. 2003, Makita, Hong et al. 2006, An
and Wang 2008, Szkulmowska, Szkulmowski et al. 2009, Tao, Kennedy et al. 2009). A dual-
beam scanning strategy was proposed to improve the sensitivity in measuring the blood flow
for Doppler OCT (Makita, Jaillon et al. 2011, Zotter, Pircher et al. 2011). The use of two
individual sample arm beams relaxed the constraint of requiring dense A-scans, which
widened the time separation between two A-scans as well as the velocity measurement
range.
Author Manuscript

2.1.2 Phase-Variance OCT—Doppler OCT and optical coherence angiography

demonstrate the original paradigm of OCT-based angiography. Based on a similar idea,
Fingler et al. developed a motion contrast technique based on FD-OCT to visualize the
vasculature in zebrafish (Fingler, Schwartz et al. 2007), and subsequently in the retina and
choroid of the mouse (Fingler, Readhead et al. 2008). They then adapted the technique for
human retinal imaging (Fingler, Zawadzki et al. 2009). By measuring the phase variance

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 6

between adjacent B-scans, the motion-contrast technique, called phase-variance OCT, is

Author Manuscript

capable of visualizing a wider range of velocities and flow orientations than Doppler OCT
(Fingler, Zawadzki et al. 2009). The flow signal in phase-variance OCT is calculated based
on the following equation:

where N represents the repetition number of B-scans at the same location, Φi(x, z, t) and
ΔΦi(x, z, t) indicate the phase value and phase difference in the i-th B-scans at lateral
location x, depth position z, and time t, T is the time interval between two consecutive B-
scans, and i is the index of the i-th B-scan. With a proper choice of the repeated scanning
Author Manuscript

along the B-scan, e.g. B-M scan, the time interval between two A-scans that are used for
phase measurement is significantly increased. As a consequence, the sensitivity to slower
flow and microcirculation is dramatically increased, even though the velocity information of
the flow is lost. By using phase-variance, instead of phase-resolved difference, the detected
vasculatures have less dependence on vessel orientation and flow velocity (Zhang, Zhang et
al. 2015). Kim et al. (Kim, Fingler et al. 2011) reported a faster phase-variance OCT system
that had an image acquisition A-scan rate of 125 kHz and a larger field of view for human
retinal circulation imaging. Schwartz and his colleagues later demonstrated the angiogram
from phase-variance OCT obtained from patients with dry age-related macular degeneration
(AMD), exudative AMD, and nonproliferative diabetic retinopathy (NPDR) (Schwartz,
Fingler et al. 2014). By correcting the lateral and axial motion of the eyes, the phase noise
was significantly reduced. High-resolution volumetric images of the retina and choroid were
Author Manuscript

presented. Areas of geographic atrophy and choroidal neovascularization (CNV), imaged by

FA, as well as regions of capillary nonperfusion from DR were also depicted by phase-
variance OCT (Schwartz, Fingler et al. 2014). Kurokawa et al. further proposed using
Doppler power imaging with adaptive optics. In their methods, the flow signal intensity was
determined by the squared power of the Doppler shift. With the use of adaptive optics, the
sensitivity to flow signal remained similar, while an increased lateral resolution for vascular
imaging was observed (Kurokawa, Sasaki et al. 2012).

2.2 Intensity-signal-based OCTA Techniques

2.2.1 Speckle-Variance OCT—Doppler OCT initiated the functional extension of the
OCT technique. However, the technique suffered from an angular dependence of the
measured blood flow and it was insensitive to the flow perpendicular to the scanning beam
Author Manuscript

(Barton and Stromski 2005, Enfield, Jonathan et al. 2011). In order to resolve this issue,
Barton and Stromski developed an alternative method to extracting flow information (Barton
and Stromski 2005). Based on a TD-OCT system with Doppler capability, their method
measured the speckle change in the OCT signal (Barton and Stromski 2005). It has been
shown that the speckles in OCT signals play a dual role; both as a source of noise and as a
carrier of information about tissue microstructure and flow (Schmitt, Xiang et al. 1999).
Adopting the idea from laser speckle technique, Barton and Stromski hypothesized that the

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 7

flow measurement techniques developed for laser speckle could be adapted to flow
Author Manuscript

measurements in OCT (Barton and Stromski 2005). By measuring the speckle variance
within the adjacent 4-pixel region using only the amplitude information in the OCT signal,
the authors were able to successfully visualize the flow image in an in vitro tube phantom
and in in vivo hamster skin. This was the first time speckle analysis was applied to OCT
images in order to determine depth-resolved flow (Barton and Stromski 2005). Later,
Mariampillai et al. used a similar speckle variance concept based on FD-OCT to image the
microcirculation, demonstrating that speckle variance OCT could detect vessel size-
dependent vascular shutdown and transient vessel occlusion during photodynamic therapy
(Mariampillai, Standish et al. 2008). By imaging the same transverse location several times,
the inter-frame speckle variance signal can be acquired using the following equation:
Author Manuscript

where N represents the repetition number of B-scans at the same location, Ii(x, z) indicates
the intensity value in i-th B-scans at lateral location x, depth position z, and

is the average of the intensity values over the same set of pixels. The
proposed method was further optimized in the separation interval (by adjusting number of
repetition or field of view) to improve the image contrast and signal-to-noise ratio for
visualizing microcirculation in tissues with both low and high bulk motion (Mariampillai,
Leung et al. 2010).

Recently, Xu et al. developed a hardware-accelerated speckle variance OCT for visualizing

blood flow in the human retina (Xu, Han et al. 2015). The proposed speckle variance OCT
Author Manuscript

was based on a custom-built SS-OCT system, which operated at an A-line rate of 100-kHz.
With the help of graphics processing units, the reported system allowed for the visualization
of blood flow in the human retinal capillary network in real-time. Comparing it with FA, the
capillary density detected in speckle variance OCT appeared greater than FA. In addition,
speckle variance OCT was able to identify the terminal capillaries around the foveal
avascular zone (FAZ) with greater precision. Mammo et al. (Mammo, Balaratnasingam et al.
2015) later investigated the utility of speckle variance OCT by comparing the retinal
capillary network around the FAZ in normal human eyes and donor eyes using FA and
confocal scanning laser microscopy. Yu et al. (Yu, Balaratnasingam et al. 2015) focused on
the radial peripapillary capillaries in the peripheral region around the disc. The results
demonstrated that speckle variance OCT was able to stratify the foveal circulation into inner
and deep capillary plexuses as well as reliably and reproducibly quantify and assess the
Author Manuscript

morphometric dimensions of the human FAZ (Mammo, Balaratnasingam et al. 2015, Yu,
Balaratnasingam et al. 2015). The morphological characteristics of RPE on speckle variance
OCT were comparable to histological images (Mammo, Balaratnasingam et al. 2015, Yu,
Balaratnasingam et al. 2015). These further highlighted the utility of speckle variance OCT
for human retina imaging.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 8

2.2.2 Correlation-Mapping OCT—Another intensity-signal-based OCTA method was

Author Manuscript

introduced by Jonathan et al. (Jonathan, Enfield et al. 2011) and Enfield et al. (Enfield,
Jonathan et al. 2011) in 2011. By taking advantage of the time-varying speckle effect and
after observing the phenomenon that vascular regions and their immediate vicinities show
stronger speckle signals as compared to the non-flow regions (static tissue), Jonathan et al.
proposed a simpler method to detecting the flow signal (Jonathan, Enfield et al. 2011). They
calculated the correlation of OCT signals between adjacent scans; therefore, the method was
named correlation mapping (Jonathan, Enfield et al. 2011). Since flow regions showed lower
correlation coefficient values and static tissues showed higher correlation magnitudes, it is
possible to distinguish micro-vasculatures from static tissues by estimating its correlation
with a set threshold. Multiple B-scans were captured at the same transverse location
(Jonathan et al. acquired 8 B-scans for mouse brain in vivo through a cranial window, while
Enfield et al. adjusted to 2 B-scans for human volar forearm). The flow signal was further
Author Manuscript

acquired by cross-correlating a grid from frame A (IA) to the same grid from frame B (IB)
using the following equation: (Enfield, Jonathan et al. 2011)

where M and N indicate the grid size and Ī is the mean intensity value within the grid. The
same notation as we showed before, Ii(x, z), indicates the intensity value in i-th B-scans at
Author Manuscript

the lateral location x and depth position z. The grid is then shifted across the entire B-scan
and a two-dimensional (2D) map is generated. The correlation values ranged from −1 to 1,
where 0 indicated weak correlation and −1 and 1 indicated strong inverse correlation and
strong correlation, respectively. The grid size used in the study was arbitrarily chosen for
optimal image quality. Larger grid sizes lead to higher signal-to-noise ratios, but may also
result in longer processing times, blurring effects, and loss of smaller vessels. In their first
demonstration, correlation mapping successfully showed the capillary pattern in a multi-
layered capillary tube phantom as well as in the capillary networks of mice brains and
human volar forearms. Later, McNamara et al. (McNamara, Subhash et al. 2013) employed
the same correlation mapping technique to full-field OCT to perform non-scanning en face
flow imaging from pairs of en face images. In contrast with most OCT approaches, full-field
OCT directly takes 2D en face images with megapixel cameras (Dubois, Vabre et al. 2002).
Author Manuscript

Since the large depth-of-field information is omitted, full-field OCT is able to provide 2D or
3D images with a resolution of 1μm, at least matching the cellular resolution in skin tissue
(Dalimier and Salomon 2012). The study demonstrated the first application of correlation
mapping to full-field OCT to provide in vivo functional imaging of blood vessels
(McNamara, Subhash et al. 2013).

2.2.3 Split-Spectrum Amplitude-Decorrelation Angiography (SSADA)

Algorithm—Based on the same time-varying speckle effect concept, Jia et al. (Jia, Tan et

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 9

al. 2012) improved the correlation mapping method by proposing a split-spectrum

Author Manuscript

amplitude-decorrelation angiography (SSADA) algorithm to extract the flow signal and to

distinguish vessels from static tissues in 2012. In contrast to correlation mapping, the
amplitude decorrelation algorithm generates the flow signal by measuring the decorrelation
between two consecutive B-scans. In order to reduce the noise caused by tissue bulk motion,
they further employed split-spectrum algorithm to diminish the sensitivity in the axial
direction to pulsatile bulk motion (Zhang, Zhang et al. 2015) and combined split-spectrum
with amplitude decorrelation to improve the signal-to-noise ratio. With SSADA, the full
OCT spectrum was split into several narrower bands, the inter-B-scan decorrelation was
computed for each sub-band, and it was subsequently averaged to get the final flow signal,
as shown in the following equation:
Author Manuscript

where M is the number of split-spectrums, N indicates the repetition number of B-scans at

the same location, and Iim(x, z) indicates the intensity value in i-th B-scans of m-th split-
spectrum at lateral location x and depth position z. By increasing the number of split-
spectrums, the decorrelation signal-to-noise ratio can be improved without increasing the
scan acquisition time. The optimized number for split-spectrum was later discovered to be 9
(Gao, Liu et al. 2015, Gao, Liu et al. 2016). Due to the spectrum splitting for contrasting
blood flow, the axial resolution of SSADA method is reduced to typically three times lower
resolution than that of conventional OCT images. For example, if the OCT system used for
angiographic imaging is designed with an axial resolution of 5μm microns, then SSADA
algorithm results in ~ 15μm axial resolution for flow imaging.
Author Manuscript

It has been demonstrated that the SSADA algorithm is able to detect retinal vessels and
capillary networks in the macular and optic disc regions of the human retina, and it can be
used to differentiate diseased eyes from normal controls for glaucoma and retinal diseases
including AMD (Jia, Bailey et al. 2014, Jia, Wei et al. 2014, Hwang, Jia et al. 2015, Jia,
Bailey et al. 2015, Liu, Jia et al. 2015, Spaide 2015, Spaide, Klancnik et al. 2015, Chalam
and Sambhav 2016).

2.3 Complex-signal-based OCTA Techniques

2.3.1 Optical Microangiography (OMAG)—The third category utilizes both the
intensity and phase information of the OCT signal, i.e. coherent information, in order to
calculate the flow signal. The representative of complex-signal-based OCTA technique is
Author Manuscript

optical microangiography, proposed first by Wang et al. in 2007 (Wang, Jacques et al. 2007)
and later refined into its current implementation in 2010 (Wang 2010, Wang, An et al. 2010).
Even though using the phase change, caused by moving particles, to calculate the flow
signal is vulnerable to bulk motion and may easily be affected by the Doppler angle,
measuring the flow signal only based on intensity information may decrease the sensitivity
of flow detection if the induced change only happens in the phase signal. Therefore, Wang et
al. included both the phase and intensity components of the OCT signal in the flow signal

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 10

calculation in order to increase its sensitivity. With the help of phase compensation methods,
Author Manuscript

the phase variation induced by pulsatile bulk motion can be reduced (Huang, Zhang et al.
2014, Thorell, Zhang et al. 2014). After phase compensation, the flow signal based on the
OMAG algorithm is calculated by subtracting consecutive complex signals, as shown in the
following equation:

where N indicates the repetition number of B-scans at the same location, and Ci(x, z)
indicates the complex signal (having both intensity and phase values) in i-th B-scans at
lateral location x and depth position z. As indicated in the equation, the final flow intensity
is obtained by calculating the average of the absolute values of the complex signal
Author Manuscript

differences in each B-scan pair, i.e. the coherent averaging. With the use of the Hilbert
transformation, OMAG is also able to discriminate the directions of the moving blood cells
relative to the incident OCT beam direction (Wang 2010), and therefore, OMAG can provide
the flow image either with or without directional information.

Considering the trade-off between the scanning time and the number of B-scan repetitions
(more repetitions can provide a higher signal-to-noise ratio), they achieved high flow image
quality with 4 B-scan repetitions at the same location in its first demonstration. It was later
reported that 2 B-scans at the same location would also be able to detect the capillary
network with good image quality (Wang, Zhang et al. 2016).

Optical microangiography has been used to illustrate the microcirculation in mice brains
(Wang 2010), human skin tissue beds (An, Qin et al. 2010), and human retina (Wang, An et
Author Manuscript

al. 2010, Wang, An et al. 2010, An, Shen et al. 2011). With its high sensitivity in detecting
retinal capillaries, choroiocapillaris, and radial retinal capillaries, it was later demonstrated
to be capable of differentiating diseased eyes from normal eyes (Thorell, Zhang et al. 2014,
Zhang, Wang et al. 2015, Bojikian, Chen et al. 2016, Chen, Zhang et al. 2016, Roisman,
Zhang et al. 2016, Zhang, Lee et al. 2016). Thus, it may add insightful information to
disease developments.

2.3.2 Multiple Signal Classification OMAG—In addition to OMAG, Yousefi et al.

(Yousefi and Wang 2014) proposed a multiple signal classification OMAG method, which is
a super-resolution spectral estimation method based on the principle of orthogonality, to
detect the flow signal. The proposed method modeled the OCT signal at each voxel as a
superposition of three independent components: tissue signal (stationary and slowly moving
Author Manuscript

tissue structures), hemodynamic signal (mostly comes from moving red blood cells), and
noise (system noise and shot noise). By applying eigen-decomposition (Yousefi, Zhi et al.
2011), the multiple signal classification OMAG method is capable of decomposing the
backscattered OCT signal into orthogonal basis functions and distinguishing the flow signal
caused by moving RBCs from static tissue and noise. The flow signal obtained using this
approach enabled the visualization of functional microvascular networks within skin tissue
in vivo, and it was shown to be correlated with the product of the concentration and flow

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 11

velocity of blood (Zhang, Zhang et al. 2015). The more important feature of this method is
Author Manuscript

its adaptive nature: it rejects the static tissue signal in order to contrast the blood flow signal.
This is achieved because it suppresses the static tissue signal according to the Eigen
components in the ensemble signal composition. Therefore, unlike conventional OMAG, the
multiple signal classification OMAG method does not require phase-compensation due to
bulk tissue movement in order to achieve OCT angiograms of scanned tissue volume.

2.3.3 Imaginary Part-based Correlation Mapping OCT—To solve the blurry side
effect that is introduced after the correlation window size is increased for a higher signal-to-
noise ratio in correlation mapping of OCT images, Chen et al. (Chen, Shi et al. 2015)
proposed an imaginary part-based correlation mapping OCT to reconstruct microcirculation
maps with higher flow image quality and smaller vessel detection sensitivity. In their
method, a complex analytic signal in the spatial domain was obtained by performing Fourier
transform in the wavenumber domain. The extracted imaginary part of an OCT signal, i.e.
Author Manuscript

the complex OCT signal, was later correlated between consecutive B-scans to get the flow
information. In order to suppress the false flow signal caused by tissue motion, an intensity
OCT signal-based sub-pixel cross-correlation registration and the Kasai estimator were
applied to register between two B-scans before the correlation calculation, similar to phase
compensation of bulk tissue motion. The imaginary part-based correlation was then
calculated using the following equation:

where M and N indicate the grid size, and C̄ is the mean complex value within the grid. The
Author Manuscript

same notation as we showed before, Ci(x, z) indicates the intensity value in i-th B-scans at
the lateral location x and depth position z. The same as what is done in intensity-based
correlation mapping OCT, the grid was shifted across the entire image to obtain a 2D
correlation map. The correlation values range from −1 to 1, with the value of 0 indicating a
weak correlation, and the values of −1 and 1 indicating a strong inverse-correlation and a
strong correlation, respectively. Similar to the concept of OMAG, since complex signals
contain both intensity and phase information, the phase changes caused by the displacements
of curve form of RBCs, which does not change the intensity, is able to be detected.
Therefore, imaginary part-based correlation mapping OCT is more sensitive to motion, and
it can provide improved sensitivity for extracting blood flow information in small vessels.
The proposed method was tested with an in vitro phantom and an in vivo mouse ear.
Author Manuscript

Compared with intensity-based correlation mapping OCT, their results showed small blood
vessels, which were missed by the conventional correlation mapping OCT method. This is
the first study that introduced phase information into conventional intensity-based
correlation mapping in order to increase the sensitivity for small vessels and signal-to-noise
without increasing the grid size.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 12

2.4 Imaging Artifacts in OCTA

Author Manuscript

Image artifacts in OCTA are in many ways similar to, and derived from, artifacts that occur
in OCT. In general, image artifacts in OCTA occur as a result of one or more of the
following: (1) the scanning methodology used to generate the motion contrast signal, (2)
data processing, (3) movement of the eye, and (4) the intrinsic properties of the eye and
pathology. An extensive discussion of these artifacts is already available (Spaide, Fujimoto
et al. 2015) and a more synthesized review is presented below with particular emphasis on
projection artifacts.

OCTA images are generally made by repeating B-scans over the same tissue location 2 or
more times. Therefore OCTA images require either more time to scan the same area of retina
as a standard SD-OCT or a smaller field-of-view. In either case, the need for repeating B-
scans in the exact same location makes OCTA imaging much more sensitive to both axial
Author Manuscript

and transverse motion artifact from microsaccades, breathing, and cardiac cycle pulsations.
Commercial systems compensate for these artifacts by implementing motion-tracking
technology and post-processing image registration software. In addition, some OCTA image
processing methods, such as SSADA, use reduced axial resolution with averaging to
minimize the appearance and effect of these movement artifacts as discussed below (Jia, Tan
et al. 2012). The adoption of faster OCT systems, such as SS-OCT, will also minimize the
effect of increased scan times and motion artifact.

Another major source of artifacts in OCTA images is derived from the combination of the
structure of retinal vessels and the source of OCTA signal. The flow signals detected by
OCTA techniques are based on differentiating the backscattered OCT signals from the tissue
and vessels. When the incident OCT beam hits a blood vessel, the light beam can be
reflected, refracted, absorbed, or passed through the vessel. The light passing through
Author Manuscript

moving blood can further encounter tissues below the vessels. When the underlying tissue is
hypereflective, such as the retinal pigment epithelium, light will be backscattered again,
which inevitably generates false or ghost blood flow signals (Spaide, Fujimoto et al. 2015).
On the other hand, it may be more difficult to detect blood flow in the regions surrounding
and under hyporeflective lesions (such as intraretinal fluid pockets or floaters). Given the 3D
nature of OCT, the fluctuating shadows from flowing blood cells in the superficial vessels
will also cast extra flow signals to the deeper vascular networks, generating false vessel
networks when producing the en face flow images of deeper retinal tissue. This effect is
called an OCTA projection artifact (Zhang, Zhang et al. 2015, Zhang, Hwang et al. 2016).
These artifacts are observed in structures that are located below the vasculature, and may
either limit our ability to visualize true retinal vessels in the same region or may erroneously
suggest there is a vessel where in fact there is none. This is particularly problematic in the
Author Manuscript

detection and measurement of choroidal neovascularization as well as the implementation of

quantitative metrics, which we discuss in detail below.

To minimize the projection artifacts in the outer retinal avascular space (defined as the space
between the outer plexiform layer to Bruch’s membrane), Zhang et al. (Zhang, Zhang et al.
2015) proposed a model to mimic the angiogram. The hypothesis was that the projection
artifacts appearing in the en face flow images of the outer retinal avascular space came from
the blood vessels in the retina. Thus, the detected flow signals in the outer retinal avascular

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 13

space were a combination of the actual flow signal and the projection artifacts from the
Author Manuscript

superficial retinal vasculature, which can be represented as the following equation:

where AORAS(x, y) indicates the en face flow image of detected flow signal in the outer
retinal avascular space, AT(x, y) indicates the true flow signal in the ORAS, ARetina(x, y)
indicates the flow signal in the retina, and α represents a scaling factor to properly scale the
level of retinal flow signals. With a logarithmic operation, the equation can be rewritten as:

Therefore, the true flow signals in the outer retinal avascular space can be acquired by
Author Manuscript

subtracting the retinal flow signals, with proper scaling, from the detected flow signals in the
outer retinal avascular space. Due to the hyper-reflection signal observed from the RPE, the
performance of the artifact removal algorithm can be substantially improved if the structural
signal of the outer retinal avascular space is considered into the formulation of the algorithm
(Zhang, Zhang et al. 2015). This has been particularly useful in the visualization of
choroidal neovascular lesions. The proposed method successfully removed the projection
artifacts in the outer retinal avascular space, demonstrated the avascular layer in a normal
eye, and revealed the outer retinal neovascularization in an eye with Type 1 CNV. With a
similar concept, Liu et al (Liu, Gao et al. 2015) removed the projection artifacts in the
deeper retinal layer by subtracting the inner retinal angiogram (retina slab from inner
limiting membrane to the outer plexiform layer) from the outer retinal avascular layer.
Afterwards, a saliency algorithm was applied to detect the choroidal neovascularization
Author Manuscript

region for area measurements.

Contrary to the slab-subtraction methods, Zhang et al. proposed a project-resolved algorithm

to remove the projection artifacts in OCTA (Zhang, Hwang et al. 2016). The authors
observed that the intensity of projected or false flow signals from individual A-scans are
almost always weaker than the actual flow signals. Based on this observation, they designed
a method to search for successive higher peaks in the normalized decorrelation value, from
the end of each peak towards the deep tissue along each A-scan. The highest peak then
effectively identifies the real vessels and allows for the removal of the projection artifacts.
The authors concluded that unlike the slab-subtraction methods (Liu, Gao et al. 2015,
Zhang, Zhang et al. 2015) the projection-resolved algorithm eliminated the projected signals
in the cross-sectional images, preserved vessels hidden under large retinal vessels, and did
Author Manuscript

not need the information of pre-defined superficial retinal layer (SRL) boundaries. The
result of this algorithm was called projection-resolved OCTA. Projection-resolved OCTA
may be able to preserve the continuity of vessel networks and capillary plexuses after
saliency algorithm processing, and it provides more information than the standard OCTA.

2.5. Ability to Quantify Blood Flow versus Capillary Anatomy

The ability to noninvasively visualize microvascular flow in vivo and to display pathologic
changes related to disease progression using OCTA has been well established. However, the

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 14

quantitative relationship between the flow signal and the flow volume or “blood flow”
Author Manuscript

information is still not clear. To investigate the relationship between the OMAG signal and
flow information, Choi et al (Choi, Qin et al. 2016) developed a simplified analytic model
and tested it with simulation and in vitro microfluidic flow phantom by varying preset flow
parameters. In this model, the intralipid concentration varied from 1% to 4% with velocity
ranging from 1-mm/s to 4-mm/s (with 1-mm/s increments). In the proposed analytic model,
the difference of complex OCT signals could be viewed as the product of concentration (i.e.
how many particles within one scanning voxel) and flow velocity (from amplitude
decorrelation), representing the concept of flux (i.e. the number of particles passing through
a unit cross-section within a unit of time). The results from the simulation and the in vitro
microfluidic phantom supported each other, and indicated that (1) the OMAG signal
intensity had a linear relationship with flow velocity within a certain velocity range that is
dependent on the OCT B-scan rate. When the time interval between successive B-scans is
Author Manuscript

50-μs, the OMAG signal is approximately linear to flow velocity (ranging from 0.3 to 5-
mm/s), and (2) the OMAG signal intensity is linearly proportional to the intralipid
concentration. However, in the current commercial OMAG protocol parameters, the
separation time between two consecutive B-scans is about 3.4-ms. At this time scale, the
saturation velocity is lower than 0.3-mm/s for a spectral-domain OCT with a center
wavelength of 840-nm (that is commercially used for SD-OCTA devices). It has been
observed that the velocity of RBCs in normal human retinal capillaries ranges from 0.3 to
3.3-mm/s (Bedggood and Metha 2012), and therefore, the OMAG signal may be saturated
and only related to information regarding the red blood cell concentration.

On the other hand, Tokayer et al (Tokayer, Jia et al. 2013) tested the relationship between
SSADA signal and blood flow velocity using an in vitro phantom experiment with whole
blood to mimic in vivo retinal imaging. They found that the decorrelation signal and the flow
Author Manuscript

velocity had a linear relationship when the time interval between two consecutive A-scans
ranged approximately from 56 to 280-μs. When the flow speed reached 2-mm/s, the SSADA
decorrelation signal reached saturation, i.e. the SSADA decorrelation value would be
independent of the velocity change, with an A-scan time interval around 500-μs. Their
results also indicate that with the clinical SD-OCTA imaging protocol, where the time
interval between two consecutive B-scans is around 2 to 3-ms, it is difficult to absolutely
quantify flow using OCTA images at present. The easily saturated relationship of OCTA
flow signal may be improved with current OCT devices by using an M-mode scan protocol
or by using an ultrafast OCT system that provides a shorter inter-frame time interval. In
contrast to an A-scan, an M-mode scan, repeatedly captures multiple A-scans at the same
point in a short amount of time before moving on to the next sampling location.
Author Manuscript

Although the time interval of millisecond scale between consecutive B-scans reached the
plateau of the relationship curve between the OCTA signal and blood flow velocity, Choi et
al (Choi, Moult et al. 2015) noticed that increasing the time interval between adjacent B-
scans increases the sensitivity of flow detection. Choi and colleagues used their custom-built
ultrahigh-speed SS-OCT system to acquire OCTA images in 3×3-mm2 and 6×6-mm2 areas
centered at the foveola. At each transverse location, 5 repeated B-scans were acquired to
assess the difference in OCT signal over time. A variable interscan time analysis (VISTA)
method was proposed to investigate the effect of different interscan times on vascular

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 15

changes in the choriocapillaris of patients with nonexudative AMD and geographic atrophy.
Author Manuscript

The VISTA method calculated the flow signals between sequential OCT B-scans (1 and 2, 2
and 3, 3 and 4, and 4 and 5, where interscan time was approximately 1.5-ms) and between
every two B-scans (1 and 3, 2 and 4, and 3 and 5, where interscan time was approximately 3-
ms) respectively (Ploner, Moult et al. 2016). Their results demonstrated that VISTA was able
to shift the range of the detectable flow speeds. In addition, areas showing low decorrelation
flow signal had an increased decorrelation signal when the interscan time increased,
especially around the margins of geographic atrophy. Therefore, it further enabled the
visualization of varying degrees of choriocapillaris. However, this method still only provides
a relative blood flow measurement, and is only applicable to much slower flows, typically <
300-μm/s.

3. Two Dimensional versus Three Dimension OCT Angiography

Author Manuscript

Color coding and volume rendering are common ways to visualize 3D OCT and OCTA data.
The 3D data in an OCTA is typically projected as an en face image of each tissue layer
coded with a different color (Figure 2). En face images are comparable to the vantage point
of fluorescein angiograms with which clinicians are familiar. The color-coded composite
OCTA images provide the additional depth information from the OCTA in a visually
appealing manner. Quantitative analysis of blood flow or circulation is performed by
measuring 2D metrics, such as skeleton density, vessel density, fractal dimension, vessel
diameter index, flow index, and neovascularization area from the en face image of each slab.
The 2D en face representation reduces noise and allows clinicians to easily read and analyze
OCTA images. However, it requires accurate segmentation of tissue slabs of interest, and
may mask underlying capillaries due to projection artifacts. The 2D quantitative metrics
derived from en face projection artifacts of the 3D OCTA data inevitably obscure the
Author Manuscript

geometric and topological information in the original 3D vasculature networks.

Instead of the 2D projection approach, volume rendering has been used to visualize the full
3D information present in the OCTA of human retinal vessels (Makita, Hong et al. 2006,
Spaide, Klancnik et al. 2015). Recently, Spaide et al. used volume rendering of OCTA to
evaluate the vascular abnormalities associated with macular telangiectasia type 2 (Spaide,
Klancnik et al. 2015) and diabetic macular edema (Spaide 2015). This method provides a
unique perspective on the relationship between pathologic elements (e.g. intraretinal cystoid
spaces) and retinal vessels. However, this method does not allow quantitative analysis of the
3D volume data. Generally, interactive rendering of the large OCTA volume is
computationally expensive. In addition, the opacity and color functions in a rendering tool
need to be adjusted separately for every dataset and are not easy to optimize, especially for
Author Manuscript

OCTA data which has a considerable amount of noise.

