In vivo morphometry of the lamina cribrosa and its relation to visual field loss in glaucoma

Assessment of the Corneal Biomechanical Features of Sturge-Weber Syndrome Using Dynamic Ultrahigh-speed Scheimpflug Imaging

PURPOSE

To evaluate the corneal biomechanical characteristics of eyes with Sturge-Weber syndrome (SWS) secondary glaucoma (SSG) by analyzing corneal biomechanical parameters obtained using the Corneal Visualization Scheimpflug Technology instrument (Corvis ST).

METHODS

In patients with SWS, eyes affected by SSG were designated as the SSG group while the contralateral eyes were designated as the SWS contralateral group (SC group). Patients from the myopia clinic served as the control group. Dynamic corneal response parameters (DCRs) including the stress-strain index (SSI)-a critical material stiffness parameter that excludes interference from IOP and central corneal thickness (CCT)-were analyzed.

RESULTS

For CCT, no significant difference was observed between the SSG and SC groups. However, significant differences were found between the SSG and control groups and between the SC and control groups. Parameters such as HC Time, A1 Deformation Amp., A2 Deformation Amp., length of Whole Eye Movement (WEM), DA Ratio Max (2 mm), PachySlope, DA Ratio Max (1 mm), and ARTh showed significant differences between the SSG group and control group. In the SSG group, 4 of night eyes had an SSI of less than 0.85.

CONCLUSIONS

Some DCRs indicated a stiffer cornea in the SSG group, possibly due to a thicker cornea in this group. On analyzing SSI, it was found that corneal material properties change, becoming less stiff in some of the patients with SSG. In conclusion, our study provides a preliminary exploration of the biomechanical properties of SWS secondary glaucoma.

Lamina Cribrosa Microstructure in Nonhuman Primates With Naturally Occurring Peripapillary Retinal Nerve Fiber Layer Thinning

Purpose

The lamina cribrosa (LC) is hypothesized to be the site of initial axonal damage in glaucoma with the circumpapillary retinal nerve fiber layer thickness (RNFL-T) widely used as a standard metric for quantifying the glaucomatous damage. The purpose of this study was to determine in vivo, 3-dimensional (3D) differences in the microstructure of the LC in eyes of nonhuman primates (NHPs) with naturally occurring glaucoma.

Methods

Spectral-domain optical coherence tomography (OCT) scans (Leica, Chicago, IL, USA) of the optic nerve head were acquired from a colony of 50 adult rhesus monkeys suspected of having high prevalence of glaucoma. The RNFL-T was analyzed globally and in quadrants using a semi-automated segmentation software. From a set of 100 eyes, 18 eyes with the thinnest global RNFL-T were selected as the study group and 18 eyes with RNFL-T values around the 50th percentile were used as controls. A previously described automated segmentation algorithm was used for LC microstructure analysis. Parameters included beam thickness, pore diameter and their ratio (beam-to-pore ratio [BPR]), pore area and shape parameters, beam and pore volume, and connective tissue volume fraction (CTVF; beam volume/total volume). The LC microstructure was analyzed globally and in the following volumetric sectors: quadrants, central and peripheral lamina, and three depth slabs (anterior, middle, and posterior).

Results

Although no significant difference was detected between groups for age, weight, or disc size, the study group had significantly thinner RNFL than the control group (P < 0.01). The study group had significantly smaller global and sectoral pore diameter and larger BPR compared with the control group. Across eyes, the global RNFL-T was associated positively with pore diameter globally. BPR and CTVF were significantly and negatively associated with the corresponding RNFL-T in the superior quadrant.

Conclusions

Global and sectoral microstructural differences were detected when comparing thin and normal RNFL-T eyes. Whether these LC differences are the cause of RNFL damage or the result of remodeling of the LC requires further investigation.

Translational Relevance

Our findings indicate structural alterations in the LC of NHP exhibiting natural thinning of the RNFL, a common characteristic of glaucomatous damage.

Risk factors for structural and functional progression of primary open-angle glaucoma in an African ancestry cohort

BACKGROUND/AIMS

To investigate the rates of structural and functional progression of primary open-angle glaucoma in an African ancestry cohort and identify risk factors for progression.

METHODS

This retrospective study included 1424 eyes from glaucoma cases in the Primary Open-Angle African American Glaucoma Genetics cohort, with ≥2 visits for retinal nerve fibre layer (RNFL) thickness and mean deviation (MD) measurements over ≥6-month follow-up. The rates of structural progression (change in RNFL thickness/year) and functional progression (change in MD/year) were calculated from linear mixed effects models, accounting for intereye correlation and longitudinal correlation. Eyes were categorised as slow, moderate or fast progressors. Risk factors for progression rates were assessed using univariable and multivariable regression models.

RESULTS

The median (interquartile) rates of progression were -1.60 (-2.05 to -1.15) µm/year for RNFL thickness and -0.40 (-0.44 to -0.34) decibels/year for MD. Eyes were categorised as slow (structural: 19%, functional: 88%), moderate (structural: 54%, functional: 11%) and fast (structural: 27%, functional: 1%) progressors. In multivariable analysis, faster RNFL progression was independently associated with thicker baseline RNFL (p<0.0001), lower baseline MD (p=0.003) and beta peripapillary atrophy (p=0.03). Faster MD progression was independently associated with higher baseline MD (p<0.0001), larger cup-to-disc ratios (p=0.02) and lower body mass index (p=0.0004).

CONCLUSION

The median rates of structural and functional progression in this African ancestry cohort were faster than the rates reported from previously published studies in other ethnic groups. Higher baseline RNFL thickness and MD values were associated with faster progression rates. Results highlight the importance of monitoring structural and functional glaucoma progression to provide timely treatment in early disease.

Microstructural Deformations Within the Depth of the Lamina Cribrosa in Response to Acute In Vivo Intraocular Pressure Modulation

Purpose

The lamina cribrosa (LC) is a leading target for initial glaucomatous damage. We investigated the in vivo microstructural deformation within the LC volume in response to acute IOP modulation while maintaining fixed intracranial pressure (ICP).

Methods

In vivo optic nerve head (ONH) spectral-domain optical coherence tomography (OCT) scans (Leica, Chicago, IL, USA) were obtained from eight eyes of healthy adult rhesus macaques (7 animals; ages = 7.9-14.4 years) in different IOP settings and fixed ICP (8-12 mm Hg). IOP and ICP were controlled by cannulation of the anterior chamber and the lateral ventricle of the brain, respectively, connected to a gravity-controlled reservoir. ONH images were acquired at baseline IOP, 30 mm Hg (H1-IOP), and 40 to 50 mm Hg (H2-IOP). Scans were registered in 3D, and LC microstructure measurements were obtained from shared regions and depths.

