Name: Doppler Optical Coherence Tomography of Retinal Circulation (Video) | JoVE Journal
Uploaded: 2012-09-18T12:00:00.000+00:00
Duration: 10 min 46 s
Description: Learn to measure total retinal blood flow using Doppler OCT and semi-automated grading software. This non-invasive method enables accurate assessment of retinal hemodynamics for diagnosing ocular diseases.

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5 minutes

This study is supported by NIH grant RO1 013516 and a grant form Optovue.

1. Protocol Text
<ol>
	<li>Patients are scanned by RTVue Fourier-domain optical coherence tomography (OCT) system (Optovue Inc., Fremont, CA, USA) using the circumpapillary double-circular scan (CDCS) and the 3D optic disc scan.
	<ol>
		<li>The CDCS pattern consists of two concentric circles around the optic nerve head. The inner ring diameter is 3.40 mm and the outer ring diameter is 3.75 mm. This pattern transects all branch retinal arteries and veins emanating from the optic nerve head. The double circles are performed 6 times in a single scan to cover about 2 cardiac cycles. To calculate Flow velocity, Doppler shift and Doppler will be estimated on vessel detected in the OCT image. (Figure 1a, Figure 1b)</li>
		<li>A "dual angle" protocol is used to acquire Doppler OCT scans. In the "dual-angle" protocol, 3 scans are obtained with the OCT beam passing through the superonasal portion of the pupil and 3 scans through the inferonasal portion.</li>
		<li>The quality of each scan is evaluated for signal strength, motion error, and Doppler angle. The technician is required to re-do any scan that did not pass the quality check. A total of 6 acceptable CDCS scans are performed for each eye. The "dual-angle" protocol ensures that, for each vessel, at least half of the scans provide good Doppler angles.</li>
		<li>The 3D disc scan pattern is a raster scan covering a 6x6 mm region around the optic disc. It is only done once and provides a detailed en face image of this area. (Figure 1b)</li>
		<li>A color photograph of the optic disc is also imported to help distinguish arteries and veins.</li>
	</ol>
	</li>
</ol>
<img alt="Doppler effect diagram with probe beam intersecting vessel; shows flow vector and Doppler angle." src="/files/ftp_upload/3524/3524fig1a.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
 Figure 1a. Measuring total blood flow with the circumpapillary double-circular scan and the 3D disk scan using DOCTORC.
<ol class="lalpha">
	<li>The Doppler angle is the angle between probe beam and normal vector of the vessel, and the Doppler signal is the Doppler frequency shift proportional to the flow velocity component parallel to the axis of the probe beam. Thus flow velocity can be estimated from Doppler angle and Doppler signal. However, both Doppler angle and Doppler signal become unreliable when they are below the noise level. On the other hand, when Doppler angle is large, The Doppler shift will be out of the measureable range. When the Doppler angle is appropriate, about 5-15 degrees for the FD-OCT system used in this study, the flow velocity can be correctly estimated by Doppler shift and angle.</li>
</ol>
<img alt="3D disk scan diagram with Doppler angle, probe beam, and flow vector for vessel analysis." src="/files/ftp_upload/3524/3524fig1b.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
 Figure 1b. 
<ol start="2" type="a">
	<li>The Doppler angle in each vessel is measured by the relative positions of the vessel lumina in the two concentric circular scans. The axial component of the flow velocity is obtained by the Doppler shift measured from the relative phase of adjacent OCT axial scans. The total flow velocity is calculated from the axial flow component and the Doppler angle. The flow in each vessel is then calculated by integrating the total velocity profile over vessel cross-sectional area. The vessel pattern is matched to the en face image of the 3D disk scan and fundus photograph to identify each vessel as either a vein or an artery. The total retinal flow is calculated by summing flow in the major retinal veins, i.e., those with luminal diameters above 33 μm.</li>