To robustly compute quantitative 3D metrics for the automated analysis of OCTA data in
large-scale eye studies, there is a need for 3D algorithms that will reduce motion, projection,
and shadow artifacts (Spaide, Fujimoto et al. 2015, Gao, Jia et al. 2016), as well as noise
from the OCTA that significantly interferes with interpretation of quantitative results. As
discussed above, projection and shadow artifacts produced by superficial vessels are always
observed in OCTA, and result in an elongation of the superficial vessels relative to the

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 16

deeper layers. As discussed in the section on projection artifacts, algorithms have been
Author Manuscript

developed to minimize these artifacts in the deeper retinal layers (Zhang, Zhang et al. 2015,
Zhang, Zhang et al. 2015, Zhang, Hwang et al. 2016). Further validation of these methods
on larger data sets is warranted before determining its clinical utility. One potential
limitation of these methods is that they may not recover small capillaries located underneath
larger superficial vessels.

Another challenge to recovery of the small capillaries from OCTA data is the noise present
within the original OCTA data. Conventional filtering methods tend to obscure small vessels
when they try to suppress the noise in 3D OCTA data. However, there has been little attempt
to develop a 3D algorithm that reduces the noise and enhances the small vessels from
OCTA. A Hessian-based filter has been used to improve the vasculature visualization, but it
has only been applied to 2D en face data (Camino, Zhang et al. 2016). Recently, a model-
based filtering approach, using the 3D curvelet transform, was proposed (Shi, Gahm et al.
Author Manuscript

2017). The key idea is that the curvelet basis functions provide a multi-scale representation
of edges and singularities along curve-like structures in 3D images. This matches well with
the geometry of retinal vasculature in OCTA images. This approach has been introduced as
shown in Figure 3, but its validation with a variety of OCTA data is needed. The curvelet
transform has been applied to structural OCT data to reduce the speckle noise (Jian, Yu et al.
2010), but it may be more appropriate when applied to vessel enhancement in OCTA.

4. Commercially Available and Research Based OCTA Devices

There are currently several OCTA devices that are available throughout the world for
research use. In the United States and Europe, both Carl Zeiss Meditec (AngioPlex™) and
Optovue (AngioVue™) have Food and Drug Administration and Conformite Europeene
Author Manuscript

approvals for clinical use of SD-OCT technology. In addition, Zeiss has an SS-OCTA device
(PlexElite™) that is available for sale in the United States and Europe, but this device is
limited to research use with IRB approval. Topcon Medical Systems has a SS-OCT device
(Triton™ DRI SS-OCT) that is commercially available in Japan, Brazil and England. Most
other major OCT manufacturers including Heidelberg, Optopol and Nidek have
demonstrated OCTA platforms at major meetings and have these devices available for
research use only at specific sites. In the next few years, it is very likely that most
manufacturers will have some OCTA enabled platform.

5. Normal Retinal Vascular Anatomy and Physiology

OCTA has been very useful for understanding normative human vascular anatomy and
physiology in a way that has not been possible before, due to the invasive nature of FA and
Author Manuscript

the fixation artifacts in post-mortem tissue. In addition, OCTA is not subject to the artifacts
of fixation and sectioning that occur in histologic sections. Just as the OCT helped us
understand the normal variation in human retinal thickness (Kashani, Zimmer-Galler et al.
2010, Chalam, Bressler et al. 2012), OCTA is helping define the normal variation in retinal
vascular anatomy. This understanding is important for interpreting OCTA images with
pathology. In this section, we will review several studies that have used OCTA in human
subjects for understanding normal human retinal anatomy and physiology. In general, these

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 17

studies demonstrate that OCTA-based assessment of capillary density and morphology are
Author Manuscript

very similar to histology-based studies, while also providing a wealth of new information.
For example, OCTA has enabled several novel studies that assess the correlation of FAZ
with foveal pit morphology. As we discuss below, OCTA has also enabled studies of the
vascular response to retinal stimulation that were much more technically challenging in the
past.

5.1 Normative Retinal Capillary Size, Distribution and Density

A number of pioneering anatomic studies have defined the distribution and the
characteristics of retinal capillaries. As mentioned above, Weinhaus et al. did a comparative
study of FA and anatomic drawings of retinal vessels from retinal whole mounts of primate
retina (Weinhaus, Burke et al. 1995). That study showed that capillary visibility on FA
decreased significantly from the edge of the FAZ and reached a low of 40% beyond 900-μm
Author Manuscript

from the foveal center. Interestingly, all of the widest capillary segments, with diameters
ranging from 6.1 to 7.0-μm, were visible on FA, but only 43% of capillaries, with diameters
ranging from 4.1 to 4.5-μm, were visible on FA. Among capillaries between 4 and 5-μm in
diameter, the visibility on FA decreased linearly with increasing depth in the retina. They
concluded that capillary visibility on FA is a function of both capillary size and retinal depth
(Weinhaus, Burke et al. 1995).

In another study conducted by Snodderly et al, the detailed orientation, size, and distribution
of retinal capillaries were described in relation to the neurosensory retinal tissue in whole
mounts from macaque retina (Snodderly, Weinhaus et al. 1992). In this study, the retinal
capillary circulation was noted to have 4 layers, and it was divided into the superficial or
inner “vitread” network and the deep or outer “sclerad” network. The inner network
consisted of retinal capillaries that surround and nourish the nerve fiber layer and ganglion
Author Manuscript

cell layers, whereas the deeper retinal capillaries surround the inner nuclear layer. Median
capillary diameters are greater in the deeper retinal layers (~5.0-μm) than in the inner retinal
layers (~4.5-μm). The thickness of the inner retinal circulation was significantly greater near
the optic nerve head than other regions of the retina owing to the increased thickness of the
nerve fiber layer. In addition, the authors noted that the capillaries in the nerve fiber layer
were oriented parallel to the course of the nerve fibers, whereas the capillaries in the other
layers were less regular in their orientation. The excellent spatial resolution and depth-
resolved capability of OCTA is demonstrated by the reliable and accurate visualization of
these peripapillary vessels as well as the deeper capillaries in living human subjects
(Matsunaga, Yi et al. 2014, Spaide, Klancnik Jr et al. 2015, Campbell, Zhang et al. 2017).

Tan et al. demonstrated a correlation of histological measurements from 12 human donor

Author Manuscript

cadaver eyes and speckle variance OCTA (svOCTA) from 14 healthy human eyes.
Morphologic features of svOCTA were very similar to histology. Capillary density measures
were significantly larger in the svOCTA, except for in the retinal ganglion cell capillaries.
Mean age of the control histology group was 39.7±3.6 years, and the mean age of the
svOCTA group was 45.6±5.3 years. The mean capillary diameters for all of the capillaries
measured were 8.26±0.03μm and 8.8±0.04μm in histology and svOCTA data, respectively.
Comparison of individual capillary diameters within individual retinal layers demonstrated

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 18

that only the capillary diameter of the retinal ganglion cell layer on svOCTA was
Author Manuscript

significantly larger than on histology. In contrast, capillary density was greater on svOCTA
than histology for all layers except the retinal ganglion cell layer. For example, the nerve
fiber layer mean capillary density, as measured by manual tracing, was 10.2±0.02% in
histology and 16.97±0.02% on svOCTA (p=0.044). The inner nuclear layer-outer plexiform
capillary density was 16.04±0.01% on histology and 25.61±0.01% on svOCTA (p=0.006)
(Tan, Balaratnasingam et al. 2015). The higher density measures on svOCTA in this study
may be reflective of projection artifacts that were not accounted for. Nevertheless, similar
findings have been reported by Matsunaga et al. using a different intensity-based OCTA
algorithm and different segmentation parameters, suggesting that OCTA is generally
reliable, but may overestimate capillary density due to imaging artifacts (Matsunaga, Yi et
al. 2014). Another OCTA study of 113 eyes of 70 subjects demonstrates that mean capillary
density in the superficial and deep capillary layers decreases with age and FAZ area
Author Manuscript

increases with age (Iafe, Phasukkijwatana et al. 2016). In the latter study, the capillary
density is reported as the number of capillaries per millimeter, so a direct comparison with
percentage measurements from other studies is not possible.

In general, measurements of retinal capillary density ranging from ~30 to 60% have been
demonstrated with several different OCTA devices and methods (Matsunaga, Yi et al. 2014,
Tan, Balaratnasingam et al. 2015, Lupidi, Coscas et al. 2016). These measurements are in
very good agreement with histology-based measures from previous studies (Weinhaus,
Burke et al. 1995, Mendis, Balaratnasingam et al. 2010). Higher capillary densities are
generally associated with younger age (Wang, Chan et al. 2016). One of the main limitations
in these measurements is the un-standardized segmentation and layer definitions, which are
used among studies.
Author Manuscript

5.2 Foveal Pit Morphology and Foveal Avascular Zone (FAZ) Size
The role of the foveal pit and FAZ in vision has been studied extensively. ETDRS Report 11
(1991) demonstrated that intergrader agreement for qualitatively defining FAZ size, shape,
and capillary loss within the central 1000-μm was only good on FA (weighted kappa 0.46 to
0.58). The report states that the border of the FAZ typically falls along the boundary of the
central circle on the ETDRS grid, suggesting that the average radius is 300-μm. This
corresponds to an area of 0.28-mm2 (1991). OCT and OCTA have provided a novel tool for
revisiting the changes in the FAZ in health and disease. Previous studies have shown that
subjects without a foveal pit can have normal vision, cone density, and multifocal ERG
measurements; therefore, the exact role of a foveal pit is still controversial (Marmor, Choi et
al. 2008). An OCT-based study of 110 eyes of 57 healthy adults showed a wide variation in
the size, depth, and shape of the foveal pit. A limited number of subjects had an incidental
Author Manuscript

FA in the normal contralateral eye, which showed that the edge of the FAZ seemed to
correlate to the inner edge of the ganglion cell layer. Lastly, the size of the FAZ was
inversely correlated with the central foveal thickness (Tick, Rossant et al. 2011).

An adaptive optics scanning laser ophthalmoscope (AOSLO) study of FAZ size and foveal
pit morphology shows an average foveal pit volume of 0.081-mm3 (range 0.022 to 0.190-
mm3) and FAZ area ranging from 0.05 to 1.05-mm2 with an average of 0.43±0.25-mm2.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 19

There was significant variability in foveal pit morphology among subjects. FAZ area was
significantly correlated with foveal pit area (ρ2=0.33, p<0.0001), depth (ρ2=0.29, p<0.0002),
Author Manuscript

and volume (ρ2=0.46, p<0.0001). In general, deeper and larger pits were associated with
larger FAZs (Dubis, Hansen et al. 2012). Studies in healthy subjects with FA show mean
FAZ ranging from 0.15 to 0.405-mm2 (Mansour, Schachat et al. 1993, Arend, Wolf et al.
1995, Conrath, Giorgi et al. 2005, Samara, Say et al. 2015).

Several studies have utilized OCTA to demonstrate similar or complementary findings.

OCTA of 105 healthy Chinese volunteers showed a mean FAZ of 0.35± 0.12-mm2 (Wang,
Chan et al. 2016). Studies in healthy subjects with OCTA show FAZ values ranging from
0.25 to 0.30-mm2 in the SRL and up to 0.495-mm2 in the deep retinal layer (DRL)
(Kuehlewein, Tepelus et al. 2015, Carpineto, Mastropasqua et al. 2016). In another study, a
custom built FD-OCT was used to perform phase variance OCTA on several normal and
diabetic subjects. The range of FAZ was from 0.162-mm2 to 0.581-mm2 in the whole
Author Manuscript

population (Kim, Fingler et al. 2012).

Another prospective study of 117 healthy volunteers (234 eyes; mean age 22.5) with 3×3-
mm OCTA scans, manually graded for the size of superficial and deep FAZs, showed that
the mean superficial FAZ area was 0.24-mm2 (range 0.04 to 0.48-mm2) and that the mean
deep FAZ area was 0.38-mm2 (range 0.10 to 0.70-mm2) (Tan, Lim et al. 2016). The average
deep FAZ was significantly larger than the mean superficial FAZ by 0.13-mm2 (P<0.001).
The mean FAZ measurements between the two eyes of an individual were highly correlated,
with mean differences of 0.004 to 0.005-mm2. Full thickness FAZ measurements correlated
highly with superficial FAZ measurements, and both shared the same mean of 0.24-mm2.
Multivariable linear regression analysis showed that females had larger superficial (0.28-
mm2 vs 0.21-mm2; P<0.001) and deep FAZ (0.42 vs 0.35mm2; P<0.001) areas than males.
Author Manuscript

In addition, multivariable analysis showed that superficial and deep FAZ varied with central
retinal thickness.

Among subjects with high myopia, both superficial and deep FAZs varied significantly with
central retinal thickness, gender, and choroidal thickness (Tan, Lim et al. 2016).
Measurements of FAZ area showed excellent intergrader and intragrader reliability at this
reading center based study (ICC>0.99 for both). This study shows that there is an inverse
correlation between central subfield thickness and FAZ size in any layer and in the full
thickness slab. Therefore, a thicker retina corresponds to a smaller FAZ (Tan, Lim et al.
2016). OCTA of subjects with persistent macular-foveal capillaries (anomalous small FAZ)
showed that the severity of the abnormally small FAZ anomaly did not correlate with BCVA
(Cicinelli, Carnevali et al. 2016).
Author Manuscript

Another OCTA study of 64 healthy Chinese subjects (121 eyes; mean age 38) was
performed to assess the correlation of retinal thickness and retinal perfusion (Yu, Gu et al.
2016). A linear-mixed model corrected for age, spherical error, heart rate, ocular perfusion
pressure, and intraocular pressure. This analysis showed that vessel area density correlated
with inner retinal thickness (P<0.05) but not full retinal thickness. Also, the area of the
manually measured FAZ was negatively correlated with the inner and full retinal thickness
(P<0.001). The FAZ was also positively correlated with age (P<0.05). The peripapillary

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 20

vessel area density was positively correlated with retinal nerve fiber layer thickness
Author Manuscript

(P<0.001). The results show that for each 1 standard deviation decrease in inner retinal
thickness, there is a 1.3 to 1.6% decrease in the vessel area density of the corresponding area
(Yu, Gu et al. 2016). Interestingly, previous studies either showed a lack of correlation
between retinal blood flow velocity and retinal thickness (Burgansky-Eliash, Lowenstein et
al. 2013) or a strong correlation (Landa, Jangi et al. 2012). Previous investigators have
shown that for each 1 standard deviation decrease in retinal nerve fiber layer thickness, there
is a 2.1 to 2.6% decrease in vascular caliber of both retinal arteries and veins (Cheung,
Huynh et al. 2008).

Another retrospective OCTA study of 47 eyes from 47 healthy subjects, using the
Heidelberg prototype SD-OCTA, found the FAZ area in the superficial and deep capillary
plexus to be 0.28±0.11-mm2 and 0.30±0.1-mm2, respectively (Lupidi, Coscas et al. 2016).
There was a strong negative correlation between the FAZ area and the central retinal
Author Manuscript

thickness and central retinal volume, in both the superficial capillary plexus (r=0.7, P<0.001)
and deep capillary plexus (r=069, P<0.001). There was no statistically significant difference
between measures derived from the OCTA scans from the three separate visits. Interestingly,
the authors note that in at least 27% of cases, segmentation of the foveal region was not
consistent, thus highlighting the importance of reliable segmentation methods. Nevertheless,
manual correction of this error resulted in no significant difference between the FAZ of the
different capillary plexi (Lupidi, Coscas et al. 2016).

Despite these interesting results, it is worth noting that the FAZ is the result of anatomical
fusion of all the capillary layers within the inner retina. Therefore, any segmentation of the
foveal and perifoveal capillaries may be largely an artifact of current segmentation
algorithms which were not designed with detailed foveal anatomy in mind. For example, one
Author Manuscript

could hypothesize that since Henle’s nerve fiber layer is by definition a prominent
component of the foveal photoreceptors and not elsewhere, it is displacing the deep capillary
plexus away from the foveal center. This would explain why the FAZ has consistently larger
size in the deep retinal plexus. As we learn more about the foveal microcirculation with
OCTA, it may be useful to develop a novel segmentation scheme for the FAZ that
appropriately accounts for the unique anatomy of its neurosensory and vascular tissue.

5.3 Refractive Error

The impact of refractive error and optical aberration on OCT measurements is well-known
and similar aberrations are likely to impact OCTA measurements (Bennett, Rudnicka et al.
1994, Moghimi, Hosseini et al. 2012). This is particularly important to consider in subjects
with high myopia. In an OCTA-based study, FAZ area measurements in high myopes
Author Manuscript

(0.28±12-mm2), with spherical equivalent <-5D and without pathologic changes, was not
significantly different from controls (0.28±13-mm2), with spherical equivalent >-3D. Retinal
vascular density was approximately 3% lower (p<0.05) in myopia than in controls, as
measured in concentric annuli around the fovea. Retinal vascular density as measured by
fractal analysis negatively correlated with axial length and refractive error. There was no
correlation between blood flow velocity and either axial length or refraction. There was also

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 21

no correlation between vessel density and blood flow velocity. Importantly, this paper
Author Manuscript

corrects for the refractive error influence on the size of retinal features (Li, Yang et al. 2017).

5.4 Radial Peripapillary Capillaries and Retinal Nerve Fiber Layer

One particularly important use of OCTA is to assess the peripapillary radial capillary
network that is not visualized on FA at all (Matsunaga, Yi et al. 2014, Spaide, Klancnik Jr et
al. 2015). The original description of peripapillary radial capillaries in humans, monkeys,
pigs, and cats used India Ink (Henkind 1967) and was also confirmed by histology
(Weinhaus, Burke et al. 1995). These lie in a 2D network in the nerve fiber layer and are
superficial to the 3D network of capillaries within the inner retina. In humans, these
capillaries arise from unique arterioles around the disc and not from vessels within the disc.
In general, retinal peripapillary capillaries rarely anastomose (in contrast to other intraretinal
capillaries) and are limited in scope to the posterior pole. (Henkind 1967) Elevated
Author Manuscript

intraocular pressure (IOP) decreases or eliminates India Ink filling of peripapillary

capillaries in cats in 10/10 animals. This suggests that these capillaries are susceptible to
IOP fluctuations (Alterman and Henkind 1968). Comparison of in vivo AOSLO-FA
measurements of peripapillary retinal capillaries, retinal nerve fiber layer thickness, and ex
vivo measurements in monkey eyes using confocal microscopy and histological sections
show that the retinal nerve fiber layer is thicker than the retinal peripapillary capillary layer
at all locations measured. The area deep to the retinal nerve fiber layer showed a similar
network of capillaries as reported in the macula. In vivo AOSLO-FA and ex vivo confocal
measurements agreed well (Scoles, Gray et al. 2009).

Several OCTA studies have revisited imaging the peripapillary plexus because direct
visualization of this layer in human subjects could have an impact on the diagnosis and
management of diseases, such as glaucoma which primarily affect the retinal nerve fiber
Author Manuscript

layer. In one OCTA study, a montage of 3×3-mm2 OCTA images of 20 eyes from 20 healthy
subjects was performed to assess the peripapillary capillary density and its correlation with
retinal nerve fiber layer thickness. It was noted that the resolution from 6×6-mm2 and 8×8-
mm2 scans was insufficient to visualize retinal peripapillary capillaries. Manual
segmentation was used to define the radial peripapillary capillary plexus to the temporal
macula. The study noted that segmentation depth of the retinal peripapillary plexus
decreased with increasing distance from optic disc edge (range 78±8-μm next to disc to
~36±3-μm in superior or inferior macula). Radial peripapillary capillary plexus density
measurements were made in 0.5×0.5-mm2 sample regions from binarized and skeletonized
manually segmented images. The retinal peripapillary capillary density was 13.6±0.8,
11.9±0.9, 10.4±0.0 per mm2 at 0.5, 2.5 and 5-mm2 from the optic disc edge, respectively.
The density significantly decreased with increasing eccentricity from the disc (P<0.0001).
Author Manuscript

The capillary density was also significantly and proportionally correlated with retinal nerve
fiber layer thickness (r=0.64, P<0.0001) (Mase, Ishibazawa et al. 2016).

5.5 Retinal Blood Flow and Velocity

As mentioned in the section above, OCTA is based on the motion of particulate material
within the retina. In most cases, the particulate material consists of RBCs within the retinal
vessels. However, the presence of leukocytes and RBC aggregates may also contribute to the

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 22

signal. Previous studies have suggested that the velocity of RBCs and leukocytes may vary,
Author Manuscript

but it is not clear if the difference is truly physiological or merely an artifact of the
measurement methods (Arend, Harris et al. 1995). OCTA provides a direct measure of
particulate movement and provides a promising method for assessing retinal blood
movement. However, technical challenges still remain in understanding the actual basis of
the OCTA signal. As a result, current commercial OCTA devices do not provide any
validated quantitative information about blood flow. Rather, OCTA images are used as a
static map of the vascular network with the understanding that any regions with flow above
or below the threshold sensitivity may be undetected. In most cases, the clinical significance
of this is relevant at very slow flow rates, which may lead to erroneous appearance of
regions with “nonperfusion”.

In order to understand the limitations of OCTA in detecting flow, a few simple calculations
can be made. Capillary blood flow is on the order of 1.5 to 3-mm per second, so a RBC will
Author Manuscript

move about 1500 to 3000μm in 1-second. Most commercial OCT devices scan between 50
to 100-kHz. Assuming a 70-kHz scan rate, a 3×3-mm2 size field, 300 A-scans per B-scan,
and 300 B-scans per image the following calculation apply. Each A-scan and B-scan is
0.010-mms (10μm) apart. At 70-kHz, it takes 0.005-seconds to acquire one B-scan. Each B-
scan needs to be repeated at least twice, so at least 0.010-seconds is needed at each position.
Theoretically, this complete scan will take between 3 to 4-seconds. The fastest that a RBC
can move and still be detected by this OCTA scan is 300-mm/s. This upper limit of detection
is not likely a problem in detecting high flow rates because capillary blood does not move
this fast. However, the slowest a RBC can move and still be detected is limited by the
background noise. In addition, the average length of the cardiac cycle, assuming a heart rate
of 75-bpm, is ~0.8-seconds. Approximately 0.25-seconds is occupied in systole and 0.55-
seconds is occupied in diastole. Consequently, the likelihood of scanning two times during
Author Manuscript

diastole is much higher than once in systole and once in diastole. Therefore, gating the
OCTA to heart beat may be necessary in future studies to ensure accurate measurements.
However, the impact of the cardiac cycle may be minimized by the fact that capillary flow is
fairly constant.

Nevertheless, custom OCTA algorithms and devices have been used to examine the blood
flow changes in retinal layers during flicker stimulation. These studies show preferential
changes in the plexiform layers presumably due to the increased metabolic demand from
synaptic activity (Son, Wang et al. 2016). With an experimental OCTA-based parafoveal
flow index and a SS-OCTA device, flicker stimulation of the retina seems to increase the
parafoveal blood flow by a modest, but significant amount (~6%) (Wei, Jia et al. 2013).
Hyperoxia seems to decrease blood flow and vessel density on OCTA by a modest amount
Author Manuscript

(~9% and ~3% respectively) in human subjects as well (Pechauer, Huang et al. 2015). This
is consistent with other studies showing OCTA of 10 eyes from 10 healthy Chinese subjects
with autoregulatory response to hyperoxia. In this study, after breathing 80% oxygen for 5-
minutes, the perfused vessel densities in the perifoveal, parafoveal, and peripapillary regions
decreased significantly by 15.17%, 13.66%, and 9.52%, respectively. The decrease in the
peripapillary region was significantly different from the decrease in the other regions
(P<0.05 for both). The decrease in perfusion density was reversible after breathing room-air

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 23

for 5-minutes (Xu, Deng et al. 2016). Similar findings have been described by laser Doppler
Author Manuscript

velocimetry (Riva, Grunwald et al. 1983, Tomic, Bjärnhall et al. 2005).

As we mention above, the fastest that a RBC can move and still be detected by this OCTA
scan is 300-mm/s. This upper limit of detection is not likely a problem in detecting flow
rates in retinal capillaries but it may be a problem in detecting flow in the choroid and
choriocapillaris. Choroidal blood flow velocity has been characterized in a relative manner
by previous studies using laser Doppler and laser speckle flowgraphy methods but absolute
measurements are lacking (Riva CE, Cranston SD et al., IOVS 1994; Hirooka K, Saito W et
al., BMC Ophthalmol 2014). Due to the high reflectance and scattering properties of the
RPE it is very challenging to reliably image the choroidal and choriocapillaris circulation in
general. Therefore, accurate measurements of flow velocity are likely not feasible with
current devices. Adoption of swept-source instruments with longer wavelength may allow
advances in this area.
Author Manuscript

6. Segmentation Methods and Retinal Layer Designation

One of the key variables in the analysis of OCTA images is the method by which the layers
are segmented and how predefined retinal layers are assigned to the “superficial” and “deep”
retinal slabs. As we emphasized in several sections above, the segmentation methods are not
standardized among studies and commercial devices, and even the same segmentation
method can be prone to unpredictable errors in the setting of normal anatomic variation or
pathologic changes. Standardization of segmentation methods would significantly improve
the clinical applications of OCTA and a few studies have attempted to develop a general
segmentation scheme. For example, Campbell et al recently described a detailed
segmentation scheme with 2–4 distinct vascular plexi depending on the region of retina
Author Manuscript

being studied (Campbell, Zhang et al. 2017). In any case, it is important to understand the
differences in the segmentation methods between any two OCTA studies and a brief
discussion of this is provided below before further continuing the discussion of clinical
studies.

In most cases, commercial software has been designed to separate the retinal vasculature
into a “superficial” and “deep” slab. The software predefines the retinal layers that are
included in these retinal slabs and that are used for the output images. The user has little
input in this decision and re-segmenting the retinal layers is a laborious and often impossible
task without custom analysis software. The segmentation scheme in any study can vary from
another and users should be aware that even the commercial systems have significant
differences from one another that may or may not be clinically significant. Below, we review
the segmentation schemes used by the two SD-OCTA systems commercially available in the
Author Manuscript

United States. In many studies, investigators may have redefined these boundaries; therefore,
particular attention should be directed towards the detailed methods of all studies to
understand how the segmentation scheme impacts the results. Constant software upgrades
also may change these definitions since the writing of this review.

In general, the studies that use the OptoVue AngioVue™ systems designate the vasculature
as either superficial or deep plexus depending on the layer boundaries. The superficial slab

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 24

or “plexus” is located between the inner limiting membrane (ILM) and the posterior
Author Manuscript

boundary of the inner plexiform layer (IPL). The deep “plexus” is defined by the capillaries
between the posterior boundary of the IPL and the posterior boundary of the outer plexiform
layer (OPL). Similarly the choriocapillaris is defined as a layer of capillaries in a 30-μm
thick section located immediately posterior to the RPE (Agemy, Scripsema et al. 2015).

The segmentation scheme on the Zeiss AngioPlex™ system defines three retinal slabs
corresponding to the superficial, deep, and avascular retinal slabs. The superficial slab
consists of 60% of the retinal depth from the ILM to 110-μm above the RPE. This junction is
approximately at the anterior boundary of the IPL. The deep retinal slab consists of the
remaining 40% of the retinal depth, which is approximately the posterior IPL boundary to
the anterior edge of the ONL. The avascular layer extends from 110-μm above the RPE to
the external limiting membrane (ELM) (Kim, Chu et al. 2016, Kim, Rodger et al. 2016).
Author Manuscript

The definition of retinal layers changes slightly when looking at the peripapillary retina.
OptoVue AngioVue™ systems provide various definitions of the peripapillary superficial
retinal slab: the slab extending 52-μm from the ILM, or the slab between ILM and the outer
boundary of retinal nerve fiber layer (the RNFL slab, software version 2015.1.0.90)
(Yarmohammadi, Zangwill et al. 2016). The segmentation scheme for peripapillary retina
remains similar on the Zeiss AngioPlex™ system. With self-developed automatic, semi-, or
manual segmentation software, it is possible to precisely segment out the RNFL or the
retinal layer containing the small branches of the retinal arterioles and venules to investigate
the radial peripapillary capillaries (Chen, Zhang et al. 2016, Mase, Ishibazawa et al. 2016).

Although no systematic studies comparing different segmentation strategies have been

performed, the difference between these two segmentation schemes (and others) is not likely
Author Manuscript

to be significant when retinal anatomy is normal. However, there can be significant

differences in abnormal cases where macular edema or inner retinal atrophy are present. The
exact nature of the differences has not been studied, and since the details of the segmentation
algorithms are proprietary, it is not possible to speculate on how each may respond to
different pathologic cases.

7. OCTA, Fluorescein Angiography (FA) and Indocyanine Green

Angiography (ICG) in the Clinical Management of Retinal Vascular Disease
One of the most commonly asked questions after the FDA approval of OCTA has been,
“When is it appropriate to use FA or ICG and when is appropriate to use OCTA?” In order to
address this question, we need to revisit the fundamental basis of FA, ICG, and OCTA
Author Manuscript

imaging methods as well as the strengths and limitations of each method. We will then
consider the current role of OCTA keeping in mind that this role is rapidly evolving as we
learn more and as it is steadily improved by software and hardware modifications.

7.1 Fluorescein Angiography (FA)

Since Novotny and Alvis first described intravenous injection of fluorescein dye in a human
and simultaneous fundus imaging with custom filters in 1961, it has become the mainstay of
assessment for retinal vascular health and disease (NOVOTNY and ALVIS 1961). FA has

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 25

been used extensively to identify normal flow patterns as well as to demonstrate abnormal
Author Manuscript

vessels such as choroidal and retinal neovascularization. FA has also been used to measure
blood flow in a quantitative way using video rate imaging methods (Bursell, Clermont et al.
1996). There is no doubt that FA has been an indispensable tool for diagnosis of retinal
vascular changes and disease. Nevertheless, the limitations of FA are that it requires an
invasive dye injection with a limited “transit window”, which can make imaging challenging
and suboptimal in subsequent frames. More importantly, recent evidence has clearly
demonstrated that even under ideal circumstances FA has limited resolution compared to
histology and may be significantly underestimating vascular features of the retina. One
estimate suggests that FA assessment of capillary density is ~50% less than histology-based
assessments (Mendis, Balaratnasingam et al. 2010). Matsunaga et al. (Matsunaga, Yi et al.
2014) and Spaide et al. (Spaide, Klancnik Jr et al. 2015) have shown that OCTA clearly and
reliably demonstrates the radial peripapillary plexus, whereas Spaide et al. and others have
Author Manuscript

shown that FA does not (Spaide, Klancnik Jr et al. 2015).

