Oct and Optic Nerve Thea Website

OCT & Optic nerve
Pr. Jean-Philippe Nordmann

Glaucoma Centre - Hpital des Quinze-Vingts, Paris
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Code art. 425).
Pr. Jean-Philippe Nordmann
Centre Hospitalier National dOphtalmologie des Quinze-Vingts
28, rue de Charenton
75012 Paris - France
[email protected]
Preface
Like many complementary examinations in ophthalmology, OCT was designed

as a collaboration between ophthalmologists and orthoptists. This book is
also based on such a collaboration. I want to thank the orthoptics team of
Quinze-Vingts Hospital, especially Mrs. Frdrique Brion, Audrey Payeras,
Cybelle Blatrix and Mr. Meddy Metref. Thanks to their energy, most diseases
of the optic nerve have been presented here and OCTs have been compared
with other complementary examinations, in particular visual fields and
photographs of the optic nerve. I would also like to thank Prof. Philippe Denis,
President of the French Society of Ophthalmology for his help and in particular
the provision of interesting examples.
Knowledge has no meaning unless shared. Laboratoires Tha and Carl Zeiss
have agreed to write, publish and distribute this book free of charge.
I am very grateful to them.
Contents
Introduction Page 13
Principles of OCT Page 16
General principles Page 18
What does OCT really show? Page 20
Analysis methods of ocular structures with OCT Page 22
- Optic nerve Page 22
- Optical fibres around the papilla Page 23
- Complex of macular ganglion cells Page 24
Error sources with OCT Page 26
-Signal receiving errors Page 26
-Errors related to the positioning of the head Page 26
- Errors related to the optics of the eye Page 29
- Errors related to ghost images Page 30
Presentation of the results in OCT Page 32
Cirrus HD-OCT (Carl Zeiss) Page 34
-P
resentation head of optic nerve and retinal nerve fibre analysis
(RNFL and ONH: Optic Disc Cube) Page 34
-P
resentation Analysis of macular ganglion cells: Macular Cube Page 37
OCT Optovue (RTVue) Page 38
-P
resentation Layer of parapapillary retinal nerve fibres and optic nerve Page 38
-G
eneral presentation Macular ganglion cells and layer
of retinal parapapillary nerve fibres Page 39
Glaucoma Page 40
The three structures to be analysed by OCT in glaucoma Page 42
-O
ptic nerve Page 42
-R
etinal nerve fibres (RNFL) Page 42
-C
omplex of macular ganglion cells Page 44
-O
ptic nerve or retinal nerve fibres: that look first in glaucoma? Page 45
-W
hat if there is an isolated optic nerve damage? Page 46
Preperimetric glaucoma Page 48
-P
reperimetric glaucoma: impairment isolated from the OCT Page 48
-P
reperimetric glaucoma: impairment of the RNFL layer and the FDT Matrix visual field Page 50
-P
reperimetric glaucoma: impairment of the RNFL layer, macula
and the FDT Matrix visual field Page 52
-P
reperimetric glaucoma: impairment of the FDT Matrix, OCT at the limit of normal Page 54
Early open-angle glaucoma Page 56
-G
laucoma with incipient open angle: location of the impairment matches
between OCT and the visual field Page 56
-E
arly open-angle glaucoma: depth of the impairment matches
between OCT and the visual field Page 58
-E
arly open-angle glaucoma: primary impairment in the OCT Page 60
-E
arly open-angle glaucoma: primary impairment of the optic nerve
without impairment in the optical fibres Page 62
-E
arly open-angle glaucoma: comparison between OCT Time Domain
and Spectral Domain Page 64
Moderate open-angle glaucoma moderate Page 66
-G
laucoma with moderate open angle: impairment matches in the OCT and the visual field Page 66
-M
oderate open-angle glaucoma: primary disease in the OCT Page 68
Advanced open-angle glaucoma Page 70
-G
laucoma with advanced open angle: impairment matches in the OCT and the visual field Page 70
-A
dvanced open-angle glaucoma: primary impairment in the visual field Page 72
-A
dvanced open-angle glaucoma: impairment does not match between OCT and the visual field Page 74
Normal pressure glaucoma Page 76
-N
ormal-pressure glaucoma: isolated fascicular deficit Page 76
-E
arly normal pressure glaucoma Page 78
-M
oderate normal pressure glaucoma Page 80
Angle-closure glaucoma or sequelae of acute hypertension Page 82
Follow-up of open-angle glaucoma Page 84
-C
an OCT improve in glaucoma? Page 87
-C
omparison between Spectral Domain OCTs in glaucoma Page 87
-O
CT and analysis of the cribriform lamina Page 87
Non-glaucomatous optic neuropathies Page 88
Multiple sclerosis Page 91
-A
cute neuropathy and MS Page 91
-C
orrelation between OCT and visual field in MS Page 92
- L ocation of impairment by OCT in MS Page 93
-M
ajor sequela of neuropathy in MS Page 94
-C
an we detect subclinical MS neuropathy through OCT? Page 96
Acute optic neuropathy unrelated to MS Page 98
Toxic optic neuropathy Page 100
-T
oxic optic neuropathy without apparent papillary impairment Page 100
-T
oxic optic neuropathy with papillary and macular impairment Page 102
Anterior ischemic neuropathy Page 104

Optic neuropathy and uveo-papillitis Page 106
Papillary oedema Page 107
- I solated oedema of the papilla without retinal diffusion Page 108
-O
edema of the optic disc with subretinal oedema Page 110
Compression of the optic nerve Page 112
Chiasma impairment Page 114
Amblyopia Page 116
Perinatal impairment of the central nervous system Page 118
Impairment of the central nervous system in adults Page 120
Determination of the organic character of visual impairment Page 122
Non ophthalmological neurodegenerative pathologies Page 124
Atypical appearances of the optic nerve that may show

optic neuropathy in OCT Page 126
Myopia Page 128
Dysversion the optic disc Page 130
Physiological excavation Page 132
Papillary coloboma Page 134
Atypical appearances of the retina that may show

optic neuropathy in OCT Page 136
Vein occlusion sequelae Page 138
Pigmentary retinopathy Page 140
Conclusion Page 143
References Page 145

Introduction
OCT (Optical Coherence Tomography for) is a relatively new technique that

allows images of biological tissue to be obtained by measuring the reflection
of light from the structure in question. Depending on the wavelength used,
the discernible details are in the range of 1 to 15 m, i.e. at least twice as thin
as is possible with the highest-performance conventional methods such as
MRI or high-resolution ultrasound echography. Its main limitation is the need
to analyse structures allowing sufficient light to pass through to obtain a
reflected image.
The eye is clearly an ideal organ in this sense, because a very large number
of ocular structures are mainly or partially transparent: cornea, lens, vitreous
humour, neurosensory retina, as well as the front layers of the iris. Other highly
reflective surface structures such as the pigment epithelium of the retina can
be studied.
In 10 years, OCT has developed a key role in the diagnosis and follow-up of
retinal and particularly macular impairments. This is due to the very descriptive
nature of OCT images that seem to reproduce an almost histological appear-
ance of the lesions observed. The latest generations of OCT, by multiplying
the measurements, can not only reproduce this descriptive aspect, but can
also perform a quantitative analysis of structures: thickness of the retina and
each of its components such as the ganglion cell layer, analysis of the neuro-
retinal rim, etc.
Retinal imaging by OCT has thus emerged as a crucial element for the analysis
of glaucomatous disease, since it is now possible to quantify the thickness of
the nerve fibre layer (called either optical fibre layer or retinal nerve fibre layer,
RNFL), a structure that is predominantly affected by this impairment. The optic
nerve has also benefited from this quantification (surface of the neuroretinal
rim, cavity volume, etc.), so that all parts of the eye that are potentially altered
in glaucoma have become accessible with OCT. Obtaining quantitative values
and comparing them with the standards allows us to determine the existence
and severity of glaucomatous disease and allows for follow- up.
It is also possible to analyse the iridocorneal angle, but in a less precise way,
especially because what happens at the back of the pigment epithelium of the
iris remains inaccessible to OCT.
Glaucoma is one of a range of optic neuropathies, and OCT also appears useful
in the analysis of all diseases of the optic nerve and, to some extent, the central
nervous system when ocular impacts are present.
13
Introduction
However, as with any new technology, analysis of the results of OCT requires
careful interpretation because the method of data acquisition is complex and
does not involve simple photography of the structures studied. It is always
desirable to examine the quality of the results, not only in an overview, but
also in closer detail when a zone appears suspect.
Once these pitfalls have been avoided, a new field of exploration and in
particular investigations opens up. What is the clinical meaning of one impair-
ment or another? How should a worsening of the impairment of the optical
fibres be interpreted if all other exams are stable? How can we explain, on the
contrary, that a particular structure is no longer changing in the OCT when the
glaucoma is indisputably worsening?
OCT is advancing so quickly that it is impossible to clearly define its use pro-
file, and any document is certain to become obsolete quite quickly. Currently
indispensable for analysing the retina, it is becoming so for glaucoma and
other optic neuropathies. This little book aims to simply give an update on
OCT in glaucoma and pathologies of the optic nerve. The first chapter concerns
the principles and interpretation of OCT and has a purely practical function, to
help the reader understand the results. Glaucoma is obviously an important
part of this book, but one part is devoted to other eye diseases and especially
neuro-ophthalmological diseases, because they can mimic glaucoma or be
a source of confusion if they are also present. Regardless of this facet of
differential diagnosis, OCT has acquired its place in the evaluation of the optic
nerve in general.
Cirrus HD-OCT (Carl Zeiss)
14
15
Principles
of OCT
OCT works by analysing the light reflected by zones crossed by an incident
light generated by a laser with a wavelength in the infrared range around
840 nm. Logically, when a beam of light passes through a structure, one
part of the light will continue its path (especially if the structure is quite
transparent), one part will beabsorbed by the structure, one part will be
reflected in all directions and the final part will be reflected towards the
emission zone.
It is this last part of the light that is analysed in OCT. It corresponds to

between one-billionth and one-millionth of the incident light, so it is very
weak.
16 17
General principles
Sound waves propagate relatively slowly (300m/sec in air) and it is possible

to record the return time of this wave directly, as with UBM. However, the high
propagation speed of light waves (300,000 km/sec) does not allow this time to
be recorded, which is in the order of 30 femtoseconds (30 x 10-15 sec).
OCT uses the principle of interferometry to analyse this delay. An incident

wave is divided into two, one part being projected onto a plane mirror and
the other onto the eye. The two waves thus created are reflected; the wave
sent to the mirror returns as a single echo; the wave sent to the eye returns
as multiple echoes depending on the structure it has passed through. These
waves are compared by an interferometer which measures the coherence
between them (hence the term OCT, Optical Coherence Tomography). This
allows us to deduce the thickness of the structure passed through by the wave
sent to the eye.
This simple measurement at a given point and a given depth is called an