Results

Only half of the eyes exhibited LC beam-to-pore ratio (BPR) and microstructure deformations. The maximal BPR change location within the LC volume varied between eyes. BPR deformer eyes had a significantly higher baseline connective tissue volume fraction (CTVF) and lower pore aspect ratio (P = 0.03 and P = 0.04, respectively) compared to BPR non-deformer. In all eyes, the magnitude of BPR changes in the anterior surface was significantly different (either larger or smaller) from the maximal change within the LC (H1-IOP: P = 0.02 and H2-IOP: P = 0.004).

Conclusions

The LC deforms unevenly throughout its depth in response to IOP modulation at fixed ICP. Therefore, analysis of merely the anterior LC surface microstructure will not fully capture the microstructure deformations within the LC. BPR deformer eyes have higher CTVF than BPR non-deformer eyes.

Real-time imaging of optic nerve head collagen microstructure and biomechanics using instant polarized light microscopy

Current tools lack the temporal or spatial resolution necessary to image many important aspects of the architecture and dynamics of the optic nerve head (ONH). We evaluated the potential of instant polarized light microscopy (IPOL) to overcome these limitations by leveraging the ability to capture collagen fiber orientation and density in a single image. Coronal sections through the ONH of fresh normal sheep eyes were imaged using IPOL while they were stretched using custom uniaxial or biaxial micro-stretch devices. IPOL allows identifying ONH collagen architectural details, such as fiber interweaving and crimp, and has high temporal resolution, limited only by the frame rate of the camera. Local collagen fiber orientations and deformations were quantified using color analysis and image tracking techniques. We quantified stretch-induced collagen uncrimping of lamina cribrosa (LC) and peripapillary sclera (PPS), and changes in LC pore size (area) and shape (convexity and aspect ratio). The simultaneous high spatial and temporal resolutions of IPOL revealed complex ONH biomechanics: i) stretch-induced local deformation of the PPS was nonlinear and nonaffine. ii) under load the crimped collagen fibers in the PPS and LC straightened, without torsion and with only small rotations. iii) stretch-induced LC pore deformation was anisotropic and heterogeneous among pores. Overall, with stretch the pores were became larger, more convex, and more circular. We have demonstrated that IPOL reveals details of collagen morphology and mechanics under dynamic loading previously out of reach. IPOL can detect stretch-induced collagen uncrimping and other elements of the tissue nonlinear mechanical behavior. IPOL showed changes in pore morphology and collagen architecture that will help improve understanding of how LC tissue responds to load.

Elucidation of the role of the lamina cribrosa in glaucoma using optical coherence tomography

Glaucoma is a chronic and progressive optic neuropathy characterized by the death of retinal ganglion cells and corresponding visual field loss. Despite the growing number of studies on the subject, the pathogenesis of the disease remains unclear. Notwithstanding, several studies have shown that the lamina cribrosa (LC) is considered an anatomic site of glaucomatous optic nerve injury, thus having a key role in the pathophysiology of glaucoma development and progression. Different morphological alterations of the LC have been described in vivo in glaucomatous eyes after the evolution of optical coherence tomography (OCT) devices. The most relevant findings were the reduction of laminar thickness, the presence of localized defects, and the posterior LC displacement. These new laminar parameters documented through OCT are not only promising as possible additional tools for glaucoma diagnosis and monitoring, but also as predictors of disease progression. In spite of the advance of technology, however, proper evaluation of the LC is not yet viable in all eyes. We describe OCT-identified LC changes related to the development and progression of glaucoma and provide future directions based on a critical data analysis, focusing on its clinical relevance and applicability.

THE INFERENCE OF THE CHANGES OF AXONAL TRANSPORT OF OPTIC NERVE BY DEFORMATIONS OF LAMINA CRIBROSA

Understanding the relationship between the changes in the axonal transport of the optic nerve (ON) and lamina cribrosa (LC) deformation will be helpful to estimate the degree of axonal transport block by measuring the LC deformation in vivo. First, the changes in the axonal transport of the ON were studied using an acute high intraocular pressure (IOP) model, which was established by perfusing saline water into the anterior chamber of cats. The IOP of cat was unilaterally elevated to and maintained at 30, 40, and 50[Formula: see text]mmHg. The axonal transport of the ON was examined by confocal laser scanning microscope. Then the deformations and stress distributions of the LC and ON were calculated using a three-dimensional finite element model of the LC microstructure including ON. The results showed axonal transport changes of ON increased with elevation of the IOPs. While Young’s modulus of the LC and ON were assumed as 0.1[Formula: see text]MPa and 0.03[Formula: see text]MPa, the numerical simulation results showed that LC had displacements of 0.02, 0.03, and 0.04[Formula: see text]mm backward at the IOPs of 30, 40, and 50[Formula: see text]mmHg, respectively. The calculated compressive strain applied to the ON were 0.0425, 0.0567, and 0.0709 under 30, 40, and 50[Formula: see text]mmHg IOP, respectively. The results of strain and stress analysis of LC and ON showed that the deformation of LC would compress the ON. The axonal transport abnormalities could be inferred by measuring the LC deformation in vivo.

Imaging of the lamina cribrosa and its role in glaucoma: a review

The lamina cribrosa of the optic nerve head serves two contrasting roles; it must be porous to allow retinal ganglion cell axons to pass through, and yet at the same time, it must also provide adequate structural support to withstand the stresses and strains across it. Improvements in imaging such as optical coherence tomography image capture and image processing have allowed detailed in vivo studies of lamina cribrosa macro- and micro-architectural characteristics. This has aided our understanding of the optic nerve head as a complex biomechanical structure. In this review, we first aim to frame the biomechanical considerations of lamina cribrosa in a clinical context; in doing so, we also explore the concept of the translaminar pressure difference. Second, we aim to highlight the technological advances in imaging the lamina cribrosa and its accompanying clinical implications, and future directions in this quickly progressing field.

Lamina Cribrosa Pore Shape and Size as Predictors of Neural Tissue Mechanical Insult

Purpose

The purpose of this study was to determine how the architecture of the lamina cribrosa (LC) microstructure, including the shape and size of the lamina pores, influences the IOP-induced deformation of the neural tissues within the LC pores using computational modeling.

