Eye (2008) 22, 1251–1256

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Imaging the M Restori

CAMBRIDGE OPHTHALMOLOGY SYMPOSIUM

vitreous: optical
coherence
tomography and
ultrasound imaging

Abstract that of light in the vitreous is a factor of 105 times

greater at B2.3
108 m/s. In ultrasound imaging,
Imaging the vitreous in optically transparent
separating out the scattered echo data from
and translucent ocular media using OCT and
different depths is by means of measuring time
in optically opaque ocular media using
delays of echoes. In OCT, however, the echo data
ultrasound is discussed.
have extremely short time-delays necessitating
Optical coherence tomography and colour flow
the use of interferometric techniques to extract
mapping are briefly described. Images of
the depth information.
tomograms, B-mode sections, and colour flow
maps illustrate the use of these techniques in
Time-domain OCT
imaging the vitreous.
Eye (2008) 22, 1251–1256; doi:10.1038/eye.2008.30; The technique is based on Michelson’s
published online 22 February 2008 interfometer and has been widely described.1,2
For ophthalmic systems, a low-coherence
Keywords: vitreous; fourier domain OCT; 820 nm wavelength pulsed source is used.
B-mode; colour flow mapping Shorter wavelengths allow improved axial
resolution, but there is a trade-off with reduced
tissue penetration and sensitivity. Echoes from
Optical coherence tomography the eye tissue are combined with a variable
delay reference pulse. Correlation (a
‘The existence of light allows us to walk along mathematical description for, in essence, what
the tightrope between translucency and means a type of combination of the two signals)
transparency’FSir Nicolas Grimshaw. between these two signals provides data on
Optical coherence tomography (OCT) allows fluctuations of scattered light intensity as a
cross-sectional imaging of eyes with a micron- function of time. Plots of this A-line (by analogy
scale resolution. The requirements are the to ultrasound imaging) are as either brightness-
ocular media should be optically transparent or modulated spots, the brightness of the spots
translucent and the pupil diameter should be a indicating the amplitude of the echo or more Department of Ultrasound,
minimum of 4 mm. Patients are seated with the commonly, a false colour is ascribed to Moorfields Eye Hospital,
head positioned and stabilised with a chin rest particular amplitudes (Figure 1). The London, UK
and forehead support. It is common to combine convention is to show high-amplitude echoes in
OCT with the fundus image to allow a choice in warm shades (red, yellow, and white) and low- Correspondence: M Restori,
OCT section locations. Ultrasound, Moorfields Eye
amplitude echoes in cold shades (blue, green,
OCT images are comparable to ultrasound Hospital, London EC1V 2PD,
and black). The position of the spot indicates the UK.
B-mode sections, both presenting serial (or radial) depth in tissue from which the echo was Te1: þ 020 756 622 17;
cross-sectional images in the same planes and generated. A large series of such A-lines are Fax: þ 020 756 622 17.
data on the amplitude of echoes scattered from generated to produce the OCT image. E-mail: restoriharrison@
the tissues at measured depths. Hence, blueyonder.co.uk
terminology is often used interchangeably for
Fourier-domain OCT Received: 18 January 2008
both techniques. An important difference
Accepted in revised form:
between the techniques, however, is how the data Recent advances in component specifications 18 January 2008
regarding echo depth is obtained. The speed of and reliability have allowed the practical Published online:
sound in the vitreous is B1.5
103 m/s, whereas implementation of fourier-domain OCT.3 22 February 2008
 Imaging the vitreous
M Restori
1252

Figure 1 Time-domain OCT image: PVD; pseudo macular hole (Status OCT 3 (Carl Zeiss Meditec Inc.).

Figure 2 Fourier-domain OCT images: (a and b) Retinal layers (Topcon 3D 1000). (c) PVD;cyst (S OCT Copernicus). (d) PVD shown in
3D inserting into macular hole (Topcon 3D 1000).

A broad-spectrum light source (alternatively, the spectrum undergoes mathematical manipulation (fourier
frequency of a narrowband continuous wave can be transform) to produce the correlation function from
swept. This obviates the need for a spectrometer) is used which the depth information is read.
to illuminate the sample and the depth information is This technique has the advantage that it allows
extracted from the interference spectrum of the scattered- improved axial resolution. The technique is considerable
tissue signal. The scattered-light intensity fluctuations faster than the time-domain OCT and allows more
are combined with a broadband reference beam as same A-scan lines producing improved lateral resolution,
as the interrogating beam and are then passed through a signal to noise and sensitivity. Faster time allows the use
spectrum analyser and the output sent to an array of of 3D imaging software at practical speeds (Figure 2)
detectors. The resultant output interference power allowing data to be displayed as individual B-scans,

