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CHAPTER 2
2.1 Introduction
One of the first confocal tomographs to be applied to clinical practice was the Laser
Tomographic Scanner (LTS) [1,2,3,4]. It was a large instrument that required a long ex-
posure time to obtain images. It could take both retinal and corneal tomographs. How-
ever, it was not widely distributed due to its high cost. Today, there are only a few exist-
ing prototypes (figure 2.1).
A more advanced version of the LTS is the Heidelberg Retina Tomograph (HRT),
which unlike its predecessor, cannot take corneal tomographies. However, it is better
accepted because it requires a shorter laser exposure time and is a smaller machine. There
are more than 300 HRTs worldwide (figure 2.2). Other devices for confocal retina tomo-
graphies, such as the TOP SS, are also available.
Another advantage of the HRT over the LTS is that the LTS requires greater ob-
server specialization. In the HRT, interobserver variation is less than 2.7% and less than
1% between tomographies taken by the same observer. In addition, HRT software can be
installed from 3.5 inch diskettes, which allows for constant updating.
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Fig. 2.3
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image shifts abruptly, then the patient did fail to keep fixation, and the series must be
repeated.
The standard study depth for a normal optic nerve ranges from 1.5 and 2.5 mm; this
depth may increase to 4 mm in glaucomatous optic discs. Also, a depth of 0.5 or 1.0 mm
should be used when the macula is examined.
Sometimes the chosen study depth does not coincide with the patient’s retinal thick-
ness; when the series is completely illuminated, the study depth should be increased, and
when it is dark, the study depth should be decreased [3]. The most adequate procedure is
to illuminate the images progressively in the first 5 planes, reaching maximum luminosity
in the 10th plane, and then decreasing luminosity up to total darkness in the last 5 planes
of the series (figures 2.4 and 2.5).
If upon the examination the image seems to lack its usual contrast, then the study
depth should be increased and conversely, when contrast is too high, the study depth
Fig. 2.4
Fig. 2.5
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should be decreased. To do this, the laser emission should be stopped, the study depth
changed and the laser emission reactivated.
Sometimes the first planes are very bright, and illumination decreases progressively.
This may be due to a problem in the selected refraction with the coarse diopter and fine
diopter control.
It may happen that the brightness of the image fails to increase. If this occurs with a
4 mm. study depth, it indicates that the object studied is far too deep to be examined. This
is usually the case with deep glaucomatous optic discs (or steep glaucomatous optic
discs) in terminal stages and in deep macular foramen.
Once the first series is obtained it can be saved and stored with the Save Series
command, then a second and a third series can be taken and stored in the same way. Be-
tween each series the patient must be told that he or she can blink normally until further
notice.
Once the third series is taken it can be saved and stored with the Main Menu com-
mand, as it is the last one. From this point on the guidelines laid out in the "Information
Processing" section should be followed.
Fig. 2.6
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Fig. 2.7
deviates the beam 256 times within the anteroposterior plane is responsible for this. Once
the plane is scanned, the mirror shifts on this axis to scan the next plane, and so forth
until scanning of the 32 planes is completed.
Each image is scanned when it is in a focal plane, which is not the case with the an-
terior and posterior planes at that moment. When the 32 planes are aligned, 32 confocal
planes are obtained.
If we multiply the 256 vertical lines by the 256 horizontal lines we find that each
plane consists of 65,536 points. Each of these points has a value in the "X", "Y" and "Z"
axes. When the 32 planes are joined, each point of a plane aligns with its fellow on the
posterior plane. Thus, the final image resulting from the alignment process is composed
of 2,192,152 points that result from the multiplication of the 65,536 points in each plane
by 32, the total number of planes that form the final image. A volume obtained by the
multiplication of the 256 points in each axis "X" and "Y" by the 32 depth planes making
up axis "Z", is thus achieved [4].
S ORIGINAL SERIES
A ALIGNED SERIES
T TOPOGRAPHIC DATA
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Batch Mean Topography should then be chosen with which the computer groups
the three series, each one with its S, A and T data, and then builds a mean, which is an
average result of the three tomographies. At the bottom of the screen, the mean standard
deviation between the three topographies will appear. Its value must be less than 30 mi-
crons for the mean topography to be reliable useful [4] (figure 2.8).
The contour line that is drawn to obtain the optic disc parameters can be drawn di-
rectly on the mean topography (which appears with the letter M) or on one of the 3 origi-
nal tomographies, from where it can be exported to the mean. The advantage of drawing
the contour line on one of the original tomographies is that the 32 images can be seen,
making its drawing easier. (This is more extensively described in chapter 3).
The S, A, and T data can be stored on an optical disk system, from where they can
be extracted as needed. The S and A data are deleted from the hard disc, where only the T
topographic data are kept. With this procedure, all the optic disc data, except for the 32
Fig. 2.8
Fig. 2.9
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Bibliography
1. Nasemann JE, Burk ROW: Scanning Laser Ophthalmoscopy and Tomography.
Quintessenz, München, 1990.
2. Weinreb RN, Dreher AW: Reproducibility and accuracy of topographic measure-
ments of the optic nerve head with the Laser Tomographic Scanner. In: Nasemann
JE and Burk ROW (eds): Scanning Laser Ophthalmology and Tomography. Quin-
tessenz, Munchen, 1990.
3. Zinser G: Heidelberg Retina Tomograph Operation Manual, Software Version 2.01.
Heidelberg Engineering GmbH, Heidelberg, Germany, January 1997.
4. Sampaolesi R, Sampaolesi JR: Annual Lecture S.A.O., “Revista de la Sociadad
Argentina de Oftalmologia”, Argentina , May/April, 1996.
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