Methods

We built seven specimen-specific finite element models of LC microstructure with distinct nonlinear anisotropic properties for LC beams and neural tissues based on histological sections from three sheep eyes. Changes in shape (aspect ratio and convexity) and size (area and perimeter length) due to IOP-induced hoop stress were calculated for 128 LC pores. Multivariate linear regression was used to determine if pore shape and size were correlated with the strain in the pores. We also compared the microstructure models to a homogenized model built following previous approaches.

Results

The LC microstructure resulted in focal tensile, compressive, and shear strains in the neural tissues of the LC that were not predicted by homogenized models. IOP-induced hoop stress caused pores to become larger and more convex; however, pore aspect ratio did not change consistently. Peak tensile strains within the pores were well predicted by a linear regression model considering the initial convexity (negative correlation, P < 0.001), aspect ratio (positive correlation, P < 0.01), and area (negative correlation, P < 0.01). Significant correlations were also found when considering the deformed shape and size of the LC pores.

Conclusions

The deformation of the LC neural tissues was largely dependent on the collagenous LC beams. Simple measures of LC pore shape and area provided good estimates of neural tissue biomechanical insult.

Lamina depth and thickness correlate with glaucoma severity

Purpose:

To evaluate the correlation between lamina cribrosa (LC) morphology and glaucoma severity in patients with primary forms of open-angle glaucoma (OAG) using enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT) and Humphrey visual field test (HVF).

Subjects and Methods:

Patients with OAG (n = 166), divided into normal-tension glaucoma (NTG) and high-tension glaucoma (HTG) groups (n = 66 and n = 100), were imaged using SD-OCT to obtain horizontal B-scan images of the optic nerve head (ONH). Laminar depth (LD) and laminar thickness (LT) were measured at the center of ONH.

Results:

The mean (±standard deviation) values of LD, LT, and visual field mean deviation (MD) were 555.4 ± 142.3 μm, 179.9 ± 49.7 μm, and − 5.7 ± 6.4 dB, respectively. In the multivariate linear regression analysis, LD, LT, and intraocular pressure (IOP) were significantly correlated with MD (P = 0.007, P = 0.037, and P = 0.004, respectively). In the subgroup analyses, only LD was associated with MD in the NTG group (n = 66), whereas LT and IOP were correlated with MD in the HTG group (n = 100). Neither axial length nor central corneal thickness was associated with LD or LT.

Conclusions:

Glaucoma severity, as measured by HVF MD, shows significant correlations with LD and LT, with greater severity associated with increasing LD and decreasing LT. Normal- and high-tension OAG patients have different associations with LD and LT, which implies that the pathogenesis of these two entities might be different.

Glaucomatous changes in lamina pores shape within the lamina cribrosa using wide bandwidth, femtosecond mode-locked laser OCT

PURPOSE

The lamina cribrosa (LC) is known to play a critical role in the pathogenesis of glaucoma. Although it has been reported that striae-shaped or slit-shaped lamina pores are more frequent in eyes with primary open angle glaucoma (POAG), this observation is based only on fundus photography. The primary object of this study is to perform layer-by-layer comparisons of the shape of lamina pores within the LC in vivo.

DESIGN

Cross-sectional study.

METHODS

Optic nerve head B-scans were obtained using custom-made broad-wavelength optical coherence tomography with a mode-locked laser. A total of 300 single B-scans per eye were obtained and three-dimensional images were rendered from these image sequences to obtain 2-μm thin-slice en face images of the LC. Elongation indices (EIs) of the lamina pores were measured from the anterior surface (AS) of the LC to the deeper layers in 40-μm increments.

RESULTS

Thirteen eyes from 10 primary open angle glaucoma (POAG) patients of mean deviation -15.2 (-16.5, -12.9) (median [25,75 percentile]) dB and 10 eyes from 7 normal controls were studied. Although the EI value was not significantly different between the superior, temporal and inferior regions of the LC at any depth level in either group, it was greater at the AS than at the 40 μm and 80 μm depth levels (P < .001) in both groups, and was greater in the POAG group only at the AS and 40 μm depth level (P ≤ .05). After adjustment for age and refraction, the effects of depth and presence of POAG on the EI value remained significant. Also, the severity of glaucoma and depth were significant factors associated with EI in multivariate analysis.

CONCLUSIONS

Elongation of lamina pores was significantly more evident at the anterior surface and the 40-μm depth level of the LC in POAG eyes than in normal eyes, suggesting that nerve fiber bundles passing through the LC were under greater stress in the anterior layers of the LC.

A Novel Method for Assessing Lamina Cribrosa Structure Ex Vivo Using Anterior Segment Enhanced Depth Imaging Optical Coherence Tomography

PURPOSE

The purpose of this study is to investigate the use of anterior segment enhanced depth imaging (EDI) optical coherence tomography (OCT) for ex vivo lamina cribrosa (LC) imaging.

MATERIALS AND METHODS

After removing anterior segment and vitreous, the optic nerve head (ONH) tissue of porcine eyes was placed on a customized eye holder for imaging. Serial EDI OCT B-scans (interval, ∼35 μm) of the ONH were obtained using anterior segment module of spectral-domain OCT. Various conditions were tested for better quality LC images. After EDI OCT, serial histologic sections were obtained (distance between sections, ∼5 μm). LC structures in OCT scans were compared with those in histologic sections. Three-dimensional LC reconstructions created using serial OCT scans were compared with LC structures in disc photographs.

RESULTS

ONHs of 3 enucleated eyes were examined. The LC was more clearly imaged when the retina and part of the prelaminar tissue were removed (quality score, 39.01±3.30 vs. 26.40±5.85; P<0.001) and when the tissue was kept moist during imaging (quality score, 38.70±2.11 vs. 36.18±5.98; P<0.001). LC image quality was similar before and after fixation (quality score, 38.84±6.57 vs. 39.21±9.69; P=0.79). LC beams and part of retrolaminar glial columns identified in OCT scans matched those in histologic sections. LC beams and pores in 3-dimensional reconstructions matched those in disc photographs.

CONCLUSIONS

High-resolution cross-sectional images of the LC, comparable to histologic sections, can be obtained using anterior segment EDI OCT in ex vivo eyes with proper tissue preparation.

[Imaging of the lamina cribrosa for early detection of glaucoma : Latest trends from the annual ARVO meeting 2016]

Studying the lamina cribrosa (LC) is relevant to understand the mechanisms of retinal ganglion cell degeneration in glaucoma and develop new diagnostic and therapeutic strategies. We would like to present some of the emerging trends and hot topics in imaging of the lamina cribrosa in glaucoma from the 2016 ARVO (The Association of Research in Vision and Ophthalmology) annual meeting, which was held in Seattle, WA, USA. Presentation of the path of ganglion cells through the pores of the lamina cribrosa as well as changes to the shape of the lamina cribrosa with increase of the intraocular and intracerebral pressure have been of great international interest.

