Quantification of characteristic blood-flow parameters in the vessels of the retina with a picture analysis system for video-fluorescence angiograms: initial findings

How to measure retinal microperfusion in patients with arterial hypertension

PURPOSE

Assessment and monitoring of changes in microcirculatory perfusion, perfusion dynamic, vessel structure and oxygenation is crucial in management of arterial hypertension. Constant search for non-invasive methods has led the clinical focus towards the vasculature of the retina, which offers a large opportunity to detect the early phase of the functional and structural changes in the arterial hypertension and can reflect changes in brain vasculature. We review all the available methods of retinal microcirculation measurements including angiography, oximetry, retinal vasculature assessment software, Optical Coherence Tomography Angiography, Adaptive Optics and Scanning Laser Doppler Flowmetry and their application in clinical research.

MATERIALS AND METHODS

To further analyse the applicability of described methods in hypertension research we performed a systematic search of the PubMed electronic database (April 2020). In our analysis, we included 111 articles in which at least one of described methods was used for assessment of microcirculation of the retina in hypertensive individuals.

RESULTS

Up to this point, the methods most commonly published in studies of retinal microcirculation in arterial hypertension were Scanning Laser Doppler Flowmetry followed shortly by Optical Coherence Tomography Angiography and retinal vasculature assessment software.

CONCLUSIONS

While none of described methods enables the simultaneous measurement of all microcirculatory parameters, certain techniques are widely used in arterial hypertension research, while others gain popularity in screening.

Adaptive optics imaging of the human retina

Adaptive Optics (AO) retinal imaging has provided revolutionary tools to scientists and clinicians for studying retinal structure and function in the living eye. From animal models to clinical patients, AO imaging is changing the way scientists are approaching the study of the retina. By providing cellular and subcellular details without the need for histology, it is now possible to perform large scale studies as well as to understand how an individual retina changes over time. Because AO retinal imaging is non-invasive and when performed with near-IR wavelengths both safe and easily tolerated by patients, it holds promise for being incorporated into clinical trials providing cell specific approaches to monitoring diseases and therapeutic interventions. AO is being used to enhance the ability of OCT, fluorescence imaging, and reflectance imaging. By incorporating imaging that is sensitive to differences in the scattering properties of retinal tissue, it is especially sensitive to disease, which can drastically impact retinal tissue properties. This review examines human AO retinal imaging with a concentration on the use of the Adaptive Optics Scanning Laser Ophthalmoscope (AOSLO). It first covers the background and the overall approaches to human AO retinal imaging, and the technology involved, and then concentrates on using AO retinal imaging to study the structure and function of the retina.

Regulation of retinal blood flow in health and disease

Optimal retinal neuronal cell function requires an appropriate, tightly regulated environment, provided by cellular barriers, which separate functional compartments, maintain their homeostasis, and control metabolic substrate transport. Correctly regulated hemodynamics and delivery of oxygen and metabolic substrates, as well as intact blood-retinal barriers are necessary requirements for the maintenance of retinal structure and function. Retinal blood flow is autoregulated by the interaction of myogenic and metabolic mechanisms through the release of vasoactive substances by the vascular endothelium and retinal tissue surrounding the arteriolar wall. Autoregulation is achieved by adaptation of the vascular tone of the resistance vessels (arterioles, capillaries) to changes in the perfusion pressure or metabolic needs of the tissue. This adaptation occurs through the interaction of multiple mechanisms affecting the arteriolar smooth muscle cells and capillary pericytes. Mechanical stretch and increases in arteriolar transmural pressure induce the endothelial cells to release contracting factors affecting the tone of arteriolar smooth muscle cells and pericytes. Close interaction between nitric oxide (NO), lactate, arachidonic acid metabolites, released by the neuronal and glial cells during neural activity and energy-generating reactions of the retina strive to optimize blood flow according to the metabolic needs of the tissue. NO, which plays a central role in neurovascular coupling, may exert its effect, by modulating glial cell function involved in such vasomotor responses. During the evolution of ischemic microangiopathies, impairment of structure and function of the retinal neural tissue and endothelium affect the interaction of these metabolic pathways, leading to a disturbed blood flow regulation. The resulting ischemia, tissue hypoxia and alterations in the blood barrier trigger the formation of macular edema and neovascularization. Hypoxia-related VEGF expression correlates with the formation of neovessels. The relief from hypoxia results in arteriolar constriction, decreases the hydrostatic pressure in the capillaries and venules, and relieves endothelial stretching. The reestablished oxygenation of the inner retina downregulates VEGF expression and thus inhibits neovascularization and macular edema. Correct control of the multiple pathways, such as retinal blood flow, tissue oxygenation and metabolic substrate support, aiming at restoring retinal cell metabolic interactions, may be effective in preventing damage occurring during the evolution of ischemic microangiopathies.

