Motion Contrast, Phase Gradient, and Simultaneous OCT Images Assist in the Interpretation of Dark-Field Images in Eyes with Retinal Pathology

The cellular-level visualization of retinal microstructures such as blood vessel wall components, not available with other imaging modalities, is provided with unprecedented details by dark-field imaging configurations; however, the interpretation of such images alone is sometimes difficult since multiple structural disturbances may be present in the same time. Particularly in eyes with retinal pathology, microstructures may appear in high-resolution retinal images with a wide range of sizes, sharpnesses, and brightnesses. In this paper we show that motion contrast and phase gradient imaging modalities, as well as the simultaneous acquisition of depth-resolved optical coherence tomography (OCT) images, provide additional insight to help understand the retinal neural and vascular structures seen in dark-field images and may enable improved diagnostic and treatment plans.

Non-Rigid Registration for High-Resolution Retinal Imaging

Adaptive optics provides improved resolution in ophthalmic imaging when retinal microstructures need to be identified, counted, and mapped. In general, multiple images are averaged to improve the signal-to-noise ratio or analyzed for temporal dynamics. Image registration by cross-correlation is straightforward for small patches; however, larger images require more sophisticated registration techniques. Strip-based registration has been used successfully for photoreceptor mosaic alignment in small patches; however, if the deformations along strips are not simple displacements, averaging can degrade the final image. We have applied a non-rigid registration technique that improves the quality of processed images for mapping cones over large image patches. In this approach, correction of local deformations compensates for local image stretching, compressing, bending, and twisting due to a number of causes. The main result of this procedure is improved definition of retinal microstructures that can be better identified and segmented. Derived metrics such as cone density, wall-to-lumen ratio, and quantification of structural modification of blood vessel walls have diagnostic value in many retinal diseases, including diabetic retinopathy and age-related macular degeneration, and their improved evaluations may facilitate early diagnostics of retinal diseases.

Modelling eye lengths and refractions in the periphery

PURPOSE

To create a simplified model of the eye by which we can specify a key optical characteristic of the crystalline lens, namely its power.

METHODS

Cycloplegic refraction and axial length were obtained in 60 eyes of 30 healthy subjects at eccentricities spanning 40° nasal to 40° temporal and were fitted with a three-dimensional parabolic model. Keratometric values and geometric distances to the cornea, lens and retina from 45 eyes supplied a numerical ray tracing model. Posterior lens curvature (PLC) was found by optimising the refractive data using a fixed lens equivalent refractive index ( n eq $$ {n}_{eq} $$ ). Then, n eq $$ {n}_{eq} $$ was found using a fixed PLC.

RESULTS

Eccentric refractive errors were relatively hyperopic in eyes with central refractions ≤-1.44 D but relatively myopic in emmetropes and hyperopes. Posterior lens power, which cannot be measured directly, was derived from the optimised model lens. There was a weak, negative association between derived PLC and central spherical equivalent refraction. Regardless of refractive error, the posterior retinal curvature remained fixed.

CONCLUSIONS

By combining both on- and off-axis refractions and eye length measurements, this simplified model enabled the specification of posterior lens power and captured off-axis lenticular characteristics. The broad distribution in off-axis lens power represents a notable contrast to the relative stability of retinal curvature.

The Fovea in Retinopathy of Prematurity

Purpose

Because preterm birth and retinopathy of prematurity (ROP) are associated with poor visual acuity (VA) and altered foveal development, we evaluated relationships among the central retinal photoreceptors, postreceptor retinal neurons, overlying fovea, and VA in ROP.

Methods

We obtained optical coherence tomograms (OCTs) in preterm born subjects with no history of ROP (none; n = 61), ROP that resolved spontaneously without treatment (mild; n = 51), and ROP that required treatment by laser ablation of the avascular peripheral retina (severe; n = 22), as well as in term born control subjects (term; n = 111). We obtained foveal shape descriptors, measured central retinal layer thicknesses, and demarcated the anatomic parafovea using automated routines. In subsets of these subjects, we obtained OCTs eccentrically through the pupil (n = 46) to reveal the fiber layer of Henle (FLH) and obtained adaptive optics scanning light ophthalmograms (AO-SLOs) of the parafoveal cones (n = 34) and measured their spacing and distribution.

Results

Both VA and foveal depth decreased with increasing ROP severity (term, none, mild, severe). In severe subjects, foveae were broader than normal and the parafovea was significantly enlarged compared to every other group. The FLH was thinner than normal in mild (but not severe) subjects. VA was associated with foveal depth more than group. Density of parafoveal cones did not differ significantly among groups.

Conclusions

Foveal structure is associated with loss of VA in ROP. The preserved FLH in severe (relative to mild) eyes suggests treatment may help cone axon development. The significantly larger parafovea and increased outer nuclear layer (ONL) thickness in ROP hint that some developmental process affecting the photoreceptors is not arrested in ROP but rather is supranormal.

Carbonic anhydrase inhibition in X-linked retinoschisis: An eye on the photoreceptors

The retinoschisin protein is encoded on the short arm of the X-chromosome by RS1, is expressed abundantly in photoreceptor inner segments and in bipolar cells, and is secreted as an octamer that maintains the structural integrity of the retina. Mutations in RS1 lead to X-linked retinoschisis (XLRS), a disease characterized by the formation of cystic spaces between boys' retinal layers that frequently present in ophthalmoscopy as a "spoke-wheel" pattern on their maculae and by progressively worsening visual acuity (VA). There is no proven therapy for XLRS, but there is mixed evidence that carbonic anhydrase inhibitors (CAIs) produce multiple beneficial effects, including improved VA and decreased volume of cystic spaces. Consequently, linear mixed-effects (LME) models were used to evaluate the effects of CAI therapy on VA and central retinal thickness (CRT, a proxy for cystic cavity volume) in a review of 19 patients' records. The mechanism of action of action of CAIs is unclear but, given that misplaced retinoschisin might accumulate in the photoreceptors, it is possible-perhaps even likely-that CAIs act to benefit the function of photoreceptors and the neighboring retinal pigment epithelium by acidification of the extracellular milieu; patients on CAIs have among the most robust photoreceptor responses. Therefore, a small subset of five subjects were recruited for imaging on a custom multimodal adaptive optics retinal imager for inspection of their parafoveal cone photoreceptors. Those cones that were visible, which numbered far fewer than in controls, were enlarged, consistent with the retinoschisin accumulation hypothesis. Results of the LME modeling found that there is an initial benefit to both VA and CRT in CAI therapy, but these wane, in both cases, after roughly two years. That said, even a short beneficial effect of CAIs on the volume of the cystic spaces may give CAI therapy an important role as pretreatment before (or immediately following) administration of gene therapy.