In Vivo Changes in Lamina Cribrosa Microarchitecture and Optic Nerve Head Structure in Early Experimental Glaucoma

The lamina cribrosa likely plays an important role in retinal ganglion cell axon injury in glaucoma. We sought to (1) better understand optic nerve head (ONH) structure and anterior lamina cribrosa surface (ALCS) microarchitecture between fellow eyes of living, normal non-human primates and (2) characterize the time-course of in vivo structural changes in the ONH, ALCS microarchitecture, and retinal nerve fiber layer thickness (RNFLT) in non-human primate eyes with early experimental glaucoma (EG). Spectral domain optical coherence tomography (SDOCT) images of the ONH were acquired cross-sectionally in six bilaterally normal rhesus monkeys, and before and approximately every two weeks after inducing unilateral EG in seven rhesus monkeys. ONH parameters and RNFLT were quantified from segmented SDOCT images. Mean ALCS pore area, elongation and nearest neighbor distance (NND) were quantified globally, in sectors and regionally from adaptive optics scanning laser ophthalmoscope images. In bilaterally normal monkeys, ONH parameters were similar between fellow eyes with few inter-eye differences in ALCS pore parameters. In EG monkeys, an increase in mean ALCS Depth (ALCSD) was the first structural change measured in 6 of 7 EG eyes. A decrease in mean minimum rim width (MRW) simultaneously accompanied this early change in 4 of 6 EG eyes and was the first structural change in the 7th EG eye. Mean ALCS pore parameters were among the first or second changes measured in 4 EG eyes. Mean ALCS pore area and NND increased in superotemporal and temporal sectors and in central and peripheral regions at the first time-point of change in ALCS pore geometry. RNFLT and/or mean ALCS radius of curvature were typically the last parameters to initially change. Survival analyses found mean ALCSD was the only parameter to significantly show an initial change prior to the first measured loss in RNFLT across EG eyes.

In vivo imaging methods to assess glaucomatous optic neuropathy

The goal of this review is to summarize the most common imaging methods currently applied for in vivo assessment of ocular structure in animal models of experimental glaucoma with an emphasis on translational relevance to clinical studies of the human disease. The most common techniques in current use include optical coherence tomography and scanning laser ophthalmoscopy. In reviewing the application of these and other imaging modalities to study glaucomatous optic neuropathy, this article is organized into three major sections: 1) imaging the optic nerve head, 2) imaging the retinal nerve fiber layer and 3) imaging retinal ganglion cell soma and dendrites. The article concludes with a brief section on possible future directions.

Three-dimensional optic nerve head images using optical coherence tomography with a broad bandwidth, femtosecond, and mode-locked laser

Purpose

The aim of this study was to demonstrate the fine laminar structure of the optic nerve head (ONH), in vivo, using a broad wavelength, ultra-high resolution, and optically coherent tomography (OCT) system.

Methods

This high-resolution OCT system, based on a 200 nm bandwidth spectrometer and an 8 femtosecond ultra-short, mode-locked, coherent laser light source, enabled in vivo cross-sectional ONH imaging with 2.0 μm axial resolution. A total of 300 optic disc B-scans, which consisted of 300 × 2048 pixels, were obtained in 10 μm steps. Three-dimensional images were rendered from these images to obtain n face images of the optic disc. Fundus photography, scanning laser ophthalmoscopy (SLO), and standard OCT were also performed for all subjects.

Results

Thirty-six eyes of normal subjects and ten eyes of glaucoma patients with mean age of 40.0 ± 10.0 years were enrolled in this study. Sequential en face images, from the ONH surface to deeper layers, were reconstructed in 2.0 μm steps. Observation of the images indicated variations in the shape and arrangement of the lamina pores at different depths. Clear lamina pores were identified by this technique in 44 eyes, compared with the fundus camera (identified in six eyes), SLO (identified in 14 eyes), and standard OCT (identified in 24 eyes) (all comparisons, p < 0.001).

Conclusions

The fine structure of the ONH could be resolved in vivo using our OCT, providing improved imaging that can be used in research and clinical applications for a better characterization of the anatomical and pathological features associated with glaucoma.

Electronic supplementary material

The online version of this article (doi:10.1007/s00417-014-2870-5) contains supplementary material, which is available to authorized users.

Comparison of optic disc morphology of optic nerve atrophy between compressive optic neuropathy and glaucomatous optic neuropathy

Objectives

To compare the optic nerve head (ONH) structure between compressive optic neuropathy (CON) and glaucomatous optic neuropathy (GON), and to determine whether selected ONH quantitative parameters effectively discriminate between GON and CON, especially CON cases presenting with a glaucoma-like disc.

Methods

We prospectively assessed 34 patients with CON, 34 age-matched patients with moderate or severe GON, and 34 age-matched healthy control subjects. The quantitative parameters of ONH structure were compared using the Heidelberg Retina Tomograph 2 (HRT2) and Spectralis optical coherence tomography with an enhanced depth imaging method.

Results

The mean and maximum cup depths of CON were significantly smaller than those with GON (P<0.001 and P<0.001, respectively). The distance between Bruch's membrane opening and anterior surface of the lamina cribrosa (BMO-anterior LC) of CON was also significantly smaller than that of glaucoma but was similar to that of the healthy group (P<0.001 and P = 0.47, respectively). Based on Moorfields regression analysis of the glaucoma classification of HRT2, 15 eyes with CON were classified with a glaucoma-like disc. The cup/disc area ratio did not differ between cases of CON with a glaucoma-like disc and cases of GON (P = 0.16), but the BMO-anterior LC and mean and maximum cup depths of CON cases with a glaucoma-like disc were smaller than those in GON (P = 0.005, P = 0.003, and P = 0.001, respectively).

Conclusions

Measurements of the cup depths and the LC depth had good ability to differentiate between CON with a glaucoma-like disc and glaucoma. There was no laminar remodeling detected by laminar surface position in the patients with CON compared to those with GON.

In vivo three-dimensional characterization of the healthy human lamina cribrosa with adaptive optics spectral-domain optical coherence tomography

PURPOSE

To characterize the in vivo three-dimensional (3D) lamina cribrosa (LC) microarchitecture of healthy eyes using adaptive optics spectral-domain optical coherence tomography (AO-SDOCT).

