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A technique for examining the fundus of the eye was devised by Jan Evangelista Purkinje a generation before Helmholtz invented the ophthalmoscope. Yet, Purkinje's technique of ophthalmoscopy went virtually unnoticed by his contemporaries. This neglect of Purkinje's discovery has never been fully explained and warrants re-examination.
Using intravitreal gas injection of sulfur hexafluoride after retinopexy utilizing a binocular indirect ophthalmoscope argon laser delivery system, the authors treated 12 primary rhegmatogenous retinal detachments and 10 detachments which recurred after previous scleral buckle surgery. Topical anesthesia only was used in most of the cases (18 of 22). Detachments in all quadrants of the fundus were repaired. Twenty cases remained successfully attached after a minimum follow-up of 6 months. Two failures occurred early in eyes with primary retinal detachments and both were successfully repaired by conventional scleral buckling techniques. The authors found pneumatic retinal reattachment in conjunction with laser retinopexy to be particularly valuable in repairing secondary detachments, thereby avoiding conventional surgical reoperations.
The authors performed fluorescein fundus angiography in 130 eyes using a scanning laser ophthalmoscope (SLO). Capillaries were observed in the perifoveal area in 63 eyes. In these 63 eyes, numerous fluorescent dots were seen flowing through the capillaries. This feature allowed identification of the direction and velocity of blood flow in the retinal capillaries. The distance from 1 dot to the next was widely variable and averaged 100 microM. The velocity of flow was faster in precapillary arterioles, slower in capillaries, and again faster in postcapillary venules. The dots were much more numerous in an eye with leukemia and less numerous in an eye with idiopathic thrombocytopenic purpura. Staining of whole blood from three healthy persons with fluorescein sodium resulted in prompt and intense staining of leukocytes and platelets. These findings indicate that the observed fluorescent dots in perifoveal capillaries correspond to leukocytes and platelets in the circulating blood.
PURPOSE: This study aimed to define the confocal laser scanning ophthalmoscope (Heidelberg Retina Tomograph [HRT]) parameters that best separate patients with early glaucoma from normal subjects. STUDY DESIGN: A cross-sectional study. PARTICIPANTS: A total of 80 normal subjects and 51 patients with early glaucoma participated (average visual field mean deviation = -3.6 dB). INTERVENTION: Imaging of the optic nerve head with the HRT and analysis using software version 1.11 were performed. MAIN OUTCOME MEASURES: The relation between neuroretinal rim area and optic disc area, and cup-disc area ratio and optic disc area, was defined by linear regression of data derived from the normal subjects. The normal ranges for these two parameters were defined by the 99% prediction intervals of the linear regression between the parameter and optic disc area, for the whole disc, and for each of the predefined segments. Normal subjects and patients were labeled as abnormal if the parameter for either the whole disc or any of the predefined segments was outside the normal range. The sensitivity and specificity values of the method were calculated. RESULTS: The highest specificity (96.3%) and sensitivity (84.3%) values to separate normal subjects and those patients with early glaucoma were obtained using the 99% prediction interval from the linear regression between the optic disc area and the log of the neuroretinal rim area. Similar specificity (97.5%) and lower sensitivity (74.5%) values were obtained with the 99% prediction interval derived from regression between the disc area and cup-disc area ratios. Poor separation between groups was obtained with the other parameters. CONCLUSIONS: The HRT, using the technique of linear regression to account for the relationship between optic disc size and rim area or cup-disc area ratio, provides good separation between control subjects and patients with early glaucoma in this population.