Two-photon microscope using a fiber-based approach for supercontinuum generation and light delivery to a small-footprint optical head

In this Letter, we report a low-cost, portable, two-photon excitation fluorescence microscopy imager that uses a fiber-based approach for both femtosecond supercontinuum (SC) generation and light delivery to the optical head. The SC generation is based on a tapered polarization-maintaining photonic crystal fiber that uses pre-chirped femtosecond narrowband pulses to generate a coherent SC spectrum with a bandwidth of approximately 300 nm. Using this approach, high-power, near-transform-limited, wavelength-selectable SC pulses are generated and directly delivered to the imaging optical head. Preliminary testing of this imager on brain slices is presented, demonstrating a high signal-to-noise ratio and sub-cellular imaging capabilities to a depth of approximately 200 µm. These results demonstrate the suitability of the technology for ex vivo and potentially in vivo cellular-level biomedical imaging applications.

Visualizing the vasculature of the entire human eye posterior hemisphere without a contrast agent

The platform described here combines the non-invasive measurement of the retina/choroid structure and ocular blood flow based on optical coherence tomography (OCT) and wide-field semi-quantitative global flow visualization using line-scanning Doppler flowmetry (LSDF). The combination of these two imaging modalities within the same platform enables comprehensive assessment of blood flow in the retina and choroid in animals and human subjects for diagnostic purposes. Ultra-widefield vasculature visualization is demonstrated here for the first time without injecting additional contrast agents and based only on the motion of particles within the vasculature.

In vivo near-infrared autofluorescence imaging of retinal pigment epithelial cells with 757 nm excitation

We demonstrate near-infrared autofluorescence (NIRAF) imaging of retinal pigment epithelial (RPE) cells in vivo in healthy volunteers and patients using a 757 nm excitation source in adaptive optics scanning laser ophthalmoscopy (AOSLO). NIRAF excited at 757 nm and collected in an emission band from 778 to 810 nm produced a robust NIRAF signal, presumably arising from melanin, and revealed the typical hexagonal mosaic of RPE cells at most eccentricities imaged within the macula of normal eyes. Several patterns of altered NIRAF structure were seen in patients, including disruption of the NIRAF over a drusen, diffuse hyper NIRAF signal with loss of individual cell delineation in a case of non-neovascular age-related macular degeneration (AMD), and increased visibility of the RPE mosaic under an area showing loss of photoreceptors. In some participants, a superposed cone mosaic was clearly visible in the fluorescence channel at eccentricities between 2 and 6° from the fovea. This was reproducible in these participants and existed despite the use of emission filters with an optical attenuation density of 12 at the excitation wavelength, minimizing the possibility that this was due to bleed through of the excitation light. This cone signal may be a consequence of cone waveguiding on either the ingoing excitation light and/or the outgoing NIRAF emitted by fluorophores within the RPE and/or choroid and warrants further investigation. NIRAF imaging at 757 nm offers efficient signal excitation and detection, revealing structural alterations in retinal disease with good contrast and shows promise as a tool for monitoring future therapies at the level of single RPE cells.

Extrafoveal Cone Packing in Eyes With a History of Retinopathy of Prematurity

Purpose

To study the density and packing geometry of the extrafoveal cone photoreceptors in eyes with a history of retinopathy of prematurity (ROP). We used a multimodal combination of adaptive optics (AO) scanning light ophthalmoscopy (SLO) and optical coherence tomography (OCT).

Methods

Cones were identified in subjects (aged 14–26 years) with a history of ROP that was either severe and treated by laser ablation of avascular peripheral retina (TROP; n = 5) or mild and spontaneously resolved, untreated (UROP; n = 5), and in term-born controls (CT; n = 8). The AO-SLO images were obtained at temporal eccentricities 4.5°, 9°, 13.5°, and 18° using both confocal and offset apertures with simultaneous, colocal OCT images. Effects of group, eccentricity, and aperture were evaluated and the modalities compared.

Results

In the SLO images, cone density was lower and the packing pattern less regular in TROP, relative to CT and UROP retinae. Although SLO image quality appeared lower in TROP, root mean square (RMS) wavefront error did not differ among the groups. In TROP eyes, cone discrimination was easier in offset aperture images. There was no evidence of cone loss in the TROP OCT images.

Conclusions

Low cone density in TROP confocal SLO images may have resulted from lower image quality. Since AO correction in these eyes was equivalent to that of the control group, and OCT imaging showed no significant cone loss, the optical properties of the inner retina or properties of the cones themselves are likely altered in a way that affects photoreceptor imaging.

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.

Adaptive optics optical coherence tomography with dynamic retinal tracking

Adaptive optics optical coherence tomography (AO-OCT) is a highly sensitive and noninvasive method for three dimensional imaging of the microscopic retina. Like all in vivo retinal imaging techniques, however, it suffers the effects of involuntary eye movements that occur even under normal fixation. In this study we investigated dynamic retinal tracking to measure and correct eye motion at KHz rates for AO-OCT imaging. A customized retina tracking module was integrated into the sample arm of the 2nd-generation Indiana AO-OCT system and images were acquired on three subjects. Analyses were developed based on temporal amplitude and spatial power spectra in conjunction with strip-wise registration to independently measure AO-OCT tracking performance. After optimization of the tracker parameters, the system was found to correct eye movements up to 100 Hz and reduce residual motion to 10 µm root mean square. Between session precision was 33 µm. Performance was limited by tracker-generated noise at high temporal frequencies.

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.

Optical coherence tomography-based micro-particle image velocimetry

We present a new application of optical coherence tomography (OCT), widely used in biomedical imaging, to flow analysis in near-wall hydrodynamics for marine research. This unique capability, called OCT micro-particle image velocimetry, provides a high-resolution view of microscopic flow phenomena and measurement of flow statistics within the first millimeter of a boundary layer. The technique is demonstrated in a small flow cuvette and in a water tunnel.