A study conducted by Weinhaus et al. in primates showed that while FA can delineate the
FAZ very well, less than 40% of the retinal vasculature, beyond 900μm from the foveal
center, is visualized on FA as compared to histology of the same animal post-mortem
(Weinhaus, Burke et al. 1995). These studies strongly suggest that the appearance of
“nonperfusion” or impaired capillary perfusion in humans is a relatively late finding on FA.
It is very likely that a significant amount of impaired perfusion is not detectable on FA. This
may underlie the reason why there is a long period of subclinical DR that is essentially
without clinical or angiographic findings in DR. Similarly, the sensitivity of FA for choroidal
neovascularization is not nearly perfect compared to ICG (Pece, Sannace et al. 2005). We
will discuss ICG in further detail below.
Author Manuscript

A notable strength and limitation of FA is that fluorescein dye leaks out of retinal vessels.
This helps identify abnormal vessels but also increases the background signal in later frames
and obscures other potentially relevant details. Nevertheless, leakage helps identify very
important details such as neovascularization, edema, and otherwise abnormal vessels. This
has been a unique and useful feature of FA, even in the era of OCT. Although OCT does not
demonstrate leakage, it should be noted that qualitative OCT findings of retinal edema
correlate reasonably well with FA leakage in DR (Danis, Scott et al. 2010) and AMD. For
example, a retrospective study comparing SD-OCT and FA images from 93 eyes of 93
patients with history of neovascular AMD and anti-VEGF treatment showed significant
correlation between SD-OCT findings of retinal edema and FA leakage. Specifically, there
was a statistically significant association between SD-OCT findings of any retinal edema,
neurosensory detachment, intraretinal flecks, and low reflectivity from subretinal material
Author Manuscript

and FA leakage. There was not a significant association with pigment epithelial detachment
or intraretinal fluid. SD-OCT findings of any fluid was 94% sensitive and 24% specific for
FA leakage from CNV (Giani, Luiselli et al. 2011).

In diabetic subjects, the presence of cystoid spaces on OCT is highly predictive of

fluorescein staining. There also appears to be some relationship between the reflectivity of
the cystoid spaces on OCT and the severity of fluorescein pooling, although this is still a
subjective measurement (Horii T, Murakami T et al., Ophthalmology 2012). The severity of

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 26

retinal edema on OCT correlates with the severity of leakage on FA in diabetic macular
Author Manuscript

edema. Importantly, loss of inner retinal layers on OCT correlates with capillary
nonperfusion on FA (Yeung, Lima et al. 2009).

Perhaps, the most important limitation of FA is the possibility of minor and severe adverse
reactions. Side effects are reported in ~5% of cases with intravenous sodium fluorescein
administration. Most side-effects are mild, including nausea, vomiting, sneezing, and
pruritis. In more rare cases, side-effects can include severe reactions, such as syncope, local
tissue necrosis, thrombophlebitis and local skin eruptions at the injections site (Kwiterovich,
Maguire et al. 1991). The mortality rate for FA has been estimated at 1 in 220000 due to
causes, such as cardiovascular shock, myocardial infarction, laryngeal edema, and
bronchospasm (Yannuzzi, Rohrer et al. 1986). Skin testing suggests some or many of these
reactions may be IgE mediated mechanism (López-Sáez, Ordoqui et al. 1998).
Author Manuscript

Oral use of FA (10-ml of sodium fluorescein with 4-grams of sugar) has been shown to be
another possible, although inferior, method of visualizing the retinal vasculature. In many
cases, this method takes over 1-hour, and still has the potential of eliciting mild to severe
systemic side-effects. In one study, investigators systematically used hypodermic injections
of 2-ml of 0.5% dexamethasone sodium phosphate and 2-ml of 0.5% metoclopramide 15-
minutes before the sodium fluorescein ingestion to mitigate against side-effects. In ~3% of
all cases, usable images were not obtained (Gómez-Ulla, Gutiérrez et al. 1991, Hara and
Inami 1998). Nevertheless, oral FA administration with use of confocal laser scanning
ophthalmoscope demonstrate quality similar to conventional intravenous angiogram in 47%
of cases with visualization of the FAZ (Garcia, Rivero et al. 1999).

7.2 Indocyanine Green Angiography (ICG)

Author Manuscript

Originally described by Yannuzzi et al. (Yannuzzi, Slakter et al. 1992), ICG aided in
visualizing lesions with recurrent choroidal neovascularization (Reichel, Pollock et al.
1995), occult choroidal neovascularization (Guyer, Yannuzzi et al. 1994), and choroidal
neovascularization complicated with subretinal hemorrhage (Reichel, Duker et al. 1995). In
many ways, the strengths and limitations of ICG, as they relate to OCTA, are similar to FA,
with the notable exceptions that ICG has a longer emission wavelength, and it is ~98%
bound to albumin (Hope-Ross, Yannuzzi et al. 1994). The longer emission wavelength
allows improved visualization of deeper structures. The higher fraction of albumin-bound
dye decreases the “leakage” of the ICG dye and improves the signal-to-noise ratio. Both of
these features make it more amenable to imaging the choroidal vasculature and choroidal
neovascularization. Nevertheless, at least 11% of subjects with occult CNV demonstrate
intraretinal leakage of ICG dye that may obscure CNV features or retinal features. For
Author Manuscript

example, the presence of subretinal fluid, subretinal hemorrhage, subretinal lipid, and retinal
pigment epithelial detachment are associated with ICG leakage into the retina in subjects
with occult choroidal neovascularization (Ho, Yannuzzi et al. 1994). Severe adverse
reactions to ICG have also been documented, especially for those with Iodine allergies
(Benya, Quintana et al. 1989, Hope-Ross, Yannuzzi et al. 1994). A recent and detailed
review of ICG angiography is available for readers with further interest in this subject
(Yannuzzi 2011).

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 27

7.3 Practical Applications of OCTA Today

Author Manuscript

Above, we highlighted the strengths and limitations of FA and ICG, and these observations
help define situations where the use of OCTA is clearly warranted and those in which it is
optional. First, any individual with a known allergy to fluorescein sodium dye or
indocyanine green dye would clearly benefit from OCTA imaging, rather than not being
imaged at all. In addition, subjects with relative contraindications to FA or ICG would
benefit from OCTA as well including: (1) pregnant subjects, (2) breast-feeding subjects, (3)
subjects with severe kidney disease, and (4) subjects with poor or impossible intravenous
access. In all of these cases, the physician should keep in mind that OCTA is limited to
imaging the vasculature of the macula and peripheral pathology needs to be assessed
clinically. In some cases, directed OCTA of peripheral pathology is possible and useful as
well (Lang, Cakir et al. 2016). Nevertheless, in most cases clinicians and researchers are still
learning how and when to apply OCTA to clinical situations, so a conservative approach to
Author Manuscript

the use of OCTA is warranted when making treatment decisions.

We also suggest that OCTA is useful and practical in regular assessment of macular
complications of retinal vascular disease that do not warrant FA or ICG, or for which
frequent FA or ICG exams are not practical. In diseases such as DR, AMD, and retinal vein
occlusion (RVO) the need for monthly examinations and treatment is critical, but FA and
ICG are impractical at that frequency. In most cases, the accepted standard-of-care in the
management of those diseases is to “interpolate” the status of the retinal vasculature between
semiannual or annual FA or ICG examinations. In many cases, FA and ICG are not
performed to confirm the presence or absence of neovascularization and the activity of the
disease is inferred by secondary findings, such as intraretinal fluid or subretinal fluid. While
this strategy works well for many cases, it is suboptimal because the actual cause of the
disease process is not directly visualized or quantified.
Author Manuscript

In contrast to FA and ICG, OCTA can be performed as regularly as OCT and can provide
frequency of information that was not available in the past. For example, one practical
application of OCTA is to assess the real-time changes in retinal capillary perfusion or
choroidal neovascularization during anti-VEGF treatment. A few notable studies have
suggested that capillary reperfusion occurs in subjects with DR (Campochiaro, Wykoff et al.
2014) and RVO (Sophie, Hafiz et al. 2013), who are undergoing anti-VEGF treatment.
Regression of choroidal neovascularization in real-time with anti-VEGF treatment has also
been documented (Huang, Jia et al. 0002). OCTA presents a safe, powerful, and feasible
method of assessing these phenomena in more detail and with less risk than either FA or
ICG. It should be emphasized again that clinicians are still learning how and when to use
OCTA in clinical settings so a conservative approach to using OCTA for treatment decisions
Author Manuscript

is warranted.

When considering whether to use OCTA, FA, or ICG it is important to keep in mind that
OCTA measures different biologic phenomena than FA or ICG. As discussed in detail above,
OCTA is based on light scattering from RBCs and particulate debris; therefore, there is no
“leakage” of dye on OCTA. In contrast, FA and ICG are based on the tissue distribution and
fluorescence of molecules that are not strictly confined to vessels, even in normal subjects.
Thus, as far as we know, OCTA cannot identify abnormal vascular permeability like FA.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 28

One clear manifestation of this difference is revealed in how microaneurysms appear on FA

Author Manuscript

and OCTA. Matsunaga et al. and others have shown that microaneurysms are not detected as
frequently on OCTA as on FA (Matsunaga, Yi et al. 2015). The likely reason for this is that
some microaneurysms may be sclerosed or clotted without blood flow, while others are
patent. Since OCTA only detects movement of RBCs, sclerosed or clotted microaneurysms
will not appear on OCTA, but may still stain with dye. Even though OCTA cannot detect
leakage, it can detect some instances of macular edema that we describe further below.

In contrast to FA, the ability of OCTA to reliably resolve capillary level detail with
unprecedented depth resolution has been demonstrated in humans (Matsunaga, Yi et al.
2014, Spaide, Klancnik Jr et al. 2015, Hwang, Zhang et al. 2016). OCTA images
demonstrate capillary detail that approaches the resolution of histological studies on human
cadaver eyes (Mendis, Balaratnasingam et al. 2010, Matsunaga, Yi et al. 2014, Spaide,
Klancnik Jr et al. 2015, Tan, Balaratnasingam et al. 2015). As a result, numerous studies
Author Manuscript

have suggested that OCTA images are at least equal to FA for detecting macular
complications of retinal vascular diseases, including DR (Ishibazawa, Nagaoka et al. 2015,
Matsunaga, Yi et al. 2015, Hwang, Zhang et al. 2016), RVO (Kashani, Lee et al. 2015,
Casselholmde Salles, Kvanta et al. 2016), AMD (Coscas, Lupidi et al. 0002, Moult, Choi et
al. 2014, PhD, Md et al. 2014), and macular telangiectasia (Thorell, Zhang et al. 2014)
among others. It is well established that OCTA can detect areas of impaired perfusion (a.k.a.
“nonperfusion”) in both the superficial and deep capillary plexi, whereas FA cannot resolve
the deep capillary plexus at all (Figure 4) (Weinhaus, Burke et al. 1995, Spaide, Klancnik Jr
et al. 2015). Therefore, OCTA provides a whole new dimension of depth information
regarding the severity of impaired perfusion that we did not have with the FA. The clinical
relevance of this additional information remains to be determined, but at the least OCTA will
allow us to assess the severity of ischemia with much more precision. For example, OCTA
Author Manuscript

has already been used to study diseases that are thought to primarily affect the DRL, such as
paracentral acute maculopathy (Nemiroff, Kuehlewein et al. 2016) and DR (Kim, Chu et al.
2016).

OCTA can also detect intraretinal (intraretinal microvascular anomalies, IRMA) and
extraretinal neovascularization (neovascularization of the disc or elsewhere, NVD or NVE)
with excellent reliability as long as the pathology is within the field-of-view (Figure 5)
(Ishibazawa, Nagaoka et al. 2015, Matsunaga, Yi et al. 2015, de Carlo, Bonini Filho et al.
2016). Accordingly, one of the main limitations of OCTA is the field-of-view, though this is
rapidly improving. Commercially available devices have several field-of-view options,
including 3×3-mm2, 6×6-mm2, and 8×8-mm2 (Figure 2). It is very likely that larger fields
will be available shortly. In most cases, as the field-of-view increases in size, the resolution
Author Manuscript

of the scan decreases because the same number of A-scans are being used to scan a larger
area. Nevertheless, the standard scan patterns on current SD-OCT devices are sufficient to
detect clinically relevant pathologic changes in DR and RVO (Hwang, Jia et al. 2015,
Kashani, Lee et al. 2015, Matsunaga, Yi et al. 2015, Kim, Chu et al. 2016). The bottom line
is that physicians still need to perform wide-field FA to detect extramacular lesions,
including neovascularization and peripheral nonperfusion in DR. Follow-up examinations
for assessing macular ischemia can be done with OCTA.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 29

OCTA can demonstrate novel pathologic features that do not correlate with features on FA
Author Manuscript

or OCT. For example, certain types of intraretinal edema are detected very well on OCTA,
but these regions do not correlate with typical intraretinal fluid pockets on OCT or late
staining regions on fluorescein angiograms (Figure 6) (Kashani, Lee et al. 2015, Matsunaga,
Yi et al. 2015). This finding has been demonstrated by our group in both DR (Matsunaga, Yi
et al. 2015) and RVO (Kashani, Lee et al. 2015), and it is the subject of current ongoing
studies. It has been postulated that this finding occurs because even trace amounts of small
light-scattering particles (lipid and extracellular protein deposits such as hard exudates)
within retinal tissue can generate an OCTA signal from Brownian-like motion. This finding
is appropriately called small light-scattering particles in motion or SPPiM. We demonstrate
SPPiM findings in DR (Figure 6) and AMD (Figure 10). The clinical significance of SPPiM
is not yet clear, but this is the subject of ongoing investigation.

Another novel finding on OCTA is sub-clinical vascular changes that are noted in subjects
Author Manuscript

with minimal DR (Figure 7). We have observed many subjects with excellent vision and sub-
clinical variations in the appearance of macular capillaries (unpublished observations). The
clinical significance of these variations is not known, but it is possible that OCTA is
detecting vascular changes before a clinically detectable disease has occurred. If this were
shown to be the case, then OCTA could be a very powerful tool for detecting DR before
clinically evident changes occur.

As mentioned previously, microaneurysms have been demonstrated on OCTA, but are not
identified as frequently as in FA (Ishibazawa, Nagaoka et al. 2015, Matsunaga, Yi et al.
2015). It is possible that this is because microaneurysms have a life-cycle. In addition,
histology studies have shown that microaneurysms can be patent, clotted, or sclerosed.
Therefore, any microaneurysm that doesn’t have blood flow (e.g. sclerosed) is unlikely to
Author Manuscript

show up on an OCTA scan, but will still stain with fluorescein dye. Also, the flow rate of
blood in microaneurysms can vary and may be below the threshold of detection for current
OCTA devices. In general, users should be aware that regions that lack OCTA signal may
have blood flow that is too slow for the OCTA to detect. Currently, it is not known what the
threshold flow rate for detection of blood flow is using SD-OCTA. OCTA may allow us to
revisit the relevance of microaneurysms in diabetic macular edema with additional studies,
but it is likely that additional improvements on OCTA hardware and software will be
necessary for this. For example, using variable interscan intervals (VISTA) during the
acquisition for OCTA images allows measurement of a relative blood flow in DR (Ploner,
Moult et al. 2016) and AMD (Choi, Moult et al. 2015). At this time, VISTA is only possible
with the very high scan speeds (400-KHz) of a prototype SS-OCT instrument using a
vertical cavity surface emitting laser (VCSEL). These studies utilizing VISTA do show
Author Manuscript

modest differences in the apparent blood flow of pathologic regions, such as

microaneurysms and choriocapillaris surrounding geographic atrophy.

OCTA images generally do not show hyporeflective intraretinal fluid pockets that are
typically seen in diseases with macular edema. However, since OCTA images are always
accompanied by structural OCT scans this is not an issue. Physicians can use OCTA in
conjunction with structural OCT to detect intraretinal fluid (just as they do with standard
OCT scans). In some cases, OCTA can detect hyperreflective fluid pockets, and as we

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 30

mentioned above, this is an area of ongoing study. The additional time it takes to perform an
Author Manuscript

OCTA scan is negligible and viewing the OCT concurrently with the OCTA also takes
marginally more effort than viewing the OCT by itself. In some cases, OCTA images are not
necessarily easy to interpret and are also not currently reimbursed. The lack of
reimbursement is certainly a problem that needs to be addressed in the medium- or long-
term, but the growing capabilities of OCTA will probably encourage its adoption for clinical
efficiency (OCTA is faster than an FA all other factors being equal) rather than as a new
source of revenue in the short-term.

Some of the key differences between FA-based retinal angiography and OCTA have been
well illustrated in a study comparing adaptive optics scanning laser ophthalmoscopy-based
FA (AOSLO-FA) and OCTA. In a study of 11 vasculopathic patients and 4 healthy controls,
the authors compared the images generated by the high-resolution AOSLO-FA system with
those generated by the OCTA from the same retinal regions. Mean foveal avascular zone
Author Manuscript

area on AOSLO-FA and OCTA were similar at 0.378±0.245-mm2 and 0.384±0.249-mm2,

respectively, but were statistically different (P=0.004). It is unlikely that the small magnitude
of this difference has any clinical relevance. Mean vessel density on AOSLO-FA and OCTA,
within the 300-micron region of interest, were not found to be significantly different. This
reinforces the earlier observations that OCTA seems to provide very accurate, high-
resolution images of the retinal capillaries, with near histology-level resolution and without
the need for dye injection.

However, there were some key differences between the AOSLO-FA and OCTA, which
highlight the strengths and weaknesses of OCTA. Capillary lumen diameters were
significantly larger on OCTA than on AOSLO-FA (14.2±6.3-μm vs 19.9±5.9-μm
respectively; P<0.001). This was attributed to the lower lateral resolution of OCTA. Also,
Author Manuscript

OCTA images did not demonstrate vessel segments in some cases where AOSLO-FA clearly
did show vessel segments. As mentioned above, this was probably attributed to the fact that
OCTA has a threshold sensitivity to flow ~0.3-mm/sec, below which flow is not detected
(Tokayer, Jia et al. 2013). In addition, microaneurysms either appeared very differently or, as
evident in many cases, were completely missing on OCTA as compared to AOSLO-FA,
likely due to the same reason (Mo, Krawitz et al. 2016). Matsunaga et al. also noted that
microaneurysms that do appear on OCTA are often not the same shape or size as those on
FA (Matsunaga, Yi et al. 2015). This could be explained by the fact that the region of a
microaneurysm which has RBC flow may only be a small portion of the whole
microaneurysm. Histology of cadaver eyes show that microaneurysms can have recanalized
segments, which support RBC flow even though the majority of any given microaneurysm is
sclerosed (Stitt, Gardiner et al. 1995).
Author Manuscript

OCTA is more useful than FA or ICG in evaluating subretinal hypereflective material

(SHRM) for neovascular activity. SHRM is a generic term applied to material in the
subretinal space that includes Type 2 choroidal neovascularization, fibrosis, exudation,
vitelliform material, and hemorrhage. In some cases, SHRM regresses with anti-VEGF
therapy, and in others, it does not (Willoughby, Ying et al. 2015). Distinguishing between the
vascular and avascular components of SHRM is difficult on structural OCT. In most cases,
FA and ICG tend to demonstrate non-specific diffuse staining patterns and are often

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 31

considered to be not helpful. The utility of OCTA in assessing SHRM was explored in 33
Author Manuscript

eyes of 25 subjects with mean age of 76 years and a range of retinal diagnoses (Dansingani,
Tan et al. 2016). This qualitative study showed that it was possible to use OCTA to detect
neovascularization within SHRM lesions. However, this required a significant amount of
manual segmentation and reading effort. The authors also suggest that SHRM lesions vary in
their optical properties and are differentially susceptible to projection artifacts. For example,
the authors show that smooth surfaces and hypereflective SHRM lesions are more prone to
projection artifacts than irregular contours and hyporeflective lesions. The application of
OCTA in clinical cases that include neovascular, myopic choroidal neovascularization, and
vitelliform lesions demonstrates the novel practical applications of OCTA that were either
not possible with FA and ICG or are now significantly better with OCTA (Dansingani, Tan et
al. 2016). While these OCTA applications are currently labor-intensive, it is likely that rapid
advancements in OCTA technology will overcome most of these problems and allow for
Author Manuscript

clinical adoption.

There is mounting evidence that one of the most important applications of OCTA will be
detecting subclinical changes or, more accurately, quantifying milder stages of DR, where
FA is absolutely not indicated or useful (de Carlo, Chin et al. 2015). For example, in subjects
with mild NPDR and no macular edema, a FA is not indicated. However, it is clear from
epidemiologic, pathologic, and clinical studies that microvascular changes are present at that
stage of disease beyond what is detected on clinical examination (de Carlo, Chin et al.
2015). The non-invasive nature of OCTA makes it possible to image patients without posing
a significant risk. Our group and others have observed that subtle, sub-clinical OCTA
changes in this patient population are not uncommon (Kashani AH unpublished
observations). Comprehensive quantitative metrics will be needed to objectively capture
these subtle changes and provide evidence of DR severity. Several studies show that OCTA-
Author Manuscript

based metrics of capillary density, branching complexity, and capillary diameter correlate
well with the clinical severity of DR (Agemy, Scripsema et al. 0002, Kim, Chu et al. 2016),
RVO (Koulisis, Kim et al. 2016), and some of the clinical features of uveitis (Kim, Rodger et
al. 2016). Larger scale studies are underway. These studies are aimed at determining whether
OCTA can in fact detect sub-clinical DR changes that would pave the way for earlier
intervention and prevention of vision loss, rather than treatment of vision loss.

8. Review of Clinical Studies Utilizing OCTA

8.1 Diabetic Retinopathy (DR)
DR remains a leading cause of visual impairment and blindness in the world. An estimated
285 million people world-wide are estimated to have diabetes mellitus. Approximately 33%
Author Manuscript

have signs of any DR and ~11% have vision-threatening DR (Lee, Wong et al. 2015). One of
the major challenges in the diagnosis and management of DR is that the clinical presentation
of the disease occurs 10 to 20-years after the diagnosis of diabetes mellitus type II or 5 to 10
years after the diagnosis of type I diabetes mellitus (Klein 2007). Histologic studies on
human cadaver eyes and animal models have suggested that the onset of pathologic changes
occurs many years before the clinical presentation (Campochiaro 2015, Stitt, Curtis et al.
2016). Therefore, it is very likely that clinical grading of NPDR detects the disease at a

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 32

relatively advanced stage of microscopic vascular changes that are not otherwise clinically
Author Manuscript

or angiographically detectable.

OCTA is a novel modality that safely, quickly, and noninvasively demonstrates the retinal
microvasculature with resolution that exceeds FA and approaches histologic accuracy.
Therefore, OCTA presents an opportunity for clinicians to detect the ongoing subclinical
changes that are occurring in DR, during the long period before the onset of clinical signs
and symptoms. It has already been demonstrated that OCTA can successfully reveal almost
all of the clinically relevant findings in the macula of diabetic subjects (Hwang, Jia et al.
2015, Ishibazawa, Nagaoka et al. 2015, Jia, Bailey et al. 2015, Matsunaga, Yi et al. 2015, de
Carlo, Bonini Filho et al. 2016). In addition to these qualitative findings, OCTA offers a
significant advantage for quantitative and objective assessments. Here, we will review
several additional studies that demonstrate the application of OCTA in assessing DR.
Author Manuscript

Recent OCTA studies have demonstrated qualitative assessments of retinal vascular changes
in subjects with DR, including impaired capillary perfusion, intraretinal microvascular
anomalies, neovascularization, as well as some types of microaneurysms (Hwang, Jia et al.
2015, Ishibazawa, Nagaoka et al. 2015, Jia, Bailey et al. 2015, Matsunaga, Yi et al. 2015, de
Carlo, Bonini Filho et al. 2016). Matsunaga et al. have also demonstrated that some types of
intraretinal edema can be visualized on OCTA images (Matsunaga, Yi et al. 2015). These
qualitative findings are sufficient in most cases for the diagnosis and management of
macular complications of DR with a few caveats. The earliest and most straight-forward use
of OCTA is for the assessment of areas with impaired capillary perfusion (otherwise known
as “nonperfusion”). We prefer to avoid the term “nonperfusion” because even in cases where
OCTA signal is absent it is still possible that there is blood flow below the threshold of
detection for OCTA (or even FA). The most widely recognized use of this OCTA capability
Author Manuscript

has been to assess the shape and size of FAZ among diabetics of varying severity and normal
subjects. For example, OCTA of 63 eyes of 63 patients showed significant enlargement of
FAZ from 0.25-mm2 in controls to 0.37-mm2 in diabetic eyes without DR and to 0.38-mm2
in eyes with DR (Takase, Nozaki et al. 2015). In a separate study, quantitative assessment of
FAZ area in 110 high quality FA of diabetic subjects and 31 healthy controls showed that
FAZ surface area ranged from mean of 0.15±0.09-mm2 in controls, 0.30±0.19-mm2 in
baseline DR, 0.42±0.25-mm2 in NPDR, and 0.61±0.41-mm2 in PDR subjects. The increase
was statistically significant between all stages. Interestingly, the study showed that ETDRS
qualitative criteria correlated significantly with FAZ area measurements for all grades,
except for the two mildest (Conrath, Giorgi et al. 2005). Other OCTA studies of diabetic
subjects without DR also showed an enlargement of the FAZ (de Carlo, Chin et al. 2015). In
addition, OCTA of 13 healthy subjects and 13 subjects with mild NPDR showed that the
Author Manuscript

NPDR group has larger avascular areas as compared to controls, using an automated
algorithm (0.85±0.47-mm2 versus 0.46±0.29-mm2; p=0.017) (Zhang, Hwang et al. 2016).
Although previous investigators have demonstrated similar findings using FA (Bresnick,
Condit et al. 1984, Mansour, Schachat et al. 1993), this has not been widely adopted in
clinical practice due to the invasive nature of FA. OCTA provides a practical and clinically
available method of assessing FAZ in diabetic subjects who would otherwise not have FA
but the clinical significance and reliability of these OCTA results is still a subject of ongoing
research.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 33

Several groups have performed larger studies to demonstrate whether more formal
Author Manuscript

quantitative metrics of capillary density correlate with DR severity. For example, OCTA of
56 eyes of 34 subjects with DR and 12 age-matched control eyes of 12 subjects showed a
significant decrease in the skeletonized capillary density of all eyes with DR as compared to
the control eyes (Agemy, Scripsema et al. 2015). Statistical comparisons among all groups
(normals and all stages of DR) showed significant differences between normal and all DR
stages, mild and severe NPDR, and mild NPDR and proliferative DR (PDR), as well as all
NPDR and PDR for 3×3-mm2 images. Interestingly, there were no significant differences
found among varying stages of DR with 6×6-mm2 images in this study. The trend towards
decreasing capillary density was significant in both 3×3 and 6×6-mm2 images in the DRL
for only two comparisons (mild NPDR with PDR and all NPDR with PDR). Therefore,
OCTA is at least capable of distinguishing between large changes in DR severity in all
layers. It is interesting that this study showed the most significant changes in the DRL, but it
Author Manuscript

is now known that this layer is the most likely to be confounded by projection artifacts and
segmentation error. Overall, this is the first study to suggest that quantitative OCTA of DR
can be useful in stratifying disease severity, although it did not demonstrate that OCTA can
actually distinguish between each of the clinical stages of DR in a reliable fashion. It is
unclear why even in the more severe cases of DR there are no differences in the SRL
comparisons among DR levels (Agemy, Scripsema et al. 2015).

Another retrospective OCTA study of 13 eyes with DR without macular edema and 56
control eyes showed that the mean fractal dimension in the DR group was significantly less
than the control for both SCL and DCL (P<0.005 for each; (Zahid, Dolz-Marco et al. 2016)).
In the control group, the mean vessel density in the SCL and DCL was 55.6±1.7% and
60.6±1.5%, respectively. In the diabetic group, the mean vessel density in the SCL and DCL
was 48.2±4.6% and 53.6±3.2%, respectively, which was consistent with the previous results.
Author Manuscript

One weakness of this study was the very small sample size of diabetic subjects (only 13
diabetic eyes). Another weakness was that the diabetic group was significantly older than the
control group, and it is widely known that capillary density decreases with age. The mean
age of the control group and diabetic group was 32±7 and 57±13-years, respectively.
Nevertheless, the study showed a significantly lower capillary density and fractal dimension
in both SCL and DCL of diabetic subjects compared with controls. However, there was no
difference in the comparison among different severity levels of DR, possibly due to the small
sample size and lack of age-matching (Zahid, Dolz-Marco et al. 2016).

In another OCTA study of 209 eyes of 122 Type 2 DR subjects and 60 eyes of 31 normal
Indian subjects, FAZ area and vessel density measurements were assessed. Patients with
macular edema, renal disease, and history of intravitreal injection were excluded, which
Author Manuscript

heavily biases this group towards healthier subjects with DR, and also minimizes the
likelihood of segmentation errors. Systemic variables, including finger stick blood glucose,
post-prandial blood sugar, blood pressure, body mass index, hemoglobin, hemoglobin A1c,
low density lipoprotein, and high density lipoprotein were measured. In this study, normal
eyes had significantly higher vessel density and smaller FAZ area than all DR subjects
combined. However, the results of this study are somewhat unusual in that the size of the
FAZ and average vessel density did not significantly change with increasing DR severity.
This may be attributable to differences in segmentation and layer definitions among studies.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 34

Overall, the findings in the DRL were less robust than those in the SRL in keeping up with
Author Manuscript

most OCTA studies of DR (Bhanushali, Anegondi et al. 2016).