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animated 3D data cubes, or serial sections within a data position corresponds to a B-mode section. Images are
cube, which can be viewed in ‘fly-through’ timed refreshed at rates of up to 25 B-scans/s. Dynamic studies
sequence. are performed by asking the patient to deviate the eye
while the probe is held in a stationary position.
Real-time B-mode imaging illustrates the dynamic and
Ultrasound imaging
topographical characteristics of pathology. CFM is used
Diagnostic ultrasound is used in the assessment of eyes to image blood flow. The absence of blood CFM can be
in which opaque ocular media precludes used to distinguish the avascular vitreous from vascular
ophthalmoscopic visualisation of the fundus. tissues. All images shown were taken with a Sequoia 512
Real-time B-mode imaging and colour flow mapping (Acuson: Siemens).
(CFM) are used in the diagnosis of vitreoretinal disease.

The vitreous
Real-time B-mode imaging and CFM
The normal vitreous cavity on ultrasound B-mode
Patients are examined seated with the head positioned section (Figure 3a) appears echolucent. Typical axial
and stabilised with a chin rest and forehead support. The resolutions at 12 MHz are 130 mm and lateral resolutions
probe is smeared with a coupling gel, applied to the 800 mm. Optical opacities may give rise to echoes of
closed eyelid and moved in a systematic fashion over the varying amplitudes. Generally, inflammatory debris
eyelid to produce a series of B-mode sections. Each probe cannot be distinguished from haemorrhage (Figures 3b,

Figure 3 Transverse ultrasound B-scans: (a) Central section: normal vitreous; foveal dip (arrow). (b) Post-vitrectomy haemorrhage;
residual gel frill (arrow). (c) Intragel asteroid hyalosis; PVD. (d) Intraocular foreign body on retinal surface (arrow) casting shadow;
PVD. (e) Intravitreal larva (arrow). (f) Intravitreal bleed with source (arrow) indicated by region of fresh highly echogenic
haemorrhage. (g) Intravitreal haemorrhage with lacunae; no PVD. (h) Optically clear vitreous; PVD.

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Figure 4 Transverse ultrasound B-scans. (a) Intragel haemorrhage outlining PVD; fluid level (arrow). (b) Retrohyaloid haemorrhage
outlining PVD; fluid level (arrow). (c) Intragel and retrohyaloid haemorrhage; incomplete PVD (disc adhesion; arrow) outlined by
fresh haemorrhage on posterior hyaloid interface. (d) Intragel and retrohyaloid haemorrhage; PVD outlined by fresh haemorrhage on
posterior hyaloid interface. (e) Deviated gaze; central gel and retrohyaloid haemorrhage; clear cortical gel; temporal retinal tear
(arrow). (f) Deviated gaze; intragel asteroid hyalosis; retrohyaloid haemorrhage; vitreoretinal adhesion at site of branch vein occlusion
(arrow). (g) Laterally deviated gaze to demonstrate gel movement: intragel haemorrhage. (h) Same eye as (g) Nasally deviated gaze to
demonstrate gel movement: intragel haemorrhage.

d, f–h, 4, and 5). Calcium-laden asteroid hyalosis (Figures moves sinuously during eye deviations. The echoes from
3c and 4f), however, is clearly distinguishable from other the interface of gel and retrohyaloid fluid are very low in
opacities as it generates very high-amplitude echoes. amplitude due to the similarity of acoustic impedance
Foreign bodies give rise to very high-amplitude (density X velocity of sound in medium) between the gel
individual echoes and may cast a shadow (Figure 4d), and clear retrohyaloid fluid.
but may show comet tail type (Figure 5a) reverberation The presence of vitreous opacities aids in the
artefacts. Small gas bubbles in the vitreous can be ultrasound diagnosis of vitreous detachment
distinguished from foreign bodies by head positioning. allowing the outline of the posterior hyaloid interface to
The presence of lacunae within dispersed vitreous be clearly delineated. Various patterns of PVD exist.
opacities suggests probable progression to posterior Echoes arising from fresh haemorrhage (Figure 4c and d)
vitreous detachment (PVD). In such instances, care must or fibrous tissue scattered from the detached gel
be taken not to confuse posterior located lacunae boundary (Figure 5h) may outline the PVD. More
(Figure 3g) with the posterior hyaloid face. commonly, diagnosis of PVD can be made when echoes
arising from opacities are compartmentalised to and
Posterior vitreous detachment
fill either the vitreous gel (Figures 3c and 4a) or the
PVD in an eye with an optically transparent vitreous is retrohyaloid space (Figure 4b). Retrohyaloid
seen on the B-scan as a faint line (Figure 3h), which haemorrhage frequently bleeds into the central gel