Accurate prediction of collapse temperature using optical coherence tomography-based freeze-drying microscopy

The objective of this study was to assess the feasibility of developing and applying a laboratory tool that can provide three-dimensional product structural information during freeze-drying and which can accurately characterize the collapse temperature (Tc ) of pharmaceutical formulations designed for freeze-drying. A single-vial freeze dryer coupled with optical coherence tomography freeze-drying microscopy (OCT-FDM) was developed to investigate the structure and Tc of formulations in pharmaceutically relevant products containers (i.e., freeze-drying in vials). OCT-FDM was used to measure the Tc and eutectic melt of three formulations in freeze-drying vials. The Tc as measured by OCT-FDM was found to be predictive of freeze-drying with a batch of vials in a conventional laboratory freeze dryer. The freeze-drying cycles developed using OCT-FDM data, as compared with traditional light transmission freeze-drying microscopy (LT-FDM), resulted in a significant reduction in primary drying time, which could result in a substantial reduction of manufacturing costs while maintaining product quality. OCT-FDM provides quantitative data to justify freeze-drying at temperatures higher than the Tc measured by LT-FDM and provides a reliable upper limit to setting a product temperature in primary drying.

Combined reflectance confocal microscopy/optical coherence tomography imaging for skin burn assessment

A combined high-resolution reflectance confocal microscopy (RCM)/optical coherence tomography (OCT) instrument for assessing skin burn gravity has been built and tested. This instruments allows for visualizing skin intracellular details with submicron resolution in the RCM mode and morphological and birefringence modifications to depths on the order of 1.2 mm in the OCT mode. Preliminary testing of the dual modality imaging approach has been performed on the skin of volunteers with some burn scars and on normal and thermally-injured Epiderm FTTM skin constructs. The initial results show that these two optical technologies have complementary capabilities that can offer the clinician a set of clinically comprehensive parameters: OCT helps to visualize deeper burn injuries and possibly quantify collagen destruction by measuring skin birefringence, while RCM provides submicron details of the integrity of the epidermal layer and identifies the presence of the superficial blood flow in the upper dermis. Therefore, the combination of these two technologies within the same instrument may provide a more comprehensive set of parameters that may help clinicians to more objectively and nonivasively assess burn injury gravity by determining tissue structural integrity and viability.

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.

Multimodal adaptive optics retinal imager: design and performance

Optical coherence tomography (OCT) and scanning laser ophthalmoscopy (SLO) are complementary imaging modalities, the combination of which can provide clinicians with a wealth of information to detect retinal diseases, monitor disease progression, or assess new therapies. Adaptive optics (AO) is a tool that enables correction of wavefront distortions from ocular aberrations. We have developed a multimodal adaptive optics system (MAOS) for high-resolution multifunctional use in a variety of research and clinical applications. The system integrates both OCT and SLO imaging channels into an AO beam path. The optics and hardware were designed with specific features for simultaneous SLO/OCT output, for high-fidelity AO correction, for use in humans, primates, and small animals, and for efficient location and orientation of retinal regions of interest. The MAOS system was tested on human subjects and rodents. The design, performance characterization, and initial representative results from the human and animal studies are presented and discussed.

In vivo imaging of photoreceptor disruption associated with age-related macular degeneration: A pilot study

BACKGROUND AND OBJECTIVE

Age-related macular degeneration is one of the leading causes of vision loss in the developed world. As the disease progresses, the central part of the retina, called the macula, is compromised leading to a disruption of both structure and visual function. In this study, we investigate the disruption of macular photoreceptor cells in vivo as a function of disease stage in patients with the dry form of age-related macular degeneration AMD.

MATERIALS AND METHODS

An investigational confocal Adaptive Optics Scanning Laser Ophthalmoscope (AO-SLO) was used to obtain high resolution images of the macular photoreceptor mosaic in patients previously diagnosed with AMD. Four patients were selected as representative cases, comprising each of the four clinical stages of AMD progression.

RESULTS

AO-SLO imaging revealed slight disruption in the photoreceptor mosaic in early stage AMD due to focal drusen formation and identified several small drusen deposits that were not observed with standard clinical imaging techniques. An increase in photoreceptor disruption was visualized within the macula in direct correlation with the stage of AMD progression leading to a decrease in visual acuity. Large coalescent drusen and areas of geographic atrophy in advanced stage dry AMD exhibited a significant decrease in visible photoreceptor density. Significant decrease in photoreceptor counts (∼35-50%) were observed when comparing earlier stages of AMD progression (Categories I and II) to later stages of the disease (Categories III and IV).

CONCLUSIONS

This study demonstrates the capabilities of adaptive optics retinal imaging to monitor disruption of individual photoreceptor cells as a function of disease progression yielding valuable diagnostic findings in early stage AMD beyond what can be learned about the health of photoreceptors using conventional retinal imaging techniques. Lasers Surg. Med. 44: 603-610, 2012. © 2012 Wiley Periodicals, Inc.

Imaging flow dynamics in murine coronary arteries with spectral domain optical Doppler tomography

Blood flow in murine epicardial and intra-myocardial coronary arteries was measured in vivo with spectral domain optical Doppler tomography (SD-ODT). Videos at frame rates up to 180 fps were collected and processed to extract phase shifts associated with moving erythrocytes in the coronary arteries. Radial averaging centered on the vessel lumen provided spatial smoothing of phase noise in a single cross-sectional frame for instantaneous peak velocity measurement without distortion of the flow profile. Temporal averaging synchronized to the cardiac cycle (i.e., gating) was also performed to reduce phase noise, although resulting in lower flow profiles. The vessel angle with respect to incident imaging beam was measured with three-dimensional raster scans collected from the same region as the high speed cross-sectional scans. The variability in peak phase measurement was 10-15% from cycle to cycle on a single animal but larger for measurements among animals. The inter-subject variability is attributed to factors related to real physiological and anatomical differences, instrumentation variables, and measurement error. The measured peak instantaneous flow velocity in a ~40-µm diameter vessel was 23.5 mm/s (28 kHz Doppler phase shift). In addition to measurement of the flow velocity, we observed several dynamic features of the vessel and surrounding myocardium in the intensity and phase sequences, including asymmetric vessel deformation and rapid flow reversal immediately following maximum flow, in confirmation of known coronary artery flow dynamics. SD-ODT is an optical imaging tool that can provide in vivo measures of structural and functional information on cardiac function in small animals.

