This observational case series presents three eyes of three myopic patients to illustrate the pathomorphologic features of the myopic macular changes using three-dimensional optical coherence tomography (OCT). The OCT system records the interferometric information using a Fourier-domain spectrometer method, with an acquisition rate of 20,000 axial scans/second, an axial resolution of 5 μm, and a lateral resolution of 20 μm. Three-dimensional images of the macular pathology and corresponding simultaneous acquisition of OCT fundus photographs were obtained for all patients. Three-dimensional OCT imaging using the Fourier-domain system has enabled unprecedented precise views of macular pathology, facilitating understanding and visualization of the pathology of macular diseases. This multidimensional view of retina structures will aid in early detection and monitoring of disease progression in the future.
Enhanced Visualization of Myopic Macular Changes with Three-Dimensional OCT
From Singapore National Eye Centre, Singapore.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Shu Yen Lee, FRCS, 11 Third Hospital Avenue, Singapore 168751.
Accepted: September 03, 2008
Posted Online: March 09, 2010
Advances in optical coherence tomography (OCT) have improved our understanding of the pathogenesis and staging of macular diseases through detailed visualization of the vitreoretinal interface and intraretinal layers. Ultrahigh-resolution OCT provided an improved axial resolution of approximately 3 μm compared to 10 μm in standard-resolution OCT.1–4 This has significantly improved the visualization of intraretinal structures, in particular the inner and outer retinal segments of the photoreceptors, which have been identified as possible indicators of subsequent visual potential of macular diseases.5–7 Recently, novel technologies that employ the Fourier-domain spectrometer system have enabled the acquisition speeds to increase by up to 100 times that of conventional OCT time-domain systems.7,8 This major advancement has led to enhanced visualization and comprehensive three-dimensional images of the retina. Several articles have illustrated the advantages of these three-dimensional OCT scans in providing realistic and complete visualization of macular pathology.3,9,10
We describe three patients with high myopia who had macular diseases where the pathology was clearly delineated on three-dimensional OCT. The Topcon three-dimensional OCT-1000 (Topcon Inc., Paramus, NJ) based on the Fourier-domain spectrometer technology integrated with the Topcon nonmydriatic camera was used for all patient examinations. It employs a superluminescent light-emitting diode laser with a wavelength of 840 μm.
A 63-year-old woman presented with pathological myopia. Her refraction at presentation was −16.00/−2.25 × 90 in the right eye and −16.00/−1.50 × 90 in the left eye. She had experienced blurring of vision for 1 year and was found to have posterior staphyloma and marked myopic changes in the fundi bilaterally. Her best-corrected visual acuity was 6/21 in the right eye and 6/15 in the left eye. She subsequently returned with a decrease in visual acuity in both eyes (6/45 in the right eye and 6/60 in the left eye). She was diagnosed as having bilateral macular schisis and a macular hole in the left eye (Fig. 1).
Figure 1. (A) Optical Coherence Tomography (OCT) Fundus Photograph of Case 1 Showing Myopic Changes of the Atrophic Macular Hole (black Arrow) Within the Area of Chorioretinal Atrophy in the Left Eye. The Corresponding Three-Dimensional OCT Images are Constructed from the 6.0 × 6.0 mm Scan Area with a Scan Density of 512 × 128 Pixels (cut Taken from the Central Green Line Within the Green Box). (B) the Two-Dimensional OCT Cross-Sectional Cut Showing the Macular Hole and Surrounding Schitic Spaces Within the Retina. (C) Three-Dimensional OCT Image Clearly Depicting the Macula Hole, Seen as a Central Depression (white Arrow) Surrounded by Distinct Central Retinal Elevation. (D) Selected Three-Dimensional OCT Side Profile Showing the Retinal Detachment (space Defined by the White Arrows).
A 53-year-old woman presented with blurring of vision in the left eye. She had high myopia of −17 diopters. Her presenting visual acuity was 6/21 in the right eye and counting fingers in the left eye. On examination, she was found to have a left macular hole detachment (Fig. 2). She underwent trans pars plana lensectomy, vitrectomy, internal limiting membrane peeling, and fluid–air exchange with intraocular injection of C3F8 gas.
Figure 2. (A) Optical Coherence Tomography (OCT) Fundus Photograph of Case 2 Showing the Left Macular Hole Detachment on a Background of Posterior Staphyloma and Chorioretinal Atrophy. (B) Two-Dimensional OCT Cross-Sectional Cut Showing the Macular Hole Detachment. The Neurosensory Retina is Grossly Seen to be in Layers, with Subretinal Fluid Corresponding to the Macular Hole Detachment. (C) Selected Cross-Sectional Three-Dimensional Reconstruction of the Macular Hole (white Arrow) and its Intraretinal Structure. The Red Arrow Points to the Schitic Spaces Within the Intraretinal Layers.
A 59-year-old woman presented with high myopia. Her refraction at presentation was −14.50 in the right eye and −14.50/−0.50 × 80 in the left eye. She presented with complaints of blurring of vision in the left eye during the past year. Her best-corrected visual acuity was 6/7.5 in the right eye and 6/18 in the left eye. Her initial clinical picture was that of a myopic tessellated fundus with a possible lamellar hole in the left eye (Fig. 3).