METHODS

A multimodal retinal imaging system with a light source centered at 1050 nm and AO confocal scanning laser ophthalmoscopy was used in this study. One randomly selected eye from 18 healthy subjects was scanned in a 6° × 6° window centered on the LC. Subjects also underwent scanning with Cirrus HD-OCT. Lamina cribrosa microarchitecture was semiautomatically segmented and quantified for connective tissue volume fraction (CTVF), beam thickness, pore diameter, pore area, and pore aspect ratio. The LC was assessed in central and peripheral regions of equal areas and quadrants and with depth. A linear mixed effects model weighted by the fraction of visible LC was used to compare LC structure between regions.

RESULTS

The nasal quadrant was excluded due to poor visualization. The central sector showed greater CTVF and thicker beams as compared to the periphery (P < 0.01). Both superior and inferior quadrants showed greater CTVF, pore diameter, and pore mean area than the temporal quadrant (P < 0.05). Depth analysis showed that the anterior and posterior aspects of the LC contained smaller pores with greater density and thinner beams as compared to the middle third (P < 0.05). The anterior third also showed a greater CTVF than the middle third (P < 0.05).

CONCLUSIONS

In vivo analysis of healthy eyes using AO-SDOCT showed significant, albeit small, regional variation in LC microarchitecture by quadrant, radially, and with depth, which should be considered in further studies of the LC.

Repeatability of in vivo 3D lamina cribrosa microarchitecture using adaptive optics spectral domain optical coherence tomography

We demonstrate the repeatability of lamina cribrosa (LC) microarchitecture for in vivo 3D optical coherence tomography (OCT) scans of healthy, glaucoma suspects, and glaucomatous eyes. Eyes underwent two scans using a prototype adaptive optics spectral domain OCT (AO-SDOCT) device from which LC microarchitecture was semi-automatically segmented. LC segmentations were used to quantify pore and beam structure through several global microarchitecture parameters. Repeatability of LC microarchitecture was assessed qualitatively and quantitatively by calculating parameter imprecision. For all but one parameters (pore volume) measurement imprecision was <4.7% of the mean value, indicating good measurement reproducibility. Imprecision ranged between 27.3% and 54.5% of the population standard deviation for each parameter, while there was not a significant effect on imprecision due to disease status, indicating utility in testing for LC structural trends.

In vivo lamina cribrosa micro-architecture in healthy and glaucomatous eyes as assessed by optical coherence tomography

PURPOSE

The lamina cribrosa (LC) is a prime location of glaucomatous damage. The purpose of this study was to compare LC 3-dimensional micro-architecture between healthy and glaucomatous eyes in vivo by using optical coherence tomography (OCT).

METHODS

Sixty-eight eyes (19 healthy and 49 glaucomatous) from 47 subjects were scanned in a 3.5 × 3.5 × 3.64-mm volume (400 × 400 × 896 pixels) at the optic nerve head by using swept-source OCT. The LC micro-architecture parameters were measured on the visible LC by an automated segmentation algorithm. The LC parameters were compared to diagnosis and visual field mean deviation (VF MD) by using a linear mixed effects model accounting for age.

RESULTS

The average VF MD for the healthy and glaucomatous eyes was -0.50 ± 0.80 dB and -7.84 ± 8.75 dB, respectively. Beam thickness to pore diameter ratio (P = 0.04) and pore diameter standard deviation (P < 0.01) were increased in glaucomatous eyes. With worse MD, beam thickness to pore diameter ratio (P < 0.01), pore diameter standard deviation (P = 0.05), and beam thickness (P < 0.01) showed a statistically significant increase while pore diameter (P = 0.02) showed a significant decrease. There were no significant interactions between any of the parameters and age (all P > 0.05).

CONCLUSIONS

Glaucomatous micro-architecture changes in the LC, detected by OCT analysis, reflect beams remodeling and axonal loss leading to reduction in pore size and increased pore size variability.

Improved visualization of deep ocular structures in glaucoma using high penetration optical coherence tomography

The introduction of optical coherence tomography (OCT) has revolutionized ophthalmology through the ability to non-invasively image the retina in vivo. Glaucoma is the leading cause of irreversible blindness worldwide. Despite major advances in imaging techniques, the pathogenesis of glaucoma remains poorly understood at present. The lamina cribrosa (LC) is the presumed site of axonal injury in glaucoma. Its thinning and deformation have been suggested to contribute to glaucoma development and progression by impeding axoplasmic flow within the optic nerve fibers, leading to apoptosis of retinal ganglion cells. To visualize the deep ocular structures such as the choroid and the LC, OCT imaging has been used, particularly the enhanced depth imaging (EDI)-OCT modality of spectral domain (SD)-OCT. However, the posterior laminar surface especially is not seen clearly using this method. A new generation of OCTs, swept-source (SS)-OCT, is able to image the LC and the choroid in vivo. SS-OCT employs a longer wavelength compared with the conventional OCT, generally set at 1050 nm (instead of 840 nm). We review current knowledge of the LC, findings from trials that use SD-OCT and EDI-OCT, and our experience with a prototype SS-OCT to quantify choroid changes and visualize the LC in its entirety.

3D modeling to characterize lamina cribrosa surface and pore geometries using in vivo images from normal and glaucomatous eyes

En face adaptive optics scanning laser ophthalmoscope (AOSLO) images of the anterior lamina cribrosa surface (ALCS) represent a 2D projected view of a 3D laminar surface. Using spectral domain optical coherence tomography images acquired in living monkey eyes, a thin plate spline was used to model the ALCS in 3D. The 2D AOSLO images were registered and projected onto the 3D surface that was then tessellated into a triangular mesh to characterize differences in pore geometry between 2D and 3D images. Following 3D transformation of the anterior laminar surface in 11 normal eyes, mean pore area increased by 5.1 ± 2.0% with a minimal change in pore elongation (mean change = 0.0 ± 0.2%). These small changes were due to the relatively flat laminar surfaces inherent in normal eyes (mean radius of curvature = 3.0 ± 0.5 mm). The mean increase in pore area was larger following 3D transformation in 4 glaucomatous eyes (16.2 ± 6.0%) due to their more steeply curved laminar surfaces (mean radius of curvature = 1.3 ± 0.1 mm), while the change in pore elongation was comparable to that in normal eyes (-0.2 ± 2.0%). This 3D transformation and tessellation method can be used to better characterize and track 3D changes in laminar pore and surface geometries in glaucoma.