</ol>
<ol start="2">
	<li>All scans of the same eye are exported as raw data using the RTVue software. The raw OCT images, including both Doppler and intensity images, are first tested for image quality using "Doppler optical coherence tomography of retinal circulation" (DOCTORC) software.
	<ol>
		<li>Eye movements are measured by the pooled standard deviation of the inner limiting membrane and the maximum difference between two frames that is estimated by the bulk motion.</li>
		<li>Signal strength (reflectance and estimation of average Doppler angle) are also calculated.</li>
		<li>According to the average eye movement and signal strength of the repeated scans, the data is classified as either "good" or "poor" in quality. Only good quality data are graded.</li>
	</ol>
	</li>
	<li>For acceptable scans, an automated segmentation algorithm is applied to each OCT image for vessel detection.
	<ol>
		<li>An automated algorithm that matches vessels is used to locate the same vessel in each frame. The frames on the same circle are registered, and two averaged frames of the inner ring and outer ring are created. Both reflectance and Doppler images are averaged.</li>
		<li>For an overview, the detected vessel is projected as a line segment onto the en face fundus image calculated from the 3D disc scan.</li>
	</ol>
	</li>
	<li>Graders review each vessel on a small portion of the averaged inner and outer ring frames overlaid with a circle that represents the automated segmentation result.
	<ol>
		<li>The grader judges if the location, vessel diameter, and vessel type (vein/artery) matching the vessel on the two rings are correct according to the OCT image, en face OCT image, and disc photograph of the same eye.</li>
		<li>The grader is allowed to change any of the above values if he thinks it is necessary. The grader also judges the quality of the Doppler signal in the vessel and gives a subjective confidence score for the vessel label on each scan.</li>
		<li>A confidence score of 0-5 is automatically given to each vessel based on Doppler signal strength in the vessel area. It is then manually corrected by the grader based on the strength of the vessel Doppler signal, regularity of vessel boundary, agreement between inner and outer rings of vessel size, and sign agreement of Doppler shift between inner and outer rings.</li>
	</ol>
	</li>
	<li>After all vessels are verified and corrected, an automated algorithm is applied to calculate the blood flow of each vein with a method adapted from our previous publication.1
	<ol>
		<li>The Doppler signal is integrated over the vessel area and then averaged among all frames. Then the Doppler flow is calculated as the summed Doppler signal divided by the Doppler angle.</li>
		<li>For each vessel, 6 scans are evaluated on subjective confidence scores, Doppler angles, and Coefficient of variation of the Doppler angles. The flow of a vein is considered valid only if more than 1 scan passes the quality check. For vessels that pass the quality check, the flow is averaged among valid scans.</li>
		<li>For vessel with invalid results, the flow is estimated using the vessel area and the average flow speed from valid veins. The average flow speed is calculated by summing the flows in the valid veins and dividing by the summed areas of those veins. The estimate of flow starts from the average flow speed and is then corrected for the dependence of flow velocity on vessel area. Larger vessels have a higher average flow velocity. Thus the correction is made based upon the slope of average velocity versus vessel diameter, 2.13, that we previously reported.2</li>
		<li>The calculated flow of valid veins and the estimated flow of invalid veins are added to determine the total retinal blood flow.</li>
		<li>The total retinal blood flow result is evaluated based on the valid venous area percentage, eye movement, and signal strength.</li>