Angiography with a multifunctional line scanning ophthalmoscope

A multifunctional line scanning ophthalmoscope (mLSO) was designed, constructed, and tested on human subjects. The mLSO could sequentially acquire wide-field, confocal, near-infrared reflectance, fluorescein angiography (FA), and indocyanine green angiography (ICGA) retinal images. The system also included a retinal tracker (RT) and a photodynamic therapy laser treatment port. The mLSO was tested in a pilot clinical study on human subjects with and without retinal disease. The instrument exhibited robust retinal tracking and high-contrast line scanning imaging. The FA and ICGA angiograms showed a similar appearance of hyper- and hypo-pigmented disease features and a nearly equivalent resolution of fine capillaries compared to a commercial flood-illumination fundus imager. An mLSO-based platform will enable researchers and clinicians to image human and animal eyes with a variety of modalities and deliver therapeutic beams from a single automated interface. This approach has the potential to improve patient comfort and reduce imaging session times, allowing clinicians to better diagnose, plan, and conduct patient procedures with improved outcomes.

Fluorescence-guided optical coherence tomography imaging for colon cancer screening: a preliminary mouse study

A new concept for cancer screening has been preliminarily investigated. A cancer targeting agent loaded with a near-infrared (NIR) dye was topically applied on the tissue to highlight cancer-suspect locations and guide optical coherence tomography (OCT) imaging, which was used to further investigate tissue morphology at the micron scale. A pilot study on ApcMin mice has been performed to preliminarily test this new cancer screening approach. As a cancer-targeting agent, poly(epsilon-caprolactone) microparticles (PCLMPs), labeled with a NIR dye and functionalized with an RGD (argenine-glycine-aspartic acid) peptide, were used. This agent recognizes the α(ν)β(3) integrin receptor (ABIR), which is over-expressed by epithelial cancer cells. The contrast agent was administered topically in vivo in mouse colon. After incubation, the animals were sacrificed and fluorescence-guided high resolution optical coherence tomography (OCT) imaging was used to visualize colon morphology. The preliminary results show preferential staining of the abnormal tissue, as indicated by both microscopy and laser-induced fluorescence imaging, and OCT's capability to differentiate between normal mucosal areas, early dysplasia, and adenocarcinoma. Although very preliminary, the results of this study suggest that fluorescence-guided OCT imaging might be a suitable approach for cancer screening. If successful, this approach could be used by clinicians to more reliably diagnose early stage cancers in vivo.

Optical coherence tomography-based freeze-drying microscopy

A new type of freeze-drying microscope based upon time-domain optical coherence tomography is presented here (OCT-FDM). The microscope allows for real-time, in situ 3D imaging of pharmaceutical formulations in vials relevant for manufacturing processes with a lateral resolution of <7 μm and an axial resolution of <5 μm. Correlation of volumetric structural imaging with product temperature measured during the freeze-drying cycle allowed investigation of structural changes in the product and determination of the temperature at which the freeze-dried cake collapses. This critical temperature is the most important parameter in designing freeze-drying processes of pharmaceutical products.

Differentiation of pancreatic cysts with optical coherence tomography (OCT) imaging: an ex vivo pilot study

We demonstrate for the first time that optical coherence tomography (OCT) imaging can reliably distinguish between morphologic features of low risk pancreatic cysts (i.e., pseudocysts and serous cystadenomas) and high risk pancreatic cysts (i.e., mucinous cystic neoplasms and intraductal papillary mucinous neoplasms). In our study fresh pancreatectomy specimens (66) from patients with cystic lesions undergoing surgery were acquired and examined with OCT. A training set of 20 pathology-OCT correlated tissue specimens were used to develop criteria for differentiating between low and high risk cystic lesions. A separate (validation) set of 46 specimens were used to test the OCT criteria by three clinicians, blinded to histopathology findings. Histology was finally used as a 'gold' standard for testing OCT findings. OCT was able to reveal specific morphologic features of pancreatic cysts and thus to differentiate between low-risk and high-risk cysts with over 95% sensitivity and specificity. This pilot study suggests that OCT could be used by clinicians in the future to more reliably differentiate between benign and potentially malignant pancreatic cysts. However, in vivo use of OCT requires a probe that has to fit the bore of the pancreas biopsy needle. Therefore, we have developed such probes and planned to start an in vivo pilot study within the very near future.

Preliminary evaluation of a nanotechnology-based approach for the more effective diagnosis of colon cancers

AIM

The goal of this research was to develop and preliminarily test a novel technology and instrumentation that could help to significantly increase the diagnostic yield of current colon cancer screening procedures. This technology is based on a combined fluorescence-optical coherence tomography (OCT) imaging, and topical delivery of a cancer-targeting agent.

MATERIALS & METHODS

Gold colloid-adsorbed poly(ε-caprolactone) microparticles were labeled with a near-infrared dye, and functionalized with argentine-glycine-aspartic acid (RGD peptide) to effectively target cancer tissue, and enhance fluorescence-imaging contrast. The RGD peptide recognizes the α(v)β(3)-integrin receptor, which is overexpressed by epithelial cancer cells. OCT was used under fluorescence guidance to visualize tissue morphology and, thus, to serve as a confirmatory tool for cancer presence.

RESULTS

A preliminary testing of this technology on human colon cancer cell lines, a mouse model of colon cancer, as well as human colon tissue specimens, was performed. Strong binding of microparticles to cancer cells and no binding to cells that do not significantly express integrins, such as mouse fibroblasts, was observed. Preferential binding to cancer tissue was also observed. Strong fluorescence signals were obtained from cancer tissue, owing to the efficient binding of the contrast agent. OCT imaging was capable of revealing clear differences between normal and cancer tissue.

CONCLUSION

A dual-modality imaging approach combined with topical delivery of a cancer-targeting contrast agent has been preliminarily tested for colon cancer diagnosis. Preferential binding of the contrast agent to cancer tissue allowed the cancer-suspicious locations to be highlighted and, thus, guided OCT imaging to visualize tissue morphology and determine tissue type. If successful, this multimodal approach might help to increase the sensitivity and the specificity of current colon cancer-screening procedures in the future.