Automated lamina cribrosa microstructural segmentation in optical coherence tomography scans of healthy and glaucomatous eyes

We demonstrate an automated segmentation method for in-vivo 3D optical coherence tomography (OCT) imaging of the lamina cribrosa (LC). Manual segmentations of coronal slices of the LC were used as a gold standard in parameter selection and evaluation of the automated technique. The method was validated using two prototype OCT devices; each had a subject cohort including both healthy and glaucomatous eyes. Automated segmentation of in-vivo 3D LC OCT microstructure performed comparably to manual segmentation and is useful for investigative research and in clinical quantification of the LC.

Imaging of the Lamina Cribrosa using Swept-Source Optical Coherence Tomography

The lamina cribrosa (LC) is the presumed site of axonal injury in glaucoma. Its deformation has been suggested to contribute to optic neuropathy by impeding axoplasmic flow within the optic nerve fibers, leading to apoptosis of retinal ganglion cells. To visualize the LC in vivo, optical coherence tomography (OCT) has been applied. Spectral domain (SD)-OCT, used in conjunction with recently introduced enhanced depth imaging (EDI)-OCT, has improved visualization of deeper ocular layers, but in many individuals it is still limited by inadequate resolution, poor image contrast and insufficient depth penetrance. The posterior laminar surface especially is not viewed clearly using these methods. New generation high-penetration (HP)-OCTs, also known as swept-source (SS)-OCT, are capable to evaluate the choroid in vivo to a remarkable level of detail. SS-OCTs use a longer wavelength (1,050 nm instead of 840 nm) compared to the conventional techniques. We review current knowledge of the LC, findings from trials that use SD-OCT and EDI-OCT, and our experience with a prototype SS-OCT to visualize the LC in its entirety.

Key Points

What is known?

•     The LC is the presumed site of axonal injury in glaucoma

•     Compared to spectral domain-OCT, enhanced depth imaging-OCT improves imaging of the LC

•     Even so, currently used SD-OCT techniques are restricted by poor wavelength penetrance of the deeper ocular layers

What our findings add?

•    SS-OCT may be a superior imaging modality for deep ocular structures

•    Prior studies used SS-OCT to evaluate choroidal thickness in both healthy and ‘normal tension glaucoma’ eyes

•    SS-OCT enables good evaluation of three-dimension (3D) lamina cribrosa morphology.

How to cite this article: Nuyen B, Mansouri K, Weinreb RN. Imaging of the Lamina Cribrosa using Swept-Source Optical Coherence Tomography. J Current Glau Prac 2012;6(3): 113-119.

Structural basis of glaucoma: the fortified astrocytes of the optic nerve head are the target of raised intraocular pressure

Increased intraocular pressure (IOP) damages the retinal ganglion cell axons as they pass through the optic nerve head (ONH). The massive connective tissue structure of the human lamina cribrosa is generally assumed to be the pressure transducer responsible for the damage. The rat, however, with no lamina cribrosa, suffers the same glaucomatous response to raised IOP. Here, we show that the astrocytes of the rat ONH are "fortified" by extraordinarily dense cytoskeletal filaments that would make them ideal transducers of distorting mechanical forces. The ONH astrocytes are arranged as a fan-like radial array, firmly attached ventrally to the sheath of the ONH by thick basal processes, but dividing dorsally into progressively more slender processes with only delicate attachments to the sheath. At 1 week after raising the IOP by an injection of magnetic microspheres into the anterior eye chamber, the fine dorsal processes of the ONH astrocytes are torn away from the surrounding sheath. There is no indication of distortion or compression of the axons. Subsequently, despite return of the IOP toward normal levels, the damage to the ONH progresses ventrally through the astrocytic cell bodies, resulting in complete loss of the fortified astrocytes and of the majority of the axons by around 4 weeks. We propose that the dorsal attachments of the astrocytes are the site of initial damage in glaucoma, and that the damage to the axons is not mechanical, but is a consequence oflocalized loss of metabolic support from the astrocytes (Tsacopoulos and Magistretti (1996) J Neurosci 16:877-885).

Reproducibility of measuring lamina cribrosa pore geometry in human and nonhuman primates with in vivo adaptive optics imaging

PURPOSE

The ability to consistently resolve lamina cribrosa pores in vivo has applications in the study of optic nerve head and retinal disease mechanisms. Repeatability was assessed in imaging laminar pores in normal living eyes with a confocal adaptive optics scanning laser ophthalmoscope (AOSLO).

METHODS

Reflectance images (840 nm) of the anterior lamina cribrosa were acquired using the AOSLO in four or more different sessions in two normal rhesus monkey eyes and three normal human eyes. Laminar pore areas, elongations (ratio of major to minor axes of the best-fit ellipse) and nearest neighbor distances were calculated for each session. Measurement repeatability was assessed across sessions.

RESULTS

Pore areas ranged from 90 to 4365 μm(2) in monkeys and 154 to 6637 μm(2) in humans. Mean variabilities in measuring pore area and elongation (i.e., mean of the standard deviation of measurements made across sessions for the same pores) were 50 μm(2) (6.1%) and 0.13 (6.7%), respectively, in monkeys and 113 μm(2) (8.3%) and 0.17 (7.7%), respectively, in humans. Mean variabilities in measuring nearest neighbor distances were 1.93 μm (5.2%) in monkeys and 2.79 μm (4.1%) in humans. There were no statistically significant differences in any pore parameters across sessions (ANOVA, P > 0.05).

CONCLUSIONS

The anterior lamina cribrosa was consistently imaged in vivo in normal monkey and human eyes. The small intersession variability in normal pore geometry suggests that AOSLO imaging could be used to measure and track changes in laminar pores in vivo during glaucomatous progression.

High resolution in vivo imaging of the lamina cribrosa

The lamina cribrosa (LC) is considered to be the principal site of retinal ganglion cell axon injury in glaucoma. Imaging technology has steadily improved in recent years, allowing greater resolution of fine details of laminar structure. Histological studies have elucidated the details of LC structure, both in normal and glaucomatous eyes, but such studies are limited by smaller sample size, greater difficulty of conducting prospective studies, and possibility of altered tissue architecture during histologic processing. We reviewed the literature describing the LC in primate and human eyes using in vivo imaging devices and provided a brief explanation of the imaging technology and main results of the articles. We also discuss the advantages and limitations of each imaging modality described, including optic disk photography, confocal scanning laser ophthalmoscopy (CSLO) and optical coherence tomography (OCT). These modalities provide en face and/or cross-sectional images of the LC in vivo. Enhanced depth imaging OCT has recently led to important advances in imaging deeper structures of the posterior segment, including the LC. Adaptive optics has been adopted in CSLO and OCT imaging to correct for ocular aberration and has improved resolution and contrast of the LC images. Post-image processing techniques to compensate for light attenuation and enhance contrast in OCT images enabled better visualization of the LC beneath the neuroretinal rim, vascular structures, and scleral rim. Long-wavelength probe OCT has shown good visualization of the LC with improved penetration when combined with swept-source OCT. Contrast agents for enhanced visualization of selective target structures in OCT have been developed. All these technologies hold great promise for improved in vivo imaging of the LC and require further investigation.