		<li>Venous area and total arterial area are also obtained by adding the vessel areas. Assuming the total retinal blood flow is same in arteries and veins, the arterial and venous velocities are calculated by dividing total blood flow with arterial area and venous area.</li>
	</ol>
	</li>
</ol>
2. Representative Results
Normal and glaucomatous eyes are selected from the Advanced Imaging for Glaucoma Study (AIGS, <a href="http://www.aigstudy.net" target="_blank">www.aigstudy.net</a>). 48 eyes were scanned by the "dual-angle" protocol and produced scans that passed the image quality check. Using the DOCTORC software, valid flow measurements could be obtained from 83% of the eyes.
To evaluate the reproducibility of the DOCTORC system, another small dataset with 20 eyes was graded by 3 graders. This dataset was also used to train and test graders. 2 graders used the semi-automated DOCTORC software and 1 used an earlier totally manual software employed in previous publications.2,3 The total retinal blood flows (Table 1) determined by the two graders using DOCTORC software are similar to one another and to flow rates determined by the other grader using the manual software. Only 65% of the eyes had valid results because some of the data were not based on dual angle protocol, but single angle protocol.2 The single angle protocol includes 5 Doppler scans obtained with the OCT beam passing through the center of the pupil. Therefore the Doppler angle is more often small and therefore a greater portion of vessels are usually not gradable.
For all graders, the inter-grader reproducibility, as measured by the coefficient of variation, is similar for both glaucomatous and normal eyes (Table 2). Likewise, the reproducibility measurements for the two methods, DOCTORC and the Manual software,1-5 are similar (Table 2). For three graders, a good correlation exists between total blood flow and the pattern standard deviation from visual field tests (Figure 2) for glaucomatous eyes.
<table border="1">
	<tbody>
		<tr>
			<td> </td>
			<td colspan="3">DOCTORC software Manual software3</td>
		</tr>
		<tr>
			<td>Condition</td>
			<td>Grader 1</td>
			<td>Grader 2</td>
			<td> </td>
		</tr>
		<tr>
			<td>Normal</td>
			<td>47.0±9.1</td>
			<td>48.7±7.2</td>
			<td>48.0±6.5</td>
		</tr>
		<tr>
			<td>Glaucoma</td>
			<td>36.5±5.5</td>
			<td>36.7±5.9</td>
			<td>34.9±5.1</td>
		</tr>
	</tbody>
</table>
Table 1. Total Retinal Blood Flow using 2 Different Software.
<table border="1">
	<tbody>
		<tr>
			<td> </td>
			<td colspan="2">Coefficient of Variation</td>
		</tr>
		<tr>
			<td>Glaucoma (7 eyes)</td>
			<td> </td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 1 vs. Grader 2(DOCTORC)</td>
			<td>9.58%</td>
			<td> </td>
		</tr>
		<tr>
			<td>DOCTORC vs. manual method3</td>
			<td> </td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 1</td>
			<td>8.00%</td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 2</td>
			<td>9.74%</td>
			<td> </td>
		</tr>
		<tr>
			<td>Normal (6 eyes)</td>
			<td> </td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 1 vs. Grader 2 (DOCTORC)</td>
			<td>5.99%</td>
			<td> </td>
		</tr>
		<tr>
			<td>DOCTORC vs. manual method</td>
			<td> </td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 1</td>
			<td>8.87%</td>
			<td> </td>
		</tr>
		<tr>
			<td>Grader 2</td>
			<td>9.98%</td>
			<td> </td>
		</tr>
	</tbody>
</table>
Table 2. Reproducibility of Total Retinal Blood Flow Measurements.
<img alt="Retinal blood flow analysis; scatter plots with linear regression; two graders; pattern deviation correlation." src="/files/ftp_upload/3524/3524fig2.jpg" data-altupdatedat="1788304762000" data-alt="Figure 2"> 
 Figure 2. Correlation between Total Retinal Blood Flow and Visual Field in Glaucoma. a. Grader 1 using DOCTORC software. Visual field loss is summarized by pattern standard deviation (p=0.048). b. Grader 2 using DOCTORC software. Visual field loss is summarized by pattern standard deviation (p=0.032).