Figure 3. (A) Optical Coherence Tomography (OCT) Fundus Photograph of Case 3 Showing the Marked Myopic Tessellated Fundus. The Macula Looks Atrophic with Surrounding Neurosensory Elevation. (B) Two-Dimensional OCT Showing Macular Schisis. (C) The Reconstructed Three-Dimensional OCT Image Further Demonstrates the Lamellar Macular Hole. The White Arrow Points to Continued Attachment Between the Intraretinal Layers. The Red Arrow Points to the Elevation of the Posterior Layer of the Retina.
Two-dimensional OCT showed a left macular schisis and vitreomacular traction. However, the vitreoretinal interfaces and traction were more clearly delineated on three-dimensional OCT, which confirmed the diagnosis of a left macular lamellar hole with the presence of vitreomacular traction. She was initially monitored for 9 months before she underwent a 23-gauge trans pars plana vitrectomy with membrane peeling in the left eye. At 2 weeks postoperatively, visual acuity in the left eye was counting fingers with some residual intraocular gas.
The continuous advancements in OCT imaging have led to improvements in our diagnostic abilities. Three-dimensional imaging allows an unprecedented detailed visualization of the retina and its vitreoretinal interface and interactions. It provides a comprehensive depth and volume to structures in detail that was previously only possible with histopathology sections. The 6.0 × 6.0 mm area, which is imaged by 60 or more parallel sections in the three-dimensional OCT scans instead of the single-sectioned two-dimensional OCT scans, also allows us to see the extent of involvement over the whole macula.
As illustrated in our patients, macular pathology such as macular schisis and holes is often difficult to diagnose clinically in view of the background of marked chorioretinal atrophy and posterior staphyloma. They are often dismissed as having poor vision secondary to severe myopic changes and hence might be identified late. As shown in case 3, the OCT fundus photograph shows a subtle atrophic macular hole with surrounding retinal elevation that could have been missed at first glance. However, both the two-dimensional and three-dimensional OCT images clearly showed the macular hole. The three-dimensional OCT image provided a detailed topographical overview of the whole macula and its pathology. This aids diagnosis and possibly monitoring of the progress of the disease subsequently. Furthermore, this instrument allows the acquisition of corresponding OCT fundus photographs, which provides point-by-point correlation between the color fundus photograph and the three-dimensional OCT image rather than a rough estimation or extrapolation as to where the cross-sectional OCT image corresponded to.
Three-dimensional OCT imaging using the Fourier-domain system is a useful modality for providing greater insight into the morphology and pathogenesis of macular diseases. Although it is not likely to replace the current imaging instruments, it will definitely complement our current diagnostic tools by enabling a visual representation of the depth and breadth of the intraretinal and vitreoretinal structures. This would be beneficial in both clinical and research settings.
- Drexler W, Sattmann H, Hermann B, et al. Enhanced visualization of macular pathology with the use of ultrahigh-resolution optical coherence tomography. Arch Ophthalmol. 2003;121:695–676. doi:10.1001/archopht.121.5.695 [CrossRef]
- Catier A, Tadayoni R, Paques M, et al. Characterization of macula edema from various aetiologies by optical coherence tomography. Am J Ophthalmol. 2005;140:200–206.
- Hangai M, Ojima Y, Gotoh N, et al. Three-dimensional imaging of macular holes with high-speed optical coherence tomography. Ophthalmology. 2007;114:763–773. doi:10.1016/j.ophtha.2006.07.055 [CrossRef]
- Wojtkowski M, Srinivasan V, Fujimoto JG, et al. Three-dimensional retinal imaging with high-speed ultrahigh-resolution optical coherence tomography. Ophthalmology. 2005;112:1734–1746. doi:10.1016/j.ophtha.2005.05.023 [CrossRef]
- Chen TC, Cense B, Pierce MC, et al. Spectral domain optical coherence tomography: ultra-high resolution ophthalmic imaging. Arch Ophthalmol. 2005;123:1715–1720. doi:10.1001/archopht.123.12.1715 [CrossRef]
- Hangai M, Yoshimura N, Yasuno Y, et al. Clinical application of high contrast three-dimensional imaging of the retina, choroid and optic nerve with three-dimensional Fourier domain optical coherence tomography. Proc SPIE. 2006;6138:19–25.
- Ko TH, Fujimoto JG, Duker JS, et al. Comparison of ultrahigh- and standard-resolution optical coherence tomography for imaging macular hole pathology and repair. Ophthalmology. 2004;111:2033–2043. doi:10.1016/j.ophtha.2004.05.021 [CrossRef]
- Leitgeb RA, Hitzenberger CK, Fercher AF. Performance of fourier domain vs time domain optical coherence tomography. Opt Express. 2003;11:889–894.
- Schimdt-Erfuth U, Leitgeb RA, Michels S, et al. Three-dimensional ultrahigh-resolution optical coherence tomography of macular diseases. Invest Ophthalmol Vis Sci. 2005;46:3393–3402. doi:10.1167/iovs.05-0370 [CrossRef]
- Yamaike N, Tsujikawa A, Ota M, et al. Three-dimensional imaging of cystoid macular edema in retinal vein occlusion. Ophthalmology. 2008;115:355–362. doi:10.1016/j.ophtha.2007.04.052 [CrossRef]