Analysis of mean retinal transit time from fluorescein angiography in human eyes: normal values and reproducibility

OBJECTIVE

To evaluate three different techniques to quantify retinal blood flow transit times in normal human eyes from fluorescein angiograms.

SUBJECTS AND METHODS

Fluorescein angiograms were recorded on two different occasions in 18 normal individuals with a scanning laser ophthalmoscope. The angiograms were digitized (5 frames per second) and the images were aligned. Mean transit times (MTT) were analysed with a newly developed technique based on an impulse-response analysis (MTTIR) and again with the conventional technique (MTTSLOPE). Arterio-venous passage times (AVP) were also calculated.

RESULTS

At the first determination, mean values (SD) for MTTIR, MTTSLOPE, and AVP were 3.22 (0.78), 4.88 (1.86), and 1.46 (0.57) seconds, respectively. Detection of an increase of 25% with a power of 80% requires groups of 12, 86 and 17 individuals for the three techniques, respectively.

CONCLUSIONS

Mean transit time is a well-defined physiological parameter. The technique based on impulse-response analysis allows for analysis of even badly defined dye curves. We found this technique to be superior to the conventional technique in terms of reproducibility.

Hemodynamic changes in two patients with retinal circulatory disturbances shown by fluorescein angiography using a scanning laser ophthalmoscope

PURPOSE

To assess hemodynamic changes in two patients with severely affected retinal circulation.

METHODS

A 62-year-old man with central retinal artery occlusion and a 46-year-old woman with branch retinal vein occlusion were studied by fluorescein angiography with a scanning laser ophthalmoscope (SLO). Fluorescein angiography with SLO revealed hypofluorescent clumps of different sizes and hyperfluorescent dots in large retinal vessels. The velocities of the hypofluorescent clumps were calculated between two points on the same vessel, and movements of the hypofluorescent clumps and the hyperfluorescent dots were investigated.

RESULTS

The velocities of the hypofluorescent clumps were slow and varied in the same vessel. The velocities of the hypofluorescent clumps increased at the sites with narrow calibers. The hypofluorescent clumps occasionally changed size in the bloodstream. The hypofluorescent clumps flowed along the walls of retinal vessels. Distance between consecutive hypofluorescent clumps was wide. Some vessels filled with hypofluorescent clumps were also detected. Rolling hyperfluorescent dots were seen in fluorescent plasma.

CONCLUSIONS

The hypofluorescent clumps were concluded to be packed erythrocytes and the hyperfluorescent dots corresponded to leukocytes and platelets moving in the vessels. Fluorescein angiography with SLO is a useful method for evaluating hemodynamic changes using the hypofluorescent clumps in severely affected retinal circulation.