<ol><li>Wang, Y., Bower, B. A., Izatt, J. A., Tan, O., Huang, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+measurement+by+circumpapillary+Fourier+domain+Doppler+optical+coherence+tomography%5BTitle%5D)+AND+%22J.+Biomed.+Opt%22%5BJournal%5D)">Retinal blood flow measurement by circumpapillary Fourier domain Doppler optical coherence tomography.</a> J. Biomed. Opt. 13, 064003(2008).</li>
<li>Wang, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pilot+study+of+optical+coherence+tomography+measurement+of+retinal+blood+flow+in+retinal+and+optic+nerve+diseases%5BTitle%5D)+AND+%22Invest.+Ophthalmol.+Vis.+Sci%22%5BJournal%5D)">Pilot study of optical coherence tomography measurement of retinal blood flow in retinal and optic nerve diseases.</a> Invest. Ophthalmol. Vis. Sci. 52, 840-845 (2011).</li>
<li>Wang, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Measurement+of+total+blood+flow+in+the+normal+human+retina+using+Doppler+Fourier-domain+optical+coherence+tomography%5BTitle%5D)+AND+%22Br.+J.+Ophthalmol%22%5BJournal%5D)">Measurement of total blood flow in the normal human retina using Doppler Fourier-domain optical coherence tomography.</a> Br. J. Ophthalmol. 93, 634-637 (2009).</li>
<li>Wang, Y., Bower, B. A., Izatt, J. A., Tan, O., Huang, D. In vivo total retinal blood flow measurement by Fourier domain Doppler optical coherence tomography. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aWang%2C+Y+%22J.+Biomed.+Opt%22">J. Biomed. Opt</a>. 12, 041215(2007).</li>
<li>Wang, Y., Fawzi, A., Tan, O., Gil-Flamer, J., Huang, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+detection+in+diabetic+patients+by+Doppler+Fourier+domain+optical+coherence+tomography%5BTitle%5D)+AND+%22Opt.+Express%22%5BJournal%5D)">Retinal blood flow detection in diabetic patients by Doppler Fourier domain optical coherence tomography.</a> Opt. Express. 17, 4061-4073 (2009).</li>
<li>Berisha, F., Feke, G. T., Hirose, T., McMeel, J. W., Pasquale, L. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+and+nerve+fiber+layer+measurements+in+early-stage+open-angle+glaucoma%5BTitle%5D)+AND+%22Am.+J.+Ophthalmol%22%5BJournal%5D)">Retinal blood flow and nerve fiber layer measurements in early-stage open-angle glaucoma.</a> Am. J. Ophthalmol. 146, 466-472 (2008).</li>
<li>Cuypers, M. H., Kasanardjo, J. S., Polak, B. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+changes+in+diabetic+retinopathy+measured+with+the+Heidelberg+scanning+laser+Doppler+flowmeter%5BTitle%5D)+AND+%22Graefes+Arch.+Clin.+Exp.+Ophthalmol%22%5BJournal%5D)">Retinal blood flow changes in diabetic retinopathy measured with the Heidelberg scanning laser Doppler flowmeter.</a> Graefes Arch. Clin. Exp. Ophthalmol. 238, 935-941 (2000).</li>
<li>Hafez, A. S., Bizzarro, R. L., Lesk, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+optic+nerve+head+and+peripapillary+retinal+blood+flow+in+glaucoma+patients%2C+ocular+hypertensives%2C+and+normal+subjects%5BTitle%5D)+AND+%22Am.+J.+Ophthalmol%22%5BJournal%5D)">Evaluation of optic nerve head and peripapillary retinal blood flow in glaucoma patients, ocular hypertensives, and normal subjects.</a> Am. J. Ophthalmol. 136, 1022-1031 (2003).</li>