Adaptive optics scanning laser ophthalmoscope with integrated wide-field retinal imaging and tracking

We have developed a new, unified implementation of the adaptive optics scanning laser ophthalmoscope (AOSLO) incorporating a wide-field line-scanning ophthalmoscope (LSO) and a closed-loop optical retinal tracker. AOSLO raster scans are deflected by the integrated tracking mirrors so that direct AOSLO stabilization is automatic during tracking. The wide-field imager and large-spherical-mirror optical interface design, as well as a large-stroke deformable mirror (DM), enable the AOSLO image field to be corrected at any retinal coordinates of interest in a field of >25 deg. AO performance was assessed by imaging individuals with a range of refractive errors. In most subjects, image contrast was measurable at spatial frequencies close to the diffraction limit. Closed-loop optical (hardware) tracking performance was assessed by comparing sequential image series with and without stabilization. Though usually better than 10 μm rms, or 0.03 deg, tracking does not yet stabilize to single cone precision but significantly improves average image quality and increases the number of frames that can be successfully aligned by software-based post-processing methods. The new optical interface allows the high-resolution imaging field to be placed anywhere within the wide field without requiring the subject to re-fixate, enabling easier retinal navigation and faster, more efficient AOSLO montage capture and stitching.

High resolution multimodal clinical ophthalmic imaging system

We developed a multimodal adaptive optics (AO) retinal imager which is the first to combine high performance AO-corrected scanning laser ophthalmoscopy (SLO) and swept source Fourier domain optical coherence tomography (SSOCT) imaging modes in a single compact clinical prototype platform. Such systems are becoming ever more essential to vision research and are expected to prove their clinical value for diagnosis of retinal diseases, including glaucoma, diabetic retinopathy (DR), age-related macular degeneration (AMD), and retinitis pigmentosa. The SSOCT channel operates at a wavelength of 1 microm for increased penetration and visualization of the choriocapillaris and choroid, sites of major disease activity for DR and wet AMD. This AO system is designed for use in clinical populations; a dual deformable mirror (DM) configuration allows simultaneous low- and high-order aberration correction over a large range of refractions and ocular media quality. The system also includes a wide field (33 deg.) line scanning ophthalmoscope (LSO) for initial screening, target identification, and global orientation, an integrated retinal tracker (RT) to stabilize the SLO, OCT, and LSO imaging fields in the presence of lateral eye motion, and a high-resolution LCD-based fixation target for presentation of visual cues. The system was tested in human subjects without retinal disease for performance optimization and validation. We were able to resolve and quantify cone photoreceptors across the macula to within approximately 0.5 deg (approximately 100-150 microm) of the fovea, image and delineate ten retinal layers, and penetrate to resolve features deep into the choroid. The prototype presented here is the first of a new class of powerful flexible imaging platforms that will provide clinicians and researchers with high-resolution, high performance adaptive optics imaging to help guide therapies, develop new drugs, and improve patient outcomes.

Compact adaptive optics line scanning ophthalmoscope

We have developed a compact retinal imager that integrates adaptive optics (AO) into a line scanning ophthalmoscope (LSO). The bench-top AO-LSO instrument significantly reduces the size, complexity, and cost of research AO scanning laser ophthalmoscopes (AOSLOs), for the purpose of moving adaptive optics imaging more rapidly into routine clinical use. The AO-LSO produces high resolution retinal images with only one moving part and a significantly reduced instrument footprint and number of optical components. The AO-LSO has a moderate field of view (5.5 deg), which allows montages of the macula or other targets to be obtained more quickly and efficiently. In a preliminary human subjects investigation, photoreceptors could be resolved and counted within approximately 0.5 mm of the fovea. Photoreceptor counts matched closely to previously reported histology. The capillaries surrounding the foveal avascular zone could be resolved, as well as cells flowing within them. Individual nerve fiber bundles could be resolved, especially near the optic nerve head, as well as other structures such as the lamina cribrosa. In addition to instrument design, fabrication, and testing, software algorithms were developed for automated image registration and cone counting.

Automated algorithm for breast tissue differentiation in optical coherence tomography

An automated algorithm for differentiating breast tissue types based on optical coherence tomography (OCT) data is presented. Eight parameters are derived from the OCT reflectivity profiles and their means and covariance matrices are calculated for each tissue type from a training set (48 samples) selected based on histological examination. A quadratic discrimination score is then used to assess the samples from a validation set. The algorithm results for a set of 89 breast tissue samples were correlated with the histological findings, yielding specificity and sensitivity of 0.88. If further perfected to work in real time and yield even higher sensitivity and specificity, this algorithm would be a valuable tool for biopsy guidance and could significantly increase procedure reliability by reducing both the number of nondiagnostic aspirates and the number of false negatives.

Spectral-domain low coherence interferometry/optical coherence tomography system for fine needle breast biopsy guidance

A novel technology and instrumentation for fine needle aspiration (FNA) breast biopsy guidance is presented. This technology is based on spectral-domain low coherence interferometry (SD-LCI). The method, apparatus, and preliminary in vitro/in vivo results proving the viability of the method and apparatus are presented in detail. An advanced tissue classification algorithm, preliminarily tested on breast tissue specimens and a mouse model of breast cancer is presented as well. Over 80% sensitivity and specificity in differentiating all tissue types and 93% accuracy in differentiating fatty tissue from fibrous or tumor tissue was obtained with this technology and apparatus. These results suggest that SD-LCI could help for more precise needle placement during the FNA biopsy and therefore could substantially reduce the number of the nondiagnostic aspirates and improve the sensitivity and specificity of the FNA procedures.

Reduced peptide bond cyclic somatostatin based opioid octapeptides Synthesis, conformational properties and pharmacological characterization

The conformational and pharmacological properties that result from peptide bond reduction as well as the use of secondary amino acids in a series of cyclic peptides related to the mu opioid receptor selective antagonist D-Phe1-Cys2-Tyr3-D-Trp4-Orn5-Thr6-Pen7+ ++-Thr8-NH2 (IV), have been investigated. Peptide analogues that contain [CH2NH] and [CH2N] pseudo-peptide bonds (in primary and secondary amino acids, respectively) were synthesized on a solid support. Substitution of Tyr3 in IV by the cyclic, secondary amino acid 1,2,3,4-tetrahydroisoquinoline carboxylate (Tic) and of D-Trp4 with D-1,2,3,4-tetrahydro-beta-carboline(D-Tca4), gave peptides 4 and 1, respectively. Both analogues displayed reduced affinities for mu opioid receptors. Conformational analysis based on extensive NMR investigations demonstrated that the backbone conformations of 1 and 4 are similar to those of the potent and selective analogue D-Phe-Cys-Tyr-D-Trp-Lys-Thr-Pen-Thr-NH2 (I), while the conformational properties of the side chains of Tic3 (4) and D-Tca4 (1) resulted in topographical properties that were not well recognized by the mu opioid receptor. Peptide bond modifications were made including (Tyr3-psi[CH2NH]-D-Trp4), 3; (Tyr3-psi[CH2N]-D-Tca4), 2; and (Cys2-psi[CH2N]-Tic3), 6. These analogues showed decreases in their mu opioid receptor affinities relative to the parent compounds IV, 1, and 4, respectively. 1H NMR based conformational analysis in conjunction with receptor binding data led to the conclusion that the reduced peptide bonds in 2, 3, 5, and 6 do not contribute to the process of discrimination between mu and delta opioid receptors, and in spite of their different dynamic behaviors (relative to 1 and 4), they are still capable of attaining similar receptor bound conformations, possibly due to their increased flexibility.