Correlation between local stress and strain and lamina cribrosa connective tissue volume fraction in normal monkey eyes

PURPOSE

To investigate the biomechanical response to IOP elevation of normal monkey eyes using eye-specific, three-dimensional (3-D) finite element (FE) models of the ONH that incorporate lamina cribrosa (LC) microarchitectural information.

METHODS

A serial sectioning and episcopic imaging technique was used to reconstruct the ONH and peripapillary sclera of four pairs of eyes fixed at 10 mm Hg. FE models were generated with local LC material properties representing the connective tissue volume fraction (CTVF) and predominant LC beam orientation and used to simulate an increase in IOP from 10 to 45 mm Hg. An LC material stiffness constant was varied to assess its influence on biomechanical response.

RESULTS

Strains and stresses within contralateral eyes were remarkably similar in both magnitude and distribution. Strain correlated inversely, and nonlinearly, with CTVF (median, r (2) = 0.73), with tensile strains largest in the temporal region. Stress correlated linearly with CTVF (median r(2) = 0.63), with the central and superior regions bearing the highest stresses. Net average LC displacement was either posterior or anterior, depending on whether the laminar material properties were compliant or stiff.

CONCLUSIONS

The results show that contralateral eyes exhibit similar mechanical behavior and suggest that local mechanical stress and strain within the LC are correlate highly with local laminar CTVF. These simulations emphasize the importance of developing both high-resolution imaging of the LC microarchitecture and next-generation, deep-scanning OCT techniques to clarify the relationships between IOP-related LC displacement and CTVF-related stress and strain in the LC. Such imaging may predict sites of IOP-related damage in glaucoma.

Second harmonic generation imaging of the pig lamina cribrosa using a scanning laser ophthalmoscope-based microscope

We describe a novel scanning laser ophthalmoscope (SLO)-based on a video-rate second harmonic generation imaging microscope. A titanium:sapphire femtosecond laser was coupled to a modified SLO. The laser beam was scanned over the sample, and the light produced by second harmonic generation (SHG) was collected for imaging at video-speed. The device was used for imaging the lamina cribrosa (LC) of enucleated pig eyes. A resolution comparable to that of commercial multiphoton microscopes was reached. The SHG images were used for determining the average pore size of the LC determined from the images; the pressure dependence of the pore size was studied by the artificial increasing of the hydrostatic pressure in the eye. A pressure increase of 44.3 mmHg enlarged the average pore size of 62 analyzed pores by a statistically significant amount. The relative pore growth was measured at four different pressure levels in 25 pores. The pressure was increased in 15 mmHg steps. A general tendency for monothonic growth was observed, although single pores grew by no means linearly.

Three-dimensional high-speed optical coherence tomography imaging of lamina cribrosa in glaucoma

OBJECTIVE

To evaluate the appearance of the optic nerve head and lamina cribrosa in patients with glaucoma using spectral/Fourier-domain optical coherence tomography (SD-OCT) and to test for a correlation between lamina cribrosa thickness measured on SD-OCT images and visual field loss.

DESIGN

Observational case series.

PARTICIPANTS

We evaluated 52 eyes of 30 patients with glaucoma or ocular hypertension.

METHODS

The high-speed SD-OCT equipment used was a prototype system developed for 3-dimensional (3D) imaging. It had a sensitivity of 98 decibels (dB), a tissue axial resolution of 4.3 mum, and an acquisition rate of approximately 18,700 axial scans per second. For 3D analyses, a raster scan protocol of 256 x 256 axial scans covering a 2.8 x 2.8 mm disc area was used. Lamina cribrosa thickness was measured on 3D images using 3D image processing software. Correlation between lamina cribrosa thickness and mean deviation (MD) values obtained using static automatic perimetry were tested for statistical significance.

MAIN OUTCOME MEASURES

Clarity of lamina cribrosa features, lamina cribrosa thickness, and MD values on static automatic perimetry.

RESULTS

On 3D images, the lamina cribrosa appeared clearly as a highly reflective plate that was bowed posteriorly and contained many circular areas of low reflectivity. The dots of low reflectivity visible just beneath the anterior surface of the lamina cribrosa in en face cross-sections corresponded with dots representing lamina pores in color fundus photographs. The mean (+/-1 standard deviation) thickness of the lamina cribrosa was 190.5+/-52.7 mum (range, 80.5-329.0). Spearman rank testing and linear regression analysis showed that lamina cribrosa thickness correlated significantly with MD (Spearman sigma = 0.744; P<0.001; r(2) = 0.493; P<0.001). Different observers performed measurements of the lamina cribrosa thickness in SD-OCT cross-sectional images with high reproducibility (intraclass correlation coefficient = 0.784).

CONCLUSIONS

These 3D SD-OCT imaging clearly demonstrated the 3D structure of the lamina cribrosa and allowed measurement of its thickness, which correlated significantly with visual field loss, in living patients with glaucoma. This noninvasive imaging technique should facilitate investigations of structural changes in the optic nerve head lamina cribrosa in eyes with optic nerve damage due to glaucoma.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Ultrahigh-speed optical coherence tomography for three-dimensional and en face imaging of the retina and optic nerve head

PURPOSE

To demonstrate ultrahigh-speed optical coherence tomography (OCT) imaging of the retina and optic nerve head at 249,000 axial scans per second and a wavelength of 1060 nm. To investigate methods for visualization of the retina, choroid, and optic nerve using high-density sampling enabled by improved imaging speed.

METHODS

A swept-source OCT retinal imaging system operating at a speed of 249,000 axial scans per second was developed. Imaging of the retina, choroid, and optic nerve were performed. Display methods such as speckle reduction, slicing along arbitrary planes, en face visualization of reflectance from specific retinal layers, and image compounding were investigated.

RESULTS

High-definition and three-dimensional (3D) imaging of the normal retina and optic nerve head were performed. Increased light penetration at 1060 nm enabled improved visualization of the choroid, lamina cribrosa, and sclera. OCT fundus images and 3D visualizations were generated with higher pixel density and less motion artifacts than standard spectral/Fourier domain OCT. En face images enabled visualization of the porous structure of the lamina cribrosa, nerve fiber layer, choroid, photoreceptors, RPE, and capillaries of the inner retina.