A-scan. With Time Domain technology, the mirror moves repeatedly at dif-
ferent depths to analyse the different layers of the retina.
Acquisition of an A-scan:
Time Domain
Time Domain OCT technology:

a reference mirror moves to
successively study the different
depths of the retina.
18
Principles of OCT
The fastest devices in Time Domain allow the measurement of 17,000 A-scans
per second. These measurements in one dimension are then reassembled
into 2 dimensions to obtain a slice of the retina at a given place (B-scan). Time
Domain technology is limited by these movement of the mirrors, since an
examination cannot reasonably take more than a few seconds when it is
necessary for the eye to remain relatively fixed.
A very different technology that has led to a dramatic improvement in the

quality of OCT images is Spectral Domain technology. Instead of using the
coherence between two waves, it uses the interference spectrum between the
two reflected beams of broad-spectrum waves. This interference is studied
by mathematical analysis using the Fourier transform. The great advantage
of this Spectral/Fourier Domain technology is that it is possible to analyse
the reflected ray not successively at each depth, but at the same time. The
reference mirror therefore no longer has to move and this allows the process
to become 50 to 100 times faster.
Acquisition of an A-scan:
Spectral Domain
Spectral Domain
OCT technology: the reference
mirror is fixed and the different
depths of the retina are analysed
at the same time.
It is thus possible to make much more precise measurements (around 2 m)

during a reasonable examination time. Nevertheless, the examination itself
is not instantaneous like a single photograph, and the quality of the results
may be affected by an eye movement. It is not instantaneous because if the
different depths of the retina can be studied at the same time, it is necessary
for the laser beam to successively scan the different regions of this retina.
19
What does OCT really show?
OCT shows the reflection of light in different eye structures. This reflection is
particularly strong when there are sharp edges between two media having
different refractive indices. This is particularly the case in the cornea, which
is perfectly imaged in OCT. In addition, these reflections are sharper when
the structure crossed is perpendicular to the incident light, rather a glass
that partially reflects light. In general, reflection of light (only a part of
which occurs towards the incident source) is a property of inhomogeneous
structures responsible for microchanges in the refractive index, such as
cell membranes, nuclei, cytoplasm, axons of cells, etc. The most reflective
structures of the retina are the retinal nerve fibre layer (RNFL or optical fibres),
the pigment epithelium and the interplexiform layers. The more reflective a
structure is, the more red it appears, due to the colour code used in OCT.
Some structures contain melanin, which absorbs light strongly. At this level,
reflection and absorption are responsible for an exponential reduction in the
power of the incident beam, preventing it from exploring more distant areas.
That is why OCT does not allow the precise study of structures beyond the
pigment epithelium of the retina, which has the dual property of being highly
reflective in the part first hit by light, and highly absorbent in the most basal
area.
From this light reflection data, OCT measures the thickness of the layer
studied in a calculation that considers the time that the incident beam
takes to return and the known refractive index of the structure crossed.
It is therefore very important to note that OCT images are not direct
images of the retina, but rather a reconstruction based on mathematical
calculations transposed subsequently into images of the ocular fundus. You
can understand this quite easily by looking for example at the changes in the
appearance of the optical fibres in the optic nerve when these fibres change
direction to exit the eye. The reflection of light on the layer of the optical fibres
appears in red. When these fibres change direction when moving towards
the optic nerve, this colour changes. OCT is therefore not an anatomical slice
of the retina.
20
Principles of OCT
Strong reflection because the

layer of optical fibres is perpen-
dicular to the light.
Weak reflection because the layer

of optical fibres becomes parallel
to the light.
These simple remark allow us, in case of doubt about a result, to view the
images obtained and get an idea about whether the impairment exists or not.
When OCT analyses a layer of cells (for example, the ganglion cell layer of the
macula), it must be remembered that the measurement corresponds to the
entire layer (ganglion cells, support cells, interstitial fluid, etc.) This explains
why, when glaucoma is very advanced or even passed, the layer in question
does not completely disappear, because some support cells remain.
21
Mthodes danalyse des structures oculaires en OCT
In this brief chapter we review only those structures liable to be modified

in glaucoma and optic nerve pathologies, namely the optic nerve head, the
parapapillary optical fibre layer and the macular ganglion cell complex.
Optic nerve
The initial problem of analysis of the optic nerve is how to define the con-
tours of the optic nerve and what can be considered the start of the cavity. It
was chosen to define a reference plane arbitrarily set at 150 m above the
level of the peripapillary pigment epithelium. Based on this level, everything
below it is considered to correspond to an cavity, whether physiological or
not. It is then possible to measure the papillary parameters: width and surface
of the neuroretinal rim on the different meridians, size of the disc and cav-
ity, C/D ratio, etc. It is important to understand these points because when
the disc is irregular, the measurements may be distorted by erroneous
identification of this plane.
The papillary region is regular, the

pink line clearly determines the
boundary between the retina and
the cavity.
Eye with normal configuration
22
Principles of OCT
The papillary region is irregular;

the pink line does not readily
demarcate the boundary between
the retina and the cavity.
Strong myopia
Optical fibres around the optic disc
The devices program first identifies the two most refractive zones of the retina,
which are the front of the optical fibre layer and the pigment epithelium. It then
evaluates the location where the reflection of the optical fibre layer decreases
sharply, thus allowing its thickness to be measured. The speed of the Spec-
tral Domain OCT examination allows the measuring of a cube around the
optic nerve, but it is necessary to choose what zone is to be detailed. In fact,
the thickness of the optical fibres is measured at 3.4 mm from the centre of
the optic disc. This distance was chosen because it is the best compromise
Thickness of optical fibre layer/interindividual variability. In fact, the
closer you get to the disc, the thicker the layer is, and we could therefore be
expected to be able to detect small changes in it. However, close to the op-
tic disc, the results vary from one person to the next, and depending on the
location of the vessels and the shape of the disc. Conversely, if the
measurement is done a long way from the disc, the results are more consistent
between people, but the fibre layer narrows quickly and small changes become
less detectable. In practice, it was therefore decided to measure the fibre layer
at 3.4 mm from the centre of the disc.
23
Analysis methods of ocular structures with OCT
Circle located 3.4 mm from the

centre of the optic nerve corre-
sponding to the measuring zone
of the optical fibre layer.
However, it is not always at this level where the first disease signs are found
or where follow-up will be done best. In the follow-up, the zones closest to the
disc would be likely to allow a better analysis of progression.
Complex of macular ganglion cells
Thanks to Spectral Domain technology, it is possible to measure the

thickness of each layer of the retina and in particular the ganglion cell layer in
the macular region.
This zone is particularly interesting because the cells in this region correspond
to around 30% of the entire thickness of the structure. The foveal region is
not of interest because, conversely, it is endowed with too few ganglion cells.
Most devices measure a range including internal interplexiform layer - bodies

of ganglion cells - axons of ganglion cells passing above them.
24
Principles of OCT
ganglion horizontal
cell
amacrine cell
cell
Light
cone
bipolar Diagram of the retina

cell
rod
layer layer internal external layer of external pigment

of of ganglion granular granular segments of the epithelium
optical cells internal layer external layer photoreceptors
fibres plexiform plexiform
layer layer
Retinal nerve fibres

Ganglion cells
Internal interplexiform
The three layers studied in the
complex of ganglion cells.
It is possible to refine this measurement to better locate the impairment by

eliminating the axons of ganglion cells that correspond to cell bodies located
at a distance. This is offered by some devices (e.g. the Cirrus HD-OCT (Carl
Zeiss)), which eliminates the axon layer and thus measures only the internal
interplexiform - ganglion cell bodies layer.
25
Sources of error with OCT
OCT appears as an objective examination, so it is less prone to patient-related

errors. However, many errors can occur, related either to the imaging or to the
structure of the eye.
Signal receiving errors
The quality of imaging is crucial and is not straightforward, since only less
than one-millionth of the incident light sent by the laser is reflected towards
the sensor. This quality is expressed in the results by the expression
Signal Strength and must be greater than 6/10 with the Cirrus HD-OCT
(Carl Zeiss) or 50 with the Optovue (RTVue). A poor signal is often responsible
for an underestimation of the thickness of the optical fibres.
Errors related to head positioning
The measuring principle of OCT is based on reflection of incident light, which

depends on two key things: microchanges in the refractive index of the
medium crossed, and the orientation of the structure crossed; the more the
latter is perpendicular to the incident beam, the stronger the reflection. Head
positioning errors lead to changes in the axis of the eye and are therefore
responsible for variations in the results.
This can easily be seen in the example below, remembering that the colour
code in OCT indicates that the redder the colour is, the more reflective it is.
If the presentation is well done, the parapapillary optical fibre layer is thick.
When the depth setting is incorrect (for example, too distant), this layer seems
to decrease strongly, or when the head is tilted back.
This does not always result in insufficient signal quality, and therefore it
cannot be detected easily.
26
Principles of OCT
Correct head position. The optical

fibre layer (red) is normal.
Head tilted back. The optical fibre

layer is reduced.
Same eye as in the previous
patient.
Poor adjustment in myopia. The

optical fibre layer is reduced.
Same eye as in the previous
patient.
27
Another factor responsible for poor quality is the artefact related to eye
movements because the examination time is around 1.5 sec. OCT offers
programs to correct these artefacts, or even eye tracking during the
examination. Nevertheless, it should be ensured that there are no
discontinuities in the results.
Shifting of the image