<li>Klaver, C. C., Wolfs, R. C., Vingerling, J. R., Hofman, A., de Jong, P. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Age-specific+prevalence+and+causes+of+blindness+and+visual+impairment+in+an+older+population%3A+the+Rotterdam+Study%5BTitle%5D)+AND+%22Arch.+Ophthalmol%22%5BJournal%5D)">Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study.</a> Arch. Ophthalmol. 116, 653-658 (1998).</li>
<li>Logan, J. F., Rankin, S. J., Jackson, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+measurements+and+neuroretinal+rim+damage+in+glaucoma%5BTitle%5D)+AND+%22Br.+J.+Ophthalmol%22%5BJournal%5D)">Retinal blood flow measurements and neuroretinal rim damage in glaucoma.</a> Br. J. Ophthalmol. 88, 1049-1054 (2004).</li>
<li>Chung, H. S., Harris, A., Kagemann, L., Martin, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peripapillary+retinal+blood+flow+in+normal+tension+glaucoma%5BTitle%5D)+AND+%22Br.+J.+Ophthalmol%22%5BJournal%5D)">Peripapillary retinal blood flow in normal tension glaucoma.</a> Br. J. Ophthalmol. 83, 466-469 (1999).</li>
<li>Deokule, S., Vizzeri, G., Boehm, A., Bowd, C., Weinreb, R. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Association+of+visual+field+severity+and+parapapillary+retinal+blood+flow+in+open-angle+glaucoma%5BTitle%5D)+AND+%22J.+Glaucoma%22%5BJournal%5D)">Association of visual field severity and parapapillary retinal blood flow in open-angle glaucoma.</a> J. Glaucoma. 19, 293-298 (2010).</li>
<li>Riva, C. E., Grunwald, J. E., Sinclair, S. H., Petrig, B. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Blood+velocity+and+volumetric+flow+rate+in+human+retinal+vessels%5BTitle%5D)+AND+%22Invest.+Ophthalmol.+Vis.+Sci%22%5BJournal%5D)">Blood velocity and volumetric flow rate in human retinal vessels.</a> Invest. Ophthalmol. Vis. Sci. 26, 1124-1132 (1985).</li>
<li>Garcia, J. P., Garcia, P. T., Rosen, R. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+blood+flow+in+the+normal+human+eye+using+the+canon+laser+blood+flowmeter%5BTitle%5D)+AND+%22Ophthalmic+Res%22%5BJournal%5D)">Retinal blood flow in the normal human eye using the canon laser blood flowmeter.</a> Ophthalmic Res. 34, 295-299 (2002).</li>
<li>Flammer, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+impact+of+ocular+blood+flow+in+glaucoma%5BTitle%5D)+AND+%22Prog.+Retin.+Eye+Res%22%5BJournal%5D)">The impact of ocular blood flow in glaucoma.</a> Prog. Retin. Eye Res. 21, 359-393 (2002).</li>
<li>Mitchell, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retinal+vessel+diameter+and+open-angle+glaucoma%3A+the+Blue+Mountains+Eye+Study%5BTitle%5D)+AND+%22Ophthalmology%22%5BJournal%5D)">Retinal vessel diameter and open-angle glaucoma: the Blue Mountains Eye Study.</a> Ophthalmology. 112, 245-250 (2005).</li>
<li>Nicolela, M. T., Hnik, P., Drance, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Scanning+laser+Doppler+flowmeter+study+of+retinal+and+optic+disk+blood+flow+in+glaucomatous+patients%5BTitle%5D)+AND+%22Am.+J.+Ophthalmol%22%5BJournal%5D)">Scanning laser Doppler flowmeter study of retinal and optic disk blood flow in glaucomatous patients.</a> Am. J. Ophthalmol. 122, 775-783 (1996).</li>
<li>Goebel, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Color+Doppler+imaging%3A+a+new+technique+to+assess+orbital+blood+flow+in+patients+with+diabetic+retinopathy%5BTitle%5D)+AND+%22Invest.+Ophthalmol.+Vis.+Sci%22%5BJournal%5D)">Color Doppler imaging: a new technique to assess orbital blood flow in patients with diabetic retinopathy.</a> Invest. Ophthalmol. Vis. Sci. 36, 864-870 (1995).</li>
</ol>