As the above studies illustrate, one pitfall in current OCTA studies is that layer segmentation
methods and definitions are not standardized and may account for some of the discrepancies
between studies. Although commercial OCTA devices are capable of motion correction and
eye tracking, movement artifacts can still significantly impact data availability and quality.
Abnormal retinal pathology may also limit reliable segmentation. For example, in an OCTA
study of 94 eyes, 61 eyes were excluded due to inadequate image quality (Hasegawa, Nozaki
et al. 2016). Ultimately, only 33 eyes from 27 subjects were used to examine the correlation
between the location of the microaneurysms and the macular edema in 6×6-mm2 OCTA
images. The study reports that 77% of all observed microaneurysms on OCTA were found in
the deep capillary layer. However, within areas of diabetic macular edema, 91% of all
microaneurysms were found in the DRL. There was a significant positive correlation
Author Manuscript

between increasing retinal volume and the number of microaneurysms. While the results of
this study are interesting and largely consistent with previous non-OCTA studies, it is
possible that the retinal distortion caused by macular edema confounded the segmentation
and localization of microaneurysms. Also, the use of OCTA alone for detection of
microaneurysms likely resulted in an underestimation of the total number of
microaneurysms, since several studies have demonstrated that not all microaneurysms
appear on OCTA as they do on FA. For example, in one study, only 62% of microaneurysms
detected by FA were found on OCTA (Couturier, Mane et al. 2015). Similar findings
regarding microaneurysms have been noted by other studies (Matsunaga, Yi et al. 2015,
Hasegawa, Nozaki et al. 2016). Despite these limitations of OCTA as a new methodology,
the results of these studies agree with former histopathology and OCT studies that show
microaneurysms are preferentially located in the inner nuclear layer (Moore, Bagley et al.
Author Manuscript

1999, Horii, Murakami et al. 2015).

Several studies using SS-OCTA have also been performed in assessing DR. One OCTA
study of 28 eyes from 18 subjects with DR and 40 eyes from 22 healthy subjects showed that
the mean FAZ area in the SRL was 0.52-mm2 and 0.34-mm in the DR and control groups,
respectively. Mean FAZ area in the DRL was 0.62-mm and 0.36-mm in the DR and control
groups, respectively. In this study, SS-OCTA had a central wavelength of 1050-nm and 100-
kHz acquisition speed (Topcon Triton™ DRI; Topcon Corp, Tokyo, Japan) and 3×3-mm2
scans centered on the macula were used. Automated layer segmentation was used and
defined as SRL (ILM to inner border of INL) and DRL (inner border of INL to outer border
of INL). FAZ was measured manually with GIMP™ software. Vessel density was measured
as percent of surface area covered by vessels in binarized images. Despite the use of SS-
Author Manuscript

OCTA, in this case, there were no significant differences in the FAZ area in the SRL of mild
or moderate NPDR as compared to control groups. However, there was a significant
difference in FAZ area in the DRL for all subgroups. Agreement for the FAZ area between
graders was excellent (ICC > 0.99). Mean vessel density was significantly lower in the SRL
of DR subjects as compared to controls. Mean vessel density was also significantly lower in
the DRL of DR subjects as compared to controls. Interestingly, there was a significantly
lower vessel density among subjects with diabetic macular edema than those without
diabetic macular edema (Al-Sheikh, Akil et al. 2016).

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 35

Another interesting application of OCTA is to better understand the impact of laser

Author Manuscript

treatments and anti-VEGF therapy on retinal tissue in DR subjects. For example, a study was
performed using 6×6-mm2 OCTA in 8 subjects with diabetic macular edema and a history of
focal laser. This study showed changes in the choriocapillaris on manually segmented
images, but, in most cases, there were no changes in the superficial or deep retinal
vasculature in the region of focal laser. In some cases, there were changes in the outer
plexiform layer on OCT structural scans (Cole, Novais et al. 2016). OCT-based studies have
also suggested that focal laser does not significantly alter the anatomy of the inner retina
(Bolz, Kriechbaum et al. 2010), but histologic studies performed on monkey models of focal
laser injury to the retina (Wilson, Finkelstein et al. 1988) demonstrate decreased capillary
density in the region of focal laser. Additional studies are needed to understand this
discrepancy, but OCTA now provides a powerful tool for assessing vascular changes in vivo.

The above studies highlight the salient findings in OCTA studies of DR as well as the
Author Manuscript

associated limitations. One of the main limitations is that it is very difficult to compare
quantitative metrics across studies, since segmentation methods are not standardized and
quality-controlled. In addition, the details of the metric calculations vary from study-to-
study. Lastly, most studies have not compared comprehensive capillary density and
morphology measures simultaneously on the same data set. It is very likely that both
morphologic changes in capillaries (e.g. branching pattern and capillary diameter) as well as
capillary density measures (e.g. vessel density versus skeleton density) will be important in
characterizing vascular changes in DR. Each of these parameters will need to be validated
and tested for reliability and reproducibility. In addition, each have strengths as well as
weaknesses that need to be systematically tested. In the near future, a potentially high
impact role of OCTA would be the assessment of retinal capillary reperfusion in subjects
with DR and anti-VEGF therapy. FA-based studies have demonstrated that sustained anti-
Author Manuscript

VEGF therapy in subjects with DR slows or even reverses retinal non-perfusion

(Campochiaro, Wykoff et al. 2014). However, Falavarjani et al. recently showed that there is
no difference in retinal capillary density or FAZ area in subjects with DR or RVO, before
and after a single intravitreal injection of anti-VEGF agents for macular edema (Ghasemi
Falavarjani, Iafe et al. 2017). It is likely that one month is not a sufficient duration of
treatment to observe any changes in perfusion, and future studies are needed to address this.

A few studies have begun to address the challenge of using both morphology and density
parameters in a systematic way in DR (Kim, Chu et al. 2016) as well as for other retinal
vascular diseases (Kim, Rodger et al. 2016, Koulisis, Kim et al. 2016). Kim et al. performed
a retrospective, cross-sectional study of 84 eyes with DR and 14 healthy eyes (Kim, Chu et
al. 2016). This study demonstrated that several capillary density and morphology parameters
Author Manuscript

correlate with the severity of DR in a single cohort. Capillary density was assessed as a
simple percentage of the area covered by vessels in both binarized OCTA images (Vessel
Density) as well as skeletonized images (Skeleton Density). This is important in that the
simple vessel density measure can overestimate the diameter of retinal capillaries, and
therefore overestimate capillary density. Skeleton density measures the “length” of vessels in
the OCTA images and removes the potential confounding influence of vessel diameter from
the density metric. Therefore, skeleton density may be a more sensitive measure of impaired
capillary perfusion; though, this has yet to be determined.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 36

The Kim et al. study shows that both vessel density and skeleton density demonstrate a
Author Manuscript

negative and significant correlation with clinical severity of DR (Kim, Chu et al. 2016).
Interestingly, skeleton density changes were larger in magnitude for each step change in
clinical severity of DR. Kim et al. also looked at two measures of capillary morphology—
fractal dimension and vessel diameter index. Fractal dimension was assessed by a
modification of the box counting method and provides a measure of the capillary branching
complexity. The clinical severity of DR was positively and significantly correlated with
fractal dimension. In this study, the vessel diameter index provides a unit less measure of the
capillary diameter. As expected, clinical severity of DR was inversely proportional to vessel
diameter. In almost all cases, the magnitude and significance of the changes was greatest in
the SRL. This is likely because the DRL measurements are confounded by projection
artifacts, which are very hard to compensate for with current methods. In addition, it is
interesting and encouraging that in all parameters, except for vessel diameter index, there
Author Manuscript

was a significant difference between normal controls and mild NPDR. Therefore, this is the
first study to show that early changes in DR can be detected by OCTA metrics. However, the
most reliable and reproducible metrics have yet to be identified and it may be worthwhile to
revisit these metrics when more sophisticated methods of projection artifact removal are
available (Zhang, Hwang et al. 2016) (Liu, Gao et al. 2015, Zhang, Zhang et al. 2015).
These same metrics have been applied to subjects with RVO (Koulisis, Kim et al. 2016) as
well as subjects with quiescent, but chronic uveitis (discussed below; (Kim, Rodger et al.
2016)). As described below, the same trends seem to hold in those studies suggesting that a
comprehensive analysis of OCTA-based metrics for density and morphology may play a
broader role in the assessment of retinal vascular changes.

8.2 Retinal Venous Occlusion (RVO)

Author Manuscript

Capillary level changes have long been demonstrated in subjects with RVO. Clinical findings
include areas of impaired perfusion, vascular dilation, tortuosity and shunting, cotton-wool
spots, and retinal hemorrhages, among others (Ryan, Schachat et al. 2013). Kashani et al.
showed that all of the clinically relevant macular findings of RVO can be identified on
OCTA images in a pilot study of 25 subjects with varying severity of RVO and controls
(Kashani, Lee et al. 2015). This study also suggested that the findings in the DRL were more
profound than those in the SRL in RVO subjects. Several other studies have also confirmed
those findings (Rispoli, Savastano et al. 2015, Adhi, Filho et al. 2016) and are reviewed
below. Interestingly, Kashani et al. also demonstrated that some regions of intraretinal fluid
could be visualized on OCTA in analogy to what Matsunaga et al. showed for intraretinal
fluid in DR (Kashani, Lee et al. 2015). Therefore, there is sufficient evidence to suggest that
OCTA of the macula is equally effective for management of the macular complications of
Author Manuscript

RVO as FA. Many studies in the past have explored the quantification of retinal vascular
changes in RVO similar to those described above for DR. A growing area of current interest
is to validate OCTA measurements with these and to expand on them.

Before the era of OCTA, FA and histology were used in several studies to quantify changes
in the retinal vasculature in RVO subjects. Remky et al. demonstrated significant changes in
the mean perifoveal intercapillary area (a proxy for focal capillary density), size of the FAZ,
and capillary blood flow in subjects with central RVO (CRVO) compared to controls on FA

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 37

(Remky, Wolf et al. 1997). FAZ size increased from 0.218±0.074-mm2 to 0.317±0.166-mm2
Author Manuscript

in controls and subjects with CRVO, respectively. Mean capillary blood flow using digital
high-speed FA decreased from 2.886±0.406-mm/sec in controls to 1.626±0.219-mm/sec in
CRVO subjects (Remky, Wolf et al. 1997). Lastly, mean perifoveal intercapillary area
increased from 3872±529-μm2 to 5548±1151-μm2 in control and CRVO subjects,
respectively. Notably, only mean capillary blood flow had any significant correlation with
visual acuity. In another study, subjects with branch RVO (BRVO) had similar changes in
FAZ size using FA, but there was a significant correlation with visual acuity and FAZ size
(Parodi, Visintin et al. 1995). Similarly, BRVO subjects had significant changes in blood
velocity and blood flow using laser Doppler flowmetry (Avila, Bartsch et al. 1998); however,
there is some debate regarding the accuracy of this method (Squirrell, Watts et al. 2001).
Despite these findings, clinical adoption of FA for assessment of FAZ size and blood flow
have not been adopted due to the invasive nature of FA and relatively labor-intensive image
Author Manuscript

analysis that is required to generate the blood flow data.

Due to the non-invasive nature of OCTA, several studies have taken advantage of OCTA to
assess FAZ size and shape in subjects with RVOs. These studies have confirmed the above
findings and provided novel information about the layer specific nature of impaired
perfusion in RVO subjects. For example, several studies of RVO show a decrease in both
superficial and deep capillary plexus density, FAZ enlargement, and microvascular
abnormalities (Rispoli, Savastano et al. 2015, Coscas, Glacet-Bernard et al. 2016). One such
OCTA study of 54 subjects with RVO (29 CRVO and 25 BRVO) attempted to characterize
qualitative OCTA features, such as disruption of the perifoveolar capillary arcade, capillary
abnormalities, central cysts, non-perfusion “greyish” areas, and deep capillary plexus
(Coscas, Glacet-Bernard et al. 2016). The study included subjects with macular edema. This
study showed disruption of perifoveal capillary arcade in 92% of eyes on OCTA and 72% on
Author Manuscript

FA. Perifoveal capillary arcade changes in the superficial capillary layer and network
disruption in the deep capillary layer were significantly correlated with peripheral retinal
ischemia, as defined by a region of 10-disc diameters or more on FA. However, peripheral
ischemia by FA was only noted in 63% of eyes with perifoveal capillary disruption on
OCTA. Intraretinal cystoid spaces were noted in 68% of eyes on FA, 75% on OCT, and 90%
on OCTA. Nonperfusion “greyish” areas were significantly more frequent in the deep
capillary plexus than in the superficial capillary plexus. Intra- and interobserver agreement
for OCTA parameters was between 0.61 and 0.82. The authors conclude that OCTA can
assess both perfusion and macular edema. There was no correlation between OCTA
parameters and BCVA on ETDRS charts. FAZ was not specifically measured (Coscas,
Glacet-Bernard et al. 2016).
Author Manuscript

In the above studies, it is unclear how segmentation variability due to macular edema and
retinal atrophy were addressed, but the results confirm the importance of density and
morphology assessments in this disease. Another prospective OCTA study of 24 subjects
with CRVO and without macular edema was performed to measure FAZ and correlation
with ETDRS best corrected visual acuity. In this study, all subjects were treated with anti-
VEGF agents to resolve edema before OCTA. Therefore, the confounding effect of macular
edema on segmentation should be minimal. Mean superficial FAZ area was 0.76-mm2 and
mean deep FAZ area was 1.12-mm2. A multivariable regression analysis showed a

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 38

significant negative correlation between the BCVA and the superficial FAZ area, but not the
Author Manuscript

deep FAZ area. Disruption of the ellipsoid zone was significantly correlated with poorer
vision and larger superficial FAZ. Six subjects had enlargement of the DRL beyond the 3×3-
mm2 field, thus precluding accurate measurement. The authors conclude that the DRL in
CRVO is more susceptible to capillary loss (Casselholmde Salles, Kvanta et al. 2016).

As we have mentioned throughout this paper, the field-of-view is one of the main limitations
of current OCTA devices. Most studies use 3×3-mm2 macular fields as a proxy of capillary
changes throughout the retina. However, due to recent improvements in the field-of-view of
commercial devices, some investigators have begun to take advantage of this feature. For
example, one OCTA study of 23 subjects with RVO (15 CRVO and 8 BRVO) and 8 eyes of 8
age-matched controls were assessed for FAZ size and perifoveal capillary network.
Although both 3×3 and 6×6-mm2 images were assessed, only 3×3-mm2 images are
illustrated. Mean FAZ in 3×3-mm2 scans was larger in RVO eyes than both fellow eyes
Author Manuscript

(1.13±0.25-mm2 vs 0.58±0.28-mm2; P<0.007) and control eyes (0.30±0.09mm2; P<0.0001).

Mean FAZ was also larger in fellow eyes of RVO subjects compared to controls
(0.58±0.28mm2 vs 0.30±0.09mm2; P=0.01). Approximately 60% of the group had a history
of anti-VEGF injections, suggesting that macular edema may still be a confounder in the
segmentation of these images. In order to avoid segmentation as a possible confounder, the
authors only performed a qualitative analysis of OCTA images in subjects that did not have
cystoid macular edema. This suggested a decrease in perfusion in the DRL in all RVO eyes
without CME and in 53% of fellow eyes. It is not clear what the corresponding measure is
for superficial layer or for subjects with macular edema. Vascular tortuosity and collaterals
were also subjectively noted in RVO subject eyes. The results of this paper seem to
generalize to both 3×3 and 6×6-mm2 fields, but a specific comparison of the two field sizes
is lacking in the paper (Adhi, Filho et al. 2016).
Author Manuscript

Another OCTA study of 81 eyes from 76 subjects with RVO (49% CRVO, 42% BRVO, 9%
HRVO) compared fundus photos, FA, and OCTA findings for 3×3 and 8×8-mm2 images.
Notably, out of this group, only 21 eyes had gradable 3×3-mm2 and 8×8-mm2 images. This
represents one of the fundamental problems with OCTA imaging, since subjects with poorer
fixation generally are harder to scan. Despite this, OCTA imaging provides the best method
for safely visualizing retinal capillaries because it is non-invasive. In this study, there was
good agreement between OCTA and FA for the area of impaired perfusion (ICC 0.825 for
3×3mm scan and 0.891 for 8×8mm2 scan). This study also demonstrated that 46% of eyes
had areas of impaired perfusion and 32% had retinal neovascularization outside the 8×8-
mm2 scan area. Approximately 18% only had neovascularization outside the 8×8-mm2 scan
area. Therefore, even though the field-of-view is constantly improving, clinicians and
Author Manuscript

investigators should be conscientious of potential findings outside the OCTA field (Cardoso,
Keane et al. 2016).

The findings from the above studies and others suggest that OCTA is useful for diagnosis
and management of retinal vascular complications of RVO in the macula. Similar to the
discussion above for DR, a systematic and quantitative description of the changes in
capillary density and morphology in RVO has been lacking and would be very helpful in
research studies, and even clinical management, if it were shown to be reliable and

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 39

reproducible. In an OCTA study of RVO subjects, Koulisis et al. has taken a step in this
Author Manuscript

direction using several quantitative OCTA metrics. Koulisis et al. show that a combination of
OCTA metrics describing retinal capillary density and morphology correlates well with the
clinical severity of RVO (Koulisis, Kim et al. 2016). In that study of 58 eyes with RVO and
26 control eyes, both non-segmented (full thickness) retinal capillary measurements and
segmented (superficial and deep capillary layer) capillary measurements showed
significantly lower fractal dimension and skeletal density compared to controls. Fractal
dimensions, vessel densities, and skeletal densities were also significantly lower in the RVO
eyes than in the contralateral eyes of RVO subjects. Most interesting, all of these parameters
progressively decreased as the clinical severity of RVO increased (BRVO versus CRVO).
Similar to Kim et al.’s study of OCTA-based metrics in DR discussed above, the findings in
Koulisis et al. suggest that OCTA-based metrics of morphology and density can be useful in
quantifying RVO severity. At this point, since RVO severity is essentially a binary
Author Manuscript

classification (BRVO vs CRVO), an objective and quantitative classification system would

be very useful in clinical trials and clinical management. For example, recent studies have
shown that anti-VEGF treatment in RVO subjects can stabilize or even reverse nonperfusion
on FA (Sophie, Hafiz et al. 2013). However, Falavarjani et al. recently showed that there is
no difference in retinal capillary density or FAZ area in subjects with RVO after a single
intravitreal injection of anti-VEGF agents for macular edema (Ghasemi Falavarjani, Iafe et
al. 2017). Just as in DR, it is likely that long-term studies are necessary to show any
significant changes. In addition, the segmentation and layer classifications will need to be
standardized and revisited in these studies to ensure that the best metrics are being used to
detect what are likely to be subtle changes.

8.3 Retinal Arterial Occlusion (RAO)

Author Manuscript

Similar to RVO, OCTA may have an important role to play in the diagnosis and management
of RAO. There are very few studies that have applied OCTA imaging to RAO perhaps
because of the low incidence and prevalence of this retinal vascular disease compared to
others. However, at least one study has demonstrated that OCTA can demonstrate the
impaired perfusion in RAO effectively and may even demonstrate remodeling of the
capillary layers over time (Bonini Filho, Adhi et al. 2015). We have one example of a subject
with a chronic branch RAO who presented with minimal symptoms and excellent vision.
The clinical examination of this subject was almost unremarkable, except for a slightly
atrophic appearance of some regions of the superior macula and retina. The subject refused
FA, but OCTA clearly shows the extent of capillary and neurosensory loss in the superior
macula (Figure 8).

8.4 Glaucomatous Optic Neuropathy

Author Manuscript

OCTA studies of glaucoma have demonstrated reduced perfusion in the optic nerve head,
peripapillary retina, and even macula, and support the promise of OCTA as an additional
modality to aid clinicians in the early detection and monitoring of glaucoma. Figure 9
illustrates a prominent defect in the peripapillary capillary plexus of a subject with glaucoma
compared to a normal subject. While the association between reduced perfusion and
glaucomatous damage has been established in recent OCTA studies, we still do not know
whether reduced perfusion merely results from loss of retinal ganglion cells and their axons

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 40

or whether microcirculation changes can predict and help contribute to subsequent retinal
Author Manuscript

ganglion cell loss. Current cross-sectional studies lay the framework for OCTA’s future
potential to elucidate the vascular component of the pathophysiology underlying certain
types of glaucoma.

An et al. and Jia et al. were the first to describe OCTA imaging of the human optic disc
microvasculature in 2012 (An, Johnstone et al. 2012, Jia, Morrison et al. 2012). An et al.
used the optical microangiography technique of OCTA to demonstrate the high-resolution
relationship of optic disc microvasculature with its laminar structure (An, Johnstone et al.
2012). Jia et al. used the SSADA algorithm with SS-OCTA and demonstrated, in a small
pilot study, the reduced optic nerve head perfusion in early preperimetric glaucoma eyes as
compared to normal eyes (Jia, Morrison et al. 2012).

Several studies have since used OCTA to quantify perfusion differences of the full thickness
Author Manuscript

optic nerve head between glaucoma and normal eyes. Jia et al. introduced a new disc flow
index (which is defined as the average decorrelation value within the disc) and demonstrated
that their glaucoma patients experienced a 25% reduction in disc flow index compared to
normals. The disc flow index correlated significantly with visual field pattern standard
deviation, but did not show significant correlation to average retinal nerve fiber layer
(RNFL) thickness nor average rim area (Jia, Wei et al. 2014). In a larger study, Wang et al.
evaluated both disc flow index and vessel densities of the entire optic disc in open angle
glaucoma patients and demonstrated a diagnostic accuracy of 0.82 for disc flow index and
0.80 for vessel density. They also reported a correlation between these perfusion parameters
and glaucoma stage severity, RNFL thickness, ganglion cell complex thickness, and visual
field mean deviation among open angle glaucoma patients (Wang, Jiang et al. 2015).
Leveque et al. evaluated vessel density of the entire optic nerve head as well as the temporal
Author Manuscript

disc (in order to avoid contributions from large vessels) and reported a significant reduction
in both parameters in glaucoma patients as compared to normal. Additionally, they
demonstrated significant correlations between temporal and total optic nerve head vessel
density with RNFL, ganglion cell complex, visual field mean deviation, and visual field
index (Leveque, Zeboulon et al. 2016).

Rather than using the full thickness optic nerve head slab, Chen et al. isolated the pre-
laminar layer to report perfusion differences between glaucoma and normal eyes, with good
repeatability and reproducibility (Chen C 2016, Chen C 2016). In addition, Chen et al.
introduced two new indices, termed flux and normalized flux, and demonstrated good
repeatability and reproducibility. Flux was defined as the mean flow signal intensity over the
entire optic nerve head (ONH) area. Normalized flux, with the intent of avoiding bias from
Author Manuscript

reduced vessel area in glaucomatous eyes, was the flux normalized by the vessel area. In this
study, they reported a significant reduction of flux, vessel area density, and normalized flux
in glaucoma eyes. In addition, they reported a significant correlation to be present between
these parameters and visual field mean deviation, pattern standard deviation, RNFL, and rim
area (Chen C 2016). Bojikian et al. also compared ONH perfusion between normal tension
glaucoma eyes and primary open angle glaucoma eyes (with higher baseline intraocular
pressures). While they reported reduced flux, vessel area density, and normalized flux in
glaucomatous eyes compared to normals, they did not identify a difference between normal

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 41

tension glaucoma and primary open angle glaucoma eyes. Additional longitudinal studies on
Author Manuscript

these comparisons will be useful in the future to validate these findings (Bojikian, Chen et
al. 2016).

Much of the subsequent work on OCTA in glaucoma has been focused on the peripapillary
microcirculation, which has the benefit of fewer artifacts from large blood vessels and from
disc anatomy variation, such as tilted discs, making it more difficult to segment particular
layers. By using full-thickness retinal angiograms, Liu et al. were the first to demonstrate
significantly reduced peripapillary flow index and peripapillary vessel density in
glaucomatous eyes compared to normal eyes, with strong diagnostic accuracy (0.892 and
0.938, respectively), repeatability, and reproducibility. There was also a strong correlation
with visual field pattern standard deviation and glaucoma stage, but not with average RNFL
thickness (Liu, Jia et al. 2015). Yarmahammadi et al. measured whole image vessel density
and circumpapillary vessel density of the RNFL layer of open angle glaucoma, glaucoma
Author Manuscript

suspect, and normal eyes and demonstrated strong diagnostic accuracies for differentiating
glaucoma and healthy eyes (0.94 for whole image vessel density and 0.83 for
circumpapillary vessel density compared to 0.92 for RNFL thickness) (Yarmohammadi,
Zangwill et al. 2016). Scripsema et al. evaluated peripapillary capillary density (excluding
large vessels) of the RNFL layer from patients with primary open angle glaucoma and
normal tension glaucoma, demonstrating significantly reduced capillary density in these
patients as compared to normal (Scripsema, Garcia et al. 2016). They found a mildly
reduced capillary density in patients with normal tension glaucoma as compared to patients
with primary open angle glaucoma (despite similar age and disease stage between the
groups). However, it is difficult to infer differences in pathophysiology on normal tension
glaucoma versus primary open angle glaucoma from this small study. With a relatively large
cohort of 112 glaucoma eyes and 74 normal eyes, Kumar et al. demonstrated a reduced
Author Manuscript

vessel density of the radial peripapillary capillaries with better diagnostic accuracy of
composite vascular parameters, in order to discriminate preperimetric glaucoma from
normal eyes as compared to structural parameters (Kumar, Anegondi et al. 2016). Rao et al.
also demonstrated strong diagnostic ability of the peripapillary vessel density, particularly
the inferotemporal sector, in both primary open angle glaucoma and primary angle closure
glaucoma, with similar diagnostic accuracy as RNFL thickness (Rao, Kadambi et al. 2016).
Suh et al. demonstrated that primary open angle glaucoma eyes with focal lamina cribrosa
defects had reduced vessel density both globally and sectorally as compared to eyes with
similar glaucoma severities that did not have focal lamina cribrosa defects (Suh, Zangwill et
al. 2016). From these findings, they suggested that focal lamina cribrosa defects and
impaired ocular hemodynamics are etiologically related, as suggested in prior research
(Burgoyne 2011).
Author Manuscript

Chen et al. demonstrated a significantly reduced peripapillary flux index and vessel area
density, both globally and in particular quadrants of glaucomatous eyes. They also reported a
strong correlation between these perfusion metrics and structural and functional measures of
glaucoma (RNFL thickness and visual field mean deviation) (Chen, Zhang et al. 2016).
Additionally, Mammo et al. utilized a speckle variance-based SS-OCTA, to demonstrate
significant reduction in radial peripapillary capillary density (using a manual tracing
technique) in unilateral glaucoma eyes compared to fellow eyes, glaucoma suspect eyes, and

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 42

normal eyes. They, too, demonstrated a strong correlation with RNFL thickness and visual
Author Manuscript

field index (Mammo, Heisler et al. 2016).

Akagi et al. looked specifically at primary open angle glaucoma eyes with hemifield visual
field defects and reported peripapillary vessel densities of the inner retina as well as the full
thickness of ONH vessel density. They reported reduced vessel densities and reduced RNFL
thickness of peripapillary and ONH regions corresponding to the visual field defects.
Interestingly, they found reduced RNFL thickness in the regions not corresponding to visual
field defects, but did not see a reduction in the vessel density in these locations (Akagi, Iida
et al. 2016). From this preliminary finding, they suggested that peripapillary microvascular
reduction may occur after RNFL thinning and that vessel density may be more closely
correlated with visual function than RNFL thickness. Corroborating the latter conclusion,
Yarmohammadi et al. recently reported that visual field mean deviation had a stronger
correlation with circumpapillary vessel density and whole image vessel density than with
Author Manuscript

either RNFL thickness or rim area, also suggesting that vascular perfusion may be more
closely correlated with visual function than RNFL thickness (Yarmohammadi, Zangwill et
al. 2016). They hypothesized that sick retinal ganglion cells and their axons may have
reduced perfusion before apoptosis actually occurs, thus having stronger correlation with
visual field measures. If these findings are confirmed in larger studies, clinicians and
researchers alike may be using OCTA to detect sick, poorly functioning retinal ganglion
cells that may benefit from either aggressive IOP-lowering treatments or neuroprotective
treatments. While pronounced IOP-lowering surgery has already been shown to reverse
visual field damage, presumably salvaging sick retinal ganglion cells before apoptosis
(Pederson and Herschler 1982, Tsai, Shin et al. 1991, Gandolfi 1995, Wittstrom, Schatz et
al. 2010, Caprioli, de Leon et al. 2016, Waisbourd, Ahmed et al. 2016), OCTA may provide
the tool needed to identify patients with salvageable retinal ganglion cells.
Author Manuscript

Rao et al. has published the first report looking at macular perfusion (of the inner retinal
layer from inner limiting membrane to inner plexiform layer; globally and sectorally) in
glaucomatous eyes and compared its diagnostic accuracy to that of ONH and peripapillary
regions. They showed that peripapillary vessel density actually had greater diagnostic
accuracy than ONH and macular regions. The finding that diagnostic accuracy of macular
perfusion was inferior may be due to the fact that retinal ganglion cell axons, not their cell
bodies, which make up the ganglion cell layer in the macula, are involved in glaucoma
pathogenesis (Burgoyne 2011). Alternatively, it may be related to their methodology of
using a 3mm×3mm scan, which may not be sufficient to see the area affected by glaucoma.
ONH perfusion was likely inferior to peripapillary perfusion due to the fact that measuring
perfusion of the ONH is complicated by large variations in disc anatomy and prominence
Author Manuscript

and variations of large vessels within the disc. More recently, Takusagawa et al. also
evaluated macular perfusion in glaucoma using 6mm×6mm scans and noted significantly
reduced perfusion in the superficial vascular plexus of glaucoma compared to normal eyes,
with much higher diagnostic accuracy than that reported by Rao et al. In addition to the large
scan area, this study utilized projection resolution algorithms to reduce flow projection
artifact in generation of en face images and utilized quantification algorithms with
reflectance compensation to reduce artifact from media opacities. Such improvements to
software algorithms will continue to increase the clinical utility of OCTA in glaucoma.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 43

Finally, Suh et al. has published the first report looking at a cohort of glaucomatous eyes that
Author Manuscript

had DRL dropout, providing insight into potential vascular etiological factors (Suh, Zangwill
et al. 2016). They found that focal lamina cribrosa defects, more advanced glaucoma,
reduced RNFL vessel density, thinner choroidal thickness, and lower diastolic blood
pressure were all associated with peripapillary DRL dropout. These findings suggest
possible disruption of the microvasculature within the laminar tissue, and the association of
thinner choroid and lower diastolic blood pressure may suggest etiologic factors for reduced
perfusion and subsequent glaucomatous damage. Longitudinal studies will need to validate
these findings.