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Figure 5 Ultrasound B-scans and CFM. (a) Deviated gaze; PVD incarcerated by a wide adhesion into the posterior temporal retina;
intragel haemorrhage; posterior scleral rupture; intraconal foreign body adjacent to nerve (arrow) with comet-tail reverberations.
(b and c) PVD inserting into anterior edge of retinal tear (arrow); intragel haemorrhage. (d) Deviated gaze; PVD inserting into anterior
edge of retinal tear (arrow); localised temporal retinal detachment; central gel and retrohyaloid haemorrhage. (e) PVD inserting into
retinal tear (arrow); intragel haemorrhage; rhegmatogenous retinal detachment. (f) CFM: PVD; fixed retinal detachment showing blood
flow in red. (g) PVD with partly fibrotic posterior hyaloid membrane inserted by fibrous stalk into tractional retinal detachment;
retrohyaloid haemorrhage. (h) CFM: blood flow (red) in patent persistent hyaloid vessel.

leaving clear cortical gel (Figures 4e and 5d). All patterns Post vitrectomy and silicone oil
exhibit a common feature on dynamic B-mode study in
Post-vitrectomy haemorrhage (Figure 3b) gives rise to a
that the internal gel echoes move as a corporate entity
uniform distribution of haemorrhage and the residual gel
(Figure 4g and h) flopping from side-to-side on
frill is detectable.
deviations of gaze.
The presence of silicone oil (Figure 6) makes images
Often a development adhesion of the detached
more difficult to interpret. Artefacts are caused by the
gel to the disc (Figure 4c) exists. Other vitreoretinal
differences in the oil properties compared with biological
adhesions may indicate the sites of new vessels or a
tissue. The speed of sound in silicone oil, only two-thirds
branch vein occlusion (Figure 4f). In trauma, the
of that in biological tissue, is not corrected for by the
detached gel may be incarcerated into other tissues as
scanner and causes the vitreal length to appear elongated
suggested by adhesions (Figure 5a) and an asymmetrical
on the display by a factor of 1.5.
suspension of gel on B-scan section. Vitreoretinal
adhesions may be tenuous (Figure 4f) or more
extensive (Figure 5a) and are best illustrated using
Retinal tears and retinal detachment
dynamic studies, which aid in the appreciation of
tractional forces on the retina around the base of such Retinal tears (Figures 4e, 5b and c) are imaged as two
adhesions. strong echo tags. During eye movements, the gel can be

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 Imaging the vitreous
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Figure 6 Ultrasound B-scans : silicone oil. (a) Aphakia; silicone oil-filled vitreous; low-sound speed in oil elongates the appearance of
vitreous. (b) Emulsified silicone oil in anterior chamber and silicone oil and haemorrhage in vitreous. (c) Longitudinal section; silicone
oil in vitreous; inferior half retinal detachment (arrow). (d) Post-silicone oil removal; residual oil droplets in anterior chamber and
vitreous; total retinal detachment (arrows) with subretinal silicone oil droplets.

imaged inserting into the more anterior echo tag. A drop Conclusions
in the retinal level should be discernible posterior to the
OCT offers in vivo, non-contact, static images of the
two echo tags.
vitreous and posterior coats, to the depths of typically
Differentiation between incomplete PVD tethering to
2 mm with both unprecedented resolution (micron scale)
the disc and total detached retina is based on several
and speeds, in optically transparent and translucent
features. The echogenicity of the detached retina is
tissue.
usually higher than that from the posterior hyaloid
Ultrasound imaging offers in vivo, direct contact,
interface, although the presence of fresh haemorrhage or
dynamic images of the entire globe, and orbit, typically
fibrous tissue along the posterior hyaloid interface may
to depth of 50 mm with lower resolutions (100mm scale)
give equally high-amplitude echoes. Importantly, in
in optically transparent, translucent, or optically opaque
PVD, only one interface can be imaged even at high
media.
settings of gain during dynamic scanning. For diagnosis
of retinal detachment (Figure 5d–g) in adults, two
interfaces should be imaged, one from the incomplete Acknowledgements
PVD and the other from the detached retina. The vitreous
All OCT images are courtesy of Medical Illustration
flops from side-to-side during deviations of gaze (Figure
Department, Moorfields Eye Hospital, London. I thank
4g and h), whereas fresh rhegmatogenous retinal
Drs Sidney Leeman and Andrew Healey for their helpful
detachment demonstrates an undulating type of motion,
comments.
which continues for a short period after the eye has
become stationary. In rhaegmatogenous retinal
detachment, the anterior edge of the retinal tear can be
localised by delineating the site of vitreoretinal adhesion References
(Figure 5e and f) during dynamic scanning.
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Eye