Dr. Huang receives grant support, patent royalty, stock options, travel support and lecture fees from Optovue, Inc.; Dr. Tan and Dr. Wang receives patent royalty and grant support from Optovue, Inc.; Dr. Koduru and Dr. Sadda received grant support from Optovue.

Blood flow abnormalities occur in glaucoma and vascular diseases of the retina such as diabetic retinopathy.6-10 Volumetric measurement of retinal blood flow gives valuable information about the disease process.4-6,11,12 DOCTORC provides a practical way to estimate total retinal blood flow based on the measurements in individual vessels determined by Doppler OCT using the double circle scan pattern.1-5
The mean total retinal blood flow measured by Doppler OCT ...

<table><tbody><tr><td>RTVue Fourier Domain optical coherence tomography </td><td>Optovue</td><td>N/A</td><td>Version 6.1.0.21 or higher Installed with blood flow double ring scan pattern </td></tr></tbody></table>

doppler optical coherence tomography of retinal circulation

Doppler Optical Coherence Tomography of Retinal Circulation

Noncontact retinal blood flow measurements are performed with a Fourier domain optical coherence tomography (OCT) system using a circumpapillary double circular scan (CDCS) that scans around the optic nerve head at 3.40 mm and 3.75 mm diameters. The double concentric circles are performed 6 times consecutively over 2 sec. The CDCS scan is saved with Doppler shift information from which flow can be calculated. The standard clinical protocol calls for 3 CDCS scans made with the OCT beam passing through the superonasal edge of the pupil and 3 CDCS scan through the inferonal pupil. This double-angle protocol ensures that acceptable Doppler angle is obtained on each retinal branch vessel in at least 1 scan. The CDCS scan data, a 3-dimensional volumetric OCT scan of the optic disc scan, and a color photograph of the optic disc are used together to obtain retinal blood flow measurement on an eye. We have developed a blood flow measurement software called "Doppler optical coherence tomography of retinal circulation" (DOCTORC). This semi-automated software is used to measure total retinal blood flow, vessel cross section area, and average blood velocity. The flow of each vessel is calculated from the Doppler shift in the vessel cross-sectional area and the Doppler angle between the vessel and the OCT beam. Total retinal blood flow measurement is summed from the veins around the optic disc. The results obtained at our Doppler OCT reading center showed good reproducibility between graders and methods (&lt;10%). Total retinal blood flow could be useful in the management of glaucoma, other retinal diseases, and retinal diseases. In glaucoma patients, OCT retinal blood flow measurement was highly correlated with visual field loss (R2&gt;0.57 with visual field pattern deviation). Doppler OCT is a new method to perform rapid, noncontact, and repeatable measurement of total retinal blood flow using widely available Fourier-domain OCT instrumentation. This new technology may improve the practicality of making these measurements in clinical studies and routine clinical practice.

Total retinal blood flow is measured by Doppler optical coherence tomography and semi-automated grading software.

Noncontact retinal blood flow measurements are performed with a Fourier domain optical coherence tomography (OCT) system using a circumpapillary double ...