Discontinuity of the image
during an examination due to an
eye movement. This is responsible
for errors in the calculation of the
RNFL parameters.
With OCT in the Spectral Domain, artefact phenomena in the mirror may
occur when the eye is incorrectly positioned or when significant depth
variations of the retina are present in severe myopia. The upper limit of the
OCT images corresponds to immediate reflection (no delay in reflection) and
therefore nothing can be weaker. If the eye is not positioned correctly, an even
closer image will be detected in the mirror and therefore completely inverted,
with the outer part of the eye appearing at the top and the inner part at the
bottom. In addition to the optic nerve, the retinal layers are therefore also
completely inverted.
28
Principles of OCT
Patient incorrectly positioned for

the right eye.
The image touches the upper part
of the black frames and all of the
retinal structures appear inverted.
The left eye is correct.
Errors related to the optics of the eye
The optics of the eye may also impact the result quality. Opacification of the
posterior capsule tends to reduce the evaluation of the optical fibre layer 1.
Conversely, wearing multifocal lenses does not change the results at both the
macula and parapapillary levels 2. The size of the optic disc does not influ-
ence the thickness of the optical fibres, except in the case of very small size
where false disease signs seem to exist 3. Conversely, myopia is a source of
artificial reduction of this thickness due to measurement problems when
the axial length of the eye is too high. The bigger an eye is, the bigger the
circumference located 3.4 mm from the centre of the optic nerve. The opti-
cal fibres are more spread out than in a normal eye, and this therefore leads
to a reduction in thickness, without however the number of optical fibres
being fewer than normal 4. This phenomenon is not significant in the macular
ganglion cells and we can therefore prefer to analyse this region in high
myopic patients 5.
29
Errors related to ghost images
OCT can sometimes confuse highly reflective structures that lie close to each
other. This is the case, for example, in the posterior hyaloid and the internal
boundary of the retina.
Layer of peripapillary optical

fibres that is abnormally high due
to vitreous traction in this region
(visible as a blue line).
30
Principles of OCT
In most diseases of the optic nerve, a thinning of the optical fibre layer is
observed. However, the OCT images should be consulted in case of doubt,
because this thinning may be hidden by oedema in the structure having a
different origin. This is the case when traction phenomena are noted.
Bilateral glaucoma patient with

impairment of visual field touch-
ing the central 10. On the right,
we note an impairment of the
ganglion cell complex. On the left,
there is a macular hole. Tractions
at this level and the oedema that
follows mask the thinning of this
layer, which seems to be normal.
31
Presentation of
results in OCT
Many different devices currently exist. In the United States, more than
30 devices have obtained a marketing authorisation. It is therefore not
possible to give a detailed presentation of all available OCTs. In France, the
most common devices are the Stratus and Cirrus HD-OCT (Carl Zeiss)
and the Optovue (RTVue). Most of the examples provided were produced
with these two devices. Insofar as the two most important areas in glaucoma
are the papillary and parapapillary regions, on the one hand, and the macular
ganglion cell complex on the other hand, these results are subject to detailed
interpretation.
32 33
Presentation head of optic nerve and retinal nerve fibre

analysis (RNFL and ONH: Optic Disc Cube)
The examination shows, on a single page, both eyes (OU), with the right
eye (OD) located on the left and the left eye (OS) on the right. In all of the
statistical presentations, the colour yellow indicates an anomaly at p < 5%
and red indicates an anomaly at p < 1%. Some patterns are small and difficult
to analyse, but it is possible to enlarge them on a separate page.
The values obtained are compared to a patient of the same age with an optic
disc of the same size. The size limits of the optic disc range from 1.3 mm2 to
2.5 mm2. Outside of these limits, all measured parameters are shown in grey,
because they are not compared to a standard. For each value, this number
appears on a white background if it corresponds to 5% of the best values,
and on a green background for 90% of cases. The colour yellow indicates an
anomaly at p <5% and the colour red indicates an anomaly at p < 1%.
34
Full name of the patient. It must Signal strength. This lets you
be spelled correctly in order know if the results have been
to guarantee follow-up. The correctly acquired. Values higher
patients date of birth is impor- than 6/10 are required. Even if
tant because the results are com- the signal is strong, the results
pared to age-dependent norms. may be inaccurate if the eye is
incorrectly positioned.
Thickness of the optical fibre

layer. The thicker this layer is,
the warmer the colour. Given
the physiology of optical fibres,
a watch hands appearance
centred on the disc is normal.
Image of the ocular fundus in

which the statistical values of
anomalies in the optical fibre
layer are coloured. The optic
disc is delimited, as well as the
zone 3.4 mm from the centre of
the disc where the thickness of
the parapapillary nerve fibres
is measured. It is important that
this circle is not located in a zone
of peripapillary atrophy because
the reflectance of the pigment
epithelium would be evaluated
incorrectly and the results could
be distorted.
Horizontal section of the poste-

rior pole. It is important to ensure
that the retina does not touch
the upper part of the square, as
this would distort the results. The
reflectance of the different layers
appear, as well as the boundaries
of the retina and Bruchs mem-
brane. Two small dots indicate a
zone 150 m above Bruchs mem-
brane that defines the start of the
cavity.
Vertical section of the posterior

pole. Imaged elements identical
to the previous presentation.
Position of the retina at 3.4 mm
from the optical centre, corre-
sponding to the region where the
retinal nerve fibres are studied.
35
Average thickness of the optical fibre layer (RNFL).

Symmetry of this layer between the 2 eyes (RNFL Symmetry).
Surface of the neuroretinal rim (ANR area).
Area of the optical disc.
Average C/D ratio.
Average vertical C/D ratio.
Cavity volume.
Thickness of the neuroretinal

rim in the different regions (tem-
poral, superior, nasal, inferior,
TSNIT); the right eye is shown as
a continuous line, the left eye as
a dotted line, the normal zones in
green, abnormal zones in yellow
and then red. This makes it easy
to locate a notch.
Thickness of the optical fibre layer

in different regions (temporal,
superior, nasal, inferior) at 3.4
mm from the centre of the optic
nerve; the right eye is shown as
a continuous line, the left eye as
a dotted line, normal zones in
green, abnormal zones in yellow
and then red.
Representation for each eye of the

thickness of the optical fibres, by
sections 6 hr wide. In glaucoma,
the most affected zones are the
upper and lower zones.
Representations for each eye of

the thickness of the optical fibres,
by sections 2 hr wide. In glau-
coma, the most affected areas are
located at 7 hr for the right eye
and 5 hr for the left eye.
36
Presentation Analysis of ganglion cells:

Macular Cube (Ganglion Cell OU Analysis)
The examination shows, on a single page, both eyes (OU), with the right eye
(OD) located on the left and the left eye (OS) on the right. For each value, this
number appears on a white background if it corresponds to 5% of the best
values, and on a green background for 90% of cases. The colour yellow
indicates an anomaly at p < 5% and the colour red indicates an anomaly at
p < 1%.
Full name of the

patient. It must be Signal strength. This lets you
spelled correctly in know if the results have been
order to guarantee correctly acquired. Values higher
follow-up. than 6/10 are required.
Thickness of the layer of the

ganglion cell complex. The thicker
this layer is, the warmer the
colour.
Presentation in the sector of the

macular region, without studying
the fovea, with the average thick-
ness value in each zone.
Table of average and minimum

values of the thickness of the
layer ganglion cells + internal
interplexiform, without the layer
of ganglion cell fibres.
The minimum value corresponds
to the thinnest sector of 1 width.
Horizontal scan of the macula passing

Statistical values of anomalies through the fovea.
in this layer. The colour yellow
indicates an anomaly at p < 5%
and the colour red indicates an
anomaly at p < 1%.
37
OCT Optovue (RTVue)
Presentation Layer of parapapillary retinal nerve fibres

and optic nerve
The examination shows the overall results for the head of the optic nerve and
the parapapillary region, for one eye, with statistical analysis.
Image of the ocular

Full name of the fundus; the circle
patient. It must be indicates the zone
spelled correctly in where the optical
order to guarantee fibre layer is mea- SSI: Signal Strength
follow-up. sured. Intensity.
Analysis region of the optical fi-

bres at 3.4 mm from the optical
centre.
Thickness of the optical fibre

layer in the different regions. The
warmer the colour, the greater the
thickness.
Thickness by region of the optical

fibre layer with statistical values.
Head of the optic nerve Normal zones are green, abnor-
mal zones are yellow and then
red.
Thickness of the optical fibre layer

in different regions (temporal,
superior, lower nasal TSNIT) at
Parameters of the optic nerve 3.4 mm from the centre of the
head. optic nerve.
38
OCT Optovue (RTVue)
General presentation Macular ganglion cells and layer of

parapapillary retinal nerve fibres
A single page shows all of the results without adding a direct OCT image. Many
elements described in the previous results are repeated here.
Complex of macular ganglion cells layers Thickness of the optical fibre

of optical fibre axons + ganglion cells + layer in the different regions. The
internal interplexiform. Statistical repre- warmer the colour, the greater the
sentation. thickness.
Parameters of the optic nerve

head.
Interocular differences, layer of

parapapillary fibres.
Thickness by region of the optical

fibre layer with statistical values.
Normal zones are green, abnor-
mal zones are yellow and then
red.
39
Glaucoma
Glaucoma is a slowly progressive optic neuropathy that is most often
associated with ocular hypertension. The progressive deformation of the
head of the optic nerve caused by this hypertension leads to a cavity and
destruction of the retinal nerve fibres passing through the cribriform
lamina. This destruction is responsible for visual field impairment. This
succession of structural impairment inducing functional impairment allows
us to estimate that, in theory at least, the analysis of the structure should
detect an initial impairment before the impairment of the visual field6. For
a long time, the methods available to study the structure did not allow this
approach to be confirmed.
40 41
The three structures to be analysed by OCT in glaucoma
With the new-generation Spectral Domain OCT, the structural changes can
often be detected before they have impaired the visual field. However, in
some cases, we note that the visual field is impaired before we can detect any
structural impairment. Each eye has between 800,000 and 1.2 million optical
fibres. If the starting point is close to the upper limit, significant impairment
can occur while the subject remains within the statistical standards. On the
other hand, if the initial structure of the eye is more normal, destruction of
fibres by glaucoma is more quickly visible.
Optic nerve
At the head of optic nerve, the parameters affected firstly in OCT are, in order:
the vertical thickness of the neuroretinal rim (not shown in the results),
the overall surface of this rim (Area of the ANR),
the vertical C/D ratio.
Although these parameters detect glaucoma well, they are not very effective in
differentiating early glaucoma from moderate glaucoma 7.
Retinal nerve fibres (RNFL)
The parameters that best differentiate normal subjects and early glaucoma
subjects are, in order:
the thickness of the retinal nerve fibres in the lower temporal zone,
the thickness of the retinal nerve fibres in the lower quadrant,
the average thickness of retinal nerve fibres.
Some studies seem to show that the upper temporal sector would be just as
differentiating as the lower temporal quadrant 8.
42
Main criteria of a glaucomatous disease

in OCT

- Average RNFL thickness.
Optic nerve
- Vertical thickness of the
neuroretinal rim,
- Overall surface of the
neuroretinal rim.
- Vertical C/D ratio.

