Lamina cribrosa visibility using optical coherence tomography: comparison of devices and effects of image enhancement techniques

PURPOSE

To compare the visibility of the lamina cribrosa (LC) in optic disc images acquired from 60 glaucoma and 60 control subjects using three optical coherence tomography (OCT) devices, with and without enhanced depth imaging (EDI) and adaptive compensation (AC).

METHODS

A horizontal B-scan was acquired through the center of the disc using two spectral-domain (Spectralis and Cirrus; with and without EDI) and a swept-source (DRI) OCT. Adaptive compensation was applied post acquisition to improve image quality. To assess LC visibility, four masked observers graded the 1200 images in a randomized sequence. The anterior LC was graded from 0 to 4, the LC insertions from 0 to 2, and the posterior LC either 0 or 1. The effect of EDI, AC, glaucoma severity, and other clinical/demographic factors on LC visibility was assessed using generalized estimating equations.

RESULTS

The anterior LC was the most detectable feature, followed by the LC insertions. Adaptive compensation improved anterior LC visibility independent of EDI. Cirrus+EDI+AC generated the greatest anterior LC visibility grades (2.79/4). For LC insertions visibility, DRI+AC was the best method (1.10/2). Visibility of the posterior LC was consistently poor. Neither glaucoma severity nor clinical/demographic factors consistently affected LC visibility.

CONCLUSIONS

Adaptive compensation is superior to EDI in improving LC visibility. Visibility of the posterior LC remains poor suggesting impracticality in using LC thickness as a glaucoma biomarker.

Automated analysis of angle closure from anterior chamber angle images

PURPOSE

To evaluate a novel software capable of automatically grading angle closure on EyeCam angle images in comparison with manual grading of images, with gonioscopy as the reference standard.

METHODS

In this hospital-based, prospective study, subjects underwent gonioscopy by a single observer, and EyeCam imaging by a different operator. The anterior chamber angle in a quadrant was classified as closed if the posterior trabecular meshwork could not be seen. An eye was classified as having angle closure if there were two or more quadrants of closure. Automated grading of the angle images was performed using customized software. Agreement between the methods was ascertained by κ statistic and comparison of area under receiver operating characteristic curves (AUC).

RESULTS

One hundred forty subjects (140 eyes) were included, most of whom were Chinese (102/140, 72.9%) and women (72/140, 51.5%). Angle closure was detected in 61 eyes (43.6%) with gonioscopy in comparison with 59 eyes (42.1%, P = 0.73) using manual grading, and 67 eyes (47.9%, P = 0.24) with automated grading of EyeCam images. The agreement for angle closure diagnosis between gonioscopy and both manual (κ = 0.88; 95% confidence interval [CI), 0.81-0.96) and automated grading of EyeCam images was good (κ = 0.74; 95% CI, 0.63-0.85). The AUC for detecting eyes with gonioscopic angle closure was comparable for manual and automated grading (AUC 0.974 vs. 0.954, P = 0.31) of EyeCam images.

CONCLUSIONS

Customized software for automated grading of EyeCam angle images was found to have good agreement with gonioscopy. Human observation of the EyeCam images may still be needed to avoid gross misclassification, especially in eyes with extensive angle closure.

Sectoral variations of iridocorneal angle width and iris volume in Chinese Singaporeans: a swept-source optical coherence tomography study

PURPOSE

To assess variations in the iridocorneal angle width and iris volume in Chinese subjects using swept-source optical coherence tomography (SS-OCT).

METHODS

Consecutive subjects, aged 40-80 years, with no previous ophthalmic problems were recruited from a population-based study of Chinese Singaporeans. All subjects underwent 360° SS-OCT (SS-1000 CASIA, Tomey Corporation, Nagoya, Japan) angle imaging and gonioscopy in one randomly selected eye in the dark. For each eye, 16 frames (11.25° apart) were selected for analysis from 128 cross-sectional images, and measurements of the trabecular iris space area 750 μm from the scleral spur (TISA750) and iris volume were made for each image. The measurements from four consecutive frames were further averaged as a sector of 45°. Sector-wise angle width and quadrant-wise iris volume were analyzed.

RESULTS

Two hundred and twelve subjects (90 with closed-angles) were examined. The majority of the subjects were female (70.7 %) with mean age 61 (±8.9) years. The TISA750 (mm(2)) of superior [0.101 (0.09)], inferior [0.105 (0.09)], superior-nasal [0.111 (0.09)] and superior-temporal [0.117 (0.09)] sectors were smaller compared with other sectors (P < 0.05). The nasal iris volume (mm(3)) was the smallest compared with other quadrants for the entire cohort [nasal 8.18 (1.2) < inferior 9.13 (1.3) < temporal 9.16 (1.2) < superior 9.33 (1.3), P < 0.001], as well as for open- and closed-angle groups.