The current body of literature already demonstrates the precision to which OCTA can
identify microvascular changes in glaucomatous eyes. OCTA may someday augment
structural OCT measures, such as RNFL thickness in early glaucoma detection. Future
studies will verify whether OCTA can truly detect reversible glaucomatous changes (e.g.
Author Manuscript

reduced perfusion from sick retinal ganglion cells) that will allow clinicians to intervene and
prevent vision loss. Additionally, OCTA, more so than its precursor technologies, has the
potential to clarify the degree to which microvascular changes contribute to subsequent
glaucomatous damage. Prior to such longitudinal studies, it will be important for us to first
understand the ocular, systemic, and physiologic factors (Alnawaiseh, Lahme et al. 2016,
Yang, Wang et al. 2016) that also affect microvascular perfusion, so that we can accurately
identify cause-and-effect relationships in the future. Never before has the elucidation of
vascular mechanisms in glaucoma been so palpable.

8.5 Non-Glaucomatous Optic Neuropathy

A few studies have begun to explore optic nerve head and peripapillary microcirculation
findings in non-glaucomatous optic neuropathies. Wang et al. described the optic nerve head
Author Manuscript

and parafoveal perfusion findings in patients with multiple sclerosis, an inflammatory

autoimmune disease of the central nervous system characterized by widespread endothelial
dysfunction which often manifests with optic neuritis. They demonstrated that multiple
sclerosis patients with a history of optic neuritis had a reduced disc flow index compared to
patients with multiple sclerosis that did not have an optic neuritis history as well as normal
controls (Wang, Jia et al. 2014). Hata et al. described reduced optic nerve head and
peripapillary microcirculation in a cohort of 15 chronic non-arteritic ischemic optic
neuropathy eyes compared to normal controls OCTA. Interestingly, while the peripapillary
RNFL and visual field defect correlated with peripapillary vessel density, they did not
correlate with optic nerve head vessel density. They hypothesized that this may be due to the
fact that in acute non-arteritic ischemic optic neuropathy, disc swelling may cause additional
damage to neighboring capillaries within the optic nerve head, leading to more diffusely
Author Manuscript

reduced vessel density within the optic nerve head (Hata, Oishi et al. 2016). Falavarjani et al.
also recently described the findings of 21 eyes with disc edema, pseudoedema, or atrophy as
compared to healthy normal eyes using SS-OCTA. They observed reduced peripapillary
microvasculature in the regions of RNFL loss. In Lebers hereditary optic neuropathy patients
with pseudo-disc edema, they were able to visualize telangectactic vessels characteristic of
the disease (Ghasemi Falavarjani, Tian et al. 2016). These findings have also been observed
by others (De Rojas, Rasool et al. 2016, Takayama, Ito et al. 2016). As with glaucoma,

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 44

OCTA has great potential to explore many unanswered questions about the specific vascular
Author Manuscript

mechanisms underlying several optic nerve disorders.

8.6 Age-Related Macular Degeneration (AMD)

AMD can be classified as early, intermediate, or late depending on the presence of drusen,
pigmentary changes, geographic atrophy, and CNV (Ferris, Wilkinson et al. 2013). While
structural OCT can be used for the routine diagnosis and monitoring of these AMD stages in
patients (Rosenfeld 2016), OCTA greatly facilitates the diagnosis and management of
macular neovascularization by directly and non-invasively visualizing the neovascularization
within the macula, even in the absence of exudation (Figure 10). OCTA can monitor changes
in the size and configuration of the neovascular complex before exudation begins and before
treatment is initiated. In addition, OCTA is useful for following changes in the neovascular
complex while treatment is underway with inhibitors of vascular endothelial growth factor.
Author Manuscript

8.6.1 Neovascular or Wet Age-Related Macular Degeneration (NVAMD)—

Traditionally, three types of neovascularization in AMD have been described based on the
location of abnormal vessels in subjects with AMD. Dye-based angiography has been used
to infer the type of neovascularization in the clinical setting but is not always definitive
(Freund, Zweifel et al. 2010). The location of CNV can also be frequently identified based
on structural OCT but the presence of subretinal hypereflective material can make it difficult
to determine the nature of structural OCT changes. With different OCTA segmentation
strategies, it is now possible to visualize neovascularization directly as shown in Figure 10:
neovascularization under the RPE (Type 1) (Moult, Choi et al. 2014, Kuehlewein, Bansal et
al. 2015), under retina and above the RPE (Type 2) (El Ameen, Cohen et al. 2015), and
within the retina (type 3) (Phasukkijwatana, Tan et al. 2016, Tan, Dansingani et al. 2016).
Both Type 1 and Type 2 neovascularization are derived from the choroidal circulation and
Author Manuscript

are referred to as CNV. However, type 3 neovascularization arises directly from the retinal
circulation and is initially found within the retina. Type 3 neovascularization is also referred
to as retinal angiomatous proliferation. Studies have compared the detection of CNV using
OCTA and traditional dye-based angiographic imaging, and SD-OCTA appeared to be
inferior to FA for the detection the CNV (Costanzo, Miere et al. 2016, Gong, Yu et al. 2016,
Inoue, Jung et al. 2016); however, OCTA did prove useful in many of the cases. For the best
visualization of CNV under the RPE, a longer wavelength of light is probably necessary,
which should result in better penetration through the RPE, less sensitivity roll-off, and a
better signal to noise ratio. Compared with SD-OCTA, which uses a center wavelength of
840-nm, SS-OCTA uses a longer wavelength of ~1050-nm. Three groups have reported that
SS-OCTA imaging was better than SD-OCTA for identifying more of the CNV based on
boundary identification and detection of discrete lesion characteristics (Novais, Adhi et al.
Author Manuscript

2016, Told, Ginner et al. 2016). However, a limitation of these studies was the use of
different segmentation strategies to visualize the full extent of the neovascular lesions in the
two imaging techniques. A recent study done by Miller et al avoided this limitation by using
the same segmentation strategy for both imaging techniques. The boundaries of their en face
segmentation slab extended from the outer retina to the choriocapillaris (ORCC slab). In
addition, a proprietary projection artifact removal algorithm (Zhang, Zhang et al. 2015) was
applied to all scans. The results showed that the areas of the neovascularization were

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 45

measured to be larger with SS-OCTA than with SD-OCTA, and this difference was greater
for the 6×6mm2 scans (Miller, Roisman et al. 2017). SS-OCTA can also be used to reliably
Author Manuscript

identify subclinical Type 1 CNV in asymptomatic eyes with the clinical diagnosis of “dry
AMD”, also known as non-exudative intermediate AMD (Roisman, Zhang et al. 2016). In
addition, OCTA has been a useful tool for identifying the presence or absence of choroidal
neovascularization in some masquerade conditions, such as adult-onset foveomacular
vitelliform dystrophy (Querques, Zambrowski et al. 2016) and central serous
chorioretinopathy (Bonini Filho, de Carlo et al. 2015). For NVAMD, OCT has served as a
way to indirectly assess the levels of vascular endothelial growth factor (VEGF) by detecting
the absence or presence of exudation or macular fluid. The absence or presence of exudation
and whether the volume of a retinal pigment epithelial detachment was changing have
proven to be useful OCT indicators for whether therapy with anti-VEGF agents are needed
(Rosenfeld 2016) (Penha, Rosenfeld et al. 2012, de Amorim Garcia Filho, Penha et al. 2013,
Author Manuscript

Thorell, Nunes et al. 2014). Rather than rely on these indirect measures of neovascular
activity, OCTA is able to directly visualize the neovascularization and determine whether
there are changes in the neovascular lesion that precede the onset or recurrence of exudation,
which might allow for more precise management of NVAMD using anti-VEGF (Muakkassa,
Chin et al. 2015, Dolz-Marco, Phasukkijwatana et al. 2016). If changes observed during
OCTA imaging can be used to predict impending exudation, then it might be possible to
avoid any future exudation in eyes with non-exudative dry AMD, which contain subclinical
neovascular complexes, or in eyes with established exudative disease, in which the exudation
is being suppressed with anti-vascular endothelial growth factor therapy using a “treat-and-
observe” or “treat-and-extend” strategy. These changes in the shape and complexity of
neovascular complexes may help guide clinicians when deciding whether to observe or
extend an interval between anti-VEGF injections. Moreover, the ability to acquire both
structure and flow information noninvasively from a single OCT data-set suggests that OCT
Author Manuscript

imaging will replace most, if not all, of the current imaging now performed using dye-based
angiography for the routine management of AMD patients. Now that artifact removal and
CNV quantification algorithms are available, it seems likely that SS-OCTA will become the
superior imaging technique for the diagnosis and management of NVAMD patients (Zhang,
Zhang et al., Jia, Bailey et al. 2014, Liu, Gao et al. 2015, Zhang, Zhang et al. 2015).
However, studies are needed to identify the OCTA parameters that will unambiguously
identify neovascularization in AMD patients.

8.6.2 Non-exudative or Dry Age Related Macular Degeneration—Non-exudative

AMD in the absence of any CNV accounts for most AMD and is one of the leading causes
of vision loss in people over 60 years of age in the developed world (Friedman, O’Colmain
et al. 2004, Velez-Montoya, Oliver et al. 2013). In its early stages, non-exudative AMD is
Author Manuscript

characterized by the presence of drusen and pigment abnormalities, and in its later stage, by
the presence of geographic atrophy, which correlates with the loss of photoreceptors, RPE,
and choriocapillaris (Ferris, Wilkinson et al. 2013, Nunes, Gregori et al. 2013). The
pathological events leading from early-stage dry AMD to late-stage dry AMD remain poorly
understood. However, both histological and OCT-based studies have shown that the earliest
detectable changes that characterize the progression of disease occur at the level of the
photoreceptors, RPE, Bruch’s membrane, and choriocapillaris (McLeod, Grebe et al. 2009,

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 46

Wu, Luu et al. 2014). While the initial triggering event remains unknown and is thought to
Author Manuscript

involve complement activation, it still isn’t known where this initial insult occurs; however,
the choriocapillaris has garnered the most interest. Until recently, the choriocapillaris hasn’t
been able to be visualized in situ. However, with the advent of OCTA, it is now possible to
visualize a vascular layer thought to be the choriocapillaris and to correlate the vascular
changes in this layer with structural changes in the outer retina and RPE. Several studies
have reported visualizing choriocapillaris in situ in both healthy subjects and AMD patients
(Choi, Moult et al. 2015, Moult, Waheed et al. 2016, Nesper, Soetikno et al. 2016, Spaide
2016). Due to the limitations of SD-OCTA and its shorter wavelength, the choriocapillaris
changes detected using SD-OCTA imaging are often difficult to distinguish apart from the
shadowing effect from signal attenuation caused by drusen and the RPE (Nesper, Soetikno et
al. 2016, Spaide 2016). Thus, SS-OCTA systems have proven to be more reliable for
visualizing the choriocapillaris signals. Fujimoto’s group used an ultrahigh-speed, SS-OCTA
Author Manuscript

technique to convincingly visualize alterations in the choriocapillaris vasculature (Choi,

Moult et al. 2015). By using variable interscan time analysis (VISTA), they showed that SS-
OCTA can distinguish varying degrees of choriocapillaris alteration and flow impairment
under and around regions of geographic atrophy. Later, the same group studied the eyes with
nascent geographic atrophy and drusen associated geographic atrophy (Moult, Waheed et al.
2016). They not only found focal choriocapillaris flow impairment associated with both of
these forms of geographic atrophy, they also showed diffused choriocapillaris flow
impairment throughout their field-of-view. By documenting these earliest changes in
choriocapillaris flow before anatomic abnormalities are observed, SS-OCTA imaging should
prove invaluable for studying the onset and progression of AMD and for studying the new
therapies designed to prevent vision loss.

8.7. Uveitis
Author Manuscript

Macular abnormalities such as macular edema and choroidal neovascularization are a

frequent complication of uveitis. For example, the intraocular inflammation in uveitis is
hypothesized to result from the release of inflammatory cytokines that disrupt the inner and
outer blood-retinal-barrier, in addition to other structural changes (Freeman, Matos et al.
2001). While choroidal neovascularization is a focal phenomenon, macular edema occurs
regardless of the primary location of uveitis, probably due to diffusion of inflammatory
mediators. Quantitative and objective analysis of macular involvement in uveitis has largely
been limited to measuring retinal thickness with OCT (Antcliff, Stanford et al. 2000).
Widefield FA has become an essential part of uveitis management, but it is still a qualitative
tool and is largely used for evaluation of the retinal periphery (Hong, Nazari Khanamiri et al.
2013). The macular complications of uveitis present an important disease entity where
Author Manuscript

OCTA can be applied. A few investigators have already begun to explore this potential (de
Carlo, Bonini Filho et al. 2015, Hassan, Agarwal et al. 2016, Kim, Rodger et al. 2016,
Levison, Baynes et al. 2016, Moysidis, Koulisis et al. 2016). Just as in DR and RVO, OCTA
provides excellent resolution of capillary changes in the macula in subjects with vascular
complications of uveitis (Figure 11) and has already been shown to be superior to FA in
some cases (Levison, Baynes et al. 2016).

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 47

OCTA can also potentially play a unique role in defining subclinical microvascular changes
Author Manuscript

that are hypothesized to lead to macular edema. In a recent study, Kim et al. used SD-OCTA
based metrics to quantitatively assess the density and morphology of parafoveal retinal
capillaries in subjects with a history of uveitis (Kim, Rodger et al. 2016). This study
addressed a number of important questions including: are there differences in macular
capillary density or morphology (1) between uveitic eyes and healthy eyes? (2) between
uveitic eyes with macular edema and those without macular edema? And (3) between uveitic
eyes with different anatomic foci of disease activity? This study is also unique in that the
investigators used three different image-processing and retinal segmentation algorithms to
validate the reliability of their findings. The authors showed that there are significant
qualitative and quantitative changes in the parafoveal capillary density and morphology of
subjects with uveitis that can be reliably detected using OCTA. The differences identified
between healthy and uveitic eyes were consistent and significant whether layer boundaries
Author Manuscript

were defined by semi-automated or manual segmentation methods (Kim, Rodger et al.

2016). These findings strongly suggest that quantitative assessment of parafoveal capillary
density and morphology are clinically important and measurable parameters for uveitis.

8.8 Macular Telangiectasia Type 2 (MacTel2)

MacTel2 is a bilateral retinal disease that primarily involves the capillaries of the parafoveal
macula (Gass and Blodi 1993, Charbel Issa, Gillies et al. 2013). Although the exact cause of
MacTel2 is unknown, clinical and pathologic studies demonstrate loss of retinal
transparency, intraretinal crystals, and telangiectatic-like vascular changes that are thought to
originate in the deep retinal capillary plexus during the early nonproliferative stages of the
disease (Green, Quigley et al. 1980). Neovascularization can arise from the retinal vessels
and can extend into the subretinal or sub-RPE space leading to exudation and fibrosis
Author Manuscript

(Charbel Issa, Gillies et al. 2013). This is known as proliferative MacTel2. OCT has been
used to accurately identify structural abnormalities in the inner retina including retinal
cavitation, disruption of the outer retinal banding patterns, but does not clearly demonstrate
anomalous vessels (Charbel Issa, Gillies et al. 2013, Nunes, Goldhardt et al. 2015). Since
there is no known pathology involving the peripheral retina in this disease, OCTA is an ideal
imaging modality to comprehensively characterize and follow the vascular changes that
occur in the macula (Roisman and Rosenfeld 2016).

Several studies have demonstrated the application of OCTA to MacTel2 (Thorell, Zhang et
al. 2014, Spaide, Klancnik et al. 2015, Zhang, Wang et al. 2015, Toto, Di Antonio et al.
2016). In 2014, a study using SS-OCTA of 41 eyes of 22 subjects with non-proliferative and
proliferative stages of MacTel2 demonstrated that OCTA is an ideal modality for
qualitatively demonstrating the retinal vascular changes in all stages of this disease (Thorell,
Author Manuscript

Zhang et al. 2014). The investigators concluded that there was obvious agreement between
OCTA and FA and that the microvascular changes were better visualized with OCTA in all
stages of the disease. While FA demonstrates modest abnormal hyperfluorescence and
leakage from the juxtafoveal capillaries in the early stages of MacTel2, later stages of the
disease can be characterized by non-specific diffuse hyperfluorescence making it difficult to
identify neovascularization on FA. The authors showed that the abnormal vasculature first
appears in the deep parafoveal temporal capillary plexus and extends to the superficial

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 48

capillary plexus. It then extends around the fovea while also extending to outer retina, which
Author Manuscript

is usually avascular. On the other hand, the absence of diffuse staining or leakage on OCTA
allows accurate visualization of the abnormal microvasculature and the neovascularization
that arises. Figure 12 illustrates the typical findings from eyes with MacTel2 showing
different stages based on spectral domain OCTA imaging (Figure 12A, early non-
proliferative MacTel2; Figure 12B, intermediate non-proliferative MacTel2; Figure 12C and
12D, proliferative MacTel2).

In 2016, a study used three-dimensional volume rendered OCTA to demonstrate the

relationship of vascular and neurosensory tissue changes in 24 eyes of 16 subjects with
MacTel2 (Spaide, Klancnik et al. 2015). Because OCTA images are derived from OCT, the
scaling and spatial relationship between vessels and neurosensory tissue are preserved
between the two imaging modalities. This study was able to demonstrate that areas of
cavitation were topographically associated with posteriorly displaced vessels. In addition,
Author Manuscript

the vascular changes were attributed to contraction of retinal tissue, rather than just tissue
loss. Unfortunately, no longitudinal studies with volume-rendered OCTA exist so the exact
evolution of these changes could not be validated. Collectively, the current studies reviewed
above suggest that MacTel2 is a disease in which OCTA can be used for all aspects of
management with equal or greater efficacy to FA.

The proliferative form of MacTel2 involves the development of neovascularization that

primarily arises from the abnormal parafoveal microvasculature and extends under the
retinal circulation as shown by Zhang et al. (Zhang, Wang et al. 2015). In this study, they
were able to unambiguously demonstrate that this presumed subretinal neovascularization
communicated with the choroidal circulation. This was confirmed on ICG angiography and
seen on SS-OCTA. While a choroidal contribution may not be present in all MacTel2 eyes
Author Manuscript

with subretinal neovascularization, it seems to be present in those eyes with exudation

associated with an increase in macular thickness, which can be effectively treated with anti-
VEGF therapy. After treatment, the contribution from the choroidal circulation to this
neovascular complex is even more evident.

10. Conclusions and Future Directions

OCTA has yet to achieve broadly accepted and definitive clinical indications but it is clearly
on the path to becoming a revolutionary tool in the diagnosis and management of retinal
vascular diseases. While commercial OCTA devices have only been available for a few
years, the clinical and research impact of these systems is growing rapidly. Clinical adoption
of the commercial systems has been rapid, despite several logistical hurdles, including the
lack of reimbursement and questions regarding the role of OCTA, FA, and ICG.
Author Manuscript

Nevertheless, it is clear that OCTA is at least as good as invasive dye studies for the macular
complications of retinal diseases, such as DR and RVO. The main limitation of OCTA in
clinical applications for these diseases is the field-of-view, but that will likely change as
commercial systems adopt larger scan patterns. The recent announcement of the FDA
approval of the SS-OCTA PLEX® Elite 9000 system (Carl Zeiss Meditec), which has up to a
12-mm2 field-of-view and is designed for research applications to better understand the
clinical potential of OCTA, is a clear example of this. Another limitation of SD-OCTA

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 49

systems is the difficulty with detecting CNV in diseases such as AMD. SS-OCTA systems
(e.g. PLEX® Elite 9000) with longer wavelengths of coherent light will likely overcome
Author Manuscript

these limitations although these systems are still very early in their clinical evolution. For the
spectrum of retinal vascular disease that have been managed with invasive dye studies, it is
very likely that OCTA will gradually become the dominant modality for both diagnosis and
management. For diseases such as glaucoma, OCTA provides a novel tool to assess the
peripapillary capillary plexus which was not previously visualized on any commercial
imaging modality. Lastly, for all of these clinical applications, there will be an ongoing
struggle to understand 3D vascular and anatomic structures in 2D, until we develop
computational methods that can provide fast, reliable, and meaningful 3D representations
and quantifications of the data. Given the speed with which clinical interest is evolving
around OCTA, it will not be long before all of these limitations will be overcome. It is our
opinion that OCTA stands to change the practice of ophthalmology in the next 10 years as
Author Manuscript

profoundly as OCT has changed it in the past 10 years.

Acknowledgments
The authors would like to thank Arpine Galstyan for editorial and technical help with putting the manuscript as well
as Anoush Shahidzadeh for help with the figures.

References
Early Treatment Diabetic Retinopathy Study Research Group. Classification of diabetic retinopathy
from fluorescein angiograms. ETDRS report number 11. Ophthalmology. 98(5 Suppl):807–822.
[PubMed: 2062514]
Adhi M, Filho MA, Louzada RN, Kuehlewein L, de Carlo TE, Baumal CR, Witkin AJ, Sadda SR,
Sarraf D, Reichel E, Duker JS, Waheed NK. Retinal Capillary Network and Foveal Avascular Zone
in Eyes with Vein Occlusion and Fellow Eyes Analyzed With Optical Coherence Tomography
Author Manuscript

Angiography. Invest Ophthalmol Vis Sci. 2016; 57(9):OCT486–494. [PubMed: 27442342]

Adhi M, Filho MAB, Louzada RN, Kuehlewein L, de Carlo TE, Baumal CR, Witkin AJ, Sadda SR,
Sarraf D, Reichel E, Duker JS, Waheed NK. Retinal Capillary Network and Foveal Avascular Zone
in Eyes with Vein Occlusion and Fellow Eyes Analyzed With Optical Coherence Tomography
Angiography. Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT486–489. [PubMed:
27442342]
Agemy SA, Scripsema NK, Shah CM, Chui T, Garcia PM, Lee JG, Gentile RC, Hsiao Y-S, Zhou Q,
Ko T, Rosen RB. RETINAL VASCULAR PERFUSION DENSITY MAPPING USING OPTICAL
COHERENCE TOMOGRAPHY ANGIOGRAPHY IN NORMALS AND DIABETIC
RETINOPATHY PATIENTS. Retina (Philadelphia, Pa). 0002; 35(11):1–11.
Agemy SA, Scripsema NK, Shah CM, Chui T, Garcia PM, Lee JG, Gentile RC, Hsiao YS, Zhou Q, Ko
T, Rosen RB. Retinal Vascular Perfusion Density Mapping Using Optical Coherence Tomography
Angiography in Normals and Diabetic Retinopathy Patients. Retina. 2015; 35(11):2353–2363.
[PubMed: 26465617]
Akagi T, Iida Y, Nakanishi H, Terada N, Morooka S, Yamada H, Hasegawa T, Yokota S, Yoshikawa M,
Author Manuscript

Yoshimura N. Microvascular Density in Glaucomatous Eyes With Hemifield Visual Field Defects:
An Optical Coherence Tomography Angiography Study. Am J Ophthalmol. 2016; 168:237–249.
[PubMed: 27296492]
Al-Sheikh M, Akil H, Pfau M, Sadda SR. Swept-Source OCT Angiography Imaging of the Foveal
Avascular Zone and Macular Capillary Network Density in Diabetic Retinopathy. Investigative
Ophthalmology & Visual Science. 2016; 57(8):3907–3907. [PubMed: 27472076]
Alnawaiseh M, Lahme L, Treder M, Rosentreter A, Eter N. Short-Term Effects of Exercise on Optic
Nerve and Macular Perfusion Measured by Optical Coherence Tomography Angiography. Retina.
2016

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 50

Alterman M, Henkind P. Radial peripapillary capillaries of the retina. II. Possible role in Bjerrum
scotoma. Br J Ophthalmol. 1968; 52(1):26–31. [PubMed: 5635900]
Author Manuscript

An L, Johnstone M, Wang RK. Optical microangiography provides correlation between microstructure

and microvasculature of optic nerve head in human subjects. J Biomed Opt. 2012; 17(11):116018.
[PubMed: 23128971]
An L, Qin J, Wang RK. Ultrahigh sensitive optical microangiography for in vivo imaging of
microcirculations within human skin tissue beds. Opt Express. 2010; 18(8):8220–8228. [PubMed:
20588668]
An L, Shen TT, Wang RK. Using ultrahigh sensitive optical microangiography to achieve
comprehensive depth resolved microvasculature mapping for human retina. J Biomed Opt. 2011;
16(10):106013. [PubMed: 22029360]
An L, Wang RK. In vivo volumetric imaging of vascular perfusion within human retina and choroids
with optical micro-angiography. Opt Express. 2008; 16(15):11438–11452. [PubMed: 18648464]
Antcliff RJ, Stanford MR, Chauhan DS, Graham EM, Spalton DJ, Shilling JS, Ffytche TJ, Marshall J.
Comparison between optical coherence tomography and fundus fluorescein angiography for the
detection of cystoid macular edema in patients with uveitis. Ophthalmology. 2000; 107(3):593–
Author Manuscript

599. [PubMed: 10711901]

Arend O, Harris A, Sponsel WE, Remky A, Reim M, Wolf S. Macular capillary particle velocities: a
blue field and scanning laser comparison. Graefes Arch Clin Exp Ophthalmol. 1995; 233(4):244–
249. [PubMed: 7797089]
Arend O, Wolf S, Harris A, Reim M. The relationship of macular microcirculation to visual acuity in
diabetic patients. Arch Ophthalmol. 1995; 113(5):610–614. [PubMed: 7748131]
Avila CP, Bartsch DU, Bitner DG, Cheng L, Mueller AJ, Karavellas MP, Freeman WR. Retinal blood
flow measurements in branch retinal vein occlusion using scanning laser Doppler flowmetry. Am J
Ophthalmol. 1998; 126(5):683–690. [PubMed: 9822232]
Barton J, Stromski S. Flow measurement without phase information in optical coherence tomography
images. Opt Express. 2005; 13(14):5234–5239. [PubMed: 19498514]
Bedggood P, Metha A. Direct visualization and characterization of erythrocyte flow in human retinal
capillaries. Biomed Opt Express. 2012; 3(12):3264–3277. [PubMed: 23243576]
Bennett AG, Rudnicka AR, Edgar DF. Improvements on Littmann’s method of determining the size of
Author Manuscript

retinal features by fundus photography. Graefes Arch Clin Exp Ophthalmol. 1994; 232(6):361–
367. [PubMed: 8082844]
Benya R, Quintana J, Brundage B. Adverse reactions to indocyanine green: a case report and a review
of the literature. Cathet Cardiovasc Diagn. 1989; 17(4):231–233. [PubMed: 2670244]
Bhanushali D, Anegondi N, Gadde SGK, Srinivasan P, Chidambara L, Yadav NK, Sinha Roy A.
Linking Retinal Microvasculature Features With Severity of Diabetic Retinopathy Using Optical
Coherence Tomography Angiography. Investigative Ophthalmology & Visual Science. 2016;
57(9):OCT519–517. [PubMed: 27472275]
Bojikian KD, Chen CL, Wen JC, Zhang Q, Xin C, Gupta D, Mudumbai RC, Johnstone MA, Wang RK,
Chen PP. Optic Disc Perfusion in Primary Open Angle and Normal Tension Glaucoma Eyes Using
Optical Coherence Tomography-Based Microangiography. PLoS One. 2016; 11(5):e0154691.
[PubMed: 27149261]
Bolz M, Kriechbaum K, Simader C, Deak G, Lammer J, Treu C, Scholda C, Prünte C, Schmidt-Erfurth
U, Vienna DRRG. In vivo retinal morphology after grid laser treatment in diabetic macular edema.
Ophthalmology. 2010; 117(3):538–544. [PubMed: 20045563]
Author Manuscript

Bonini Filho MA, Adhi M, de Carlo TE, Ferrara D, Baumal CR, Witkin AJ, Reichel E, Kuehlewein L,
Sadda SR, Sarraf D, Duker JS, Waheed NK. Optical Coherence Tomography Angiography in
Retinal Artery Occlusion. Retina. 2015; 35(11):2339–2346. [PubMed: 26457398]
Bonini Filho MA, de Carlo TE, Ferrara D, Adhi M, Baumal CR, Witkin AJ, Reichel E, Duker JS,
Waheed NK. Association of Choroidal Neovascularization and Central Serous Chorioretinopathy
With Optical Coherence Tomography Angiography. JAMA Ophthalmol. 2015; 133(8):899–906.
[PubMed: 25996386]
Bresnick GH, Condit R, Syrjala S, Palta M, Groo A, Korth K. Abnormalities of the foveal avascular
zone in diabetic retinopathy. Arch Ophthalmol. 1984; 102(9):1286–1293. [PubMed: 6477244]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 51

Burgansky-Eliash Z, Lowenstein A, Neuderfer M, Kesler A, Barash H, Nelson DA, Grinvald A, Barak