Real-time processing for Fourier domain optical coherence tomography using a field programmable gate array

Real-time display of processed Fourier domain optical coherence tomography (FDOCT) images is important for applications that require instant feedback of image information, for example, systems developed for rapid screening or image-guided surgery. However, the computational requirements for high-speed FDOCT image processing usually exceeds the capabilities of most computers and therefore display rates rarely match acquisition rates for most devices. We have designed and developed an image processing system, including hardware based upon a field programmable gated array, firmware, and software that enables real-time display of processed images at rapid line rates. The system was designed to be extremely flexible and inserted in-line between any FDOCT detector and any Camera Link frame grabber. Two versions were developed for spectrometer-based and swept source-based FDOCT systems, the latter having an additional custom high-speed digitizer on the front end but using all the capabilities and features of the former. The system was tested in humans and monkeys using an adaptive optics retinal imager, in zebrafish using a dual-beam Doppler instrument, and in human tissue using a swept source microscope. A display frame rate of 27 fps for fully processed FDOCT images (1024 axial pixels x 512 lateral A-scans) was achieved in the spectrometer-based systems.

Dual-beam Fourier domain optical Doppler tomography of zebrafish

We have developed a dual-beam Fourier domain optical Doppler tomography (FD-ODT) system to image zebrafish (Danio rerio) larvae. Two beams incident on the zebrafish with a fixed angular separation allow absolute blood flow velocity measurement to be made regardless of vessel orientation in a sagittal plane along which the heart and most of the major vasculature lie. Two spectrometers simultaneously acquire spectra from two interferometers with a typical (maximum) line rate of 18 (28) kHz. The system was calibrated using diluted milk and microspheres and a 0.5-mm thick flow cell. The average deviation from the set velocity from 1.4 to 34.6 mm/s was 4.1%. Three-dimensional structural raster videos were acquired of an entire fish, and through the head, heart, and upper tail of the fish. Coarse features that were resolved include the telencephalon, retina, both heart chambers (atrium and ventricle), branchial arches, and notochord. Other fine structures within these organs were also resolved. Zebrafish are an important tool for high-throughput screening of new pharmacological agents. The ability to generate high-resolution three-dimensional structural videos and accurately measure absolute flow rates in major vessels with FD-ODT provides researchers with additional metrics by which the efficacy of new drugs can be assessed.

Foveal fine structure in retinopathy of prematurity: an adaptive optics Fourier domain optical coherence tomography study

PURPOSE

To describe the fine structure of the fovea in subjects with a history of mild retinopathy of prematurity (ROP) using adaptive optics-Fourier domain optical coherence tomography (AO-FDOCT).

METHODS

High-speed, high-resolution AO-FDOCT videos were recorded in subjects with a history of ROP (n = 5; age range, 14-26 years) and in control subjects (n = 5; age range, 18-25 years). Custom software was used to extract foveal pit depth and volume from three-dimensional (3-D) retinal maps. The thickness of retinal layers as a function of retinal eccentricity was measured manually. The retinal vasculature in the parafoveal region was assessed.

RESULTS

The foveal pit was wider and shallower in ROP than in control subjects. Mean pit depth, defined from the base to the level at which the pit reaches a lateral radius of 728 microm, was 121 microm compared with 53 microm. Intact, contiguous inner retinal layers overlay the fovea in ROP subjects but were absent in the control subjects. Mean full retinal thickness at the fovea was greater in the subjects with ROP (279.0 microm vs. 190.2 microm). The photoreceptor layer thickness did not differ between ROP and control subjects. An avascular zone was not identified in the subjects with ROP but was present in all the control subjects.

CONCLUSIONS

The foveas of subjects with a history of mild ROP have significant structural abnormalities that are probably a consequence of perturbations of neurovascular development.

Three dimensional tracking for volumetric spectral-domain optical coherence tomography

We present a three-dimensional (3D) tracker for a clinical ophthalmic spectral domain optical coherence tomography (SD-OCT) system that combines depth-tracking with lateral tracking, providing a stabilized reference frame for 3D data recording and post acquisition analysis. The depth-tracking system is implemented through a real-time dynamic feedback mechanism to compensate for motion artifact in the axial direction. Active monitoring of the retina and adapting the reference arm of the interferometer allowed the whole thickness of the retina to be stabilized to within +/-100 mum. We achieve a relatively constant SNR from image to image by stabilizing the image of the retina with respect to the depth dependent sensitivity of SD-OCT. The depth tracking range of our system is 5.2 mm in air and the depth is adjusted every frame.nhancement in the stability of the images with the depth-tracking algorithm is demonstrated on a healthy volunteer.

Compact multimodal adaptive-optics spectral-domain optical coherence tomography instrument for retinal imaging

We have developed a compact, multimodal instrument for simultaneous acquisition of en face quasi-confocal fundus images and adaptive-optics (AO) spectral-domain optical coherence tomography (SDOCT) cross-sectional images. The optical system including all AO and SDOCT components occupies a 60x60 cm breadboard that can be readily transported for clinical applications. The AO component combines a Hartmann-Shack wavefront sensor and a microelectromechanical systems-based deformable mirror to sense and correct ocular aberrations at 15 Hz with a maximum stroke of 4 microm. A broadband superluminescent diode source provides 4 mum depth resolution for SDOCT imaging. In human volunteer testing, we observed up to an 8 dB increase in OCT signal and a corresponding lateral resolution of <10 microm as a result of AO correction.

Hybrid retinal imager using line-scanning laser ophthalmoscopy and spectral domain optical coherence tomography

We demonstrate for the first time the integration of two technologies, Spectral Domain Optical Coherence Tomography (SDOCT) and Line-Scanning Laser Ophthalmoscopy (LSLO) into a single compact instrument that shares the same imaging optics and line scan camera for both OCT and LSLO imaging. Co-registered high contrast wide-field en face retinal LSLO and SDOCT images are obtained non-mydriatically with less than 600 microwatts of broadband illumination at 15 frames/sec. The LSLO/SDOCT hybrid instrument could have important applications in clinical ophthalmic diagnostics and emergency medicine.