The overall goal of this procedure is to measure total retinal blood flow using Doppler Optical Coherence Tomography or OCT and a semi-automated grading software. This is accomplished by first scanning the patient with Doppler OCT according to a dual angle protocol. The second step is to automatically evaluate the quality of OCT images and detect blood vessels in the images.Next, the graders judge and revise the vessel location, diameter, and type according to OCT images and a color photograph of the optic disc. The final step is to calculate the Doppler signal and doppler angle of the detected retinal veins and estimate the blood flow and velocity in each vein. Ultimately, total retinal blood flow is obtained by summing the blood flow in all veins around the optic disc.The main advantage of this technique over existing methods, such as laser doppler techniques and ultrasound color doppler imaging, is that it provides total retinal blood flow measurements using scans taken in just two seconds. Video demonstration of this master is critical as the steps are difficult to learn, and because the accuracy of result depends on the image quality and the subjective greeting of vessel position. Demonstrating the scanning procedure will be ophthalmic technician Janis Van Norman.For this protocol, patients should be scanned using an RT view for your domain optical coherence tomography or OCT system, utilizing a circum papillary double circular scan pattern. A 3D optic disc OCT scan is also needed. The double circular scan pattern consists of two concentric circles around the optic nerve head with an inner ring diameter of 3.4 millimeters and an ounce of ring diameter of 3.75 millimeters.This pattern transects all branch retinal arteries and veins emanating from the optic nerve head. The pattern is performed six times consecutively over two seconds, so that blood flow measurement can be averaged over approximately two cardiac cycles. The Doppler scans are performed according to a dual angle protocol where three scans are obtained with the OCT beam passing through the SUP nasal portion of the pupil and three scans are obtained through the inferior nasal portion.This provides flow measurements with two incidents angles on each vessel on the OCT machine. After each scan is obtained, the image quality indices are automatically calculated, keep only scans of acceptable quality. The real-time quality check improves the likelihood of valid flow measurements.Next, perform the 3D optic disc scan. This is a raster scan covering a six by six millimeter region around the optic disc. This provides a detailed on fas image of this area.Also import a color photograph of the optic disc to help distinguish arteries and veins. To begin analysis, first, transfer the Doppler OCT images, 3D disc, OCT images and color disc photography to the blood flow grading center where grad use doctor C software to measure retinal blood flow velocity and vessel area in the reading center. The greater first classifies the data of each eye as either good or poor in quality.According to the average eye movement and signal strength of the repeated scans, only the scans with good quality are graded for acceptable scans. Apply an automated segmentation algorithm to register the frames on the same circle and to segment each OCT image for vessel detection. Then apply an automated algorithm that matches vessels to locate the same vessel in each frame.For an overview project the detected vessel as a line segment onto the on FFAs fundus image calculated from the 3D disc scan. Have the graders review each vessel on a small portion of the averaged inner and outer ring frames, overlaid with a circle that represents the automated segmentation result. The grader should judge whether the location, vessel, diameter, and vessel type correctly match the vessel on the two rings.According to the OCT image on fas OCT image and disc photograph of the same eye, allow the grader to change any of the above values if deemed necessary. A confidence score of zero to five is automatically given to each vessel based on the Doppler signal strength in the vessel area. The grader then manually corrects this based on the strength of the Doppler signal regularity of vessel boundary agreement between inner and outer rings of vessel size and sign agreement of the Doppler shift between the inner and outer rings.The confidence score will be used for weighted averaging flow among scans. After all the vessels are verified and corrected, apply an automated algorithm to calculate the blood flow S area and velocity of each vein. Grading qualities and total retinal blood flow venous and artery area velocity are calculated.The algorithms detail are illustrated in this flow chart. First, integrate the doppler signal over the vessel area and then average it among all frames. Then calculate the doppler flow as the summed doppler signal divided by the Doppler angle.The vessel area is also averaged among frames for each vessel. The blood flow is calculated based on a weighted average from the valid scans. The validity is decided by the previously calculated subjective confidence score and an objective evaluation of the reliability of the Doppler angle.The weight of the valid scans is decided by the strength of the summed doppler signal and variation of the doppler angle. Calculate the average flow speed by summing the flows in the valid veins and dividing by the summed area of those veins. The vessels with no valid scans.Estimate the flow using the vessel area and the average flow speed from valid veins. Add the calculated flow for all veins to determine the total retinal blood flow. Evaluate the reliability of total retinal blood flow measurement based on the valid venous area percentage eye movement and signal strength.Next, calculate the superior and inferior hemisphere blood flow. Also obtain venous area and total arterial area by adding the vessel areas of all veins and all arteries. Assuming the total retinal blood flow is the same in arteries and veins, calculate the arterial and venous velocities by dividing total blood flow with arterial area and venous area.The results were inputted into the Doctor C central database. Researchers can review the result online. The results include two parts, the grading qualities and the measurements.The results can also be downloaded as a spreadsheet. Here we see the total retinal blood flow as determined by two graders using Doctor Z software. The total retinal blood flow measurements from each grader are similar and similar to flow rates determined by the other grader using the manual software and literature.The yield rate using the single angle protocol is about 65%but can be improved to 80%using the dual angle protocol and realtime image quality control for three graders. A good correlation exists between total blood flow and the pattern standard deviation from visual field tests the glaucoma to eyes for all graders. The integrator reproducibility as measured by the coefficient of variation, is similar for both glaucomatous and normal eyes.Likewise, the reproducibility measurements for the two methods, Dr.C and the manual software are similar. Once mastered, the dual angle protocol can be performed in several minutes and the greeting can be done in approximately 20 minutes. While performing doper OCT scan, it is important to remember to follow the dual angle protocol and check image quality for each scan.This technique has wide applications for optic nerve and retinal diseases such as glaucoma and diabetic retinopathy.

doppler-optical-coherence-tomography-of-retinal-circulation

Research

JoVE Journal

Medicine

Source: Jagodzinska, J., et. al.,  Optical Coherence Tomography: Imaging Mouse Retinal Ganglion Cells In Vivo. J. Vis. Exp. (2017)  In this video, we demonstrate the use of spectral-domain optical coherence tomography (SD-OCT) to image retinal layers and assess structural changes in a genetically modified mouse model with optic neuropathy.

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