A. The correlation between retinal blood flow velocity measured by the retinal function imager
Author Manuscript

and various physiological parameters. Ophthalmic Surg Lasers Imaging Retina. 2013; 44(1):51–
58. [PubMed: 23418734]
Burgoyne CF. A biomechanical paradigm for axonal insult within the optic nerve head in aging and
glaucoma. Exp Eye Res. 2011; 93(2):120–132. [PubMed: 20849846]
Bursell SE, Clermont AC, Kinsley BT, Simonson DC, Aiello LM, Wolpert HA. Retinal blood flow
changes in patients with insulin-dependent diabetes mellitus and no diabetic retinopathy. Invest
Ophthalmol Vis Sci. 1996; 37(5):886–897. [PubMed: 8603873]
Camino A, Zhang M, Gao SS, Hwang TS, Sharma U, Wilson DJ, Huang D, Jia Y. Evaluation of
artifact reduction in optical coherence tomography angiography with real-time tracking and
motion correction technology. Biomedical optics express. 2016; 7(10):3905–3911. [PubMed:
27867702]
Campbell JP, Zhang M, Hwang TS, Bailey ST, Wilson DJ, Jia Y, Huang D. Detailed Vascular Anatomy
of the Human Retina by Projection-Resolved Optical Coherence Tomography Angiography. Sci
Rep. 2017; 7:42201. [PubMed: 28186181]
Author Manuscript

Campochiaro PA. Molecular pathogenesis of retinal and choroidal vascular diseases. Prog Retin Eye
Res. 2015; 49:67–81. [PubMed: 26113211]
Campochiaro PA, Wykoff CC, Shapiro H, Rubio RG, Ehrlich JS. Neutralization of vascular endothelial
growth factor slows progression of retinal nonperfusion in patients with diabetic macular edema.
Ophthalmology. 2014; 121(9):1783–1789. [PubMed: 24768239]
Caprioli J, de Leon JM, Azarbod P, Chen A, Morales E, Nouri-Mahdavi K, Coleman A, Yu F, Afifi A.
Trabeculectomy Can Improve Long-Term Visual Function in Glaucoma. Ophthalmology. 2016;
123(1):117–128. [PubMed: 26602970]
Cardoso JN, Keane PA, Sim DA, Bradley P, Agrawal R, Addison PK, Egan C, Tufail A. Systematic
Evaluation of Optical Coherence Tomography Angiography in Retinal Vein Occlusion. AJOPHT.
2016; 163:93–107.e106.
Carpineto P, Mastropasqua R, Marchini G, Toto L, Di Nicola M, Di Antonio L. Reproducibility and
repeatability of foveal avascular zone measurements in healthy subjects by optical coherence
tomography angiography. Br J Ophthalmol. 2016; 100(5):671–676. [PubMed: 26377414]
Casselholmde Salles M, Kvanta A, Amren U, Epstein D. Optical Coherence Tomography Angiography
Author Manuscript

in Central Retinal Vein Occlusion: Correlation Between the Foveal Avascular Zone and Visual
Acuity. Invest Ophthalmol Vis Sci. 2016; 57(9):OCT242–246. [PubMed: 27409478]
Cense B, Nassif N, Chen T, Pierce M, Yun SH, Park B, Bouma B, Tearney G, de Boer J. Ultrahigh-
resolution high-speed retinal imaging using spectral-domain optical coherence tomography. Opt
Express. 2004; 12(11):2435–2447. [PubMed: 19475080]
Chalam KV, Bressler SB, Edwards AR, Berger BB, Bressler NM, Glassman AR, Grover S, Gupta SK,
Nielsen JS. DR CR Network. Retinal thickness in people with diabetes and minimal or no diabetic
retinopathy: Heidelberg Spectralis optical coherence tomography. Invest Ophthalmol Vis Sci.
2012; 53(13):8154–8161. [PubMed: 23132803]
Chalam KV, Sambhav K. Optical Coherence Tomography Angiography in Retinal Diseases. J
Ophthalmic Vis Res. 2016; 11(1):84–92. [PubMed: 27195091]
Charbel Issa P, Gillies MC, Chew EY, Bird AC, Heeren TF, Peto T, Holz FG, Scholl HP. Macular
telangiectasia type 2. Prog Retin Eye Res. 2013; 34:49–77. [PubMed: 23219692]
Chen CBK, Gupta D, Wen J, Zhang Q, Xin C, Kono R, Mudumbai RC, Johnstone MA, Chen PP, Wang
Author Manuscript

RK. Optic disc perfusion in normal eyes and eyes with glaucoma using optical coherence
tomography-based microangiography. 2016
Chen CBK, Xin C, Wen J, Gupta D, Zhang Q, Mudumbai RC, Johnstone MA, Chen PP, Wang RK.
Repeatability and Reproducibility of Optic Disc Perfusion Measurements Using Optical
Coherence Tomography-based Angiography. 2016
Chen C, Shi W, Gao W. Imaginary part-based correlation mapping optical coherence tomography for
imaging of blood vessels in vivo. J Biomed Opt. 2015; 20(11):116009. [PubMed: 26618523]
Chen CL, Wang RK. Optical coherence tomography based angiography [Invited]. Biomed Opt
Express. 2017; 8(2):1056–1082. [PubMed: 28271003]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 52

Chen CL, Zhang A, Bojikian KD, Wen JC, Zhang Q, Xin C, Mudumbai RC, Johnstone MA, Chen PP,
Wang RK. Peripapillary Retinal Nerve Fiber Layer Vascular Microcirculation in Glaucoma Using
Author Manuscript

Optical Coherence Tomography-Based Microangiography. Invest Ophthalmol Vis Sci. 2016;

57(9):Oct475–485. [PubMed: 27442341]
Chen Z, Milner TE, Srinivas S, Wang X, Malekafzali A, van Gemert MJ, Nelson JS. Noninvasive
imaging of in vivo blood flow velocity using optical Doppler tomography. Opt Lett. 1997; 22(14):
1119–1121. [PubMed: 18185770]
Cheung N, Huynh S, Wang JJ, Taylor B, Islam FM, Saw SM, Wong TY, Mitchell P. Relationships of
retinal vessel diameters with optic disc, macular and retinal nerve fiber layer parameters in 6-year-
old children. Invest Ophthalmol Vis Sci. 2008; 49(6):2403–2408. [PubMed: 18281614]
Choi W, Moult EM, Waheed NK, Adhi M, Lee B, Lu CD, de Carlo TE, Jayaraman V, Rosenfeld PJ,
Duker JS, Fujimoto JG. Ultrahigh-Speed, Swept-Source Optical Coherence Tomography
Angiography in Nonexudative Age-Related Macular Degeneration with Geographic Atrophy.
Ophthalmology. 2015; 122(12):2532–2544. [PubMed: 26481819]
Choi WJ, Qin W, Chen CL, Wang J, Zhang Q, Yang X, Gao BZ, Wang RK. Characterizing relationship
between optical microangiography signals and capillary flow using microfluidic channels. Biomed
Author Manuscript

Opt Express. 2016; 7(7):2709–2728. [PubMed: 27446700]

Choma M, Sarunic M, Yang C, Izatt J. Sensitivity advantage of swept source and Fourier domain
optical coherence tomography. Opt Express. 2003; 11(18):2183–2189. [PubMed: 19466106]
Cicinelli MV, Carnevali A, Rabiolo A, Querques L, Zucchiatti I, Scorcia V, Bandello F, Querques G.
CLINICAL SPECTRUM OF MACULAR-FOVEAL CAPILLARIES EVALUATED WITH
OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY. Retina (Philadelphia, Pa). 2016:1–
8.
Cole ED, Novais EA, Louzada RN, Moult EM, Lee B-K, Witkin AJ, Waheed NK, Duker JS, Baumal
CR. Visualization of Changes in the Choriocapillaris, Choroidal Vessels, and Retinal Morphology
After Focal Laser Photocoagulation Using OCT Angiography. Investigative Ophthalmology &
Visual Science. 2016; 57(9):OCT356–356. [PubMed: 27409493]
Conrath J, Giorgi R, Raccah D, Ridings B. Foveal avascular zone in diabetic retinopathy: quantitative
vs qualitative assessment. Eye (Lond). 2005; 19(3):322–326. [PubMed: 15258601]
Coscas F, Glacet-Bernard A, Miere A, Caillaux V, Uzzan J, Lupidi M, Coscas G, Souied EH. Optical
Coherence Tomography Angiography in Retinal Vein Occlusion: Evaluation of Superficial and
Author Manuscript

Deep Capillary Plexa. Am J Ophthalmol. 2016; 161:160–171. e161–162. [PubMed: 26476211]

Coscas GJ, Lupidi M, Coscas F, Cagini C, Souied EH. OPTICAL COHERENCE TOMOGRAPHY
ANGIOGRAPHY VERSUS TRADITIONAL MULTIMODAL IMAGING IN ASSESSING THE
ACTIVITY OF EXUDATIVE AGE-RELATED MACULAR DEGENERATION. Retina
(Philadelphia, Pa). 0002; 35(11):1–10.
Costanzo E, Miere A, Querques G, Capuano V, Jung C, Souied EH. Type 1 Choroidal
Neovascularization Lesion Size: Indocyanine Green Angiography Versus Optical Coherence
Tomography Angiography. Invest Ophthalmol Vis Sci. 2016; 57(9):OCT307–313. [PubMed:
27409487]
Couturier A, Mane V, Bonnin S, Erginay A, Massin P, Gaudric A, Tadayoni R. Capillary Plexus
Anomalies in Diabetic Retinopathy on Optical Coherence Tomography Angiography. Retina.
2015; 35(11):2384–2391. [PubMed: 26469531]
Dalimier E, Salomon D. Full-field optical coherence tomography: a new technology for 3D high-
resolution skin imaging. Dermatology. 2012; 224(1):84–92. [PubMed: 22487768]
Author Manuscript

Danis RP, Scott IU, Qin H, Altaweel MM, Bressler NM, Bressler SB, Browning DJ, Kollman C. DR
CR Network. Association of fluorescein angiographic features with visual acuity and with optical
coherence tomographic and stereoscopic color fundus photographic features of diabetic macular
edema in a randomized clinical trial. Retina. 2010; 30(10):1627–1637. [PubMed: 20706173]
Dansingani KK, Tan AC, Gilani F, Phasukkijwatana N, Novais E, Querques L, Waheed NK, Duker JS,
Querques G, Yannuzzi LA, Sarraf D, Freund KB. Subretinal Hyperreflective Material Imaged
With Optical Coherence Tomography Angiography. Am J Ophthalmol. 2016; 169:235–248.
[PubMed: 27349411]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 53

de Amorim Garcia Filho CA, Penha FM, Gregori G, Rosenfeld PJ. Increasing volume of a retinal
pigmented epithelial detachment as a predictor of submacular hemorrhage during anti-VEGF
Author Manuscript

therapy. Ophthalmic Surg Lasers Imaging Retina. 2013; 44(2):204–207. [PubMed: 23510045]
de Boer JF, Cense B, Park BH, Pierce MC, Tearney GJ, Bouma BE. Improved signal-to-noise ratio in
spectral-domain compared with time-domain optical coherence tomography. Opt Lett. 2003;
28(21):2067–2069. [PubMed: 14587817]
de Carlo TE, Bonini Filho MA, Adhi M, Duker JS. Retinal and Choroidal Vasculature in Birdshot
Chorioretinopathy Analyzed Using Spectral Domain Optical Coherence Tomography
Angiography. Retina. 2015; 35(11):2392–2399. [PubMed: 26352557]
de Carlo TE, Bonini Filho MA, Baumal CR, Reichel E, Rogers A, Witkin AJ, Duker JS, Waheed NK.
Evaluation of Preretinal Neovascularization in Proliferative Diabetic Retinopathy Using Optical
Coherence Tomography Angiography. Ophthalmic Surg Lasers Imaging Retina. 2016; 47(2):115–
119. [PubMed: 26878443]
de Carlo TE, Chin AT, Bonini Filho MA, Adhi M, Branchini L, Salz DA, Baumal CR, Crawford C,
Reichel E, Witkin AJ, Duker JS, Waheed NK. Detection of Microvascular Changes in Eyes of
Patients with Diabetes but Not Clinical Diabetic Retinopathy Using Optical Coherence
Author Manuscript

Tomography Angiography. Retina. 2015; 35(11):2364–2370. [PubMed: 26469537]

De Rojas JO, Rasool N, Chen RW, Horowitz J, Odel JG. Optical coherence tomography angiography
in Leber hereditary optic neuropathy. Neurology. 2016; 87(19):2065–2066. [PubMed: 27821565]
Dolz-Marco R, Phasukkijwatana N, Sarraf D, Freund KB. Regression of Type 2 Neovascularization
into a Type 1 Pattern after Intravitreal Anti-Vascular Endothelial Growth Factor Therapy for
Neovascular Age-Related Macular Degeneration. Retina. 2016
Drexler W, Fujimoto JG. State-of-the-art retinal optical coherence tomography. Prog Retin Eye Res.
2008; 27(1):45–88. [PubMed: 18036865]
Dubis AM, Hansen BR, Cooper RF, Beringer J, Dubra A, Carroll J. Relationship between the foveal
avascular zone and foveal pit morphology. Invest Ophthalmol Vis Sci. 2012; 53(3):1628–1636.
[PubMed: 22323466]
Dubois A, Vabre L, Boccara AC, Beaurepaire E. High-resolution full-field optical coherence
tomography with a Linnik microscope. Appl Opt. 2002; 41(4):805–812. [PubMed: 11993929]
El Ameen A, Cohen SY, Semoun O, Miere A, Srour M, Quaranta-El Maftouhi M, Oubraham H,
Blanco-Garavito R, Querques G, Souied EH. Type 2 Neovascularization Secondary to Age-
Author Manuscript

Related Macular Degeneration Imaged by Optical Coherence Tomography Angiography. Retina.

2015; 35(11):2212–2218. [PubMed: 26441269]
Enfield J, Jonathan E, Leahy M. In vivo imaging of the microcirculation of the volar forearm using
correlation mapping optical coherence tomography (cmOCT). Biomed Opt Express. 2011; 2(5):
1184–1193. [PubMed: 21559130]
Ferrara D, Waheed NK, Duker JS. Investigating the choriocapillaris and choroidal vasculature with
new optical coherence tomography technologies. Prog Retin Eye Res. 2016; 52:130–155.
[PubMed: 26478514]
Ferris FL 3rd, Wilkinson CP, Bird A, Chakravarthy U, Chew E, Csaky K, Sadda SR, Beckman C.
Initiative for Macular Research Classification. Clinical classification of age-related macular
degeneration. Ophthalmology. 2013; 120(4):844–851. [PubMed: 23332590]
Fingler J, Readhead C, Schwartz DM, Fraser SE. Phase-contrast OCT imaging of transverse flows in
the mouse retina and choroid. Invest Ophthalmol Vis Sci. 2008; 49(11):5055–5059. [PubMed:
18566457]
Author Manuscript

Fingler J, Schwartz D, Yang C, Fraser SE. Mobility and transverse flow visualization using phase
variance contrast with spectral domain optical coherence tomography. Opt Express. 2007; 15(20):
12636–12653. [PubMed: 19550532]
Fingler J, Zawadzki RJ, Werner JS, Schwartz D, Fraser SE. Volumetric microvascular imaging of
human retina using optical coherence tomography with a novel motion contrast technique. Opt
Express. 2009; 17(24):22190–22200. [PubMed: 19997465]
Freeman G, Matos K, Pavesio CE. Cystoid macular oedema in uveitis: an unsolved problem. Eye
(Lond). 2001; 15(Pt 1):12–17. [PubMed: 11318279]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 54

Freund KB, Zweifel SA, Engelbert M. Do we need a new classification for choroidal
neovascularization in age-related macular degeneration? Retina. 2010; 30(9):1333–1349.
Author Manuscript

[PubMed: 20924258]
Friedman DS, O’Colmain BJ, Munoz B, Tomany SC, McCarty C, de Jong PT, Nemesure B, Mitchell P,
Kempen J. Eye Diseases Prevalence Research G. Prevalence of age-related macular degeneration
in the United States. Arch Ophthalmol. 2004; 122(4):564–572. [PubMed: 15078675]
Gabriele ML, Wollstein G, Ishikawa H, Xu J, Kim J, Kagemann L, Folio LS, Schuman JS. Three
dimensional optical coherence tomography imaging: advantages and advances. Prog Retin Eye
Res. 2010; 29(6):556–579. [PubMed: 20542136]
Gandolfi SA. Improvement of visual field indices after surgical reduction of intraocular pressure.
Ophthalmic Surg. 1995; 26(2):121–126. [PubMed: 7596538]
Gao SS, Jia Y, Zhang M, Su JP, Liu G, Hwang TS, Bailey ST, Huang D. Optical Coherence
Tomography Angiography. Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT27–
10. [PubMed: 27409483]
Gao SS, Liu G, Huang D, Jia Y. Optimization of the split-spectrum amplitude-decorrelation
angiography algorithm on a spectral optical coherence tomography system. Opt Lett. 2015; 40(10):
Author Manuscript

2305–2308. [PubMed: 26393725]

Gao SS, Liu G, Huang D, Jia Y. Optimization of the split-spectrum amplitude-decorrelation
angiography algorithm on a spectral optical coherence tomography system: erratum. Opt Lett.
2016; 41(3):496. [PubMed: 26907406]
Garcia CR, Rivero ME, Bartsch DU, Ishiko S, Takamiya A, Fukui K, Hirokawa H, Clark T, Yoshida A,
Freeman WR. Oral fluorescein angiography with the confocal scanning laser ophthalmoscope.
Ophthalmology. 1999; 106(6):1114–1118. [PubMed: 10366079]
Gass JD, Blodi BA. Idiopathic juxtafoveolar retinal telangiectasis. Update of classification and follow-
up study. Ophthalmology. 1993; 100(10):1536–1546. [PubMed: 8414413]
Ghasemi Falavarjani K, Iafe NA, Hubschman JP, Tsui I, Sadda SR, Sarraf D. Optical Coherence
Tomography Angiography Analysis of the Foveal Avascular Zone and Macular Vessel Density
After Anti-VEGF Therapy in Eyes With Diabetic Macular Edema and Retinal Vein Occlusion.
Invest Ophthalmol Vis Sci. 2017; 58(1):30–34. [PubMed: 28114569]
Ghasemi Falavarjani K, Tian JJ, Akil H, Garcia GA, Sadda SR, Sadun AA. Swept-Source Optical
Coherence Tomography Angiography of the Optic Disk in Optic Neuropathy. Retina. 2016;
Author Manuscript

36(Suppl 1):S168–S177. [PubMed: 28005675]

Giani A, Luiselli C, Esmaili DD, Salvetti P, Cigada M, Miller JW, Staurenghi G. Spectral-domain
optical coherence tomography as an indicator of fluorescein angiography leakage from choroidal
neovascularization. Invest Ophthalmol Vis Sci. 2011; 52(8):5579–5586. [PubMed: 21693602]
Gong J, Yu S, Gong Y, Wang F, Sun X. The Diagnostic Accuracy of Optical Coherence Tomography
Angiography for Neovascular Age-Related Macular Degeneration: A Comparison with Fundus
Fluorescein Angiography. J Ophthalmol. 2016; 2016:7521478. [PubMed: 27110394]
Green WR, Quigley HA, De la Cruz Z, Cohen B. Parafoveal retinal telangiectasis. Light and electron
microscopy studies. Trans Ophthalmol Soc U K. 1980; 100(Pt 1):162–170. [PubMed: 6943823]
Grulkowski I, Liu JJ, Potsaid B, Jayaraman V, Lu CD, Jiang J, Cable AE, Duker JS, Fujimoto JG.
Retinal, anterior segment and full eye imaging using ultrahigh speed swept source OCT with
vertical-cavity surface emitting lasers. Biomed Opt Express. 2012; 3(11):2733–2751. [PubMed:
23162712]
Guyer DR, Yannuzzi LA, Slakter JS, Sorenson JA, Hope-Ross M, Orlock DR. Digital indocyanine-
Author Manuscript

green videoangiography of occult choroidal neovascularization. Ophthalmology. 1994; 101(10):

1727–1735. discussion 1735–1727. [PubMed: 7524004]
Gómez-Ulla F, Gutiérrez C, Seoane I. Severe anaphylactic reaction to orally administered fluorescein.
Am J Ophthalmol. 1991; 112(1):94.
Hara T, Inami M. Efficacy and safety of fluorescein angiography with orally administered sodium
fluorescein. Am J Ophthalmol. 1998; 126(4):560–564. [PubMed: 9780101]
Hasegawa N, Nozaki M, Takase N, Yoshida M, Ogura Y. New Insights Into Microaneurysms in the
Deep Capillary Plexus Detected by Optical Coherence Tomography Angiography in Diabetic

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 55

Macular Edema. Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT348–348.

[PubMed: 27409492]
Author Manuscript

Hassan M, Agarwal A, Afridi R, daSilva MJ, Karaca I, Sadiq MA, Nguyen QD, Do DV. The Role of
Optical Coherence Tomography Angiography in the Management of Uveitis. Int Ophthalmol
Clin. 2016; 56(4):1–24.
Hata M, Oishi A, Muraoka Y, Miyamoto K, Kawai K, Yokota S, Fujimoto M, Miyata M, Yoshimura N.
Structural and Functional Analyses in Nonarteritic Anterior Ischemic Optic Neuropathy: Optical
Coherence Tomography Angiography Study. J Neuroophthalmol. 2016
Henkind P. Radial peripapillary capillaries of the retina. I. Anatomy: human and comparative. Br J
Ophthalmol. 1967; 51(2):115–123. [PubMed: 4959937]
Ho AC, Yannuzzi LA, Guyer DR, Slakter JS, Sorenson JA, Orlock DA. Intraretinal leakage of
indocyanine green dye. Ophthalmology. 1994; 101(3):534–541. [PubMed: 7510380]
Hong BK, Nazari Khanamiri H, Rao NA. Role of ultra-widefield fluorescein angiography in the
management of uveitis. Can J Ophthalmol. 2013; 48(6):489–493. [PubMed: 24314409]
Hope-Ross M, Yannuzzi LA, Gragoudas ES, Guyer DR, Slakter JS, Sorenson JA, Krupsky S, Orlock
DA, Puliafito CA. Adverse reactions due to indocyanine green. Ophthalmology. 1994; 101(3):
Author Manuscript

529–533. [PubMed: 8127574]

Horii T, Murakami T, Akagi T, Uji A, Ueda-Arakawa N, Nishijima K, Yoshimura N. Optical coherence
tomographic reflectivity of cystoid spaces is related to recurrent diabetic macular edema after
triamcinolone. Retina. 2015; 35(2):264–271. [PubMed: 25102197]
Huang D, Jia Y, Rispoli M, Tan O, Lumbroso B. OPTICAL COHERENCE TOMOGRAPHY
ANGIOGRAPHY OF TIME COURSE OF CHOROIDAL NEOVASCULARIZATION IN
RESPONSE TO ANTI-ANGIOGENIC TREATMENT. Retina (Philadelphia, Pa). 0002; 35(11):
1–5.
Huang D, Swanson EA, Lin CP, Schuman JS, Stinson WG, Chang W, Hee MR, Flotte T, Gregory K,
Puliafito CA. Optical coherence tomography. Science. 1991; 254(5035):1178–1181. [PubMed:
1957169]
Huang Y, Zhang Q, Thorell MR, An L, Durbin MK, Laron M, Sharma U, Gregori G, Rosenfeld PJ,
Wang RK. Swept-source OCT angiography of the retinal vasculature using intensity
differentiation-based optical microangiography algorithms. Ophthalmic Surg Lasers Imaging
Retina. 2014; 45(5):382–389. [PubMed: 25230403]
Author Manuscript

Hwang TS, Jia Y, Gao SS, Bailey ST, Lauer AK, Flaxel CJ, Wilson DJ, Huang D. Optical Coherence
Tomography Angiography Features of Diabetic Retinopathy. Retina. 2015; 35(11):2371–2376.
[PubMed: 26308529]
Hwang TS, Zhang M, Bhavsar K, Zhang X, Campbell JP, Lin P, Bailey ST, Flaxel CJ, Lauer AK,
Wilson DJ, Huang D, Jia Y. Visualization of 3 Distinct Retinal Plexuses by Projection-Resolved
Optical Coherence Tomography Angiography in Diabetic Retinopathy. JAMA Ophthalmol. 2016;
134(12):1411–1419. [PubMed: 27812696]
Iafe NA, Phasukkijwatana N, Chen X, Sarraf D. Retinal Capillary Density and Foveal Avascular Zone
Area Are Age-Dependent: Quantitative Analysis Using Optical Coherence Tomography
Angiography. Invest Ophthalmol Vis Sci. 2016; 57(13):5780–5787. [PubMed: 27792812]
Inoue M, Jung JJ, Balaratnasingam C, Dansingani KK, Dhrami-Gavazi E, Suzuki M, de Carlo TE,
Shahlaee A, Klufas MA, El Maftouhi A, Duker JS, Ho AC, Maftouhi MQ, Sarraf D, Freund KB.
C-S Group. A Comparison Between Optical Coherence Tomography Angiography and
Fluorescein Angiography for the Imaging of Type 1 Neovascularization. Invest Ophthalmol Vis
Author Manuscript

Sci. 2016; 57(9):OCT314–323. [PubMed: 27409488]

Ishibazawa A, Nagaoka T, Takahashi A, Omae T, Tani T, Sogawa K, Yokota H, Yoshida A. Optical
Coherence Tomography Angiography in Diabetic Retinopathy: A Prospective Pilot Study.
AJOPHT. 2015; 160(1):1–11.
Izatt JA, Kulkarni MD, Yazdanfar S, Barton JK, Welch AJ. In vivo bidirectional color Doppler flow
imaging of picoliter blood volumes using optical coherence tomography. Opt Lett. 1997; 22(18):
1439–1441. [PubMed: 18188263]
Jia Y, Bailey ST, Hwang TS, McClintic SM, Gao SS. Quantitative optical coherence tomography
angiography of vascular abnormalities in the living human eye. 2015; 112(18):E2395–2402.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 56

Jia Y, Bailey ST, Hwang TS, McClintic SM, Gao SS, Pennesi ME, Flaxel CJ, Lauer AK, Wilson DJ,
Hornegger J, Fujimoto JG, Huang D. Quantitative optical coherence tomography angiography of
Author Manuscript

vascular abnormalities in the living human eye. Proceedings of the National Academy of
Sciences of the United States of America. 2015; 112(18):E2395–E2402. [PubMed: 25897021]
Jia Y, Bailey ST, Wilson DJ, Tan O, Klein ML, Flaxel CJ, Potsaid B, Liu JJ, Lu CD, Kraus MF,
Fujimoto JG, Huang D. Quantitative optical coherence tomography angiography of choroidal
neovascularization in age-related macular degeneration. Ophthalmology. 2014; 121(7):1435–
1444. [PubMed: 24679442]
Jia Y, Morrison JC, Tokayer J, Tan O, Lombardi L, Baumann B, Lu CD, Choi W, Fujimoto JG, Huang
D. Quantitative OCT angiography of optic nerve head blood flow. Biomed Opt Express. 2012;
3(12):3127–3137. [PubMed: 23243564]
Jia Y, Tan O, Tokayer J, Potsaid B, Wang Y, Liu JJ, Kraus MF, Subhash H, Fujimoto JG, Hornegger J.
Split-spectrum amplitude-decorrelation angiography with optical coherence tomography. Optics
express. 2012; 20(4):4710–4725. [PubMed: 22418228]
Jia Y, Tan O, Tokayer J, Potsaid B, Wang Y, Liu JJ, Kraus MF, Subhash H, Fujimoto JG, Hornegger J,
Huang D. Split-spectrum amplitude-decorrelation angiography with optical coherence
Author Manuscript

tomography. Optics express. 2012; 20(4):4710–4725. [PubMed: 22418228]

Jia Y, Wei E, Wang X, Zhang X, Morrison JC, Parikh M, Lombardi LH, Gattey DM, Armour RL,
Edmunds B, Kraus MF, Fujimoto JG, Huang D. Optical coherence tomography angiography of
optic disc perfusion in glaucoma. Ophthalmology. 2014; 121(7):1322–1332. [PubMed:
24629312]
Jian Z, Yu L, Rao B, Tromberg BJ, Chen Z. Three-dimensional speckle suppression in Optical
Coherence Tomography based on the curvelet transform. Opt Express. 2010; 18(2):1024–1032.
[PubMed: 20173923]
Jonathan E, Enfield J, Leahy MJ. Correlation mapping method for generating microcirculation
morphology from optical coherence tomography (OCT) intensity images. J Biophotonics. 2011;
4(9):583–587. [PubMed: 21887769]
Kashani AH, Lee SY, Moshfeghi A, Durbin MK, Puliafito CA. Optical Coherence Tomography
Angiography of Retinal Venous Occlusion. Retina. 2015; 35(11):2323–2331. [PubMed:
26457395]
Kashani AH, Zimmer-Galler IE, Shah SM, Dustin L, Do DV, Eliott D, Haller JA, Nguyen QD. Retinal
Author Manuscript

thickness analysis by race, gender, and age using Stratus OCT. Am J Ophthalmol. 2010; 149(3):
496–502.e491. [PubMed: 20042179]
Kim AY, Chu Z, Shahidzadeh A, Wang RK, Puliafito CA, Kashani AH. Quantifying Microvascular
Density and Morphology in Diabetic Retinopathy Using Spectral-Domain Optical Coherence
Tomography Angiography. Invest Ophthalmol Vis Sci. 2016; 57(9):OCT362–370. [PubMed:
27409494]
Kim AY, Rodger DC, Shahidzadeh A, Chu Z, Koulisis N, Burkemper B, Jiang X, Pepple KL, Wang
RK, Puliafito CA, Rao NA, Kashani AH. Quantifying retinal microvascular changes in uveitis
using spectral domain optical coherence tomography angiography (SD-OCTA). Am J
Ophthalmol. 2016
Kim AY, Rodger DC, Shahidzadeh A, Chu Z, Koulisis N, Burkemper B, Jiang X, Pepple KL, Wang
RK, Puliafito CA, Rao NA, Kashani AH. Quantifying Retinal Microvascular Changes in Uveitis
Using Spectral-Domain Optical Coherence Tomography Angiography. Am J Ophthalmol. 2016;
171:101–112. [PubMed: 27594138]
Author Manuscript