Central and peripheral arteriovenous passage times of the retina in glaucoma

The purpose of this paper was to estimate arteriovenous passage (AVP) times, taking into account the non-uniform distribution of arrival times over the vessel diameter, and assessment of respective differences between 15 normal controls (N), 30 primary open-angle glaucoma (POAG) and 30 normal-pressure glaucoma (NPG) patients. Arrival times in retinal vessels were assessed from digitized scanning laser fluorescein angiograms. The arrival times were assessed as a function of position (juxtamural versus axial) in the vessel. This differentiation, based on the measurement position in the vessel, enabled the estimation of AVP times of the posterior pole and of the peripheral retina. The overall, juxtamural and axial AVP times were prolonged in POAG as compared to both N and NPG (P<0.03). The difference in axial AVP times between POAG and normal subjects was considerably larger than the juxtamural values. The distribution of AVP times was considerably larger in POAG patients than in N subjects and NPG patients. Retinal AVP times are prolonged in POAG patients as compared to N and NPG. The wider distribution of AVP times in POAG patients may point to a generalized microvascular alteration. Since the axial AVP times seem to provide the largest differences between NPG and POAG patients, this measurement may be preferred over more general AVP times. The axial AVP times may possibly reflect peripheral vascular changes, e.g. increased vascular resistance. The underlying mechanisms causing these differences are at present unknown.

Assessment of human ocular hemodynamics

Vascular abnormality and altered hemodynamics play important roles in many ophthalmic pathologies. Much of our knowledge of ocular hemodynamics was gained from invasive animal research, although a number of noninvasive methods suitable for in vivo use in humans have been developed. Data from these methods now produce a significant literature of their own. Understanding the origins of the data and appreciating their limitations can be difficult. Modern hemodynamic assessment techniques each examine a unique facet of the ocular circulation. No single facet provides a complete description of the hemodynamic state of the eye. These methods have contributed a great deal to our understanding of normal hemodynamics. More importantly, they continue to add to our understanding of altered hemodynamics found in disease. Some have found their way into limited clinical practice. The predominant ocular hemodynamic assessment techniques are reviewed with the aims of introducing the fundamental principles behind each, highlighting their inherent advantages and limitations, highlighting their contributions to understanding ocular physiology, and considering their potential to provide signs for diagnosis.

Fluorescent dots in fluorescein angiography and fluorescein leukocyte angiography using a scanning laser ophthalmoscope in humans

PURPOSE

The purpose of the study is to disclose the nature of fluorescent dots and segments traditionally observed with fluorescein angiography (FA) using a scanning laser ophthalmoscope (SLO 101; Rodenstock, München, Germany). The authors developed a new method, called fluorescein leukocyte angiography (FLA), to display directly the movement of leukocytes in human retinal vessels.

METHODS

Fluorescein angiography was performed on two normal volunteers using a scanning laser ophthalmoscope and fluorescent dots and segments were observed. Fluorescein leukocyte angiography, using an injection of fluorescent buffy coat layer from which the fluorescent plasma and nonfluorescent erythrocytes have been removed externally, was performed on seven normal volunteers. Injection fluid smears were examined through a fluorescent microscope. Peripheral blood smears taken during midphase of FA and FLA also were examined. In addition, 15 early-phase FAs of central serous chorioretinitis (CSC) were studied retrospectively.

RESULTS

In the FAs of normal volunteers, fluorescent dots were detected only in perimacular capillaries at early phase. Eight of the 15 CSC FAs examined showed both fluorescent dots and segments. In the FLAs, fluorescent dots were detected in whole retinal vessels for more than 30 minutes. Fluorescent segments were observed in FA but not in FLA. Injected fluid smears from one FLA showed fluorescent leukocytes and small platelets. However, in peripheral blood smears of the FLA, leukocytes and platelets were more visible and exhibited higher contrast than those of an FA due to background plasma fluorescence. The mean velocity of 21 flowing leukocytes in perifoveal capillaries was 1.37 +/- 0.35 mm/second in 2 FAs and that of 89 flowing leukocytes was 1.41 +/- 0.29 mm/second in 7 FLAs.

CONCLUSIONS

The authors' observations suggest that fluorescent dots in scanning laser ophthalmoscope imaging are fluorescein-stained leukocytes, whereas fluorescent segments are the hyperfluorescent plasma that is located between rouleaux formations of erythrocytes. The velocity of the fluorescent dots could be measured in the perimacular capillaries by either FA or FLA; however, only FLA can display the flow of fluorescent leukocytes in large vessels.