Line-scanning laser ophthalmoscope

Scanning laser ophthalmoscopy (SLO) is a powerful imaging tool with specialized applications limited to research and ophthalmology clinics due in part to instrument size, cost, and complexity. Conversely, low-cost retinal imaging devices have limited capabilities in screening, detection, and diagnosis of diseases. To fill the niche between these two, a hand-held, nonmydriatic line-scanning laser ophthalmoscope (LSLO) is designed, constructed, and tested on normal human subjects. The LSLO has only one moving part and uses a novel optical approach to produce wide-field confocal fundus images. Imaging modes include multiwavelength illumination and live stereoscopic imaging with a split aperture. Image processing and display functions are controlled with two stacked prototype compact printed circuit boards. With near shot-noise limited performance, the digital LSLO camera requires low illumination power (<500 microW) at near-infrared wavelengths. The line-scanning principle of operation is examined in comparison to SLO and other imaging modes. The line-scanning approach produces high-contrast confocal images with nearly the same performance as a flying-spot SLO. The LSLO may significantly enhance SLO utility for routine use by ophthalmologists, optometrists, general practitioners, and also emergency medical personnel and technicians in the field for retinal disease detection and other diverse applications.

Adaptive optics scanning laser ophthalmoscope for stabilized retinal imaging

A retinal imaging instrument that integrates adaptive optics (AO), scanning laser ophthalmoscopy (SLO), and retinal tracking components was built and tested. The system uses a Hartmann-Shack wave-front sensor (HS-WS) and MEMS-based deformable mirror (DM) for AO-correction of high-resolution, confocal SLO images. The system includes a wide-field line-scanning laser ophthalmoscope for easy orientation of the high-magnification SLO raster. The AO system corrected ocular aberrations to <0.1 mum RMS wave-front error. An active retinal tracking with custom processing board sensed and corrected eye motion with a bandwidth exceeding 1 kHz. We demonstrate tracking accuracy down to 6 mum RMS for some subjects (typically performance: 10-15 mum RMS). The system has the potential to become an important tool to clinicians and researchers for vision studies and the early detection and treatment of retinal diseases.

Toward noninvasive measurement of blood hematocrit using spectral domain low coherence interferometry and retinal tracking

We demonstrate in vivo measurements in human retinal vessels of an experimental parameter, the slope of the low coherence interferometry (LCI) depth reflectivity profile, which strongly correlates with the real value of blood hematocrit. A novel instrument that combines two technologies, spectral domain low coherence interferometry (SDLCI) and retinal tracking, has been developed and used for these measurements. Retinal tracking allows a light beam to be stabilized on retinal vessels, while SDLCI is used for obtaining depth-reflectivity profiles within the investigated vessel. SDLCI backscatter extinction rates are obtained from the initial slope of the A-scan profile within the vessel lumen. The differences in the slopes of the depth reflectivity profiles for different subjects are interpreted as the difference in the scattering coefficient, which is correlated with the number density of red blood cells (RBC) in blood. With proper calibration, it is possible to determine hematocrit in retinal vessels. Ex vivo measurements at various RBC concentrations were performed to calibrate the instrument. Preliminary measurements on several healthy volunteers show estimated hematocrit values within the normal clinical range.

Retinal nerve fiber layer assessment using optical coherence tomography with active optic nerve head tracking

PURPOSE

To develop an eye-motion-tracking optical coherence tomographic (OCT) method and assess its effect on image registration and nerve fiber layer (NFL) thickness measurement reproducibility.

METHODS

A system capable of tracking common fundus features based on reflectance changes was integrated into a commercial OCT unit (OCT II; Carl Zeiss Meditec, Inc., Dublin, CA) and tested on healthy subjects and patients with glaucoma. Twenty successive peripapillary NFL scans were obtained with tracking and 20 without tracking, for 40 images in each session for each eye. Subjects participated in one session on three different days. Composite OCT scans and composite fundus images were generated for assessment of eye tracking. NFL thickness measurement reproducibility was also assessed.

RESULTS

Seven healthy and nine glaucomatous eyes of 16 subjects were recruited. A qualitative assessment of composite OCT scans and composite fundus images showed little motion artifact or blurring along edges and blood vessels during tracking; however, those structures were less clearly defined when tracking was disengaged. There was no significant reproducibility difference with and without tracking in both intra- and intersession NFL measurement SD calculations in any location. The mean retinal pixel SD was significantly smaller with tracking than without (490.9 +/- 19.3 microm vs. 506.4 +/- 31.8 microm, P = 0.005, paired t-test).

CONCLUSIONS

A retinal-tracking system was successfully developed and integrated into a commercial OCT unit. Tracking OCT improved the consistency of scan registration, but did not influence NFL thickness measurement reproducibility in this small sample study.

Noninvasive ventilation during gastrostomy tube placement in patients with severe duchenne muscular dystrophy: case reports and review of the literature

Individuals with Duchenne muscular dystrophy may benefit from gastrostomy tube feeding due to progressive dysphagia and malnutrition. However, due to their severely impaired pulmonary function, these individuals are at risk of severe complications when they are sedated or undergo anesthesia for the procedure. We previously described a technique of noninvasive positive pressure ventilation to provide respiratory support during gastrostomy tube placement in such patients, but this technique had risks and limitations. In this case report, we examine two alternative techniques we used to provide respiratory support successfully to patients with severe muscular dystrophy and malnutrition who underwent percutaneous endoscopic gastrostomy tube placement. We then review the literature and discuss the potential benefits, risks, and limitations of the above techniques and of other options for gastrostomy placement in people with severe muscular dystrophy.

Advanced scanning methods with tracking optical coherence tomography

An upgraded optical coherence tomography system with integrated retinal tracker (TOCT) was developed. The upgraded system uses improved components to extend the tracking bandwidth, fully integrates the tracking hardware into the optical head of the clinical OCT system, and operates from a single software platform. The system was able to achieve transverse scan registration with sub-pixel accuracy (~10 microm). We demonstrate several advanced scan sequences with the TOCT, including composite scans averaged (co-added) from multiple B-scans taken consecutively and several hours apart, en face images collected by summing the A-scans of circular, line, and raster scans, and three-dimensional (3D) retinal maps of the fovea and optic disc. The new system achieves highly accurate OCT scan registration yielding composite images with significantly improved spatial resolution, increased signal-to-noise ratio, and reduced speckle while maintaining well-defined boundaries and sharp fine structure compared to single scans. Precise re-registration of multiple scans over separate imaging sessions demonstrates TOCT utility for longitudinal studies. En face images and 3D data cubes generated from these data reveal high fidelity image registration with tracking, despite scan durations of more than one minute.