Kim DY, Fingler J, Werner JS, Schwartz DM, Fraser SE, Zawadzki RJ. In vivo volumetric imaging of
human retinal circulation with phase-variance optical coherence tomography. Biomed Opt
Express. 2011; 2(6):1504–1513. [PubMed: 21698014]
Kim DY, Fingler J, Zawadzki RJ, Park SS, Morse LS, Schwartz DM, Fraser SE, Werner JS.
Noninvasive imaging of the foveal avascular zone with high-speed, phase-variance optical
coherence tomography. Invest Ophthalmol Vis Sci. 2012; 53(1):85–92. [PubMed: 22125275]
Kim J, Brown W, Maher JR, Levinson H, Wax A. Functional optical coherence tomography: principles
and progress. Phys Med Biol. 2015; 60(10):R211–237. [PubMed: 25951836]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 57

Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol. 2007;
14(4):179–183. [PubMed: 17896294]
Author Manuscript

Koulisis, N., Kim, AY., Chu, Z., Shahidzadeh, A., Burkemper, B., Olmos de Koo, LC., Moshfeghi,
AA., Ameri, H., Puliafito, CA., Isozaki, VL., Wang, RK., Kashani, AH. Quantitative
Microvascular Analysis of Retinal Venous Occlusions by Spectral Domain Optical Coherence
Tomography Angiography; Association for Research in Vision and Ophthalmology (ARVO)
Abstract 5505 - C0109; Seattle, WA. 2016.
Kuehlewein L, Bansal M, Lenis TL, Iafe NA, Sadda SR, Bonini Filho MA, De Carlo TE, Waheed NK,
Duker JS, Sarraf D. Optical Coherence Tomography Angiography of Type 1 Neovascularization
in Age-Related Macular Degeneration. Am J Ophthalmol. 2015; 160(4):739–748 e732.
[PubMed: 26164826]
Kuehlewein L, Tepelus TC, An L, Durbin MK, Srinivas S, Sadda SR. Noninvasive Visualization and
Analysis of the Human Parafoveal Capillary Network Using Swept Source OCT Optical
Microangiography. Invest Ophthalmol Vis Sci. 2015; 56(6):3984–3988. [PubMed: 26087363]
Kumar RS, Anegondi N, Chandapura RS, Sudhakaran S, Kadambi SV, Rao HL, Aung T, Sinha Roy A.
Discriminant Function of Optical Coherence Tomography Angiography to Determine Disease
Author Manuscript

Severity in Glaucoma. Invest Ophthalmol Vis Sci. 2016; 57(14):6079–6088. [PubMed:

27820876]
Kurokawa K, Sasaki K, Makita S, Hong YJ, Yasuno Y. Three-dimensional retinal and choroidal
capillary imaging by power Doppler optical coherence angiography with adaptive optics. Opt
Express. 2012; 20(20):22796–22812. [PubMed: 23037430]
Kwiterovich KA, Maguire MG, Murphy RP, Schachat AP, Bressler NM, Bressler SB, Fine SL.
Frequency of adverse systemic reactions after fluorescein angiography. Results of a prospective
study. Ophthalmology. 1991; 98(7):1139–1142. [PubMed: 1891225]
Landa G, Jangi AA, Garcia PM, Rosen RB. Initial report of quantification of retinal blood flow
velocity in normal human subjects using the Retinal Functional Imager (RFI). Int Ophthalmol.
2012; 32(3):211–215. [PubMed: 22484724]
Lang SJ, Cakir B, Evers C, Ludwig F, Lange CA, Agostini HT. Value of Optical Coherence
Tomography Angiography Imaging in Diagnosis and Treatment of Hemangioblastomas in von
Hippel-Lindau Disease. Ophthalmic Surg Lasers Imaging Retina. 2016; 47(10):935–946.
[PubMed: 27759860]
Author Manuscript

Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and
related vision loss. Eye Vis (Lond). 2015; 2:17. [PubMed: 26605370]
Leitgeb R, Hitzenberger C, Fercher A. Performance of fourier domain vs. time domain optical
coherence tomography. Opt Express. 2003; 11(8):889–894. [PubMed: 19461802]
Leitgeb R, Schmetterer L, Drexler W, Fercher A, Zawadzki R, Bajraszewski T. Real-time assessment
of retinal blood flow with ultrafast acquisition by color Doppler Fourier domain optical
coherence tomography. Opt Express. 2003; 11(23):3116–3121. [PubMed: 19471434]
Leitgeb, R., Schmetterer, LF., Wojtkowski, M., Hitzenberger, CK., Sticker, M., Fercher, AF. Flow
velocity measurements by frequency domain short coherence interferometry. International
Symposium on Biomedical Optics; International Society for Optics and Photonics; 2002.
Leitgeb RA, Werkmeister RM, Blatter C, Schmetterer L. Doppler optical coherence tomography. Prog
Retin Eye Res. 2014; 41:26–43. [PubMed: 24704352]
Leung CK. Diagnosing glaucoma progression with optical coherence tomography. Curr Opin
Ophthalmol. 2014; 25(2):104–111. [PubMed: 24370973]
Author Manuscript

Leveque PM, Zeboulon P, Brasnu E, Baudouin C, Labbe A. Optic Disc Vascularization in Glaucoma:
Value of Spectral-Domain Optical Coherence Tomography Angiography. J Ophthalmol. 2016;
2016:6956717. [PubMed: 26998352]
Levison AL, Baynes KM, Lowder CY, Kaiser PK, Srivastava SK. Choroidal neovascularisation on
optical coherence tomography angiography in punctate inner choroidopathy and multifocal
choroiditis. Br J Ophthalmol. 2016
Li M, Yang Y, Jiang H, Gregori G, Roisman L, Zheng F, Ke B, Qu D, Wang J. Retinal Microvascular
Network and Microcirculation Assessments in High Myopia. Am J Ophthalmol. 2017; 174:56–
67. [PubMed: 27818204]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 58

Liu L, Gao SS, Bailey ST, Huang D, Li D, Jia Y. Automated choroidal neovascularization detection
algorithm for optical coherence tomography angiography. Biomed Opt Express. 2015; 6(9):
Author Manuscript

3564–3576. [PubMed: 26417524]

Liu L, Jia Y, Takusagawa HL, Pechauer AD, Edmunds B, Lombardi L, Davis E, Morrison JC, Huang
D. Optical Coherence Tomography Angiography of the Peripapillary Retina in Glaucoma. JAMA
Ophthalmol. 2015; 133(9):1045–1052. [PubMed: 26203793]
Liu L, Jia Y, Takusagawa HL, Pechauer AD, Edmunds B, Lombardi L, Davis E, Morrison JC, Huang
D. Optical Coherence Tomography Angiography of the Peripapillary Retina in Glaucoma. JAMA
Ophthalmol. 2015
Lupidi M, Coscas F, Cagini C, Fiore T, Spaccini E, Fruttini D, Coscas G. Automated Quantitative
Analysis of Retinal Microvasculature in Normal Eyes on Optical Coherence Tomography
Angiography. American Journal of Ophthalmology. 2016; 169:9–23. [PubMed: 27296485]
López-Sáez MP, Ordoqui E, Tornero P, Baeza A, Sainza T, Zubeldia JM, Baeza ML. Fluorescein-
induced allergic reaction. Ann Allergy Asthma Immunol. 1998; 81(5):428–430. [PubMed:
9860035]
Makita S, Hong Y, Yamanari M, Yatagai T, Yasuno Y. Optical coherence angiography. Opt Express.
Author Manuscript

2006; 14(17):7821–7840. [PubMed: 19529151]

Makita S, Jaillon F, Yamanari M, Miura M, Yasuno Y. Comprehensive in vivo micro-vascular imaging
of the human eye by dual-beam-scan Doppler optical coherence angiography. Opt Express. 2011;
19(2):1271–1283. [PubMed: 21263668]
Mammo Z, Balaratnasingam C, Yu P, Xu J, Heisler M, Mackenzie P, Merkur A, Kirker A, Albiani D,
Freund KB, Sarunic MV, Yu DY. Quantitative Noninvasive Angiography of the Fovea Centralis
Using Speckle Variance Optical Coherence Tomography. Invest Ophthalmol Vis Sci. 2015; 56(9):
5074–5086. [PubMed: 26237197]
Mammo Z, Heisler M, Balaratnasingam C, Lee S, Yu DY, Mackenzie P, Schendel S, Merkur A, Kirker
A, Albiani D, Navajas E, Beg MF, Morgan W, Sarunic MV. Quantitative Optical Coherence
Tomography Angiography of Radial Peripapillary Capillaries in Glaucoma, Glaucoma Suspect,
and Normal Eyes. Am J Ophthalmol. 2016; 170:41–49. [PubMed: 27470061]
Mansour AM, Schachat A, Bodiford G, Haymond R. Foveal avascular zone in diabetes mellitus.
Retina. 1993; 13(2):125–128. [PubMed: 8337493]
Mariampillai A, Leung MK, Jarvi M, Standish BA, Lee K, Wilson BC, Vitkin A, Yang VX. Optimized
Author Manuscript

speckle variance OCT imaging of microvasculature. Opt Lett. 2010; 35(8):1257–1259. [PubMed:
20410985]
Mariampillai A, Standish BA, Moriyama EH, Khurana M, Munce NR, Leung MK, Jiang J, Cable A,
Wilson BC, Vitkin IA, Yang VX. Speckle variance detection of microvasculature using swept-
source optical coherence tomography. Opt Lett. 2008; 33(13):1530–1532. [PubMed: 18594688]
Marmor MF, Choi SS, Zawadzki RJ, Werner JS. Visual insignificance of the foveal pit: reassessment
of foveal hypoplasia as fovea plana. Arch Ophthalmol. 2008; 126(7):907–913. [PubMed:
18625935]
Marschall S, Sander B, Mogensen M, Jorgensen TM, Andersen PE. Optical coherence tomography-
current technology and applications in clinical and biomedical research. Anal Bioanal Chem.
2011; 400(9):2699–2720. [PubMed: 21547430]
Mase T, Ishibazawa A, Nagaoka T, Yokota H, Yoshida A. Radial Peripapillary Capillary Network
Visualized Using Wide-Field Montage Optical Coherence Tomography Angiography. Invest
Ophthalmol Vis Sci. 2016; 57(9):OCT504–510. [PubMed: 27454659]
Author Manuscript

Mase T, Ishibazawa A, Nagaoka T, Yokota H, Yoshida A. Radial Peripapillary Capillary Network

Visualized Using Wide-Field Montage Optical Coherence Tomography Angiography.
Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT504–507. [PubMed: 27454659]
Matsunaga D, Yi J, Puliafito CA, Kashani AH. OCT Angiography in Healthy Human Subjects.
Ophthalmic Surgery, Lasers and Imaging Retina. 2014; 45(6):510–515.
Matsunaga DR, Yi JJ, De Koo LO, Ameri H, Puliafito CA, Kashani AH. Optical Coherence
Tomography Angiography of Diabetic Retinopathy in Human Subjects. Ophthalmic Surg Lasers
Imaging Retina. 2015; 46(8):796–805. [PubMed: 26431294]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 59

McLeod DS, Grebe R, Bhutto I, Merges C, Baba T, Lutty GA. Relationship between RPE and
choriocapillaris in age-related macular degeneration. Invest Ophthalmol Vis Sci. 2009; 50(10):
Author Manuscript

4982–4991. [PubMed: 19357355]

McNamara PM, Subhash HM, Leahy MJ. In vivo full-field en face correlation mapping optical
coherence tomography. J Biomed Opt. 2013; 18(12):126008. [PubMed: 24343439]
Mendis KR, Balaratnasingam C, Yu P, Barry CJ, McAllister IL, Cringle SJ, Yu D-Y. Correlation of
histologic and clinical images to determine the diagnostic value of fluorescein angiography for
studying retinal capillary detail. Investigative Ophthalmology & Visual Science. 2010; 51(11):
5864–5869. [PubMed: 20505200]
Miller AR, Roisman L, Zhang Q, Zheng F, Rafael de Oliveira Dias J, Yehoshua Z, Schaal KB, Feuer
W, Gregori G, Chu Z, Chen CL, Kubach S, An L, Stetson PF, Durbin MK, Wang RK, Rosenfeld
PJ. Comparison Between Spectral-Domain and Swept-Source Optical Coherence Tomography
Angiographic Imaging of Choroidal Neovascularization. Invest Ophthalmol Vis Sci. 2017; 58(3):
1499–1505. [PubMed: 28273316]
Mo S, Krawitz B, Efstathiadis E, Geyman L, Weitz R, Chui TYP, Carroll J, Dubra A, Rosen RB.
Imaging Foveal Microvasculature: Optical Coherence Tomography Angiography Versus Adaptive
Author Manuscript

Optics Scanning Light Ophthalmoscope Fluorescein Angiography. Investigative Ophthalmology

& Visual Science. 2016; 57(9):OCT130–111. [PubMed: 27409463]
Moghimi S, Hosseini H, Riddle J, Lee GY, Bitrian E, Giaconi J, Caprioli J, Nouri-Mahdavi K.
Measurement of optic disc size and rim area with spectral-domain OCT and scanning laser
ophthalmoscopy. Invest Ophthalmol Vis Sci. 2012; 53(8):4519–4530. [PubMed: 22577077]
Moore J, Bagley S, Ireland G, McLeod D, Boulton ME. Three dimensional analysis of
microaneurysms in the human diabetic retina. J Anat. 1999; 194(Pt 1):89–100. [PubMed:
10227670]
Moult E, Choi W, Waheed NK, Adhi M, Lee B, Lu CD, Jayaraman V, Potsaid B, Rosenfeld PJ, Duker
JS, Fujimoto JG. Ultrahigh-Speed Swept-Source OCT Angiography in Exudative AMD.
Ophthalmic Surgery, Lasers and Imaging Retina. 2014; 45(6):496–505.
Moult E, Choi W, Waheed NK, Adhi M, Lee B, Lu CD, Jayaraman V, Potsaid B, Rosenfeld PJ, Duker
JS, Fujimoto JG. Ultrahigh-speed swept-source OCT angiography in exudative AMD.
Ophthalmic Surg Lasers Imaging Retina. 2014; 45(6):496–505. [PubMed: 25423628]
Moult EM, Waheed NK, Novais EA, Choi W, Lee B, Ploner SB, Cole ED, Louzada RN, Lu CD,
Author Manuscript

Rosenfeld PJ, Duker JS, Fujimoto JG. Swept-Source Optical Coherence Tomography
Angiography Reveals Choriocapillaris Alterations in Eyes with Nascent Geographic Atrophy and
Drusen-Associated Geographic Atrophy. Retina. 2016; 36(Suppl 1):S2–S11. [PubMed:
28005659]
Moysidis SN, Koulisis N, Patel VR, Kashani AH, Rao NA, Humayun MS, Rodger DC. THE SECOND
BLIND SPOT: SMALL RETINAL VESSEL VASCULOPATHY AFTER VACCINATION
AGAINST NEISSERIA MENINGITIDIS AND YELLOW FEVER. Retin Cases Brief Rep. 2016
Muakkassa NW, Chin AT, de Carlo T, Klein KA, Baumal CR, Witkin AJ, Duker JS, Waheed NK.
Characterizing the Effect of Anti-Vascular Endothelial Growth Factor Therapy on Treatment-
Naive Choroidal Neovascularization Using Optical Coherence Tomography Angiography. Retina.
2015; 35(11):2252–2259. [PubMed: 26457400]
Nassif N, Cense B, Park BH, Yun SH, Chen TC, Bouma BE, Tearney GJ, de Boer JF. In vivo human
retinal imaging by ultrahigh-speed spectral domain optical coherence tomography. Opt Lett.
2004; 29(5):480–482. [PubMed: 15005199]
Author Manuscript

Nemiroff J, Kuehlewein L, Rahimy E, Tsui I, Doshi R, Gaudric A, Gorin MB, Sadda S, Sarraf D.
Assessing Deep Retinal Capillary Ischemia in Paracentral Acute Middle Maculopathy by Optical
Coherence Tomography Angiography. Am J Ophthalmol. 2016; 162:121–132 e121. [PubMed:
26562176]
Nesper PL, Soetikno BT, Fawzi AA. Choriocapillaris Non-Perfusion is Associated with Poor Visual
Acuity in Eyes with Reticular Pseudodrusen. Am J Ophthalmol. 2016
Novais EA, Adhi M, Moult EM, Louzada RN, Cole ED, Husvogt L, Lee B, Dang S, Regatieri CV,
Witkin AJ, Baumal CR, Hornegger J, Jayaraman V, Fujimoto JG, Duker JS, Waheed NK.
Choroidal Neovascularization Analyzed on Ultrahigh-Speed Swept-Source Optical Coherence

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 60

Tomography Angiography Compared to Spectral-Domain Optical Coherence Tomography

Angiography. Am J Ophthalmol. 2016; 164:80–88. [PubMed: 26851725]
Author Manuscript

NOVOTNY HR, ALVIS DL. A method of photographing fluorescence in circulating blood in the
human retina. Circulation. 1961; 24:82–86. [PubMed: 13729802]
Nunes RP, Goldhardt R, de Amorim Garcia Filho CA, Thorell MR, Abbey AM, Kuriyan AE, Modi
YS, Shah M, Yehoshua Z, Gregori G, Feuer W, Rosenfeld PJ. Spectral-domain optical coherence
tomography measurements of choroidal thickness and outer retinal disruption in macular
telangiectasia type 2. Ophthalmic Surg Lasers Imaging Retina. 2015; 46(2):162–170. [PubMed:
25707040]
Nunes RP, Gregori G, Yehoshua Z, Stetson PF, Feuer W, Moshfeghi AA, Rosenfeld PJ. Predicting the
progression of geographic atrophy in age-related macular degeneration with SD-OCT en face
imaging of the outer retina. Ophthalmic Surg Lasers Imaging Retina. 2013; 44(4):344–359.
[PubMed: 23883530]
Parodi MB, Visintin F, Della Rupe P, Ravalico G. Foveal avascular zone in macular branch retinal vein
occlusion. Int Ophthalmol. 1995; 19(1):25–28. [PubMed: 8537192]
Pece A, Sannace C, Menchini U, Virgili G, Galli L, Isola V, Brancato R. Fluorescein angiography and
Author Manuscript

indocyanine green angiography for identifying occult choroidal neovascularization in age-related

macular degeneration. Eur J Ophthalmol. 2005; 15(6):759–763.
Pechauer AD, Huang D, Jia Y. Detecting Blood Flow Response to Stimulation of the Human Eye.
Biomed Res Int. 2015; 2015:121973. [PubMed: 26504775]
Pederson JE, Herschler J. Reversal of glaucomatous cupping in adults. Arch Ophthalmol. 1982;
100(3):426–431. [PubMed: 7065960]
Penha FM, Rosenfeld PJ, Gregori G, Falcão M, Yehoshua Z, Wang F, Feuer WJ. Quantitative imaging
of retinal pigment epithelial detachments using spectral-domain optical coherence tomography.
Am J Ophthalmol. 2012; 153(3):515–523. [PubMed: 22030354]
Phasukkijwatana N, Tan AC, Chen X, Freund KB, Sarraf D. Optical coherence tomography
angiography of type 3 neovascularisation in age-related macular degeneration after
antiangiogenic therapy. Br J Ophthalmol. 2016
YJ, STB, DJW, OT, MLK, CJF, BP, JJL, CDL, MFK, JGF, DHMD. Quantitative Optical Coherence
Tomography Angiography of Choroidal Neovascularization in Age-Related Macular
Degeneration. Ophthalmology. 2014; 121(7):1435–1444. [PubMed: 24679442]
Author Manuscript

Pircher M, Hitzenberger CK, Schmidt-Erfurth U. Polarization sensitive optical coherence tomography

in the human eye. Prog Retin Eye Res. 2011; 30(6):431–451. [PubMed: 21729763]
Ploner SB, Moult EM, Choi W, Waheed NK, Lee B, Novais EA, Cole ED, Potsaid B, Husvogt L,
Schottenhamml J, Maier A, Rosenfeld PJ, Duker JS, Hornegger J, Fujimoto JG. TOWARD
QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: Visualizing
Blood Flow Speeds in Ocular Pathology Using Variable Interscan Time Analysis. Retina. 2016;
36(Suppl 1):S118–S126. [PubMed: 28005670]
Proskurin SG, He Y, Wang RK. Determination of flow velocity vector based on Doppler shift and
spectrum broadening with optical coherence tomography. Opt Lett. 2003; 28(14):1227–1229.
[PubMed: 12885029]
Querques G, Zambrowski O, Corvi F, Miere A, Semoun O, Srour M, Souied EH. Optical coherence
tomography angiography in adult-onset foveomacular vitelliform dystrophy. Br J Ophthalmol.
2016; 100(12):1724–1730. [PubMed: 26951771]
Rao HL, Kadambi SV, Weinreb RN, Puttaiah NK, Pradhan ZS, Rao DA, Kumar RS, Webers CA,
Author Manuscript

Shetty R. Diagnostic ability of peripapillary vessel density measurements of optical coherence

tomography angiography in primary open-angle and angle-closure glaucoma. Br J Ophthalmol.
2016
Reichel E, Duker JS, Puliafito CA. Indocyanine green angiography and choroidal neovascularization
obscured by hemorrhage. Ophthalmology. 1995; 102(12):1871–1876. [PubMed: 9098290]
Reichel E, Pollock DA, Duker JS, Puliafito CA. Indocyanine green angiography for recurrent choroidal
neovascularization in age-related macular degeneration. Ophthalmic Surg Lasers. 1995; 26(6):
513–518. [PubMed: 8746571]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 61

Remky A, Wolf S, Knabben H, Arend O, Reim M. Perifoveal capillary network in patients with acute
central retinal vein occlusion. Ophthalmology. 1997; 104(1):33–37. [PubMed: 9022101]
Author Manuscript

Rispoli M, Savastano MC, Lumbroso B. Capillary Network Anomalies in Branch Retinal Vein
Occlusion on Optical Coherence Tomography Angiography. Retina. 2015; 35(11):2332–2338.
[PubMed: 26502008]
Riva CE, Grunwald JE, Sinclair SH. Laser Doppler Velocimetry study of the effect of pure oxygen
breathing on retinal blood flow. Invest Ophthalmol Vis Sci. 1983; 24(1):47–51. [PubMed:
6826314]
Roisman L, Rosenfeld PJ. Optical Coherence Tomography Angiography of Macular Telangiectasia
Type 2. Dev Ophthalmol. 2016; 56:146–158. [PubMed: 27022942]
Roisman L, Zhang Q, Wang RK, Gregori G, Zhang A, Chen CL, Durbin MK, An L, Stetson PF,
Robbins G, Miller A, Zheng F, Rosenfeld PJ. Optical Coherence Tomography Angiography of
Asymptomatic Neovascularization in Intermediate Age-Related Macular Degeneration.
Ophthalmology. 2016; 123(6):1309–1319. [PubMed: 26876696]
Rosenfeld PJ. Optical Coherence Tomography and the Development of Antiangiogenic Therapies in
Neovascular Age-Related Macular Degeneration. Invest Ophthalmol Vis Sci. 2016;
Author Manuscript

57(9):OCT14–26. [PubMed: 27409464]

Ryan, SJ., Schachat, AP., Wilkinson, CP., Hinton, DR., Sadda, SR., Wiedeman, P. Retina. 5. Elsevier;
2013.
Samara WA, Say EA, Khoo CT, Higgins TP, Magrath G, Ferenczy S, Shields CL. Correlation of
Foveal Avascular Zone Size with Foveal Morphology in Normal Eyes Using Optical Coherence
Tomography Angiography. Retina. 2015; 35(11):2188–2195. [PubMed: 26469536]
Schmitt JM, Xiang SH, Yung KM. Speckle in optical coherence tomography. J Biomed Opt. 1999;
4(1):95–105. [PubMed: 23015175]
Schwartz DM, Fingler J, Kim DY, Zawadzki RJ, Morse LS, Park SS, Fraser SE, Werner JS. Phase-
variance optical coherence tomography: a technique for noninvasive angiography.
Ophthalmology. 2014; 121(1):180–187. [PubMed: 24156929]
Scoles D, Gray DC, Hunter JJ, Wolfe R, Gee BP, Geng Y, Masella BD, Libby RT, Russell S, Williams
DR, Merigan WH. In-vivo imaging of retinal nerve fiber layer vasculature: imaging histology
comparison. BMC Ophthalmol. 2009; 9:9. [PubMed: 19698151]
Author Manuscript

Scripsema NK, Garcia PM, Bavier RD, Chui TY, Krawitz BD, Mo S, Agemy SA, Xu L, Lin YB,
Panarelli JF, Sidoti PA, Tsai JC, Rosen RB. Optical Coherence Tomography Angiography
Analysis of Perfused Peripapillary Capillaries in Primary Open-Angle Glaucoma and Normal-
Tension Glaucoma. Invest Ophthalmol Vis Sci. 2016; 57(9):OCT611–OCT620. [PubMed:
27742922]
Shi Y, Gahm J, Kashani A. Curvelet-based Vessel Enhancement for 3D OCT Angiography.
Association for Research In Vision and Ophthalmology (ARVO). 2017 Abstract 2017.
Snodderly DM, Weinhaus RS, Choi JC. Neural-vascular relationships in central retina of macaque
monkeys (Macaca fascicularis). J Neurosci. 1992; 12(4):1169–1193. [PubMed: 1556592]
Son T, Wang B, Thapa D, Lu Y, Chen Y, Cao D, Yao X. Optical coherence tomography angiography of
stimulus evoked hemodynamic responses in individual retinal layers. Biomedical optics express.
2016; 7(8):3151–3112. [PubMed: 27570706]
Sophie R, Hafiz G, Scott AW, Zimmer-Galler I, Nguyen QD, Ying H, Do DV, Solomon S, Sodhi A,
Gehlbach P, Duh E, Baranano D, Campochiaro PA. Long-term outcomes in ranibizumab-treated
patients with retinal vein occlusion; the role of progression of retinal nonperfusion. Am J
Author Manuscript

Ophthalmol. 2013; 156(4):693–705. [PubMed: 24053892]

Spaide RF. Volume-Rendered Optical Coherence Tomography of Diabetic Retinopathy Pilot Study.
Am J Ophthalmol. 2015; 160(6):1200–1210. [PubMed: 26384548]
Spaide RF. Choriocapillaris Flow Features Follow a Power Law Distribution: Implications for
Characterization and Mechanisms of Disease Progression. Am J Ophthalmol. 2016; 170:58–67.
[PubMed: 27496785]
Spaide RF, Fujimoto JG, Waheed NK. Image Artifacts in Optical Coherence Tomography
Angiography. Retina. 2015; 35(11):2163–2180. [PubMed: 26428607]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 62

Spaide RF, Fujimoto JG, Waheed NK. IMAGE ARTIFACTS IN OPTICAL COHERENCE
TOMOGRAPHY ANGIOGRAPHY. Retina (Philadelphia, Pa). 2015; 35(11):1–18.
Author Manuscript

Spaide RF, Klancnik JM, Cooney MJ, Yannuzzi LA, Balaratnasingam C, Dansingani KK, Suzuki M.
Volume-Rendering Optical Coherence Tomography Angiography of Macular Telangiectasia Type
2. Ophthalmology. 2015:1–9.
Spaide RF, Klancnik JM Jr, Cooney MJ, Yannuzzi LA, Balaratnasingam C, Dansingani KK, Suzuki M.
Volume-Rendering Optical Coherence Tomography Angiography of Macular Telangiectasia Type
2. Ophthalmology. 2015; 122(11):2261–2269. [PubMed: 26315043]
Spaide RF, Klancnik JM Jr, Cooney MJ. Retinal Vascular Layers Imaged by Fluorescein Angiography
and Optical Coherence Tomography Angiography. JAMA Ophthalmology. 2015; 133(1):45.
[PubMed: 25317632]
Squirrell DM, Watts A, Evans D, Mody C, Talbot JF. A prospective evaluation of the Heidelberg retina
flowmeter in diagnosing ischaemia following branch retinal vein occlusion: a masked, controlled
comparison with fluorescein angiography. Eye (Lond). 2001; 15(Pt 3):261–266. [PubMed:
11450717]
Stitt AW, Curtis TM, Chen M, Medina RJ, McKay GJ, Jenkins A, Gardiner TA, Lyons TJ, Hammes
Author Manuscript

HP, Simó R, Lois N. The progress in understanding and treatment of diabetic retinopathy. Prog
Retin Eye Res. 2016; 51:156–186. [PubMed: 26297071]
Stitt AW, Gardiner TA, Archer DB. Histological and ultrastructural investigation of retinal
microaneurysm development in diabetic patients. Br J Ophthalmol. 1995; 79(4):362–367.
[PubMed: 7742285]
Suh MH, Zangwill LM, Manalastas PI, Belghith A, Yarmohammadi A, Medeiros FA, Diniz-Filho A,
Saunders LJ, Weinreb RN. Deep Retinal Layer Microvasculature Dropout Detected by the
Optical Coherence Tomography Angiography in Glaucoma. Ophthalmology. 2016; 123(12):
2509–2518. [PubMed: 27769587]
Suh MH, Zangwill LM, Manalastas PI, Belghith A, Yarmohammadi A, Medeiros FA, Diniz-Filho A,
Saunders LJ, Yousefi S, Weinreb RN. Optical Coherence Tomography Angiography Vessel
Density in Glaucomatous Eyes with Focal Lamina Cribrosa Defects. Ophthalmology. 2016;
123(11):2309–2317. [PubMed: 27592175]
Szkulmowska A, Szkulmowski M, Szlag D, Kowalczyk A, Wojtkowski M. Three-dimensional
quantitative imaging of retinal and choroidal blood flow velocity using joint Spectral and Time
Author Manuscript

domain Optical Coherence Tomography. Opt Express. 2009; 17(13):10584–10598. [PubMed:

