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Welcome to Optovues Training Program

Hosted by Michael J. Sinai, Ph.D.

The meeting will begin at the top of the hour. Your phone line is muted when you join the meeting to eliminate background noise. You
can communicate to Dr. Mike by typing in the chat box on the bottom of the screen. You can also participate by selecting from the
various options on the right of the screen. If you raise your hand I will un-mute your phone line for you to ask a question.
Please participate and make sure all your questions are discussed. Enjoy the Meeting.
The RTVue 100
High Speed, High Resolution OCT

Operator Training Course


Michael J. Sinai, Ph.D.
Director of Clinical Affairs
Retinal Layers with RTVue & Histology
Temporal Nasal
Fovea Parafovea ILM
NFL
GCL
IPL
INL
OPL
ONL
PR IS/OS
RPE
Choriocapillaris
and choroid
Software Overview
Software has 3 main screens

1. Patient Folder
2. Examine
3. Analyze
Patient Folder
Patient Folder

Patient Database
Patient Folder

Database Sort and Search Options


Name
Date
Physician
Disease
Protocol
Patient Folder

Patient Information
Name
DOB
Refraction
Disease Category
Patient Folder
Visit Information
Exam date
Physician
Operator
Comments
Patient Folder

Enter New Patient or create New


Visit for existing patient
Examine Screen
Examine Screen
Scan types listed by pathology or
choose protocol
Examine Screen

Scan list shows what scans were


selected to be taken
Examine Screen

Clinical and Advanced tabs allow


user to optimize image quality
Examine Screen

Live video image during scan


procedure
Examine Screen

Live OCT image during scan


procedure
Scan Types: Retina & Glaucoma

Select scan
type based on
pathology

Retina Scans Glaucoma Scans


Glaucoma Analysis with the RTVue
Nerve Head Map (NHM) Ganglion Cell Map (GCM) RNFL circle 3-D Optic Disc

Data Captured: 9,510 A scans Data Captured: 14,810 Data Captured: 4,048 Data Captured: 51,712
(pixels) A scans (pixels) A scans (pixels) A scans (pixels)
Time: 370 msec Time: 570 msec Time: 150 msec Time: 2 seconds
Area covered: 4 mm diameter Area covered: 7 x 7 Area covered: 3.45 Area covered: 4 x 4 X 2
circle mm diameter circle mm mm

Provides
Provides Ganglion cell Provides Provides
Cup Area assessment in macula RNFL thickness in 3 D map
Rim Area Inner retina thickness is: peripapillary circle Comprehensive
RNFL Map NFL assessment
TSNIT graph Ganglion cell
body
Dendrites
Retina Analysis with the RTVue
Macula Map (MM5) Macula Map (MM5) Macula Map (MM5) 3-D Macula Map
Full retina thickness Outer retinal thickness RPE Elevation
Data Captured: 19,496 A scans Data Captured: 19,496 A Data Captured: 19,496 A Data Captured: 51,712
(pixels) scans (pixels) scans (pixels) A scans (pixels)
Time: 750 msec Time: 750 msec Time: 750 msec Time: 2 seconds
Area covered: 5 mm x 5 mm Area covered: 5 mm x 5 mm Area covered: 5 mm x 5 mm Area covered: 4 x 4 X 2
mm
Provides Provides
Outer retinal thickness RPE & Choroid
Provides Provides
assessment in macula
Full retinal assessment in macula 3 D map
Detailed B scans Detailed B scans
thickness map Comprehensive
ETDRS thickness grid
Detailed B assessment
scans
ETDRS
thickness grid
Retina: Line Scans

Use line
scans for
retina
pathologies
for macula
cross-section
information
Macula Hole with Cross Scan

Images courtesy of Dr. Tano, Osaka University


Retina: 3-D Scans
Use 3-D
macula scans
for any retina
pathology

Allows for
detailed
review of
macula
3-D Macula Scan

SLO-OCT
image

B-Scan 3-D view


Retina: Slicer Scans
Slicer scans
provide
multiple B-
scans
simultaneously

Can be
horizontal or
radial
Retina: Slicer scan

Video
image

B-Scan
Retina: Macula Maps
Macula maps
scans cover
large areas
very fast

Provide full
retina thickness,
inner & outer
retina thickness,
ILM topography,
RPE/Choroid
assessment
MM5 reveals edema with full
retina thickness map
Full retina
thickness
map