- RNFL thickness in the lower
quadrant.

- RNFL thickness in the lower
temporal zone.
43
Complex of macular ganglion cells
The study of macular ganglion cells is more recent because it is only available
in Spectral Domain OCT. The parameters most suggestive of early glaucoma
are the average minimum thickness and the lower temporal thickness.
The macula is divided into 360 sectors each one degree wide. The average
minimum thickness is that of the thinnest sector (Minimum GCL thickness).
First elements changed in glau-

coma
- Lower temporal thickness
First elements changed in glau-

coma
- Average minimum thickness
44
Optic nerve or retinal nerve fibres: which should be exam-

ined first in glaucoma?
The information provided by OCT is diverse and raises the question of

what parameters are most reliable for early detection of glaucoma and, in
particular, whether it is better to analyse the optic nerve head or the para-
papillary ganglion fibres. In fact, we can imagine that, when there is a large
number of optical fibres, it is easy to analyse them and, when this thickness
tends to reduce, the posterior edge of this layer is more difficult to differenti-
ate from adjacent structures and therefore gives more variable measurements.
By contrast, it would be easier to determine the parameters of the optic nerve,
since only the only the vitreous body is facing these fibres and the determina-
tion of the optic nerve head by analysis of the end of Bruchs membrane is
performed well by OCT.
However, the appearance of the optic nerve itself varies greatly from one
person to another, and statistical comparisons are difficult. This is particularly
the case when the optic nerve is irregular (myopia, dysversion, etc.).
In general, it is easier to detect preperimetric glaucoma in the retinal nerve

fibres (RNFL). More rarely, analysis of the optic nerve is preferred. In some
patients, analysis of the macular ganglion fibres would be as good as analysis
of the RNFL layer 9.
45
What about a case of isolated impairment of the optic nerve?
Generally, the analysis of the optic nerve in OCT is more subject to discussion
than the analysis of optical fibres due to the diversity of appearances of the
optic nerve from one person to another; this diversity is not perfectly covered
by the standards databases of the devices. The result is that we sometimes
find an isolated optic nerve impairment when the retinal nerve fibres appear
normal, both at the parapapillary level and at the level of the macular ganglion
cells when the visual field is also normal. In this situation, we must favour the
analysis of optical fibres. However, it is desirable to analyse the progression
of the parameters of the optic nerve since the comparison is then done on the
patient himself.
46
Patient with an appearance

suggesting a physiological cavity.
The entire results are normal,
apart from an abnormal cavity
volume for each eye. Glaucoma
is not established. Simple moni-
toring should be proposed.
47
Preperimetric glaucoma
In general, the term preperimetric glaucoma is used for a glaucoma that

is detected by an impairment of the structure or by an alteration of the early
detection tests in the visual field, such as the blue-yellow visual field or the
FDT Matrix, while the conventional visual field, i.e. the Humphrey-type auto-
mated perimetry or Octopus is normal.
Preperimetric glaucoma: isolated impairment in OCT
60-year-old patient with hyper-

tension at 23 mmHg. The FDT
Matrix and OCT of the optic nerve
are at the limit of normal.
48
The OCT can be the only modified examination in preperimetric glaucoma. In

general, in this situation, simple monitoring is sufficient, but treatment is a
viable alternative, especially if the deficit in the OCT is large.
Same patient as on the previous

page. The macular OCT shows
a clear and well systematised
impairment in the right eye. The
10 Matrix test is irregular.
49
Preperimetric glaucoma: impairment of the RNFL layer

and the FDT Matrix visual field
The start of impairment of the visual field by FDT Matrix and OCT corresponds
to the beginning of glaucoma, especially if the deficits are consistent. These
deficits may precede the appearance of a conventional perimetry deficit by
5 years.
74-year-old patient, ocular hyper-

tension at 24 mmHg. Normal optic
nerve. The OCT and FDT Matrix
show matching impairment of the
right eye.
50

page. There is no central impair-
ment.
51
Preperimetric glaucoma: impairment of the RNFL layer,

the macula and the FDT Matrix visual field
There is often an impairment of both the RNFL layer and the macular ganglion
cell complex in OCT. If the deficit is more present in the parapapillary region,
we can assume that hypertension likely plays a major role. Otherwise, we will
consider more vascular problems.
55-year-old patient with ocular

hypertension at 26 mmHg. The
automated perimetry is normal,
but the Matrix shows a bilateral
alteration. The OCT confirms the
impairment, both in the optic
nerve and the RNFL layer.
52
Same patient as the previous

page. There is little macular
impairment at the right and a
normal result on the left. This
profile seems to suggest early
hypertension glaucoma.
53
Preperimetric glaucoma: impairment of the FDT Matrix, OCT

at the limit of normal
It is rare to note a normal OCT in a patient who already has perimetric impair-
ment. However, such cases can hypothetically occur in glaucoma. However, it
should then suggest a more central impairment and lead to the performance
of other tests with less doubt.

hypertension at 24 mmHg. The
Matrix visual field shows a marked
impairment on the left, while the
OCT is only slightly impaired.
54

page. OCT and central 10 visual
fields. The macular ganglion cell
complex is normal on the right
and at the limit of normal on the
left, while the Matrix 10 central
test is pathological.
55
Early open-angle glaucoma
Early open-angle glaucoma: location of the matching

impairment between the OCT and the visual field
The OCT is often consistent with the visual field in early and moderate
glaucomas, except in young patients where the OCT impairment is greater
than the impairment of the visual field.

tonus at 22mmHg at the right and
26 mmHg at the left. At the right,
the visual field is normal and
the OCT shows a lower temporal
deficit typical of early glaucoma.
On the left, the impairment is
more marked and extensive.
56
In OCT, a more significant impairment in the macular region than the peripapil-
lary region is not a severity factor if the deficit remains moderate.

page. OCT and central visual fields
of 10. Impairment of the macular
region of the left eye is observed.
The average and minimum thick-
ness parameters are abnormal.
The central visual fields of 10 are
normal.
57
Early open-angle glaucoma: depth of the impairment

matches between the OCT and the visual field
The impact on the visual field of a reduction in the thickness of the fibres
depends on the severity of the impairment. It is therefore necessary to analyse
the thickness precisely in the different sectors.
70-year-old patient affected

by open-angle glaucoma since
the age of 8. The impairment is
almost concordant between the
visual field and the OCT, with
more marked changes on the left
both at the level of the retinal
nerve fibre and the level of the
cavity.
58
This may explain why an impairment may not be noticeable in the visual field
in the central region if the most deficient point remains relatively normal.
For this reason, the minimum thickness is presented in the macular OCT, in
addition to the average thickness.

page. OCT and central visual fields
of 10. Significant macular impair-
ment of both sides, without nota-
ble impact on the right visual field.
This is due to the fact that, in the
corresponding zone, the macular
ganglion complex retains a high
thickness of more than 60 m. On
the left, the thickness in the upper
sector is reduced to 44 m and
causes a deep lower paracentral
scotoma.
59
Early open-angle glaucoma :

OCT predominant impairment
The younger the patient, the more the OCT is disrupted before the visual
field shows any changes. This is due to the redundancy of receptor fields in
the ganglion cells. For each region of the visual field, several ganglion cells
are present and process the same zone. This phenomenon decreases with
age.
31-year-old patient affected by

open-angle glaucoma since the
age of 4. Significant and almost
isolated impairment of the OCT.
All parameters for the optic nerve
are abnormal, as well as most of
the elements regarding the retinal
nerve fibre layer.
60

page. Significant macular impair-
ment without loss of visual acuity
or central visual field.
61
Early open-angle glaucoma: primary impairment of the

optic nerve without impairment of the optical fibres
The absence of impairment of the RNFL layer does not allow glaucoma to
be ruled out. If there is a cavity noted clinically or in the OCT and it is is
associated with a small impairment of the visual field, you should hold back
on diagnosing glaucoma proper.

hypertension.
On the right, the diagnosis of

glaucoma is in no doubt, both at
the level of the RNFL layer and in
the macular region.
On the left, we note that the reti-

nal nerve fibre layer (RNFL) is not
affected but the OCT parameters
of the optical nerve are abnormal.
The glaucoma is indeed bilateral.
The slightly abnormal visual fields
support the diagnosis.
62
When the RNFL layer is normal, the analysis of the macular ganglion cells
allows us to differentiated isolated hypertension and early impairment of
optical fibres.
Same patient. OCT and central

visual fields of 10. Bilateral
impairment of the macular gan-
glion cell layer. The central visual
field is normal.
63
Glaucoma with incipient open angle: comparison

between OCT Time Domain and Spectral Domain
Comparison of OCT Time Domain (Stratus OCT, Carl Zeiss) and Spectral
Domain (Cirrus HD-OCT, Carl Zeiss) shows that these two methods have the
same detection capacity as regards incipient glaucoma. The main difference
resides in the fact that Spectral Domain OCT is more reproducible and there-
fore allows better monitoring than Time Domain 10.
Glaucoma. OCT Time Domain
64
OCT Time Domain et Spectral Domain
The results obtained through Time Domain and Spectral Domain OCT are not
identical. In severe glaucoma in particular, we note a 10 to 20% variation in
the results. The colour codes of Stratus OCT and Cirrus HD-OCT are not
interchangeable. In general, the thickness of RNFL is smaller with Cirrus than
with Stratus.

page. Spectral Domain OCT. The
results are approximately compa-
rable.
65
Glaucoma with moderate open angle
Glaucoma with moderate open angle:

concordant impairment with OCT and visual field testing
Perfect concordance between OCT and visual field testing is rare, as OCT often
allows detection of slightly more serious impairment than perimetry testing.
Right eye
Left eye
Moderate glaucoma on the right.