OBJECTIVE: To evaluate the efficacy of oral fluorescein angiography with a confocal scanning laser ophthalmoscope (SLO) system. DESIGN: Comparative case series. PARTICIPANTS: The authors used a confocal SLO (Heidelberg Retina Angiograph [HRA]) to perform oral fluorescein angiography in 47 patients, 13 of whom were without any retinal disease and 34 with a variety of retinal diseases including macular holes and pucker, inflammatory diseases, retinal vascular diseases, and age-related macular degeneration. The images were also compared to images taken with a fundus camera after intravenous fluorescein injections in patients on whom both studies were done. INTERVENTION: Color fundus photographs were taken of each eye (30 degrees fundus camera) before drinking 4 ml of 25% sodium fluorescein mixed with 60 ml of orange juice. After oral fluorescein ingestion, images of each eye were taken with a fundus camera (TriX film) and the HRA (using 512- x 512-pixel resolution). The images were repeated at 0-, 2.5-, 5-, 7.5-, 10-, 12.5-, 15-, 20-, 25-, and 30-minute intervals. Twenty of the 47 patients underwent intravenous fluorescein angiography performed with the fundus camera. MAIN OUTCOME MEASURE: Images were analyzed by a masked reader, and foveal avascular zone visualization, branch retinal vessel identification, and image quality were scored. Statistical analysis was performed with a t test for paired data with a two-tailed test of significance (alpha = 0.05). RESULTS: Foveal avascular zone was 100% as seen in 16 eyes (47%) in the HRA machine versus 1 eye (2%) in the conventional fundus camera (P < 0.0001). The third-order branch retinal vessels were identified in 59% of eyes in the HRA versus 26% in the fundus camera group (P < 0.0001), and the image quality was considered comparable to an intravenous angiogram in 47% with the HRA versus 9% with the conventional fundus camera (P < 0.0001). CONCLUSIONS: Oral fluorescein angiography using the HRA produces sufficiently detailed images to diagnose, treat, and follow many types of retinal pathology.
PURPOSE: To generate wide-field automated seamless retinal montage images. DESIGN: Prospective, observational, case series study. PARTICIPANTS: Eighteen eyes of 14 patients were studied. INTERVENTION: A digital scanning laser ophthalmoscope (SLO), the Heidelberg Retina Angiograph (HRA), was used to obtain overlapping images of the fundus during fluorescein angiograms, indocyanine green angiograms, or monochromatic retinal imaging using infrared or green light. Software was used to generate seamless montages. MAIN OUTCOME MEASURES: Ability to electronically synthesize retinal montages. Four laser wavelengths were used. The wide-field degrees, vertical and horizontal number of pixels, and diameter of the individual images were measured. RESULTS: High-resolution (pixel size, 10 microm), wide-field, typically 100 degrees to 140 degrees, digital montages of the postequatorial retina can be generated from HRA images. CONCLUSIONS: The software automatically and rapidly aligned the retinal blood vessels and synthesized a montage of the entire fundus that could then be overlaid on images taken at different times to illustrate change. These montages will allow improved ability to understand and follow retinal diseases.
The assessment of visual acuity is an important part of the emergency ophthalmologic examination. The ability to distinguish refractive error from other etiologies of decreased visual acuity is necessary to adequately evaluate visual function. A readily available source of corrective lenses can be found in the hand-held ophthalmoscope. These lenses can be used to identify and quantitate refractive errors and assist in identifying serious ocular pathology.
PURPOSE: To compare the relative abilities of the Potential Acuity Meter (PAM) and the Scanning Laser Ophthalmoscope (SLO) to predict the postoperative visual acuity in patients with mild to dense cataract. SETTING: Gimbel Eye Centre, Calgary, Alberta, Canada. METHODS: In this single-masked prospective study of 31 consecutive eyes with mild to dense cataract and a best corrected visual acuity (BCVA) of 20/40 or less, patients had predictive visual acuity (PVA) testing using the PAM and SLO. Preoperative and postoperative BCVA was recorded using Snellen charts. Differences between PVA and postoperative BCVA results were assessed by a two-tailed t-test and correlation analysis. RESULTS: The SLO was correct within two lines of outcome in 30 of 31 eyes and the PAM, in 19 of 31 eyes. A two-tailed dependent t-test showed a significant difference between predicted and final visual acuity for the PAM (P = .0001) and a nonsignificant difference for the predicted and final visual acuity for the SLO. A correlation analysis showed a mild correlation for the PAM (r = .49) and a good correlation for the SLO (r = .81). For a prediction of better or worse than 20/40, the SLO showed a sensitivity of 0.964 and specificity of 1.0 and the PAM, of 0.67 and 1.0, respectively. CONCLUSION: The SLO was more accurate than the PAM in predicting visual acuity after cataract surgery. The relative cost of the SLO is potentially restrictive to its widespread clinical application. However, the cost/benefit in terms of patient satisfaction with predictable surgical results should be considered.