A comparison of retinal and choroidal hemodynamics in patients with primary open-angle glaucoma and normal-pressure glaucoma

PURPOSE

To quantify, compare, and assess differences between retinal and choroidal hemodynamics in normal control subjects and patients with ocular hypertension, primary open-angle glaucoma, and normal-pressure glaucoma.

METHODS

Video fluorescein angiograms were made in 20 normal subjects, 11 patients with ocular hypertension, 45 patients with primary open-angle glaucoma, and 43 patients with normal-pressure glaucoma. Choroidal dye build-up curves were analyzed using an exponential model. The model time constant tau reflected the local blood refreshment time, the time needed to replace the blood volume in a tissue volume. Retinal arteriovenous passage time was estimated from the time lapse between retinal arterial and venous dye curves.

RESULTS

The retinal arteriovenous passage time was longer in patients with primary open-angle glaucoma compared with normal subjects and patients with normal-pressure glaucoma; the average arteriovenous passage times (+/-SEM) in normal subjects and in patients with ocular hypertension, primary open-angle glaucoma, and normal-pressure glaucoma were, respectively, 2.44 +/- 0.19, 2.90 +/- 0.37, 3.02 +/- 0.17, and 2.55 +/- 0.15 seconds. Choroidal tau was longest in the normal-pressure glaucoma group but not as long in the primary open-angle glaucoma group; tau values in normal subjects and patients with ocular hypertension, primary open-angle glaucoma, and normal-pressure glaucoma were, respectively, 4.6 +/- 0.29, 5.6 +/- 0.69, 6.2 +/- 0.39, and 7.1 +/- 0.33 seconds.

CONCLUSIONS

Whereas choroidal circulation is especially slower in patients with normal-pressure glaucoma, retinal circulation is delayed in patients with primary open-angle glaucoma. The choroidal and retinal vascular systems behave differently in primary open-angle and normal-pressure glaucoma, which may be important in the management of glaucoma.

Visualization of retinal and choroidal blood flow with fluorescein leukocyte angiography in rabbits

PURPOSE

To visualize the retinal and choroidal leukocytes in rabbits with a new technique, fluorescein leukocyte angiography using a scanning laser ophthalmoscope.

METHODS

Blood was withdrawn from an ear vein of a rabbit (New Zealand White), mixed with fluorescein dye in a test tube and centrifuged. The yellow-brown coat layer containing fluorescein-stained leukocytes was collected and injected into the ear vein of the same rabbit while performing fluorescein angiography with a scanning laser ophthalmoscope. The angiographic image displaying circulating fluorescent leukocytes in retinal and choroidal vessels was recorded on a videotape.

RESULTS

Fluorescent leukocytes were clearly visible in the retinal arteries, capillaries, veins and choroidal vessels for more than 1 h. Plugging of leukocytes was seen throughout this period of time in choroidal vessels, while plugging was rare in retinal vessels.

CONCLUSIONS

Fluorescein leukocyte angiography is a new technique which can be used for visualization of the leukocytes in retinal and choroidal vessels non-invasively and in vivo.

Measurement of retinal blood flow with fluorescein leucocyte angiography using a scanning laser ophthalmoscope in rabbits

AIMS

To measure blood flow in the rabbit retinal circulation with fluorescein leucocyte angiography using a scanning laser ophthalmoscope.

METHODS

Blood was withdrawn from the ear vein of a rabbit (New Zealand White), mixed with fluorescent dye in a test tube and centrifuged. The yellow-brown layer containing fluorescein stained leucocytes was collected and injected into the ear vein of the same rabbit while performing fluorescein angiography with a scanning laser ophthalmoscope. The image of retinal angiography displaying circulating fluorescent leucocytes was recorded on video tape. From each frame of the video tape, the consecutive positions of fluorescein stained leucocytes were digitised using an image analysis system and the velocity of blood flow was calculated.