Individual
B scans
from map

CME Patient Case courtesy of Dr. Nalin


Mehta, Colorado Retina Center
MM5 in healthy eye

Thickness map shows foveal depression


MM5 also provides RPE/Choroid
information
RPE elevation
map clearly
shows area of
CNV superior
to fovea

Individual B
scans from
map
Show CNV

Neovascular AMD PatientCase courtesy of Dr. Nalin Mehta,


Colorado Retina Center
Glaucoma Scans
Glaucoma: RNFL 3.45 Circle Scan

Use for
glaucoma to
evaluate
RNFL in circle
around disc
Glaucoma Suspect with RNFL circle scan
Glaucoma: 3-D Optic Disc Scan

Use 3-D scan on


optic disc for
comprehensive
evaluation and
to draw the
contour line
3-D Optic Disc Scan

SLO-OCT
image

B-Scan 3-D view


Marking the Optic Disc margin

Right clicking on
the 3-D image
allows user to
mark the
boundary of the
optic disc
Important Glaucoma scan is NHM4

NHM4 is a Nerve
Head Map with 4
mm diameter scan
area centered on
optic disc
providing optic
disc and RNFL
information
Glaucoma Analysis with NHM4

RNFL Thickness
Map

Neural retinal rim

Cup area

RNFL TSNIT graph


at 3.45 mm circle
Marking RPE tips after NHM4 scan

RPE Layer

RPE end
(tip)

After NHM4 scans, user must move circles to end of RPE


Optic disc margin can be marked
on video image also

We strongly recommend taking a 3D optic disc image


and marking optic disc boundary with 3D image
Unique Glaucoma scan is MM7

MM7 is a Macula
Map with 7 x 7 mm
scan area over the
macula
Measuring the ganglion cells with MM7
MM7 segments the Inner retinal
layers and provides complete
Ganglion cell assessment:
Axons (nerve fiber layer)
Cell Body (ganglion cell layer)
Dendrites (inner plexiform layer)

Images courtesy of Dr. Ou Tan, USC


Ganglion cell layer in macula analyzed
for glaucoma

Ganglion cell
atrophy can be
quantified directly
and is likely a
sensitive measure
for detecting early
damage and change
Normal vs Glaucoma

Cup
Rim
NHM4 RNFL

Ganglion cell
assessment
MM7 with inner
retinal layer
map

Normal Glaucoma
Analyze Screen
Scans acquired list

Scans that have been taken on this visit


Results Window

Scan result window


for selected scan
Printing

Print selection
will print contents
of scan report
page
Cross line printout

Patient Information

Vertical B-scan
Reflectance Image

Horizontal B-scan
3-D printout
Patient Information

Vertical B-scan
SLO OCT Image

Cube of Data
Horizontal B-scan

Fly through cube to view individual cross sections (B-scans)


NHM4 Glaucoma Printout

Reflectance Image

Circular scan

Radial line scan Optic disc


and RNFL
thickness
map

Parameter Values TSNIT graph


MM7 Glaucoma Printout

Parameter Values
Reflectance
Image
Superior/Inferior
Asymmetry
difference Map

Inner retina
thickness Map
B-scans (RNFL+Ganglion
cells +inner
plexiform layer
MM5 Macula Thickness Printout

Patient Information
Average
retinal
thickness by
Reflectance Image 9 zone grid

B- scans
selected from
thickness map

Parameter Values
Full retina
thickness
map
Scan Protocols

On the Examine window,


user can select a scan
protocol in addition to
choosing individual scans

Scan protocol loads a


previously saved scan list
to the scan list area
Recommended Scan Protocols
Scan protocols can be set up in advance to
reflect most common scan lists used
everyday
Standard Retina Protocol OU
Cross Line
MM5
Full retina thickness map
RPE/Choroid assessment
Selectable B-scans
Standard Glaucoma Protocol OU
3-D optic disc
3-D assessment with disc drawing
NHM4
RNFL map, Rim, Cup
MM7
Ganglion cell assessment
Recommended Scan Protocols: Retina

Scan protocol
selected

Added to scan list


Recommended Scan Protocols: Glaucoma

Scan protocol
selected

Added to scan list


Scan types & pathology
Retina Glaucoma Neuro-Ophthal
Cross scans 3-D optic disc NHM4
3-D macula NHM4 MM7
MM5 MM7
MM6
- Full retina
- RPE/Choroid
Course Outline