CONCLUSIONS

Ultrahigh-speed OCT imaging of the retina and optic nerve head at 249,000 axial scans per second is possible. The improvement of approximately 5 to 10x in imaging speed over commercial spectral/Fourier domain OCT technology enables higher density raster scan protocols and improved performance of en face visualization methods. The combination of the longer wavelength and ultrahigh imaging speed enables excellent visualization of the choroid, sclera, and lamina cribrosa.

Adaptive optics scanning laser ophthalmoscopy for in vivo imaging of lamina cribrosa

The lamina cribrosa has been postulated from in vitro studies as an early site of damage in glaucoma. Prior in vivo measures of laminar morphology have been confounded by ocular aberrations. In this study the lamina cribrosa was imaged after correcting for ocular aberrations using the adaptive optics scanning laser ophthalmoscope (AOSLO) in normal and glaucomatous eyes of rhesus monkeys. All measured laminar morphological parameters showed increased magnitudes in glaucomatous eyes relative to fellow control eyes, indicating altered structure. The AOSLO provides high-quality images of the lamina cribrosa and may have potential as a tool for early identification of glaucoma.

Three dimensional analysis of the lamina cribrosa in glaucoma

BACKGROUND/AIM

Structural changes in the lamina cribrosa have been implicated in the pathogenesis of glaucomatous optic atrophy. The aim of this study was to determine a measure the surface variability of the cup floor in normal subjects and patients with glaucoma.

METHODS

A sample of age matched normal subjects (NN), patients with low tension glaucoma (LTG), and primary open angle glaucoma (POAG) were included in the study. The glaucoma groups were matched for the severity of the visual field loss. Mean 10 degree topographic images of normal and glaucomatous eyes from the Heidelberg retina tomograph were imported into ERDAS image processing software where topographic analysis of the cup floor could be assessed. Each image was processed using customised spatial filters that calculated the surface depth variation in localised neighbourhood areas across each image. The local change in depth across the cup floor surface was determined and compared between the three clinical groups.

RESULTS

The depth variation in the cup floor was largest in normal subjects followed by LTG and POAG. Highly statistically significant differences in surface depth variability of the cup floor existed between normal and LTG (p = 0.005), between normal and POAG (p<0.0001), and between LTG and POAG groups (p<0.0001). The variability and skewness of depth difference across the optic cup floor were also significantly different between the three clinical groups.

CONCLUSION

A new parameter quantifying depth variations in the cup floor significantly discriminated between groups of normal and glaucoma patients. This new parameter may contribute to a better understanding of the pathogenesis of the glaucomatous optic nerve damage in different types of glaucoma.

Alterations in the morphology of lamina cribrosa pores in glaucomatous eyes

AIMS

To determine alterations which occur in the size and shape of lamina cribrosa (LC) pores in glaucomatous eyes over a period of time.

METHODS

Baseline and follow up optic disc photographs were retrospectively studied in 39 eyes of 39 patients with glaucoma. Only eyes with a vertical cup to disc ratio equal to or greater than 0.6 were included in the study. In addition, all selected eyes had to have serial optic disc photographs obtained at least 3 years apart allowing clear visualisation of LC surface. The association of the alterations in LC surface morphology with patient specific and eye specific characteristics was statistically analysed.

RESULTS

During a mean study period of 3.90 (SD 0.7) years, individual pore size (mean pore area to disc area ratio) exhibited a significant decrease between baseline and follow up measurements of each eye (p<0.0001). However, during the study period, total pore area to disc area ratio did not change (p>0.05), and the change in pore shape in some eyes (from circular to more oval and elongated) was statistically insignificant (p = 0.12). Although a relation was detectable between the optic disc and lamina cribrosa parameters at a given time, which reflects cumulative effects, during the study period, there was no significant association between the changes of the LC parameters and neural tissue damage. The rate and the magnitude of the changes in individual pore size during the study period were not significantly different among the eyes exhibiting progressive neural rim damage and those staying stable (p>0.05).

CONCLUSION

These findings demonstrate that the LC surface morphology exhibits changes along with the glaucomatous optic disc damage. However, the clinical appearance of LC surface in glaucomatous eyes may continue to change, even when the neural rim damage is clinically stable. These findings are probably associated with the chronic cellular events of tissue remodelling that occur in the glaucomatous optic nerve head.

Imaging the optic nerve and ganglion cell layer

New imaging techniques have extended the limitations of visualisation of the structures of the optic nerve and fundus in the living human eye. Quantitative reconstruction of depth of the optic nerve head is becoming widely available through the use of the confocal scanning laser ophthalmoscope (cSLO). A separate method of quantitative depth reconstruction is possible using stereo pairs which is not subject to the same artefacts as the tomographic reconstruction. We are investigating the use of these techniques both with conventional stereo imaging and using stereo pairs derived from cSLO images. In these we find that there is additional structural detail evident in the base of the optic nerve head. Further studies made with an instrument optimised to image this region show that this corresponds to the lamina cribrosa. Current work is aimed at further extending the limits of imaging using techniques based on optical coherence tomography, which provides additional depth resolution. Results to date with a prototype device show an improvement of approximately a factor of 10 in depth resolution and that some separate layers of the retina may be visualised including the photoreceptor layer. The goal is to extend these limits to allow visualisation of the ganglion cell layer.

The many faces of glaucomatous optic neuropathy

BACKGROUND: Glaucoma manifests mostly in the elderly, who frequently have otherocular changes that frustrate clear visualisation of the optic nerve head or nerve fibre layer. In the past, a large or asymmetric cup/disc ratio has been used to indicate the possibility of glaucoma. In this paper, I will argue that cup/disc ratios alone have poor sensitivity to glaucoma, and a more sophisticated approach is needed to make the earliest diagnosis. METHODS: This paper reviews the literature and describes the changes that occur at the optic nerve head and in the peripapillary region as a consequence of glaucomatous optic neuropathy (GON). RESULTS: The concept of 'risk factors' is developed to help screen for glaucoma. Glaucoma suspects require a full clinical investigation (visual field, IOP, assessment of anterior chamber, disc features and nerve fibres) and need to be monitored annually. For future reference, they should have their disc features recorded by instrumental methods or with photography at an early age. As no single sign provides the perfect diagnostic marker for the disease, clinicians need to examine for a group of signs before making the diagnosis. A clinical logic is developed in this paper to enhance the detection of glaucoma. CONCLUSION: Adoption of a protocol similar to that detailed in this paper will enhance the early and reliable detection of glaucoma.