Visual field testing highlights a
higher deficit. The optical fibres
are only affected in the lower
concordant region.
66

page. The analysis of macular
ganglion cells confirms this im-
pairment, which is concordant
with visual field testing, but also
shows a subclinical impairment in
the upper region and in the other
eye.
67
Glaucoma with moderate open angle:

OCT predominant impairment
OCT impairment in moderate glaucoma is sometimes more important than

visual field testing can predict. Thus, OCT appears to be very useful not only
for confirming perimetric deficit but also for analysing other regions appearing
normal in visual field testing.
Moderate glaucoma. Visual field

testing highlights an essentially
higher deficit. The optical fibres
are affected in the lower concor-
dant region, but also the upper
region. The right eye is normal
in Matrix visual field testing and
OCT.
68

fields. The analysis of macu-
lar ganglion cells confirms that
impairment is concordant with
visual field testing, but also
shows subclinical impairment in
the upper region. The right eye is
entirely normal.
69
Glaucoma with advanced open angle
In advanced glaucoma, OCT confirms the impairment but visual field test-
ing keeps its predominant position. In fact, other than certain seriousness,
the thickness of optical fibre layers or that of macular ganglion cells is not
reduced because of the presence, despite optical atrophy, of support struc-
tures accounting for the residual thickness of the RNFL.
Glaucoma with advanced open angle:

impairment concordant with OCT and visual field testing
In advanced glaucoma, a thickness of about 50 m corresponds to the

absolute deficit regions of visual field testing.
61-year-old patient with predomi-

nant glaucoma, left. The OCT
profile preserves a preferential
impairment in the upper and lower
sectors with relative preservation
of the temporal fasciculus.
70

fields. Moderate impairment
present, right. All macular regions
are affected, left. Note that a
simple difference of 15 m to
20 m separates incipient deficit
(right eye) and absolute deficit
zones (left eye).
71

predominant impairment of visual field testing
In the most advanced stages of glaucoma, it is difficult to rely on the thickness

of the optical fibres, both at the papillary and the macular level. This thickness
is only slightly reduced in this situation.
Right eye
Left eye
84-year-old patient with advanced

glaucoma and reduced visual
acuity, right. On this side, the
visual field MD is -26dB. It is -11dB
on the left. In OCT, this difference
is less pronounced, the aver-
age thickness of the RNFL being
54 m on the right against 60 m
on the left.
72

page. OCT and central 10 vi-
sual fields. The same is noted as
regards the absence of a clear
correlation between VF deficit
and thickness of the ganglion cell
complex. The MD is -20dB right
and -9dB left. The average thick-
nesses of the macular fibres are
57 m right and 58 m left.
73

discordant impairment between OCT and visual field testing
Sometimes, OCT only shows moderate impairment despite an obviously

abnormal visual field. This could be due to measurement errors or real
discordance.
Drop aspect associated with

vitreous opacities of the left eye.
65-year-old female patient with

more or less symmetrical bilateral
glaucoma. Nevertheless, the RNFL
only appears to be really abnor-
mal on the right. This could be due
to measurement errors associated
with serious sparkling synchysis
of the left eye, well visualised in
OCT and responsible for mediocre
signal quality.
74

fields. Macular OCT affected on
both sides.
75
Normal pressure glaucoma
In normal pressure glaucoma, we often observe central 10 visual field impair-

ment. Due to the high number of ganglion cells in this central region, this is
expressed by considerable reduction of the retina surface and, therefore,
important excavation at the advanced stage. OCT also tends to find identical
characteristics. Often, an isolated or predominant impairment of the macular
region is found.
Normal-pressure glaucoma: isolated fascicular deficit
An isolated deficit can be found in normal-pressure glaucoma, expressed by a

notch in the optical nerve head and the RNFL.
60-year-old female patient, ocu-

lar pressure of 15 mm Hg without
treatment. The results on the right
are normal. A slight fasciculate
deficit is observed on the left,
both in the optical nerve and the
parapapillary fibres. The optical
nerve parameters are normal.
76
In OCT, the characteristics of normal-pressure glaucoma are, at the early

stage, predominant or isolated impairment of the macular region.
Same patient as on the previ-

ous page. OCT and central 10
visual fields. Very localised
impairment of the left macular
ganglion cell complex.
77
Incipient normal-pressure glaucoma
In the initial phases, average RNFL is less affected in normal-pressure

glaucoma than in hypertonic glaucoma, which is logical because the affected
fasciculi are finer 12.
68-year-old female patient, ocu-

lar pressure of 16 mmHg without
treatment. OCT shows localised
impairment, right. Average RNFL
thickness is not affected but the
optical nerve parameters are
affected, right.
78
In GPN, the paracentral scotomas are deep and absolute, and only briefly pass
through a relative scotoma phase. In contrast, OCT allows quantification of
the optical fibre layer of the macular region, which can reduce gradually while
no functional indication is present.

fields. Using OCT, very localised
lower macular impairment is
observed, which is concordant
with the perimetric deficit.
79
Moderate normal-pressure glaucoma
Using OCT, the distinction between normal-pressure glaucoma and high-

pressure glaucoma is found, essentially, in the initial phases of the dis-
ease. When glaucoma is more advanced and the visual filed is affected more
specifically, this difference between normal-pressure glaucoma and hyper-
tonic glaucoma disappears gradually.
Right eye
Left eye
60-year-old female patient

affected by normal-pressure
glaucoma. The right eye associ-
ates the usual indications of open-
angle glaucoma with a nasal jump
and arched scotoma. The RNFL
remains relatively undisturbed.
A small paracentral scotoma

appears on the left, which only
slightly alters the thickness of the
optical fibre layer.
80
The analysis of the macular ganglion cell complex available in Spectral

Domain OCT allows to detect the beginning of impairment, which is expressed
by highly localised reduction of the fibres, with less global macular impair-
ment than in GPAO.

fields. The central 10 test and
OCT are concordant. Contrary to
what one often observes in hyper-
tonic glaucoma, not all the macu-
lar sectors are damaged.
81
Closed-angle glaucoma or sequelae of acute hypertension
Immediately after a glaucoma crisis by reducing the angle, OCT does not
change significantly. Nevertheless, 3 to 9 months later, the optical fibre layer
is reduced both locally in the upper and lower regions and globally, while the
perimeter remains unchanged in most cases. It might thus be interesting to
compare OCT directly and some time after the acute crisis in order to establish
the occurrence of impairment sequelae 13.
58-year-old male patient who

underwent a closed-angle glau-
coma crisis in the left eye a year
earlier, resolvent under medical
treatment and iridectomy.
Pressure is 16 mmHg on each side.
Matrix and OCT normal on the
right. On the left, the visual field
appears normal but in OCT upper
impairment is shown. The optical
nerve parameters show slightly
abnormal results on the left.
82
Closed-angle glaucoma or sequelae of acute hypertension
Even in the absence of an acute crisis and if pressure is normal, the thick-
ness of the optical fibres in the low temporal region is sometimes smaller in
patients with narrow angles, Asians in particular 14. This suggests repercus-
sions of nocturnal pressure outbursts.
Same patient. Impairment of the

macular region of the left eye is
observed. The minimum average
thickness parameter is abnormal.
83
Open-angle glaucoma monitoring
OCT allows detection and monitoring of glaucoma evolution. Spectral

Domain OCT being recent, it is difficult to find long-term longitudinal
studies; the most recent being a 4-year monitoring of patients15. Several types
of evolution are possible. The most frequent is an expansion of the deficit
surface, with a tendency to approach the macula. Less frequently, one
observes a deepening of the impairment or the appearance of impairment in
a different region. In order to detect this aggravation, the zone selected usu-
ally, 3.4 mm from the centre of the optical nerve, is too peripheral; a region at
2mm being more differentiating. In more than 50% of the cases, this aggrava-
tion in OCT is not confirmed by automated perimetry testing, thus underlining
the low correlation between these two examinations, at least during a short
evolution period. On the contrary, in 20% of the cases, isolated aggravation in
the perimeter is confirmed without OCT evolution.
Cirrus HD-OCT proposes a glaucoma monitoring programme and an analysis

of event evolution (GPA Report).
84
GPA monitoring parameters
Optical fibre thickness.
Changes in the thickness of the

optical fibres between exami-
nations, when a first change is
detected, are drawn in yellow, if
confirmed during the next exami-
nation, they appear in red.
Changes, through time, of the

average thickness of the RNFL
globally, in the upper region and
the lower region (3 tracings).
Average C/D ratio evolution.
Fibre thickness profile in the vari- Synthesis of the probability of

ous regions (TSNIT), using the stability or aggravation for three
same colour code in the case of key parameters, fibre thickness
aggravation. and TSNIT (focal progression) and
average thickness (diffused pro-
gression), as well as average C/D.
85
This GPA programme allows, like in perimetry testing, to detect significant