CONCLUSIONS

The irido-corneal angle was narrower in the superior, inferior, superior-nasal and superior-temporal sectors compared with other sectors. Iris volume in the nasal quadrant was the smallest compared with the other quadrants.

Assessment of trabecular meshwork width using swept source optical coherence tomography

PURPOSE

Measurements of the angle width by ultrasound biomicroscopy or anterior segment optical coherence tomography are usually performed 500 μm from the scleral spur, as the anterior part of trabecular meshwork (TM) is assumed to lie within this distance. The aim of this study was to measure TM width using swept source optical coherence tomography (SS-OCT, CASIA SS-1000, Tomey Corporation, Nagoya, Japan), and to investigate factors influencing this measurement.

METHODS

Participants underwent gonioscopy and SS-OCT imaging in the dark. High-definition SS-OCT images were corrected for refractive distortion; and customized software (ImageJ; National Institutes of Health, Bethesda, MD, USA) was utilized to measure TM width (distance between the scleral spur and Schwalbe's line). Linear regression analysis was performed to assess the relationship between TM width with demographic and angle parameters.

RESULTS

One hundred and forty eight Chinese subjects were analyzed. The majority was female (62.4 %); the mean age was 59.2 ± 8.68 years. Identification of the scleral spur and Schwalbe's line with SS-OCT was possible in 590 (99.7 %) and 585 angle quadrants (98.8 %) respectively. TM width was wider in the inferior and superior quadrants (mean 889 [SD 138] and 793 [136] μm), compared to the nasal and temporal quadrants (712 [137] and 724 [115] μm, P<0.001). There was a difference in average TM width between open (789 [100]) and closed angle eyes (753 [86]) (P=0.048). There was no significant association between TM width and angle parameters, laterality, or demographic factors.

CONCLUSIONS

In SS-OCT HD images, the mean TM width varied from 710 to 890 μm in the different quadrants of the eye, and the inferior quadrant TM was the widest compared to other quadrants.

Variations in iris volume with physiologic mydriasis in subtypes of primary angle closure glaucoma

PURPOSE

To compare the changes in iris volume with pupil dilation using anterior segment optical coherence tomography (AS-OCT) in eyes of subjects with different subtypes of primary angle closure.

METHODS

This prospective study examined 44 fellow eyes (FA group) of subjects with previous acute primary angle closure (APAC), and 56 subjects (AC group) with chronic primary angle closure and/or primary angle closure glaucoma. All participants underwent gonioscopy and AS-OCT imaging. The iris volume, iris cross-sectional area, and pupil diameter were measured with custom semiautomated software. The main outcome variable analyzed was mean change in iris volume between light and dark conditions in a multivariate linear regression analysis.

RESULTS

Thirty-five eyes from the FA group (79.5%) and 50 eyes from the AC group (89.3%) were included in the final analysis. When going from light to dark, iris volume did not change significantly in eyes in the FA group (+1.50 ± 6.73 mm(3); P = 0.19), but decreased in the AC group by 1.52 ± 3.07 mm(3) (P < 0.001). This difference was significant (P = 0.01). On multivariate analysis after controlling for age, sex, baseline pupil diameter, and change in pupil diameter, age (β = -0.397; P < 0.001) and diagnostic category (AC versus FA group; β = 0.347; P < 0.001) were significant determinants of iris volume change.

CONCLUSIONS

With physiologic mydriasis, the iris volume decreased in eyes with chronic angle closure but remained unchanged in fellow eyes of APAC. Such variations in iris volume responses may influence the subtype of angle closure that develops.

Comparison of EyeCam and anterior segment optical coherence tomography in detecting angle closure

PURPOSE

To compare the diagnostic performance of EyeCam (Clarity Medical Systems, Pleasanton, CA, USA) and anterior segment optical coherence tomography (ASOCT, Visante; Carl Zeiss Meditec, Dublin, CA, USA) in detecting angle closure, using gonioscopy as the reference standard.

METHODS

Ninety-eight phakic patients, recruited from a glaucoma clinic, underwent gonioscopy by a single examiner, and EyeCam and ASOCT imaging by another examiner. Another observer, masked to gonioscopy findings, graded EyeCam and ASOCT images. For both gonioscopy and EyeCam, a closed angle in a particular quadrant was defined if the posterior trabecular meshwork was not visible. For ASOCT, angle closure was defined by any contact between the iris and angle anterior to the scleral spur. An eye was diagnosed as having angle closure if ≥2 quadrants were closed. Agreement and area under the receiver operating characteristic curves (AUC) were evaluated.