RESULTS

Fluorescent leucocytes were clearly visualised in the retinal arteries, capillaries, and veins which allowed measurement of blood flow. The mean capillary velocity was 0.69 (SD 0.21) mm/s. The mean velocities of leucocytes measured in different sized vessels were as follows: 5.83 (2.42) mm/s in arteries over 50 microns, 3.33 (0.62) mm/s in those 35-50 microns, and 2.42 (1.08) mm/s in arteries under 35 microns, 3.08 (1.56) mm/s in veins over 50 microns, 2.79 (1.49) mm/s in those 35-50 microns, and 1.21 (0.50) mm/s in veins under 35 microns. Blood flow pulsation occurs in arteries, arterioles, veins, and venules but not capillaries.

CONCLUSION

Fluorescein leucocyte angiography can be used for simultaneous measurement of the blood flow in retinal arteries, veins, and capillaries.

Circulatory defects of the optic disk and retina in ocular hypertension and high pressure open-angle glaucoma

Studies using fluorescein angiography have shown that two types of circulatory defects occur in the optic disk and retina of open-angle glaucomatous eyes. The first is a defect of the microcirculation of the optic disk characterized as a fluorescein defect. Such defects begin as small areas of relatively little filling of the small vessels of the disk with fluorescein. The areas of defect show leakage for both fluorescein and indocyanine green. These defects increase in size and number with the progression of the disease. Fluorescein defects are significantly correlated with visual field loss and retinal nerve fiber layer loss. The second circulatory defect is a decrease of flow of fluorescein in the retinal vessels, especially the retinal veins, so that the greater the age, diastolic blood pressure, ocular pressure and visual field loss, the less the flow. Both the optic disk and retinal circulation defects occur in untreated ocular hypertensive eyes. These observations indicate that circulatory defects in the optic disk and retina occur in ocular hypertension and open-angle glaucoma and increase with the progression of the disease.

Measurement of retinal hemodynamics with scanning laser ophthalmoscopy: reference values and variation

High resolution video fluorescein angiography using scanning laser ophthalmoscopy allows the assessment of retinal macro- and microcirculation. Data on the retinal macrocirculation were obtained from 221 healthy subjects. The data were derived from estimations of the arm-retina time, the arteriovenous passage time and mean arterial dye velocity, characterizing the passage of fluorescein to the eye, the mean arterial plasma velocity, and the arteriovenous passage through the entire vascular bed of one segment. Additionally, the transit of hypofluorescent segments in the capillary macular network were measured in 90 healthy subjects. These parameters provide a wide range of information for understanding the physiology of healthy and diseased eyes. Fundamental for all interpretations is the knowledge of the physiological variations. In the present study the inter- and intraindividual variability of retinal hemodynamics in healthy volunteers were assessed. The interindividual variation was 23.8% for the arm-retina time, 20.7% for the arteriovenous passage time, 23.7% for the mean arterial dye velocity, and 14.2% for the capillary flow velocity; the coefficient for variation, characterizing the intraindividual variation, was 26.6%, 15.6%, 16.7%, and 7.9%, respectively. The knowledge of the inter- and intraindividual variation of retinal blood flow indices allows for a priori power estimations for pathophysiologic and pharmacological studies.

Capillary blood flow velocity measurements in cystoid macular edema with the scanning laser ophthalmoscope

Using a scanning laser ophthalmoscope, we calculated the velocity of retinal blood flow in a juxta-foveolar capillary during the course of cystoid macular edema after partial central retinal vein occlusion in a 53-year-old woman. The mean velocity of the fluorescent dots in the macular capillary of the right eye with cystoid macular edema was 1.59 +/- 0.08 mm/sec at the initial examination. Despite the systemic administration of indomethacin (75 mg/day for three weeks), best-corrected visual acuity decreased from 20/30 to 20/70, and the velocity became 0.82 +/- 0.13 mm/sec. Prednisolone (30 mg/day orally for one week) improved the cystoid macular edema, and the velocity was 0.96 +/- 0.06 mm/sec 12 days after initiation of the drug. The velocity gradually improved; one year later it was 1.65 +/- 0.17 mm/sec and visual acuity was 20/22. Velocity in the left eye, which did not have cystoid macular edema, was 2.16 +/- 0.16 mm/sec. Thus, scanning laser ophthalmoscopy proved useful for measuring the velocity of retinal blood flow.