evolution 16. Nevertheless, important limits persist because evolution is con-
sidered real in patients with glaucoma if the new examination is outside the
variability limits as determined in healthy individuals. We do not know whether
this variability is smaller in reality or greater in patients with glaucoma. In the
study by Leung et col 17, an increase in the volume of the optical fibre layer is
even found in 13% of the cases, which is difficult to accept because that would
signify an improvement of glaucoma. Undoubtedly, this result corresponds
to initial measurement errors. The same team had carried out a similar study
3 years earlier using OCT Stratus. This study shows a minimal capacity to
detect progression with previous generation OCT.
Aggravation of structural impairment and functional impairment do not evolve

in parallel. These works thus clearly show that it is not possible to avoid auto-
mated perimetry testing, when this examination is abnormal, in the monitoring
of glaucoma, but that OCT also appears to be very useful, at least in the incipi-
ent and moderate glaucoma phases.
When evaluating the aggravation of glaucoma through the reduction of optical

fibre thickness, one should consider the glaucoma stage. In fact, the relation-
ship between optical fibre loss and visual field aggravation is not linear 18. In
the initial phases of glaucoma, an optical fibre loss can increase without an
important change in the visual field. At a more advanced stage, a moderate
change in optical fibre thickness is expressed by an important aggravation
of the visual field. Finally, in the later stages, the optical fibre thickness does
not change practically, while the visual field continues to worsen. The persis-
tence of a certain optical fibre layer thickness does not mean that a significant
number of gangion cells are present, but rather that cells supporting this layer
are still present.
Simultaneous aggravation of
visual field testing and OCT in
6 months. A 3 micron decrease of
the average thickness of the RNFL
is considered significant. Here, in
the left eye, it changes from 78 m
to 74 m.
86
Can OCT improve in glaucoma?
In practice, OCT does not improve in glaucoma. Nevertheless, after an impor-

tant reduction in ocular pressure through surgery, OCT can show an increase
in the thickness of optical fibre layers, but this phenomenon is temporary and
only lasts about 3 months 19. Most often, OCT improvement is the consequence
of better images that were not optimal during the first measurements.
Comparison between Spectral Domain OCT in glaucoma
Except for 1st generation OCT (Time Domain), there are several Spectral Domain
OCT devices: Cirrus HD-OCT (Carl Zeiss), 100RTVue (Optovue), Spectralis
(Heidelberg) These devices use the same operating principle but vary as
regards acquisition speed, the existence of a system that monitors view and
the retinal layers segmentation method.
It is not possible to use the gross values of Spectral Domain OCT and trans-
pose them to another. The results with these devices are very close but
different, e.g. Cirrus HD-OCT gives lower RNFL values than RTvue 20. In particu-
lar, this is associated with the measurement zone, which differs slightly from
one device to another.
OCT and cribriform plate analysis
OCT is in constant development. OCT allows analysing practically all structures

that can be illuminated. Apart from optical fibre impairment, we know that
glaucoma leads to deformation of the cribriform plate. Thanks to a specific
programme (Enhanced Depth Imaging-Optical Coherence Tomography (EDI-
OCT)), in glaucoma, one can visualise the cribriform plate deforming towards
the back, but also shifting backwards in relation to the sclera in certain merid-
ians 21. We do not know whether this corresponds to a cause or a consequence
of impairment of this structure, but it appears that after surgical reduction of
ocular pressure, the cribriform plate gains anterior adherence and thickens
again 22. Thus, this analysis appears to be an important line of development
not as regards the content (optical fibres) but the crossed structure (position
of the cribriform plate, sectoral thinning, form of pores) 23. In contrast, there
does not appear to be a great interest in measuring the thickness of the
choroids, which is only slightly changed by glaucoma 24. Nevertheless, in case
of peripapillary atrophy, this thickness is not reduced 25.
87
Neuropathies -
optic non
glaucomatous
In essence, optic neuropathies are responsible for the deterioration of
optical fibre axons and cause OCT modification. This impairment affects
both the parapapillary and the macular fibres. OCT has thus become a very
important diagnosis tool in neuro-ophthalmology 26. In many cases, the OCT
profile helps diagnosis and evaluation of the importance of optic neuropathy.
However, the OCT profile of certain diseases resembles that of glaucoma.
It thus appears important to know the OCT semeiology of these different
neuropathies.
88 89
Multiple sclerosis
90
Multiple sclerosis
In multiple sclerosis, the analysis of the retinal ganglion fibre layer is of great
interest because it is better correlated with the functional symptomatology of
the patients (lower acuity or reduced visual field) than in other supplementary
examinations, such as MRI 27.
Acute neuropathy and MS
During the acute phase of MS optic neuropathy, the RNFL is sometimes more
voluminous than normal. This provides evidence of slight papillary oedema,
which is not clinically perceptible. This oedema is present even if the demy-
elinating plaque is quite poeterior.
Thinning of the optical fibres layer occurs between the 1st and 3rd month after
the acute crisis and stabilises around the 6th month. In the absence of a new
crisis, there is no aggravation after 6 to 8 months.
The most damaged site is the macular area where about 34% of the
retinal volume is composed of the ganglion cell layer. In this pathology, an
eye affected by optic neuropathy presents a reduction of about 35 to 45%
in macular optical fibre thickness i.e. 20 m to 40 m, for a normal thickness
of 110 m to 120 m 28. The contralateral eye is also affected in most cases,
but to a lesser degree (20% reduction in thickness). In order for impairment
to appear in perimetry testing, a 75 m reduction approximately is necessary.
It is thus very important to analyse OCT in relation with neuropathy dynamics

29. In the acute phase, the absence of layer thinning is falsely reassuring. In
fact, impairment is delayed.
The papilla and macula are affected by MS. In the initial phases, the RNFL can
be artificially enlarged by papillary oedema, which is not the case for macular
ganglion cells. In the long-term, the two structures develop in parallel 30.
91
Multiple sclerosis
Correlation between OCT and visual field testing in MS
When OCT impairment is minimal, the visual field and visual acuity remain
normal in general after an acute crisis. In contrast, if a residual thickness
threshold of 75 m is affected in the peripapillary area, the field is disturbed.
Right eye
Left eye
Multiple sclerosis after an out-

burst. The optic nerves are nor-
mal. OCT shows predominant
impairment in the temporal sec-
tors of each eye. This deficit does
not appear in Goldmanns kinetic
perimetry testing. Temporal im-
pairment is typical of non glauco-
matous neuropathies.
92
Multiple sclerosis
Localisation of OCT impairment in MS
The temporal quadrant is the most frequent location. This allows distinguish-
ing it from glaucoma where impairment is rather superior or inferior.

fields. Impairment of macular
ganglion cells is major in each
eye, despite a very slightly
affected central visual field.
This type of diffused impairment
is found frequently.
93
Multiple sclerosis
Important sequelae of MS neuropathy
When multiple sclerosis evolves, visual field and OCT deteriorate. This
evolution is not always parallel, OCT being able to appear more affected than
the visual field.
Right eye
Left eye
Female patient affected by MS,

with several optic neuropathy
outbursts. The visual field of the
left eye is highly affected. OCT
confirms this impairment and
also reveals a practically identical
change in the right eye. The optic
nerves show predominant bilat-
eral optical atrophy on the left.
There is no pathological excava-
tion.
94
Multiple sclerosis

page. Impairment of ganglion
cells is major on both sides.
95
Multiple sclerosis
Is it possible to detect subclinical MS neuropathy

using OCT?
OCT is very useful for analysing the contralateral eye of the eye
affected by acute neuropathy and in the absence of ocular impairment
in patients with known MS. In fact, it allows detection of subclinical
impairment and also monitoring of the neurological state of patients, because
impairment of the visual pathways is almost always present in this disease 31.
Right eye
Left eye
Female patient affected by MS

without known optic neuropathy
episodes. OCT shows irregular
impairment in the various sectors,
while the visual field is normal.
96
Multiple sclerosis
We could even perform OCT in order to monitor the evolution of treatments

administered in general, in the absence of a visual history. This examination
could thus provide a general evaluation of MS.

page. Diffused impairment visible.
Normal visual acuity.
97
Acute optic neuropathy not associated with MS.
Ophthalmologists are often confronted with acute optic neuropathy of

unknown origin, demyelinisating or not. Does OCT help to distinguish demy-
elinisating optic neuropathy, whether lone or associated with other types
of pathology? The clinical context is essential. In favour of demyelinisating
aetiology: occurring between the age of 20 and 50; ocular pain during eye
movement in particular; strictly unilateral character; progressive aggravation
in about a week; start of recuperation after one month.
Right eye
Left eye

bilateral blurred vision, without
reduced acuity. The MRI results
do not indicate MS. The ocular
fundus reveals more significant
papillary oedema on the left than
on the right. OCT confirms this
result through a major increase
in parapapillary optical fibre
thickness on both sides. This
result does not indicate that the
optical fibres are healthy.
98
Acute optic neuropathy not associated with MS.
Unfortunately, the OCT profile does not allow differentiation of such impair-
ment, which is expressed by initial increase in fibre thickness in the case of
oedema, and then further reduction of the RNFL.

page. The analysis of ganglion
cells shows important impairment
on the left, while visual acuity is
10/10th. Observation of the macula,
far from the papilla, allows precise
monitoring of the repercussions of
optic neuropathy.
99
Toxic optic neuropathy
Toxic or nutritional optic neuropathies are suggested in the case of impair-

ment, which is often bilateral, symmetrical and painless, classically associated
with centrocaecal scotoma. OCT often reveals bilateral and gradual impair-
ment of the RNFL 32. As regards the peripapillary optical fibres, we note a
purely temporal deficit with relative preservation of the upper and lower
sectors.
Apparent toxic optic neuropathy without papillary

impairment
In the presence of associated papillary oedema, the aspect of the parapapil-

lary fibres can appear normal because layer thickness is artificially increased
by the oedema.
Right eye
Left eye
61-year-old male patient affected

by optic neuropathy, undoubtedly
associated with alcohol/nicotine.
The optic nerves appear normal.
The visual fields show bilateral
centrocaecal deficit. OCT reveals
papillary oedema. The RNFL ap-
pears normal because it is artifi-
cially increased due to oedema.
100
In the presence of associated papillary oedema, we find a contrast between

two normal parapapillary optical fibres and major impairment of the ganglion
cell complex.