RESULTS

The majority of subjects were Chinese (69/98, 70.4%) with a mean age of 60.6 years. Angle closure was diagnosed in 39/98 (39.8%) eyes with gonioscopy, 40/98 (40.8%) with EyeCam and 56/97 (57.7%) with ASOCT. The agreement (kappa statistic) for angle closure diagnosis for gonioscopy versus EyeCam was 0.89; gonioscopy versus ASOCT and EyeCam versus ASOCT were both 0.56. The AUC for detecting eyes with gonioscopic angle closure with EyeCam was 0.978 (95% CI: 0.93-1.0) and 0.847 (95% CI: 0.76-0.92, p < 0.01) for ASOCT.

CONCLUSION

The diagnostic performance of EyeCam was better than ASOCT in detecting angle closure when gonioscopic grading was used as the reference standard. The agreement between the two imaging modalities was moderate.

Swept source optical coherence tomography measurement of the iris-trabecular contact (ITC) index: a new parameter for angle closure

PURPOSE

To evaluate the inter- and intra-observer agreement of measurement of the iris-trabecular contact (ITC) index, a measure of the degree of angle closure, using swept source optical coherence tomography (SSOCT, CASIA SS-1000, Tomey Corporation, Nagoya, Japan).

METHODS

One randomly selected eye of 60 subjects was imaged under dark room conditions. The SSOCT 3-dimensional angle scan simultaneously obtains 128 radial scans of the anterior chamber for the entire circumference of the angle. Post-imaging analysis estimated the ITC index using in-built software. For intra-observer agreement for image grading, one examiner performed the grading twice in a masked fashion and random order after a 1-week interval. A second examiner graded images to assess inter-observer agreement for image grading. For intra-observer agreement for image acquisition, a single operator imaged patients twice. For inter-observer agreement for image acquisition, a single observer graded two sets of images acquired by two different operators on the same patient. Bland-Altman plots and 95 % limits of agreement (LOA) were reported.

RESULTS

Study subjects were predominantly Chinese (54/60, 90 %) and female (42/60, 70 %), with a mean age of 65.5 years. The median ITC index for eyes with open angles (31/60) and closed angles was 20 % (95 % confidence interval [CI] - 13.6, 27.8) and 49 % (95%CI - 35.5, 69.2) respectively. The mean difference (95 % LOA) for intra-observer agreement for image grading and image acquisition were -0.8 % (-8.2, 6.5) and 0.6 % (-10.9, 9.7); corresponding inter- observer agreement were 0.1 % (-10, 10.1) and -0.3 % (-11.1, 10.5) respectively.

CONCLUSIONS

The inter- and intra-observer agreement of the ITC index, as a measure of extent of angle closure using SSOCT, was good.

Comparison of two spectral domain optical coherence tomography devices for angle-closure assessment

PURPOSE

To compare two spectral domain optical coherence tomography (SD-OCT) devices for the identification of angle structures and the presence of angle closure.

METHODS

This was a prospective comparative study. Consecutive patients underwent gonioscopy and anterior segment imaging using two SD-OCT devices (iVue and Cirrus). Images were evaluated for the ability to detect angle structures such as Schwalbe's line (SL), trabecular meshwork (TM), Schlemm's canal (SC), and scleral spur (SS), and the presence of angle closure. Angle closure was defined as iris contact with the angle wall anterior to the SS on SD-OCT, and nonvisibility of the posterior TM on gonioscopy. Angle closure in an eye was defined as ≥two quadrants of closed angles. AC1 statistic was used to assess the agreement between devices.

RESULTS

Of the 69 subjects studied (46.4% male, 84.1% Chinese, mean age 64.0 ± 10.5 years), 40 subjects (40 eyes, 58.0%) had angle closure on gonioscopy. The most identifiable structure on Cirrus SD-OCT was the SS (82.2%) and SL on iVue SD-OCT (74.5%). Angle closure was indeterminable in 14.5% and 50.7% of Cirrus and iVue scans (P < 0.001), respectively. Interdevice agreement for angle closure was moderately strong (AC1 = 0.67), but agreement with gonioscopy was only fair (AC1 = 0.35 and 0.50 for Cirrus and iVue, respectively).

CONCLUSIONS

It was more difficult to determine angle closure status with iVue compared with Cirrus SD-OCT. There was fair agreement between both devices with gonioscopy for identifying angle closure.

Novel anterior-chamber angle measurements by high-definition optical coherence tomography using the Schwalbe line as the landmark

OBJECTIVE

To propose the Schwalbe line (SL) as a new anatomical landmark, independent of the scleral spur (SS) location, for assessing anterior chamber angle (ACA) width quantitatively with high-definition optical coherence tomography (HD-OCT).