Introduction
Technology Background
Software Overview, Scan types, & Printouts
Protocols, Scan types & Pathologies
Acquiring an image: start to finish
Q/A
Acquiring an image: start to finish
1. Instruct patient on procedure
2. Enter patient information
3. Choose scan types or protocol
4. Prepare the patient
5. Align scanner to eye
6. Position OCT image
7. Adjust video or OCT parameters to optimize images
8. Take images
9. Review for quality and save
10. Choose view and print
Step 1. Instruct patient on procedure

Talk to patient about procedure


Emphasize it is like taking a photograph
Will not cause pain, patient should be comfortable
and relaxed
Give some background on new high-tech device
and how it will help the doctor
Clean chin and headrest in front of patient
Step 2. Enter patient information
From the Patient Folder screen

Enter New Patient or create New


Visit for existing patient
Step 3. Choose scan types or protocol

Retina Scans Glaucoma Scans Protocols


Step 3. Select Eye, # of scans, and add

Retina Scans Glaucoma Scans Protocols


Step 3. Selected scans/protocol will be
added to Scan list

Scan list shows scans to be imaged


Step 4. Prepare the patient
Position patient comfortably in chair
Adjust table height and chinrest height
Tell patient to place chin on chinrest and place
forehead against forehead rest
Instruct patient to look for blue fixation spot
Tell them to blink normally until you ask them
to hold still
Tell them scans take 2 seconds or less, you will
tell them when to hold still and not blink, and
when scan is over (OK to blink)
Step 5. Align Scanner to Eye
When patient is ready, press scan button
Adjust scan head so pupil is in center of video
image
Make large adjustments with chinrest and
left/right movement of scan-head
Make small adjustments in height by twisting
joystick
Adjust left/right alignment with joystick

Scan button
Step 5. Align Scanner to Eye
Once pupil is well centered, move scan head
toward patient until Fundus image inside eye
becomes visible in video image
Make video image as clear as possible with
small joystick adjustments
Avoid light reflection circles/arcs
Avoid large dark areas
Video image shows poor alignment
Video image shows good alignment
Step 6. Position OCT Image

OCT Image should be between red guidelines


Double click between lines to automatically adjust OCT
image (Z-Motor)
Can also scroll with mouse to move image up and down
If image is upside down, scroll down until right-side up
Poor position (too high)
Poor position (too low)
Good positioning
Step 7. Adjust video or OCT
parameters to optimize images

Selecting eye color or


changing illumination can
improve video image
Step 7. Adjust video or OCT
parameters to optimize images
OCT image is adjusted by:

P Motor
Can increase signal
strength
Z Motor
Adjusts position of
OCT image on screen
Focus
Can improve video
image and OCT image
Poor Signal Strength
Good Signal Strength
Step 8. Take Images
After video image is clear
After OCT image is strong and well centered
Take image by pressing button on top of joystick
Remember to instruct patient to blink, and then hold
still (dont move dont blink), and then tell them
when scan is over
The scanning process is not finished when the
thumbnail image start posting (despite when you
pressed the button)
Step 9. Review for quality and save
SSI (signal strength index) should be above 30
Higher SSI is better, 50 and above is excellent
Poor quality scans may show up as eye blink error
Check for eye-movements in 3D scan
Press save button to save images

Eye blink or low


signal strength

Save button
Step 10. Choose view and print

Print selection
will print contents
of scan result
window
Certification Training

SW Update 3.0
Normative Database
Improved Segmentation algorithms
Reports and Printouts
3D Automatic Animation
Progression / Trend / Asymmetry report

Patient information required


Last / First / DOB* / Gender / Correction if known
Why should Ethnicity be included?
NDB is retroactive to first scans taken
Customer may have to go back and insert ethnicity to
earlier patients.
Certification Training

Fundus image first


Focus is done with joystick (not Focus Motor)
Good fundus image is not required to get a good scan
3mm pupil requirement is for IR fundus image only
Scan can get through ~1.5mm (less?)
Stay away from iris
Watch cues on alignment (you may be shooting
through iris and not know it)
Some patients require you to follow them with the
joystick
Get parameters first, then go get the scan
Certification Training

Alignment for type of optical conditions


Cataract (move around pupil)
IOL (go closer to get past reflections)
AMD (fixation & getting around vitreous bleeding)
Getting the best scan
Focus (refractive condition of patient) Manifest Rx?)
P-Motor (Polarity properties of media cornea)
Always test
Blink (tear fluid required for good image)
Move around Pupil (look for area of best sigscan)
Improving the scan