Drusen are common features in the ageing macula and are associated with exudative age-related macular degeneration (ARMD). They appear as characteristic structures in indirect mode infrared scanning laser ophthalmoscope (SLO) images. Manual counting of drusen area in SLO images has shown no significant difference from that in standard fundus photographs in 6 eyes of 5 patients (p > 0.5). Computerised image processing techniques have been applied to digitised colour fundus photographs and indirect mode images to quantify the area of the macula affected by drusen in an automated fashion. Application of these methods may permit objective and repeatable assessment of the natural history of macular drusen. For a specificity of 90%, a sensitivity of 60% for colour fundus photographs and 35% for SLO images has been achieved, when compared with manual counting. The colour fundus photograph method also showed superior reproducibility compared with the SLO technique.
AIMS: A scanning laser ophthalmoscope (SLO) has been used for multifocal electroretinography (mf ERG) measurements under simultaneous fundus monitoring. The aim of this study was to prove if the SLO-mfERG measurement reflects reliably the clinically registered underlying disease, and to demonstrate the importance of its main advantage, fixation monitoring. METHODS: In all, 10 patients with macular hole stage II/III were included in the study, and 19 normal individuals served as the control group. The mf ERG device was combined with an SLO, which was used both as a stimulus and trigger unit as well as a fundus-monitoring system. Monitoring of the fundus was guaranteed by an infrared laser (780 nm). The stimulus matrix consisted of 61 hexagonal elements, covering 24 degrees of the posterior pole. We examined both, patients with macular holes and healthy individuals. RESULTS: Compared to normal controls, patients with a macular hole (Gass stage III) showed a significant decrease in response density in the centre of the stimulus array, which correlated well with the morphological alteration observed by clinical examination. However, variation of response density of the central hexagonal area has been proved to be high. CONCLUSIONS: SLO-mfERG is a feasible and reliable new technique to investigate macular function under simultaneous fundus control. The main advantage is that control of fixation can be used in order to obtain more reliable results that correlate well with visible fundus abnormalities such as in patients with macular holes. However, further investigations have to be performed in order to overcome sufficiently the problem of fixation instability.
A flexible control system for scanning laser ophthalmoscopes is described that is quick and simple to configure, easily modified or adapted, and containing many useful features. The system facilitates adjustment of several parameters to account for changes to the scan position, ambient light and temperature, including both optical and electronic components, which is otherwise difficult and time-consuming to perform. The system is portable and uses custom-designed printed circuit boards. All system parameters, such as focus, scan rate,scan depth and stereo control can be digitally controlled from a computer via a single serial port. Custom software allows changes to any system parameters by simply sending the required control data to the rack. The circuit boards in the system are multilayer,incorporating good ground-plane techniques to minimize noise, programmable logic and semicustom logic for low cost and compact size, and microcontrollers with embedded firm ware for flexible operation. Retinal images demonstrate that the system performs well.
Visuscopy and other ophthalmoscopic methods are widely applied in the assessment of fixation behaviour in amblyopia, although the reliability and inter-examiner variability of this test has not been established. Typically eccentric fixation is diagnosed solely on the basis of retinal position, but this fails to address the accompanying sensorimotor adaptations. A double-blind (masked) trial of a paediatric population was undertaken (n = 30, age range 3 years 9 months to 11 years, mean 5.6 +/- 1.5 years), involving three examiners applying a detailed protocol. The criteria for eccentric fixation were established from the non-amblyopic eyes. The most reliable criterion for the diagnosis of fixation was established from the results of the study. No single parameter proved 100% reliable, and amplitude showed greatest inconsistencies. It is recommended that a consensus of at least three parameters from position, zero retinomotor point, principal visual direction and percent foveation is required to diagnose the fixation status reliably.
In a cross-sectional study of 50 consecutive primary open-angle glaucoma cases, full threshold 30-2 visual fields on Humphrey Visual Field Analyser were correlated to stereometric parameters obtained using a scanning laser ophthalmoscope (HRT II). The strength of linear correlation between the stereometric parameters and visual thresholds was used to generate a correspondence map between the optic disc and the visual field. Rim/disc area ratio and cup/disc area ratio correlated with the visual thresholds at the highest number of points in the visual fields. Thresholds at superior hemifield locations correlated best with the rim/disc area ratio and cup/disc area ratio in the inferonasal sector and the ones in the inferior hemifield correlated best with the rim/disc area ratio and cup/disc area ratio in the superotemporal sector. Optic disc parameters correlated better with inferior field locations and non-edge points than superior field locations and edge points. The data indicate that rim/disc area ratio and cup/disc area ratio measurements on HRT II have a good correlation with visual field damage seen on automated visual fields.