fields. The central 10 visual field
confirms central impairment.
Macular OCT shows significant
bilateral, symmetrical and homo-
geneous impairment.
101
Toxic optic neuropathy with papillary and macular

impairment
Right eye
Left eye

by optic neuropathy, associated
with alcohol/nicotine. The optic
nerves are normal. Goldmanns
visual fields show distortion of
the blind spot on the right and
a normal result on the left. OCT
reveals typical impairment af-
ter bitemporal impairment. The
upper and lower sectors are not
affected. There is no pathological
excavation.
102
In incipient toxic optic neuropathies, impairment can be more evident in the

macular ganglion cells, even in the case of preserved visual acuity. In general,
it is diffuse and symmetrical.

fields. Slight diffused deficit of
the central 10 visual field present
on both sides. Macular OCT shows
significant bilateral, symmetrical
and homogeneous impairment.
This aspect suggests toxic NORB.
103
Anterior ischaemic neuropathy
It is sometimes difficult to distinguish remote sequelae of anterior ischaemic

optic neuropathy (AION) and glaucoma using OCT. Impairment of the RNFL is
temporal in both cases 33. The OCT deficit in AION is more altitudinal than in
glaucoma, affecting not only the lower temporal sector (7hr for the right eye,
5hr for the left eye), but describing more extensive impairment 34. One can also
expect that the excavation volume is smaller in AION 35.
Right eye
Left eye
63-year-old female patient, hyper-

metrope, affected 1 year earlier by
anterior ischaemic neuropathy in
the left eye. The visual field of the
right eye is normal, while that of
the left eye shows superior altitu-
dinal deficit, which is characteris-
tic of this pathology. OCT is coher-
ent with this unilateral impairment
and also shows secondary excava-
tion on the left.
104
Anterior ischaemic neuropathy
During an acute phase of AION, initial papillary oedema causes spectacular

increase of parapapillary optical fibre thickness, while the ganglion cell layer
is not altered.

page. Macular OCT shows global
impairment of the left eye. This
aspect could not be more typical
because one would expect a more
altitudinal deficit here.
105
Optic neuropathy and uveopapillitis
Inflammatory optic neuropathies within the framework of uveopapillitis ini-

tially cause significant increase of the optical fibre layer, prior to secondary
atrophy in half of the cases 36. OCT allows detection of the oedema and intra
and subretinal localisation.
Right eye
Left eye
Left unilateral uveopapillitis, of

toxoplasmic origin probably, in
a 19-year-old woman. In the best
case, OCT allows determination
of the importance of papillary
oedema and clarifies the impor-
tance of associated subretinal
oedema and its proximity in
relation to the fovea.
106
Papilla oedema
Papillary oedema, whatever the cause may be, is responsible for spectacular
increase of the optical fibre layer because OCT measures this layer in a non
specific way. During regression of oedema, the RNFL will appear reduced,
indicating the sequelae of the papillary oedema. The kinetics of the impair-
ment is therefore essential. The speed of appearance of sequelar deficits
depends on the aetiology of the oedema.
Right eye
Left eye
20-year-old male patient with

intracranial hypertension due to
an expansive intracranial process.
OCT reveals an increase in volume
of the optic nerve and RNFL thick-
ness. Monitoring of the parame-
ters of this layer allows measuring
the evolution of this oedema.
107
Papillary oedema
Lone oedema of the papilla, without retinal diffusion
In cases of lone oedema, the optic nerve parameters describe an increase

of the volume of the optic nerve, while the RNFL is normal. Nevertheless, a
normal thickness can be the consequence of oedema associated with incipient
optic atrophy. Long term assessment is necessary.

intracranial hypertension
OCT reveals an increase in the vol-

umes of the optical nerve without
associated retinal impairment.
108
Papillary oedema
The absence of optic fibre impairment is rather a good prognosis in the case of
macular oedema. A new assessment of the acute episode will allow confirming
the stability of the results.

page. Macular OCT is normal.
109
Papillary oedema
Papillary oedema with subretinal oedema
It is important to note that there is no associated subretinal oedema because,

in this case, we can predict improvement of the visual function during regres-
sion. If the oedema is not subretinal, recuperation will be weaker. OCT allows
distinguishing intra and subretinal oedema in the parapapillary region easily.
Right eye
Left eye

discreet reduction of visual acuity
of unexplained origin. The ocular
fundus reveals bilateral papil-
lary oedema and the visual fields
reveal enlargement of the blind
spot on both sides. OCT reveals
an increase of RNFL thickness.
The absence of optical fibre im-
pairment is associated with this
oedema.
110
Papillary oedema

fields. In the macular region, the
ganglion cell complex is already
altered on the right. On the left,
this impairment is hidden by
oedema. We note the absence
of good prognosis of subretinal
oedema.
111
Optic nerve compression
In the case of optic nerve compression, purely unilateral compression is

present. The optic nerve is sometimes difficult to examine because optic
atrophy can be accompanied by secondary excavation. Therefore, a glaucoma-
tous hypothesis is sometimes mentioned.
Right eye
Left eye
23-year-old female patient af-

fected by glioma in the left optic
nerve. Impairment is purely uni-
lateral, underlining the absence
of compression in the other eye.
Although the optic nerve gives the
impression of excavation, this is
not confirmed by OCT.
112
Optic nerve compression
In the case of optic nerve compression, the normality of the contralateral eye
allows to define the purely localised repercussion of this compression.

page. Diffused and lone macular
impairment of the left eye is
observed.
113
Chiasma impairment
In the case of chiasma impairment, visual field and OCT lesions are present.
After surgery, a favourable functional recuperation factor is the fact that, in
the affected zone, the RNFL thickness of at least 80 m 37 is maintained. Even
if the thickness is smaller, in general, improvement is observed after the oper-
ation. In compressive neuropathies, the volume of the optical fibre layer is
thus an indicator of the probability of regression of the clinical indications
after surgery. The greater the thickness of the fibres prior to treatment, the
better recuperation will be.
Right eye
Left eye
Female patient affected by prechi-

asmatic meningioma compressing
the left optic nerve mainly. Acuity
on the right is normal and on the
left lower than 1/20th. The optic
nerve is normal on the right and
slightly pale on the left. OCT of the
optic nerve head shows nasal and
temporal impairment with very
small fibre thickness (42 m and
37 m). There is no excavation.
While Goldmanns visual field test-

ing appears to show the begin-
ning of impairment on the right,
OCT remains normal.
114
Chiasma impairment
The RNFL is not always affected at an early stage in optic nerve or chiasma
compression, an alteration of the visual field sometimes being the first sign of
impairment. This constitutes one of the rare cases where the absence of fibre
impairment does not indicate a healthy situation.

page. Diffused and lone macu-
lar impairment of the left eye is
observed. In the case of compres-
sion, this diffused character is
usually observed.
115
Amblyopia
Amblyopia is expressed by a lowering of visual acuity in the relevant eye. The

ganglion cells are not functional from a morphoscopic point of view, but they
are still present. OCT only appears slightly modified in this situation.
48-year-old female female patient

with amblyopia in the left eye
(visual acuity 2/10th). Visual field
testing shows nasal deficit of
inexplicable origin. Peripapillary
OCT is normal, as are the optic
nerve parameters.
116
Amblyopia

fields. The central visual field of
the left eye shows diffused deficit
consistent with 2/10th acuity. OCT
is normal.
117
Perinatal impairment of the central nervous system
One would think that reduction of the optic fibre layer can only be found in the
case of direct impairment of such cells, in the cell body or the axon.
It appears that even a lone occipital cortex lesion can be expressed by hom-
onymous lateral reduction of optical fibres in OCT. This was initially evidenced
for congenital or perinatal pathologies. It is not certain whether this is the case
for acquired lesions.

sequelae of epilepsy and slight
mental retardation associated
with perinatal injury. The visual
field is irregular with lower hom-
onymous lateral deficit. The optic
nerves are normal. Although this
is central pathology, the OCT of
the optical fibres is affected.
118
Perinatal impairment of the central nervous system

fields. The central visual field is
irregular and macular OCT shows
bilateral impairment.
119
Impairment of the central nervous system in adults
Visual repercussions of lone impairment of the central nervous system in

adults is expressed by much more important alteration of the visual field than
OCT. Nevertheless, the OCT might be affected by transsynaptic degeneration
from the occipital lobe to the optic nerve 38 .
Right eye
Left eye
49-year-old female patient. The

visual fields show inexplicable
and relatively symmetrical bilat-
eral deficit in the upper field. OCT
is normal. The optic nerves also
appear clinically normal.
120
Impairment of the central nervous system in adults
OCT is thus very helpful when it is normal. With a lowering of visual acuity or
impairment of the visual field, confirmation of the absence of retina destruc-
turing in OCT allows confirming a neuro-ophthalmological cause for the
symptoms.