Optical issue (opacities & shadows)


Cataract
IOL (anterior/posterior)
Vitreous hemorrhaging
Detached retina/vitreous strand/dense floaters
Dirty objective lens ?
Blood vessel VS Floater
Fixation issues
External fixation to stabilize
Shooting on the fly (the space invaders gaze drift)
Chronic blinkers (lid speculum, thumb, line scan only)
Glaucoma

Glaucoma
Fixation light only visible at correct working distance
Oblique path through pupil low L-R tollerance
Watch for drift shooting through iris happens
alternating weak scan strong scan
Only need area around disc visible
Picking RPE endpoints Why?
3D for optic disc boundary Why?
Glaucoma RPE Endpoints
Review of Basics Disc Boundary
Glaucoma

Reprocess with Video Baseline


IR or 3D SLO boundary trace
Confusing - will be changed
No Baseline option
No RPE endpoints to find and mark
No disc boundary drawing
Very quick NFL thickness map (2.5 4mm band)
No registration capability
No Progression
Accuracy of 3.45 TSNIT
Glaucoma

Differences between the observed (stereo) C/D


ratio (by clinician) and the RTVue C/D value
Direct Observation - Visualize RPE endpoints?
Direct observation is low magnification

Stereo Fundus Photos?


Type of images (Color)
Where does the cup start? (slope?)
Glaucoma

RNFL 3.45 mm TSNIT Histogram


What is it?
Difference between RNFL 3.45 scan & NHM4
4 Fast scans around optic disk at 3.45mm diameter
VS
Calculated 3.45mm diameter from center of disc
Retina

Structure Thickness Volume


MM5 17H x 17V scans over 5mm x 5mm
Only 50% of scan required to map
Best scan for accuracy
Will be able to define boundary for volume calculation
Included in NDB
MM6 12 Radial scans over 6mm diameter
More interpolation than MM5 between scans
Higher in A-scan density (1024 VS 512)
Useful if not interested in NDB
Faster scan and denser per scan trouble patients
MM5 Mapping issues

Maps from low signal scans


White or black maps are gone
Only need 50% of scans in MM5 to map
Editing a tracing on a scan can be done in the
measurement view
Can correct the trace error caused by lifted
membrane or floater
Reprocessing the map (right click on map) to
accept the corrected tracing
Retina Examples
Normal

Rod cone dystrophy


Cystoid Macular Edema

Courtesy: Michael Turano, CRA


Columbia University.
Stage 3 Full Thickness Macular Hole
Operculum

Courtesy: Michael Turano, CRA


Columbia University.
Central Serous Chorioretinopathy

Images courtesy of Dr. Tano, Osaka University


Retinitis Pigmentosa

Images courtesy of Dr. Tano, Osaka University


Vitreomacular Traction Syndrome with CME

Courtesy: Michael Turano, CRA


Columbia University.
PED (Pigment Epithelial Detachment)
Vitreous ERM - MP
CME
Optic Pit
High Myop - VMT
New Cornea / Anterior Module (CAM)*
New Cornea / Anterior Module (CAM)
*CAM pending FDA 510K Clearance

CAM-S Lens: CAM-L Lens


Focal Length: 10mm Focal Length: 16mm
Working distance: 10mm Working distance: 13.2mm
Cornea FOV: 5.75mm x 4.3mm Cornea FOV: 12mm x 8mm
Scan length: 1-2 mm Scan length: 1- 6 mm
Pachymetry & Keratoconus Analysis

Cornea
Pachymetry

&

Keratoconus Analysis

Inferotemporal
thinning
Lasik Flap
LD044, OS

Angle TISA 500 / AOD


CP056, OD

Post-LASIK interface fluid


Tear Film

Single raw scan


FH049, OS

Reis-Bucklers Dystrophy

Single raw scan


BL048, OD

Corneal Scar

Single raw scan


LD044, OS

Narrow Angle, AOD500


LD044, OS

AOD500 after Peripheral Iridotomy


LD044, OS

3D scan after peripheral iridotomy

AOD 500
distribution
CAM Module
New Cornea - Anterior Module*

Normal Cornea
Cornea Transplant
CAM Module
CAM Module
CAM Module
CAM Module

ICL

IOL Implant
3D Imaging

Angle

Cornea
LASIK flap with prototype lens & system

Post LASIK

2mm Hi-Pwr
New Cornea / Anterior Module (CAM)*