19550454]
Takase N, Nozaki M, Kato A, Ozeki H, Yoshida M, Ogura Y. Enlargement of Foveal Avascular Zone
in Diabetic Eyes Evaluated by En Face Optical Coherence Tomography Angiography. Retina.
2015; 35(11):2377–2383. [PubMed: 26457396]
Takayama K, Ito Y, Kaneko H, Kataoka K, Ra E, Terasaki H. Optical coherence tomography
angiography in leber hereditary optic neuropathy. Acta Ophthalmol. 2016
Tan AC, Dansingani KK, Yannuzzi LA, Sarraf D, Freund KB. Type 3 Neovascularization Imaged with
Cross-Sectional and En Face Optical Coherence Tomography Angiography. Retina. 2016
Tan CS, Lim LW, Chow VS, Chay IW, Tan S, Cheong KX, Tan GT, Sadda SR. Optical Coherence
Tomography Angiography Evaluation of the Parafoveal Vasculature and Its Relationship With
Ocular Factors. Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT224–211.
[PubMed: 27409476]
Tan PE, Balaratnasingam C, Xu J, Mammo Z, Han SX, Mackenzie P, Kirker AW, Albiani D, Merkur
Author Manuscript

AB, Sarunic MV, Yu DY. Quantitative Comparison of Retinal Capillary Images Derived By
Speckle Variance Optical Coherence Tomography With Histology. Invest Ophthalmol Vis Sci.
2015; 56(6):3989–3996. [PubMed: 26098464]
Tao YK, Kennedy KM, Izatt JA. Velocity-resolved 3D retinal microvessel imaging using single-pass
flow imaging spectral domain optical coherence tomography. Opt Express. 2009; 17(5):4177–
4188. [PubMed: 19259254]
Thorell MR, Nunes RP, Chen GW, Doshi RR, Dugar J, George MK, Kim BT, Lowrance MD, Modi D,
Nahas Z, Gregori G, Yehoshua Z, Feuer W, Rosenfeld PJ. Response to aflibercept after frequent

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 63

re-treatment with bevacizumab or ranibizumab in eyes with neovascular AMD. Ophthalmic Surg
Lasers Imaging Retina. 2014; 45(6):526–533. [PubMed: 25423632]
Author Manuscript

Thorell MR, Zhang Q, Huang Y, An L, Durbin MK, Laron M, Sharma U, Stetson PF, Gregori G, Wang
RK, Rosenfeld PJ. Swept-source OCT angiography of macular telangiectasia type 2. Ophthalmic
Surg Lasers Imaging Retina. 2014; 45(5):369–380. [PubMed: 25291783]
Thorell MR, Zhang Q, Huang Y, An L, Durbin MK, Laron M, Sharma U, Stetson PF, Gregori G, Wang
RK, Rosenfeld PJ. Swept-Source OCT Angiography of Macular Telangiectasia Type 2.
Ophthalmic Surgery, Lasers and Imaging Retina. 2014; 45(5):369–380.
Tick S, Rossant F, Ghorbel I, Gaudric A, Sahel JA, Chaumet-Riffaud P, Paques M. Foveal shape and
structure in a normal population. Invest Ophthalmol Vis Sci. 2011; 52(8):5105–5110. [PubMed:
21803966]
Tokayer J, Jia Y, Dhalla A-H, Huang D. Blood flow velocity quantification using split-spectrum
amplitude-decorrelation angiography with optical coherence tomography. Biomedical optics
express. 2013; 4(10):1909. [PubMed: 24156053]
Tokayer J, Jia Y, Dhalla AH, Huang D. Blood flow velocity quantification using split-spectrum
amplitude-decorrelation angiography with optical coherence tomography. Biomed Opt Express.
Author Manuscript

2013; 4(10):1909–1924. [PubMed: 24156053]

Told R, Ginner L, Hecht A, Sacu S, Leitgeb R, Pollreisz A, Schmidt-Erfurth U. Comparative study
between a spectral domain and a high-speed single-beam swept source OCTA system for
identifying choroidal neovascularization in AMD. Sci Rep. 2016; 6:38132. [PubMed: 27917889]
Tomic L, Bjärnhall G, Mäepea O, Sperber GO, Alm A. Effects of oxygen and carbon dioxide on
human retinal circulation: an investigation using blue field simulation and scanning laser
ophthalmoscopy. Acta Ophthalmol Scand. 2005; 83(6):705–710. [PubMed: 16396648]
Toto L, Di Antonio L, Mastropasqua R, Mattei PA, Carpineto P, Borrelli E, Rispoli M, Lumbroso B,
Mastropasqua L. Multimodal Imaging of Macular Telangiectasia Type 2: Focus on Vascular
Changes Using Optical Coherence Tomography Angiography. Investigative Ophthalmology &
Visual Science. 2016; 57(9):OCT268–269. [PubMed: 27409482]
Tsai CS, Shin DH, Wan JY, Zeiter JH. Visual field global indices in patients with reversal of
glaucomatous cupping after intraocular pressure reduction. Ophthalmology. 1991; 98(9):1412–
1419. [PubMed: 1945318]
Velez-Montoya R, Oliver SC, Olson JL, Fine SL, Mandava N, Quiroz-Mercado H. Current knowledge
Author Manuscript

and trends in age-related macular degeneration: today’s and future treatments. Retina. 2013;
33(8):1487–1502. [PubMed: 23222393]
Waisbourd M, Ahmed OM, Molineaux J, Gonzalez A, Spaeth GL, Katz LJ. Reversible structural and
functional changes after intraocular pressure reduction in patients with glaucoma. Graefes Arch
Clin Exp Ophthalmol. 2016; 254(6):1159–1166. [PubMed: 26995555]
Wang Q, Chan S, Yang JY, You B, Wang YX, Jonas JB, Bin Wei W. Vascular Density in Retina and
Choriocapillaris as Measured by Optical Coherence Tomography Angiography. AJOPHT. 2016;
168(C):95–109.
Wang R, Kirkpatrick S, Hinds M. Phase Sensitive Optical Coherence Elastography for Mapping Tissue
Micro-Strains in Real Time. Applied Physics Letters. Apr.2007 90(164105)
Wang R, Ma Z, KSJ. Tissue Doppler optical coherence elastography for real time strain rate and strain
mapping of soft tissue. Applied Physics Letters. Oct.2006 89(144103)
Wang RK. Optical Microangiography: A Label Free 3D Imaging Technology to Visualize and
Quantify Blood Circulations within Tissue Beds in vivo. IEEE J Sel Top Quantum Electron.
Author Manuscript

2010; 16(3):545–554. [PubMed: 20657761]

Wang RK, An L, Francis P, Wilson DJ. Depth-resolved imaging of capillary networks in retina and
choroid using ultrahigh sensitive optical microangiography. Opt Lett. 2010; 35(9):1467–1469.
[PubMed: 20436605]
Wang RK, An L, Saunders S, Wilson DJ. Optical microangiography provides depth-resolved images of
directional ocular blood perfusion in posterior eye segment. J Biomed Opt. 2010; 15(2):020502.
[PubMed: 20459216]
Wang RK, Jacques SL, Ma Z, Hurst S, Hanson SR, Gruber A. Three dimensional optical angiography.
Opt Express. 2007; 15(7):4083–4097. [PubMed: 19532651]

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 64

Wang RK, Zhang A, Choi WJ, Zhang Q, Chen CL, Miller A, Gregori G, Rosenfeld PJ. Wide-field
optical coherence tomography angiography enabled by two repeated measurements of B-scans.
Author Manuscript

Opt Lett. 2016; 41(10):2330–2333. [PubMed: 27176995]

Wang X, Jia Y, Spain R, Potsaid B, Liu JJ, Baumann B, Hornegger J, Fujimoto JG, Wu Q, Huang D.
Optical coherence tomography angiography of optic nerve head and parafovea in multiple
sclerosis. Br J Ophthalmol. 2014; 98(10):1368–1373. [PubMed: 24831719]
Wang X, Jiang C, Ko T, Kong X, Yu X, Min W, Shi G, Sun X. Correlation between optic disc
perfusion and glaucomatous severity in patients with open-angle glaucoma: an optical coherence
tomography angiography study. Graefes Arch Clin Exp Ophthalmol. 2015; 253(9):1557–1564.
[PubMed: 26255817]
Wei E, Jia Y, Tan O, Potsaid B, Liu JJ, Choi W, Fujimoto JG, Huang D. Parafoveal Retinal Vascular
Response to Pattern Visual Stimulation Assessed with OCT Angiography. PLoS ONE. 2013;
8(12):e81343. [PubMed: 24312549]
Weinhaus RS, Burke JM, Delori FC, Snodderly DM. Comparison of fluorescein angiography with
microvascular anatomy of macaque retinas. Experimental Eye Research. 1995; 61(1):1–16.
[PubMed: 7556462]
Author Manuscript

Willoughby AS, Ying GS, Toth CA, Maguire MG, Burns RE, Grunwald JE, Daniel E, Jaffe GJ. CoA-
RMDTTR Group. Subretinal Hyperreflective Material in the Comparison of Age-Related
Macular Degeneration Treatments Trials. Ophthalmology. 2015; 122(9):1846–1853.e1845.
[PubMed: 26143666]
Wilson DJ, Finkelstein D, Quigley HA, Green WR. Macular grid photocoagulation. An experimental
study on the primate retina. Arch Ophthalmol. 1988; 106(1):100–105. [PubMed: 3337683]
Wittstrom E, Schatz P, Lovestam-Adrian M, Ponjavic V, Bergstrom A, Andreasson S. Improved retinal
function after trabeculectomy in glaucoma patients. Graefes Arch Clin Exp Ophthalmol. 2010;
248(4):485–495. [PubMed: 19865823]
Wojtkowski M, Leitgeb R, Kowalczyk A, Bajraszewski T, Fercher AF. In vivo human retinal imaging
by Fourier domain optical coherence tomography. J Biomed Opt. 2002; 7(3):457–463. [PubMed:
12175297]
Wojtkowski M, Srinivasan V, Ko T, Fujimoto J, Kowalczyk A, Duker J. Ultrahigh-resolution, high-
speed, Fourier domain optical coherence tomography and methods for dispersion compensation.
Opt Express. 2004; 12(11):2404–2422. [PubMed: 19475077]
Author Manuscript

Wu Z, Luu CD, Ayton LN, Goh JK, Lucci LM, Hubbard WC, Hageman JL, Hageman GS, Guymer
RH. Optical coherence tomography-defined changes preceding the development of drusen-
associated atrophy in age-related macular degeneration. Ophthalmology. 2014; 121(12):2415–
2422. [PubMed: 25109931]
Xu H, Deng G, Jiang C, Kong X, Yu J, Sun X. Microcirculatory Responses to Hyperoxia in Macular
and Peripapillary Regions. Invest Ophthalmol Vis Sci. 2016; 57(10):4464–4468. [PubMed:
27750288]
Xu J, Han S, Balaratnasingam C, Mammo Z, Wong KS, Lee S, Cua M, Young M, Kirker A, Albiani D,
Forooghian F, Mackenzie P, Merkur A, Yu DY, Sarunic MV. Retinal angiography with real-time
speckle variance optical coherence tomography. Br J Ophthalmol. 2015; 99(10):1315–1319.
[PubMed: 25733527]
Yang Y, Wang J, Jiang H, Yang X, Feng L, Hu L, Wang L, Lu F, Shen M. Retinal Microvasculature
Alteration in High Myopia. Invest Ophthalmol Vis Sci. 2016; 57(14):6020–6030. [PubMed:
27820633]
Author Manuscript

Yannuzzi LA. Indocyanine green angiography: a perspective on use in the clinical setting. Am J
Ophthalmol. 2011; 151(5):745–751.e741. [PubMed: 21501704]
Yannuzzi LA, Rohrer KT, Tindel LJ, Sobel RS, Costanza MA, Shields W, Zang E. Fluorescein
angiography complication survey. Ophthalmology. 1986; 93(5):611–617. [PubMed: 3523356]
Yannuzzi LA, Slakter JS, Sorenson JA, Guyer DR, Orlock DA. Digital indocyanine green
videoangiography and choroidal neovascularization. Retina. 1992; 12(3):191–223. [PubMed:
1384094]
Yarmohammadi A, Zangwill LM, Diniz-Filho A, Suh MH, Manalastas PI, Fatehee N, Yousefi S,
Belghith A, Saunders LJ, Medeiros FA, Huang D, Weinreb RN. Optical Coherence Tomography

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 65

Angiography Vessel Density in Healthy, Glaucoma Suspect, and Glaucoma Eyes. Invest
Ophthalmol Vis Sci. 2016; 57(9):OCT451–459. [PubMed: 27409505]
Author Manuscript

Yarmohammadi A, Zangwill LM, Diniz-Filho A, Suh MH, Yousefi S, Saunders LJ, Belghith A,
Manalastas PI, Medeiros FA, Weinreb RN. Relationship between Optical Coherence Tomography
Angiography Vessel Density and Severity of Visual Field Loss in Glaucoma. Ophthalmology.
2016; 123(12):2498–2508. [PubMed: 27726964]
Yeung L, Lima VC, Garcia P, Landa G, Rosen RB. Correlation between spectral domain optical
coherence tomography findings and fluorescein angiography patterns in diabetic macular edema.
Ophthalmology. 2009; 116(6):1158–1167. [PubMed: 19395034]
Yousefi S, Wang RK. Simultaneous estimation of bidirectional particle flow and relative flux using
MUSIC-OCT: phantom studies. Physics in medicine and biology. 2014; 59(22):6693. [PubMed:
25327449]
Yousefi S, Zhi Z, Wang RK. Eigendecomposition-based clutter filtering technique for optical micro-
angiography. IEEE Trans Biomed Eng. 2011; 58(8)
Yu J, Gu R, Zong Y, Xu H, Wang X, Sun X, Jiang C, Xie B, Jia Y, Huang D. Relationship Between
Retinal Perfusion and Retinal Thickness in Healthy Subjects: An Optical Coherence Tomography
Author Manuscript

Angiography Study. Investigative Ophthalmology & Visual Science. 2016; 57(9):OCT204–207.

[PubMed: 27409474]
Yu PK, Balaratnasingam C, Xu J, Morgan WH, Mammo Z, Han S, Mackenzie P, Merkur A, Kirker A,
Albiani D, Sarunic MV, Yu DY. Label-Free Density Measurements of Radial Peripapillary
Capillaries in the Human Retina. PLoS One. 2015; 10(8):e0135151. [PubMed: 26252395]
Zahid S, Dolz-Marco R, Freund KB, Balaratnasingam C, Dansingani K, Gilani F, Mehta N, Young E,
Klifto MR, Chae B, Yannuzzi LA, Young JA. Fractal Dimensional Analysis of Optical Coherence
Tomography Angiography in Eyes With Diabetic Retinopathy. Investigative Ophthalmology &
Visual Science. 2016; 57(11):4940–4948. [PubMed: 27654421]
Zhang A, Zhang Q, Chen CL, Wang RK. Methods and algorithms for optical coherence tomography-
based angiography: a review and comparison. J Biomed Opt. 2015; 20(10):100901. [PubMed:
26473588]
Zhang A, Zhang Q, Wang RK. Minimizing projection artifacts for accurate presentation of choroidal
neovascularization in OCT micro-angiography. Biomed Opt Express. 2015; 6(10):4130–4143.
[PubMed: 26504660]
Author Manuscript

Zhang M, Hwang TS, Campbell JP, Bailey ST, Wilson DJ, Huang D, Jia Y. Projection-resolved optical
coherence tomographic angiography. Biomed Opt Express. 2016; 7(3):816–828. [PubMed:
27231591]
Zhang M, Hwang TS, Dongye C, Wilson DJ, Huang D, Jia Y. Automated Quantification of
Nonperfusion in Three Retinal Plexuses Using Projection-Resolved Optical Coherence
Tomography Angiography in Diabetic Retinopathy. Invest Ophthalmol Vis Sci. 2016; 57(13):
5101–5106. [PubMed: 27699408]
Zhang Q, Chen CL, Chu Z, Zheng F, Miller A, Roisman L, Rafael de Oliveira Dias J, Yehoshua Z,
Schaal KB, Feuer W, Gregori G, Kubach S, An L, Stetson PF, Durbin MK, Rosenfeld PJ, Wang
RK. Automated Quantitation of Choroidal Neovascularization: A Comparison Study Between
Spectral-Domain and Swept-Source OCT Angiograms. Invest Ophthalmol Vis Sci. 2017; 58(3):
1506–1513. [PubMed: 28273317]
Zhang Q, Lee CS, Chao J, Chen CL, Zhang T, Sharma U, Zhang A, Liu J, Rezaei K, Pepple KL,
Munsen R, Kinyoun J, Johnstone M, Van Gelder RN, Wang RK. Wide-field optical coherence
Author Manuscript

tomography based microangiography for retinal imaging. Sci Rep. 2016; 6:22017. [PubMed:
26912261]
Zhang Q, Wang RK, Chen CL, Legarreta AD, Durbin MK, An L, Sharma U, Stetson PF, Legarreta JE,
Roisman L, Gregori G, Rosenfeld PJ. SWEPT SOURCE OPTICAL COHERENCE
TOMOGRAPHY ANGIOGRAPHY OF NEOVASCULAR MACULAR TELANGIECTASIA
TYPE 2. Retina. 2015; 35(11):2285–2299. [PubMed: 26457402]
Zhang Q, Zhang A, Lee CS, Lee AY, Rezaei KA, Roisman L, Miller A, Zheng F, Gregori G, Durbin
MK, An L, Stetson PF, Rosenfeld PJ, Wang RK. Projection Artifact Removal Improves
Visualization and Quantitation of Macular Neovascularization Imaged by Optical Coherence
Tomography Angiography. Ophthalmology Retina.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 66

Zotter S, Pircher M, Torzicky T, Bonesi M, Gotzinger E, Leitgeb RA, Hitzenberger CK. Visualization
of microvasculature by dual-beam phase-resolved Doppler optical coherence tomography. Opt
Author Manuscript

Express. 2011; 19(2):1217–1227. [PubMed: 21263663]

Author Manuscript
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 67

Highlights
Author Manuscript

OCTA images are based on the variable backscattering of light from the vascular
and neurosensory tissue in the retina and provide reliable, high resolution, and
non-invasive images of the retinal vasculature in a clinically feasible manner.

OCTA images are approaching histology level resolution and can reliably
demonstrate areas of impaired perfusion, microaneurysms, capillary remodeling,
some types of intraretinal fluid, and neovascularization within the macula.
OCTA provides high-resolution and depth-resolved information that has never
before been available with dye based angiography methods such as fluorescein
angiography.

OCTA can demonstrate clinically significant features of prevalent retinal vascular

Author Manuscript

diseases such as diabetic retinopathy, retinal venous occlusion, age-related

macular degeneration, glaucoma and uveitis.

Quantitative OCTA metrics are being developed and show good correlation with
clinical disease severity in several diseases including diabetic retinopathy, retinal
venous occlusion, and uveitis.

A key limitation of current FDA approved spectral domain OCTA systems is the
limited resolution of lesions underneath the retinal pigment epithelium and the
field-of-view that is limited to the macula. Swept-source OCTA devices are very
likely to overcome these limitations in the near future.

A key limitation of current OCTA metrics and imaging methods is that results are
displayed and interpreted in a two-dimensional manner and encompass only the
Author Manuscript

macula. Future advances in three-dimensional and wide-field metrics and

rendering methods are promising to provide more accurate and novel information
about retinal vascular changes in various diseases.
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 68
Author Manuscript
Author Manuscript

Figure 1.
Illustration of OCTA scanning methodology and signal processing scheme. This figure
illustrates the theoretical difference in the behavior of OCT beams that interact with retinal
tissue depending whether the beams strike blood vessels or neurosensory retinal tissue. At
time T1, two OCT beams are incident on the retinal tissue. Beam A1 (red) strikes a retinal
artery while beam A2 (blue) strikes adjacent neurosensory retinal tissue that is static. Each
beam is back-scattered and generates an A-scan signal shown in the middle. Similarly, at
time T2 another scan is performed and illustrated. The interaction of the incident light from
beam A1 with moving red blood cells causes more variability in the OCT signal from beam
A1 as illustrated in the A-scan signal traces. These signals are then “averaged” as shown by
the black arrows to generate a composite OCTA signal that is illustrated in the far right of
Author Manuscript

the panel. The increased variability of the OCT signal from beam A1 is illustrated and is
localized to the regions where red blood cell movement occurred. A sample B-scan is
illustrated in the lower right of the panel.
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 69
Author Manuscript

Figure 2.
Demonstration of various field-of-views in OCTA. (A) 3×3mm2 (B) 6×6mm2 and (C)
8×8mm2 field-of-view pseudocolored OCTA of a normal subject. Red represents superficial
retinal layer. Green represents deep retinal layer. Yellow represents regions of overlay.
Images are from an AngioPlex™ device (Carl Zeiss Meditec).
Author Manuscript
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 70
Author Manuscript
Author Manuscript

Figure 3.
Curvelet-based denoising of OCTA from a normal control (the first row, A–C) and from a
patient with diabetic retinopathy (the second row, D–F). The color-coded en face maximum
intensity projection of the superficial layer are shown to demonstrate the 3D depth of the
retinal vasculature for the original (the first column, A and C) and denoised (the second
column, B and E) OCTA. Non-color coded, volume rendered and denoised OCTA using 3D
Slicer are shown in the third column (C,F). Color coding in first two columns represents the
depth of retinal vessels within the displayed data set for the superficial retinal layer. (Red
represents the most superficial, green deeper and blue the deepest capillaries within the
superifical retinal layer that is shown). Note that only the superficial retinal layer is shown in
Author Manuscript

this data set so the color coding does not correspond to that in other figures.
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 71
Author Manuscript

Figure 4.
Fluorescein angiogram and corresponding OCT and OCTA images of subject with mild-
moderate nonproliferative diabetic retinopathy on clinical exam. (A) Fluorescein angiogram
in the late phase shows an area of hypofluorescence that is consistent with impaired
perfusion. The white dotted lines represent the area of the FA shown in the OCTA image in
the last panel. (B1) An B-scan from the OCTA dataset through the superior macula showing
Author Manuscript

a small area of intraretinal fluid. (B2) An B-scan through the fovea. (C) OCTA
corresponding to the area of the white-dotted box in panel (A). There are clear areas of
impaired perfusion on the OCTA. The dotted lines represent the location of the B-scans in
panel B.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 72
Author Manuscript
Author Manuscript
Author Manuscript

Figure 5.
OCTA of subject with proliferative diabetic retinopathy and neovascularization of the disc.
(A) Depth encoded OCTA of optic nerve head demonstrates a significant area of superifical
(red) OCTA signal corresponding to the neovascularziation above the disc on the (B) B-scan.
Red represents superficial retinal layer. In this case the neovascularization is red because it is
in the vitreous and above the superficial retinal layer. Green represents DRL. Yellow
Author Manuscript

represents regions of overlay.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 73
Author Manuscript

Figure 6.
Images from a subject with severe nonproliferative diabetic retinopathy and macular edema.
(A) Color fundus image shows diffuse areas of hard exudate and intraretinal hemorrhage.
Author Manuscript

(B) Fluorescein angiogram shows numerous microaneurysms but no clear leakage or

diabetic macular edema in mid to late frames. (C) OCTA of the central 3×3mm2 shows
irregularities in the capillary network and foveal avascular zone as well as an area of
increased OCTA signal covering the majority of the fovea (red). This area corresponds to the
area of hyperreflective cystoid change seen in (D) B-scan cross section through the fovea.
Note the hard exudates on the OCT B-scan. The appearance of the OCTA hyperreflectivity
is subjectively correlated with presence of hard exudates in at least some cases and referred
to as small scattering particles in motion or SPPiM
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 74
Author Manuscript
Author Manuscript

Figure 7.
Images from an asymptomatic subject with minimal nonproliferative diabetic retinopathy
and 20/20 vision. (A) Color fundus photograph, (B) Depth-encoded OCTA shows an
irregular foveal avascular zone and some pockets of mild impaired capillary perfusion in the
periphery of the images. These findings were not visible on clinical exam or other imaging
modalities. (C) B-scan through the fovea shows no intraretinal fluid.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 75
Author Manuscript

Figure 8.
OCTA of a 36 year old female with a chronic (>1 year) retinal vascular occlusion and inner
retinal atrophy involving the superior macula but sparing the fovea. (A) Depth encoded
Author Manuscript

pseudocolored map of the superficial and mid-retinal vasculature. Red = superficial

vasculature. Green = middle retinal vasculature. Yellow = red/green overlay. (B) Raw OCTA
intensity image of superficial layer demonstrates lack of superficial blood flow in most of
the superior half of the macula and apparent decreased vascular density in most of superior
retina. (C) Raw OCTA intensity image of mid-retinal vasculature demonstrates similar
extensive loss of blood flow characteristic of the mid-retinal layer in superior macula. The
OCTA signal from the larger retinal vessels in the superior macula are not characteristic of
the mid-retinal layer and appear here because of the atrophy of the inner retina and
displacement of the larger retinal vessels deeper into the retina as shown in the B-scans
below. (E–H) Segmentation of corresponding layers shown in the B-scan at the level of the
fine blue line in above images.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 76
Author Manuscript
Author Manuscript

Figure 9.
En face SD-OCTA images of the superficial retinal slab from (A) normal subject and (B)
patient’s left eye demonstrates an inferotemporal perfusion defect consistent with
inferotemporal glaucomatous damage.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 77
Author Manuscript
Author Manuscript

Figure 10.
OCTA of subjects with various types of choroidal neovascularization (CNV). (A1–4) Type 1
macular neovascularization. (A1) The CNV is shown by the en face OCTA slab with the
inner boundary as the retinal pigment epithelium (RPE) line and the outer boundary as the
Author Manuscript

RPE-fit line (Bruch’s membrane). (A2) The en face structural image shows intensity
variations within the slab. (A3–4) Corresponding B-scans with the slab segmentations lines,
with and without the flow signal. Note that the lesion is located below the RPE and above
Bruch’s membrane. (B1–4) Type 2 macular neovascularization. (B1) The CNV is shown by
the en face OCTA slab with the inner boundary defined by from the outer plexiform layer
and the outer boundary located at 37 μm under Bruch’s membrane. (B2) The en face
structural image shows intensity variations within the slab. (B3–4) Corresponding B-scans
with the slab segmentations lines, with and without the flow signal. Note that the lesion is
located above the RPE. (C1–4) Type 3 macular neovascularization (retinal angiomatous
proliferation). (C1) Depth encoded en face OCTA slab shows a bright green focal lesion just
superior to the fovea. There are focal areas with a poorly defined flow signal that represent
suspended scattering particles in motion (SSPiM) associated with cystic intraretinal cavities
Author Manuscript

(arrow). (C2) The en face structural image demonstrates hyporeflective cystic spaces
consistent with the intraretinal fluid. (C3–4) Corresponding B-scans with the slab
segmentations lines, with and without the flow signal. Note that the neovascular flow lesion
is located within the retina along with areas of SSPIM.

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 78
Author Manuscript

Figure 11.
Subject with microscopic polyangitis and macular edema. (A) Depth encoded OCTA shows
Author Manuscript

diffuse and severe vascular changes in the superior macula. There are focal dilatations of the
capillaries and regions of microaneurysmal changes. (B) Superficial retinal layer and (C)
DRL slabs shown separately for clarity. (D) B-scan through the fovea from OCTA dataset
shows macular edema.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 79
Author Manuscript
Author Manuscript
Author Manuscript

Figure 12.
Spectral Domain OCTA of subjects with various stages of macular telangiectasia type 2
(MacTel2). (A1–4) Early non-proliferative MacTel2. (A1) Depth encoded en face retina flow
image of the left eye shows the early subtle changes of retina microvasculature temporal to
the fovea. The depth-encoded color flow image of the retinal layers depicts the superficial
capillary plexus as red, the deep capillary plexus as green, and the avascular retina as blue.
Due to this color-coding, it’s possible to appreciate that the early change of retina vessels
Author Manuscript

begin from the deep retina. (A2) The en face intensity image shows intra-retinal cysts that
appear as areas of decreased reflectivity (arrow). (A3–4) Corresponding B-scans with the
slab segmentations lines, with and without the flow signal. Note that the cystic cavity with
drapping of the internal limiting membrane can be appreciated on cross-sectional B-scan and
correspond to the areas of decreased reflectivity seen on the en face image. (B1–4)
Intermediate non-proliferative MacTel2. (B1) Depth encoded en face retina flow image of
the left eye shows the the abnormal microvasculature involving all the parafoveal retinal
plexuses. (B2) The en face intensity image shows intra-retinal areas of decreased reflectivity

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.
 Kashani et al. Page 80

corresponding to intraretinal cavities (arrow). (B3–4) Corresponding B-scans with the slab
Author Manuscript

segmentations lines, with and without the flow signal. Note that the retinal cavity can be
appreciated along with disruption of the photoreceptor inner-–outer-segment band (ellipsoid
zone). (C1–4) Proliferative MacTel2. (C1) Depth encoded en face retina flow image of the
left eye showing anastomosis between the superficial and deep retina vessels and a
proliferative tangle corresponding to the neovascularization. (C2) The en face intensity
image shows intra-retinal areas of decreased reflectivity corresponding to an intraretinal
cavity (arrow). (C3–4) Corresponding B-scans with the slab segmentations lines, with and
without the flow signal. Note that the thickening of retina temporal to the fovea and the
dilated microvasculature. (D1–4) Same subject with proliferative MacTel2 as in C, but the
outer retinal slab is selected, which is normally an avascular layer. (D1) Outer retinal en face
flow image of the left eye with projection artifact removal showing the neovascularization.
(D2) The en face intensity image showing the shadows from the superficial retinal
Author Manuscript

vasculature. (D3–4) Corresponding B-scans with the slab segmentations lines, with and
without the flow signal. Note that the segmentation lines are located in the outer retina.
Author Manuscript
Author Manuscript

Prog Retin Eye Res. Author manuscript; available in PMC 2018 September 01.