[Movement correction of digital sequence angiographies of the retina]

Retinal hemodynamics can be quantified from videoangiographic image sequences by digital image processing. Intensity changes of dye dilution curves provide dynamics parameters of the local retinal blood flow. The measuring points of dye dilution curves have to be fixed on identical image contents in each image of a complete image sequence. To obtain measurements for every pixel on the retinal surface a motion-compensated image sequence is required. A new method adapted to the compensation of eye motion and movement artifacts in Scanning Laser Ophthalmoscopy in long image sequences (300-500 images) is presented in this paper. To inhibit error propagation of time sequential motion estimation, the eye movement is divided into two dynamic movements components. The method presented permits compensation for eye motion in retinal fluorescein angiographic sequences. Owing to the short calculation times, this algorithm can be used in clinical routine.

Evaluating retinal circulation using video fluorescein angiography in control and diabetic rats

Video fluorescein angiography has been used to evaluate retinal circulatory parameters in diabetic and non-diabetic Sprague-Dawley rats. Video fluorescein angiograms were recorded from the retina using a modified retinal fundus camera following a 5 ul bolus injection of sodium fluorescein dye into the jugular vein. Retinal circulatory parameters were measured using computer assisted image analysis. These analyses were performed on 25 diabetic rats with 1 week duration of diabetes and 26 matched, non-diabetic, rats. There was a significant (p = .0001) increase in retinal Mean Circulation Time (MCT) in the diabetic group (1.83 +/- 0.40 s) compared to the control group (1.09 +/- 0.27 s). There were no significant differences in arterial or venous diameters comparing diabetic and control groups. In a separate paired experiment, measurements were made from the same animals both before and after one week duration of diabetes. A paired t-test analysis demonstrated significantly increased MCT times in the 6 diabetic animals (p = .001) while there was no significant differences detected in the 4 corresponding control animals. These results indicate that significant increases in retinal circulation times can be measured as early as 1 week after streptozotocin induced diabetes in this animal model.

Measurement of circulation time in the retinal vasculature using selective angiography

Retinal circulation times (RCT) and mean circulation time (MCT) in the retinal vasculature have been used to determine the effect of ocular disease on retinal circulation. Both RCT and MCT are usually determined by measuring dye dilution curves during a traditional fluorescein angiogram. The authors present a variation of the dye dilution technique. The primary difference is that a fluorescent dye (carboxyfluorescein or calcein) was encapsulated in liposomes at a very high concentration. The dye was then released at a specific site in a retinal artery by the application of a laser pulse delivered through the pupil of the eye. The heat pulse produced by the laser lysed the liposomes in the targeted vessel, causing a stream of dye to be released. The time it took the dye front to pass through the artery and return through the vein (RCT) was then measured. To clarify the situation, two times were actually measured, the shortest path the dye traveled from the exposure site to a corresponding site on the vein (short RCT) and the longest path through the periphery to venous filling (long RCT). The measurements were made in both cynomolgus monkeys and squirrel monkeys. The local dye release achieved with this method was found to produce a more distinct dye front than traditional angiography while also eliminating the problem of recirculation. Choroidal background fluorescence, a factor that often obscures the dye front in traditional angiography, was minimal. Furthermore, it was possible to make individual measurements on each of the four arteries and to repeat the measurements several times.