Active retinal tracker for clinical optical coherence tomography systems

An active, hardware-based retinal tracker is integrated with a clinical optical coherence tomography (OCT) system to investigate the effects of stabilization on acquisition of high-resolution retinal sections. The prototype retinal tracker locks onto common fundus features, detects transverse eye motion via changes in feature reflectance, and positions the OCT diagnostic beam to fixed coordinates on the retina with mirrors driven by a feedback control loop. The system is tested in a full clinical protocol on subjects with normal and glaucomatous eyes. Experimental analysis software is developed to coalign and coadd multiple fundus and OCT images and to extract quantitative information on the location of structures in the images. Tracking is highly accurate and reproducible on all but one subject, resulting in the ability to scan the same retinal location continually over long periods of time. The results show qualitative improvement in 97% of coadded OCT scans and a reduction in the variance of the position of the optic disc cup edge to less than 1 pixel (< 60 microm). The tracking system can be easily configured for use in research on ultra-high-resolution OCT systems for advanced image modalities. For example, tracking will enable very high density 3-D scans of the retina, which are susceptible to eye motion artifacts even for new high-speed systems.

Tracking optical coherence tomography

An experimental tracking optical coherence tomography (OCT) system has been clinically tested. The prototype instrument uses a secondary sensing beam and steering mirrors to compensate for eye motion with a closed-loop bandwidth of 1 kHz and tracking accuracy, to within less than the OCT beam diameter. The retinal tracker improved image registration accuracy to <1 transverse pixel (<60 microm). Composite OCT images averaged over multiple scans and visits show a sharp fine structure limited only by transverse pixel size. As the resolution of clinical OCT systems improves, the capability to reproducibly map complex structures in the living eye at high resolution will lead to improved understanding of disease processes and improved sensitivity and specificity of diagnostic procedures.

Compact scanning laser ophthalmoscope with high-speed retinal tracker

The effectiveness of image stabilization with a retinal tracker in a multifunction, compact scanning laser ophthalmoscope (TSLO) was demonstrated in initial human subject tests. The retinal tracking system uses a co confocal reflectometer with a closed-loop optical servo system to lock onto features in the fundus. The system is multifarious and modular to allow configuration for many research a clinical applications. Adult volunteers were tested without mydriasis to optimize the tracking instrumentation and to characterize imaging performance. The retinal tracking system achieves a bandwidth of greater than 1 kHz, which permits tracking at rates that greatly exceed the maximum rate of motion of the human eye. The TSLO system stabilized images to an accuracy of 0.05 deg in all test subjects during ordinary saccades with a velocity up to approximately 500 deg/s. Feature lock was maintained for minutes despite subject eye blinking. Even when nearly 1000 frames were coadded, image blur was minimal. Successful frame coaddition allowed image acquisition with decreased noise in low-light applications. The retinal tracking system significantly enhances the imaging capabilities of the scanning laser ophthalmoscope.

Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part II

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This second part of a two-part review assesses the existing supportive evidence for the application of recently introduced transcatheter treatments for lesions that cause cerebrovascular ischemia and stroke. Studies were identified via MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, studies with at least 50 patients per treated group and a minimum follow-up duration of 6 months were included. For each application, the authors assessed the quality of evidence (efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. Although recommendations based on proven efficacy and cost-effectiveness cannot be made in general, the use of transcatheter therapies can be supported in specific circumstances based on expected reduction in procedure-related morbidity and/or mortality. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Hybrid retinal photocoagulation system using analog tracking

We describe initial in vivo experimental results of a new hybrid digital and analog design for retinal tracking and laser beam control. An overview of the design is given. The results show in vivo tracking rates which exceed the equivalent of 38 degrees per second in the eye, with automated lesion pattern creation. Robotically-assisted laser surgery to treat conditions such as diabetic retinopathy and retinal breaks may soon be realized under clinical conditions with requisite safety using standard video hardware and inexpensive optical components based on this design.

Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders

OBJECTIVE

Carotid bifurcation angioplasty and stenting (CBAS) has generated controversy and widely divergent opinions about its current therapeutic role. To resolve differences and establish a unified view of CBAS' present role, a consensus conference of 17 experts, world opinion leaders from five countries, was held on November 21, 1999.

METHODS

These 17 participants had previously answered 18 key questions on current CBAS issues. At the conference these 18 questions and participants' answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus, (prevailing opinion), or divided opinion (disagreement).

RESULTS

Conference discussion added two modified questions, placing a total of 20 key questions before the participants, representing four specialties (interventional radiology, seven; vascular surgery, six; interventional cardiology, three; neurosurgery, one). It is interesting that consensus was reached on the answers to 11 (55%) of 20 of the questions, and near consensus was reached on answers to 6 (30%) of 20 of the questions. Only with the answers to three (15%) of the questions was there persisting controversy. Moreover, both these differences and areas of agreement crossed specialty lines. Consensus Conclusions: CBAS should not currently undergo widespread practice, which should await results of randomized trials. CBAS is currently appropriate treatment for patients at high risk in experienced centers. CBAS is not generally appropriate for patients at low risk. Neurorescue skills should be available if CBAS is performed. When cerebral protection devices are available, they should be used for CBAS. Adequate stents and technology for performing CBAS currently exist. There were divergent opinions regarding the proportions of patients presently acceptable for CBAS treatment (<5% to 100%, mean 44%) and best treated by CBAS (<3% to 100%, mean 34%). These and other consensus conclusions will help physicians in all specialties deal with CBAS in a rational way rather than by being guided by unsubstantiated claims.

Initial in vivo results of a hybrid retinal photocoagulation system

We describe initial in vivo experimental results of a new hybrid digital and analog design for retinal tracking and laser beam control. An overview of the design is given. The results show in vivo tracking rates which exceed the equivalent of 38 degrees/s in the eye. A robotically assisted lesion pattern is created for laser surgery to treat conditions such as diabetic retinopathy and retinal breaks.