METHODS

Study subjects underwent dark-room gonioscopy and HD-OCT in one randomly selected eye. The authors developed a computer-aided program to define two new quantitative parameters for assessing ACA width: Schwalbe line-angle opening distance (SL-AOD) measured at the SL, and Schwalbe line-trabecular-iris space area (SL-TISA) measured 500 μm from the SL. The associations between SL parameters, SS parameters and gonioscopic grading were evaluated.

RESULTS

Seventy-three (47 females, 26 males) subjects were recruited, the majority of whom were Chinese (89%). The authors excluded 29 images (19.9%) owing to poor image quality, leaving 117 HD-OCT images (65 nasal, 52 temporal) for analysis. SL and SS could be identified in 95% and 85% of quadrants respectively (p = 0.035). SL-AOD and SL-TISA were significantly correlated with SS parameters (all r ≥ 0.85) and gonioscopic grading (all r ≥ 0.69). In eyes with closed angles (n = 36), SL parameters showed strong correlations with gonioscopic grading (r ranged from 0.43 to 0.44). Conclusions Novel angle parameters, based on SL as a landmark, may be useful to quantify ACA width and to assess for risk of angle closure.

Demonstration of angle widening using EyeCam after laser peripheral iridotomy in eyes with angle closure

PURPOSE

To evaluate EyeCam in detecting changes in angle configuration after laser peripheral iridotomy (LPI) in comparison to gonioscopy, the reference standard.

DESIGN

Prospective comparative study.

METHODS

Twenty-four subjects (24 eyes) with primary angle-closure glaucoma (PACG) were recruited. Gonioscopy and EyeCam (Clarity Medical Systems) imaging of all 4 angle quadrants were performed, before and 2 weeks after LPI. Images were graded according to angle structures visible by an observer masked to clinical data or the status of LPI, and were performed in a random order. Angle closure in a quadrant was defined as the inability to visualize the posterior trabecular meshwork. We determined the number of quadrants with closed angles and the mean number of clock hours of angle closure before and after LPI in comparison to gonioscopy.

RESULTS

Using EyeCam, all 24 eyes showed at least 1 quadrant of angle widening after LPI. The mean number of clock hours of angle closure decreased significantly, from 8.15 +/- 3.47 clock hours before LPI to 1.75 +/- 2.27 clock hours after LPI (P < .0001, Wilcoxon signed rank test). Overall, gonioscopy showed 1.0 +/- 1.41 (95% CI, 0.43-1.57) quadrants opening from closed to open after LPI compared to 2.0 +/- 1.28 (95% CI, 1.49-2.51, P = .009) quadrants with EyeCam. Intra-observer reproducibility of grading the extent of angle closure in clock hours in EyeCam images was moderate to good (intraclass correlation coefficient 0.831).

CONCLUSIONS

EyeCam may be used to document changes in angle configuration after LPI in eyes with PACG.

Use of EyeCam for imaging the anterior chamber angle

PURPOSE

To compare EyeCam (Clarity Medical Systems, Pleasanton, CA) imaging with gonioscopy for detecting angle closure.

METHODS

In this prospective, hospital-based study, subjects underwent gonioscopy by a single observer and EyeCam imaging by a different operator. EyeCam images were graded by two masked observers. The anterior chamber angle in a quadrant was classified as closed if the trabecular meshwork could not be seen. The eye was classified as having angle closure if two or more quadrants were closed.

RESULTS

One hundred fifty-two subjects were studied. The mean age was 57.4 years (SD 12.9) and there were 82 (54%) men. Of the 152 eyes, 21 (13.8%) had angle closure. The EyeCam provided clear images of the angles in 98.8% of subjects. The agreement between the EyeCam and gonioscopy for detecting angle closure in the superior, inferior, nasal, and temporal quadrants based on agreement coefficient (AC1) statistics was 0.73, 0.75, 0.76, and 0.72, respectively. EyeCam detected more closed angles than did gonioscopy in all quadrants (P < 0.05). With gonioscopy, 21/152 (13.8%) eyes were diagnosed as angle closure compared to 41 (27.0%) of 152 with EyeCam (P < 0.001, McNemar Test), giving an overall sensitivity of 76.2% (95% confidence interval [CI], 54.9%-90.7%), specificity of 80.9% (95%CI, 73.5%-87.3%), and an area under the receiver operating characteristic curve (AUC) of 0.79.

CONCLUSIONS

The EyeCam showed good agreement with gonioscopy for detecting angle closure. However, it detected more closed angles than did gonioscopy in all quadrants.