Determination of retinal blood velocity with respect to the cardiac cycle using laser-triggered release of liposome-encapsulated dye

A system of selective angiography has been developed for measuring blood velocity in retinal arteries and veins. It uses a liposome-encapsulated fluorescent dye that is released by application of laser energy in a specific retinal vessel. The method is shown to be able to distinguish between peak systolic velocity and minimum diastolic velocity. In the cynomolgus monkey, the two values were found to differ by approximately a factor of three. It is known that many ocular and systemic diseases affect retinal circulation, and therefore a method of blood velocity measurement with such sensitivity may prove highly valuable in the practice of ophthalmology. As an example, the velocity in a retinal vein was measured before and after partial occlusion by photocoagulation. The two values obtained were significantly different, and the blood velocity was found to return to the value prior to occlusion when measured at 18 days.

Retinal circulation times in quantitative fluorescein angiography

We tried to obtain an overview of the quantitative state of the retinal circulation. Optical density measurements by an image analyzer were performed on video fluorescein angiograms for the determination of dyedilution curves. To ensure that curves with a sharp peak were obtained, 1 ml sodium fluorescein 10% was flushed with 20 ml physiological saline. From dilution curves of a retinal circulation times, T(x) (x = 1, 25, 50, 75, and 100) and Tm, were calculated. T(1) corresponds to the difference in the time of initial dye appearance; T(50), to the so-called half-maxim time difference; T(100), to the difference in the time to peak intensity; and Tm, to the mean circulation time. T(50) showed the best reproducibility when it was examined at 49 retinal regions of 10 healthy volunteers with a double video-fluorescein angiogram that was obtained within 1 min. Normal values (mean +/- SD) at the temporal superior region of 37 healthy volunteers were as follows: T(1) = 0.87 +/- 0.66 s, T(25) = 1.52 +/- 0.48 s, T(50) = 1.83 +/- 0.50 s, T(75) = 2.12 +/- 0.56 s, T(100) = 2.73 +/- 0.76 s, and Tm = 2.69 +/- 1.25 s. We believe that these values give a general overview of the quantitative state of normal retinal circulation.

Electro-optic fundus imaging

Fundus imaging and photography are cornerstones of modern ophthalmic practice. The recent developments in electro-optic and computer imaging technology resulted in many improvements in the acquisition and analysis of fundus images, which already are being used in commercial fundus imaging systems. This paper reviews the basic aspects of the electro-optic methods for fundus imaging, with emphasis on the differences between these new techniques and conventional, film-based, fundus photography. Potential benefits of these systems in image acquisition, archival, communication, processing, and quantitative analysis, as as well as their current advantages and shortcomings are discussed.

Video fluorescein angiography: method and clinical application

Video fluorescein angiography, combined with a picture analyzing system, is a clinically applicable, objective method of evaluating the retinal blood-flow parameters. Optical density measurements were performed on videorecordings of fluorescence angiograms by means of a picture-analyzing system in order to determine the circulation parameters of the retina. These included: the arm-retina time (ART), the arteriovenous passage time (AVP), and the mean arterial dye-bolus velocity (MDV). Normal values for these parameters were derived from measurements in 75 healthy volunteers. The mean arm-retina time (ART) was 11.2 +/- 3.3 s, the mean arteriovenous passage time (AVP) 1.45 +/- 0.4 s and the mean arterial dye-bolus velocity (MDV) 6.39 +/- 1.7 mm/s. No significant correlation could be shown between pulse or blood pressure and one of the retinal circulation parameters. A group of ten healthy volunteers was examined twice in order to obtain the intraindividual variation for the measuring parameters. The coefficient of variation for the ART was 18%, 10% for the AVP, and 26% for the MDV.

Effects of enzymatic blood defibrination in subcortical arteriosclerotic encephalopathy

Plasma hyperviscosity is a striking abnormality in patients suffering from subcortical arteriosclerotic encephalopathy (SAE) and is thought to perpetuate the chronic ischaemic demyelinating process of the periventricular white matter. Ancrod, a defibrinating enzyme, was given to 10 patients with SAE in an attempt to reduce plasma fibrinogen, which would thus normalise hyperviscosity. This was paralleled by a significant improvement of the initially abnormal retinal arteriovenous passage time, as well as a significant augmentation of the CO2-induced cerebral vasomotor response. This did not lead, however, to any clinical improvement with respect to performance of neuropsychological tests, recurrences of strokes during a 6 month observation period or improvement of various audiological parameters. The findings indicate that hyperviscosity in patients with SAE is merely an epiphenomenon. A potentially reversible, chronic penumbral state of the brain tissue apparently does not exist in SAE.