fields.
Minor impairment of the ganglion
cell complex is in contrast with
the importance of the perimetric
deficit. A central origin remains
the most probable aetiology.
121
Determination of the organic character of visual impairment
In many situations it is difficult to establish the organic origin of important

functional symptoms. This is the case for post cranial trauma, perimetric defi-
cit of hysteric origin or ill-defined pathologies.
OCT allows definition of the organic or non organic character of this functional
complaint.
60-year-old male patient com-

plaining about 6/10th reduction
of visual acuity after general
anaesthesia. The visual fields
show inexplicable bilateral centro-
caecal deficit. Neuropathy due to
low choroidal debit is mentioned.
OCT allows revealing major diffuse
impairment of the RNFL, with-
out excavation. The optic nerves
appear clinically normal.
122
Determination of the organic character of visual impairment

fields. The ganglion cell complex
is impaired significantly, thus
confirming the organic character
of the patients complaint.
123
Non ophthalmological neurodegenerative pathologies
In more general pathologies such as Alzheimers disease or Parkinson,

we also observe a reduction of optical fibres in OCT. In certain cases, this
reduction is diffuse and sometimes located in the superior region 39.
In Alzheimers disease, a reduction of the RNFL and the macular ganglion cell
layer is observed, but this is not directly related with the level of cognitive
functions.
In Parkinsons disease, a certain relationship between reduction of the optical

fibre layer and the functional repercussions of Parkinsons disease has been
found.
124
125
Atypical aspects
of the optic nerve
that can suggest
optic neuropathy
in OCT
Numerous atypical aspects of the optic nerve are responsible for the changes
of papilla OCT. They can consider the default measurement methods and
produce a wrong pathology result. OCT measures excavation in relation to a
reference plan, arbitrarily set at 150 m below the level of the peripapillary
pigment epithelium. If OCT cannot evaluate correctly the pigment epithelium,
all the results can be wrong. This is why, papilla sections, indicating with a
red point the theoretical start of excavation, are printed. Ophthalmologists
can thus determine whether the points are placed in a consistent way.
126 127
Myopia
Moderate myopia does not cause OCT modification. In the case of peripapil-
lary atrophy, it should be ensured that the measurement made at 3.4 mm from
the centre of the optic nerve is located outside this atrophy, in order to obtain
good quality measurements.
Right eye
Left eye
Female patient with myopia of

6 dioptres and slight lower tempo-
ral dysversion. Matrix visual field
testing shows irregularities, OCT
is normal.
128
Myopia

page. Ganglion cell complex irreg-
ularities on the right. This result
only indicates that a pathological
process is evolving.
129
Papillary dysversion
Moderate dysversion of the papilla does not lead to OCT modifications,

especially if it concerns the temporal axis. Nevertheless, in such cases we
sometimes observe slight nasal deficit, an aspect that does not suggest
glaucoma.
In contrast, if impairment is more important and especially if its axis is nasal,

important alterations occur and can be sources of confusion.
The macular ganglion cell complex is simpler to evaluate in dysversion as it is

located at a distance from the optic nerve. It allows revealing the existence of
macular impairment.
Right eye
Left eye
Female patient with bilateral dys-

version. The visual field is affected
on the right mainly, with alteration
of the RNFL suggesting glaucoma.
There is no excavation using OCT.
130
Papillary dysversion
The macular ganglion cell complex is simpler to evaluate in dysversion as it is

located at a distance from the optic nerve. It allows revealing the normality or
the existence of optical fibre impairment.

fields. An analysis of the central
region confirms the repercussions
of dysversion using both perim-
etry testing and OCT.
131
Physiological excavation
Using OCT, the large papilla, which are responsible for physiological excava-
tions, are expressed as a preservation of the RNFL and the macular ganglion
cell complex. The optic nerve parameters are not often compared with a nor-
mative value because the data bases do not in general include physiological
excavation.
Right eye
Left eye
Bilateral physiological excava-

tion. The RNFL is normal. The optic
nerve parameters are in grey (not
statistically analysed), as the de-
vice does not have such large disc
surfaces in its data base.
132
Physiological excavation
In the case of important and possibly physiological excavation, the optical

fibre parameters should be analysed and those of the optic nerve should be
considered to a lesser degree.

page. The ganglion cell complex
is normal. Bilateral physiological
excavation.
133
Papillary coloboma
Localisation of the coloboma is responsible for the opposite OCT. The sectors
that are usually affected in glaucoma, the lower temporal region in particular,
are not affected if this region is the seat of the coloboma.
Right eye
Left eye
Nasal coloboma of the right

papilla. OCT impairment is oppo-
site the abnormal region.
134
Papillary coloboma
Nasal coloboma of the right

papilla. Same patient as on the
previous page. The ganglion cell
complex is normal.
135
Atypical aspects
of the retina
possibly
suggesting optical
neuropathy using
OCT
Certain macular or retinal pathologies can alter the optical fibre layer, at the
macular level, but also at the peripapillary level. Therefore, a change in these
regions does not necessarily indicate direct impairment of the optic nerve.
If initial retinal impairment is mainly macular, we frequently only observe a
change in the macular ganglion cell complex. If impairment is more impor-
tant, all the structures can be altered. Two examples are shown here, but they
are not exhaustive as regards retinal pathologies possibly suggesting optic
neuropathy.
136 137
Vein occlusion sequelae
Vein occlusion is responsible for the destruction of the ganglion cell layer in
the same way as impairment of the optic nerve. The context allows an under-
standing of the OCT aspect.

3 years earlier by upper temporal
branch occlusion in the right eye.
Both OCT and visual field testing
detect the corresponding impair-
ment.
138
Vein occlusion sequelae

fields. We observe diffuse and uni-
lateral impairment of the macular
139
Pigmentary retinopathy
Impairment of the macular ganglion cell complex is very frequent in retinal

pathologies. It is even encountered when initial impairment is not located in
the optical fibre layer, such as pigmentary retinopathy.
Right eye
Left eye
23-year-old male patient with

pigmentary retinopathy. Gold-
manns visual field testing shows
important bilateral peracentral im-
pairment. The peripapillary optical
fibre layer remains within normal
limits.
140
Pigmentary retinopathy
The example given here corresponds to pigmentary retinopathy. All the other
sources of macular injury can lead to impairment of the macular ganglion cell
complex: epiretinal membrane, DMLA, macular oedema of any origin, macu-
lopathies acquired or constitutional

page. We observe diffuse and bi-
lateral impairment of the macular
141
142
Conclusion
Optic nerve imaging using OCT is developing constantly. Most of the refer-
ences of this publication are recent because earlier ones do not concern the
Spectral Domain. In the last year, more than 300 articles on Optic nerve
and OCT have been published in international journals, underlining the inno-
vative character of this technology.
Many questions arise in view of these spectacular results: should OCT be con-
sidered a fundamental examination in the context of glaucoma monitoring or
is it just supplementary to visual field testing and ocular pressure measure-
ment? Can we ignore visual field testing, a limiting examination that is not
well accepted by a large number of patients? What should one do if the OCT
worsens significantly without an alteration in the visual field? On the contrary,
what should one think of a visual field that is degrading without confirmation
of change using OCT?
At the moment, it is reasonable to consider on the one hand that OCT has
become a key examination for glaucoma and on the other hand that it cannot
replace visual field testing.
The same type of questions are posed for other optic neuropathies. Should
OCT eventually replace visual field testing? What should one think of OCT
impairment in the absence of clinical optic nerve impairment?
OCT is still developing in terms of image precision and quality. New struc-
tures are being studied and measured, such as the cribriform plate. Other
developments are possible, in particular the capacity to analyse not only layer
thickness but also layer content. This would be very useful for counting e.g.
the number of residual ganglion cells in optic nerve diseases without integrat-
ing the support cells that are responsible for the persistence of this layer, even
after total destruction of the visual fibres.
The use of large wavelength laser beams (1000 nm or more, such as SWEPT-
OCT) also allows studying structures beyond the pigmentary epithelium of
the retina, but at the cost of lower image quality. The choroid and the region
beyond the cribriform plate of the papilla also become visible. In the future,
these technologies will allow an understanding of certain complex pathologies
involving the modification of peripapillary cladding structures and cribriform
plate impairment.
OCT has thus become a basic examination for the evaluation of optic neu-
ropathies, without however totally replacing visual function analysis, and
automated perimetry testing in particular.
143
144
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OCT & Optic nerve

Pr. Jean-Philippe Nordmann

Like many complementary examinations in ophthalmology, OCT was designed

Principles of OCT Page 16

General principles Page 18

What does OCT really show? Page 20

Analysis methods of ocular structures with OCT Page 22

- Optic nerve Page 22

- Optical fibres around the papilla Page 23

- Complex of macular ganglion cells Page 24

Error sources with OCT Page 26

-Signal receiving errors Page 26

-Errors related to the positioning of the head Page 26

- Errors related to the optics of the eye Page 29

- Errors related to ghost images Page 30

Presentation of the results in OCT Page 32

Cirrus HD-OCT (Carl Zeiss) Page 34

OCT Optovue (RTVue) Page 38

The three structures to be analysed by OCT in glaucoma Page 42

Preperimetric glaucoma Page 48

Moderate open-angle glaucoma moderate Page 66

Advanced open-angle glaucoma Page 70

Normal pressure glaucoma Page 76

Angle-closure glaucoma or sequelae of acute hypertension Page 82

Follow-up of open-angle glaucoma Page 84

Non-glaucomatous optic neuropathies Page 88

Multiple sclerosis Page 91

- L ocation of impairment by OCT in MS Page 93

Acute optic neuropathy unrelated to MS Page 98

Toxic optic neuropathy Page 100

Anterior ischemic neuropathy Page 104

Papillary oedema Page 107

- I solated oedema of the papilla without retinal diffusion Page 108

Compression of the optic nerve Page 112

Chiasma impairment Page 114

Amblyopia Page 116

Perinatal impairment of the central nervous system Page 118

Impairment of the central nervous system in adults Page 120

Determination of the organic character of visual impairment Page 122

Non ophthalmological neurodegenerative pathologies Page 124

Atypical appearances of the optic nerve that may show

Myopia Page 128

Dysversion the optic disc Page 130

Physiological excavation Page 132

Papillary coloboma Page 134

Atypical appearances of the retina that may show

Vein occlusion sequelae Page 138

Pigmentary retinopathy Page 140

Conclusion Page 143

References Page 145

OCT (Optical Coherence Tomography for) is a relatively new technique that

Cirrus HD-OCT (Carl Zeiss)

It is this last part of the light that is analysed in OCT. It corresponds to

Sound waves propagate relatively slowly (300m/sec in air) and it is possible

OCT uses the principle of interferometry to analyse this delay. An incident

This simple measurement at a given point and a given depth is called an

Time Domain OCT technology:

A very different technology that has led to a dramatic improvement in the

It is thus possible to make much more precise measurements (around 2 m)

Strong reflection because the

- L ocation of impairment by OCT in MS Page 93

- I solated oedema of the papilla without retinal diffusion Page 108