BACKGROUND: Scanning laser microperimetry allows focal sensitivity testing of any localization of the retina under direct visual control. Physiological or involuntary fixation shifts can be corrected by manual fundus-tracking. METHODS: For static fundus-controlled microperimetry we used a confocal scanning laser ophthalmoscope equipped with a helium-neon laser as light source for background illumination and for generating the stimuli by acousto-optic modulation. Fundus imaging was achieved by an infrared diode laser scanning synchronous with the helium-neon laser. In comparison computerized static projection perimetry was performed using the Humphrey Field Analyser, program 10-2. RESULTS: On the basis of four exemplary cases (macular hole, juxtafoveal pigment epithelium atrophy, subretinal neovascularization secondary to age-related macular degeneration) it is shown that extension and depth of scotomas can be recorded more precisely with scanning laser microperimetry than with conventional projection perimetry. Microscotomas can be detected. By using infrared laser for fundus imaging choroidal structures such as subretinal neovascular membranes can be visualized, even when moderate intra- or subretinal hemorrhages secondary to age-related macular degeneration are present. Thus focal sensitivity testing of the retina overlying neovascular membranes is possible. Simultaneous registration of fixation allows precise localization of the fixation point and its relationship to neovascular membranes. CONCLUSION: The advantage of fundus-controlled microperimetry is a precise examination of the impact of morphological changes on psychophysical functions of the macula. Due to its simultaneous registration of fixation fundus-oriented microperimetry is a very informative aid in the indication of laser therapy and the selection of different laser procedures in the treatment of subretinal neovascularizations.
With a scanning laser ophthalmoscope (SLO) variable patterned stimuli can be projected onto the retina. During alternation of these patterns visual evoked cortical potentials and pattern ERGs can be recorded. The configurations of the SLO-elicited potentials and peak latencies correspond to those evoked during conventional stimulation. During pattern stimulation the fundus and alternating pattern stimuli are observed simultaneously on a video monitor. Thus the examiner always knows the exact location of the stimulus on the retina. Scanning laser ophthalmoscopy could be a clinically interesting method of recording evoked potentials, because it enables the patient's retina to be viewed continuously at low light levels and makes electrophysiological examination of a defined region of the retina possible.
A portable instrument for examination of the anterior segment and of the fundus is described. With the slitlamp-microscope examinations of the cornea, anterior chamber, iris and lens can be performed which are comparable to those carried out with the office slitlamp. The instrument also serves as a monocular or binocular indirect ophthalmoscope for fundus examinations.
The scanning laser ophthalmoscope (SLO) offers the potential for retinal imaging that is complementary both to that of the fundus camera and also the newly developing technique of optical coherence tomography (OCT). It has the ability to produce rapid images at low light levels using light of specific wavelengths. This permits temporal studies of fluorescent-labelled cells which offer a unique insight into inflammatory processes in the eye. The facility to image with several different wavelengths simultaneously offers the potential for spectral imaging of retinal tissue with the aim of revealing those early changes in tissue perfusion that indicate the onset of retinal disease, so increasing the probability of successful therapy.
While many systemic diseases have ophthalmic manifestations with visible pathological features affecting the fundus, diabetic eye disease is of particular interest. There are many advantages in using digital image analysis to quantify the extent of retinal pathology in diabetes particularly to monitor its progression. However, the usual method of imaging involves photographing the retina using a fundus camera. Not only does this require that the photographs be digitized prior to analysis, but the resulting illumination across the image is non-uniform and this creates problems in digital image analysis. This paper describes the construction of a scanning laser ophthalmoscope interfaced to a computer, which has a number of significant advantages for digital retinal imaging. Firstly, it has better uniformity of illumination than the fundus camera and operates at much lower light levels. Secondly, it permits imaging at various wavelengths with no consequent degradation in image quality; in particular, the value of imaging at infrared wavelengths to give greater tissue penetration is demonstrated. Finally, by introducing the capability for confocal imaging, tomographic images can be taken, improving the perceptibility of features situated deep in the retina. Typical images are shown to demonstrate the potential of this instrument.