Enhancement of fundus photographs taken through cataracts

Image-enhancement techniques can aid the clinician in evaluating fundus pictures taken through cataracts. The degradation of the fundus image by cataracts has been described as low-pass filtering. Means to partially overcome this degradation using homomorphic filtering and adaptive enhancement are presented. The clinical value of these enhancement techniques is demonstrated with two cases of progressive glaucoma and cataracts.

Videofluoroscopy in macular disease

Fluorescein Angiography has contributed immensely to our understanding and management of macular disease. Ridley first introduced the concept of television ophthalmoscopy and in 1973 Van Heuven and Schaffer reported the value of videofluoroscopy using a low light level system and an image intensifier. Major advances in electronic imaging technology since then have permitted high quality videofluoroscopy to be developed in particular the integral silicone intensified tube (SIT) allowed ultra low light levels to be recorded. A videofluorography system has been in routine use in our department for the last six years and we have found it to have certain advantages over conventional photography in macular disease. In this presentation we demonstrate some of these.

Video and digital fluorescein angiography

A video recording system, which provides real-time imaging and instant reporting of retinal fluorescein angiograms, with improved patient comfort, is described. Digital image-processing methods can be applied to video angiograms to improve image quality, quantitate retinal blood flow, measure areas, improve storage and access, and send images via phone lines or other electronic communication channels. Video image quality is somewhat inferior to conventional photographic techniques, but is more than adequate for diagnostic interpretation.

Circulatory parameters of the retina in patients with lacunar stroke

Ophthalmological data were obtained in 40 patients presenting with lacunar stroke. The stroke was verified clinically as well as by computed tomography. Vision was tested and the visual field, intraocular pressure, retinal arteriovenous passage time, arm-retina time, and erythrocyte flow velocity in the conjunctival capillaries were all determined; ophthalmoscopy was also carried out. Microcirculatory parameters were obtained from 21 patients. Significant disturbances of the retinal arteriovenous passage time were observed, but there were no significant disturbances of the conjunctival erythrocyte flow velocity. The concurrently measured haemorheological parameters were all pathological with the exception of the haematocrit. Ophthalmoscopic examination revealed arteriosclerotic alterations in 38 of 40 patients. These angiological and rheological findings confirm the importance of disturbed microcirculation in lacunar stroke.

The haemorheological features of lacunar strokes

Clinical and haemorheological data were recorded in 40 patients with lacunar strokes confirmed clinically and by computed tomography. The following haemorheological variables were monitored: haematocrit, erythrocyte aggregation, erythrocyte deformability, plasma viscosity, fibrinogen concentration and yield shear stress. Clinically, most patients had case histories and features according to the description of Fisher. All haemorheological parameters with the exception of the haematocrit were pathological when compared with values obtained from a normal control group. In descending order of frequency the pathological changes were in erythrocyte aggregation, plasma viscosity and erythrocyte deformability.

Measurement of fluorescein angiograms of the optic disc and retina using computerized image analysis

Computerized image analysis was used to quantify objectively fluorescein angiograms of the optic disc, peripapillary choroid, and retina. Techniques were developed to measure fluorescein filling rates of the optic disc and the retinal vessels and the area of fluorescein filling defects within the optic disc. Two subjects, one with glaucoma and the other with ocular hypertension, showed increases of areas of fluorescein filling defects of the optic disc on follow-up and are presented here as examples of the application of these techniques. This methodology can be applied to the longitudinal follow-up of individual patients with glaucoma and retinal diseases, as well as to cross-sectional studies of patient populations.