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Original Investigation | Clinical Sciences

Artifacts in Spectral-Domain Optical Coherence Tomography Measurements in Glaucoma

Sanjay Asrani, MD1; Luma Essaid2; Brian D. Alder, MD1; Cecilia Santiago-Turla, MD1
[+] Author Affiliations
1Glaucoma Service, Duke Eye Center, Durham, North Carolina
2student at UNC Gillings School of Global Public Health, The University of North Carolina at Chapel Hill
JAMA Ophthalmol. 2014;132(4):396-402. doi:10.1001/jamaophthalmol.2013.7974.
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Published online

Importance  Spectral-domain optical coherence tomography (SD-OCT) has an integral role in the diagnosis and treatment of glaucoma. Understanding the types of artifacts commonly seen in the imaging of patients being evaluated for glaucoma will help physicians better implement these data in the care of patients.

Objectives  To determine the frequency and distribution of SD-OCT imaging artifacts in patients being evaluated for glaucoma and to provide examples of common artifacts.

Design, Setting, and Participants  A retrospective cross-sectional study design was used to examine SD-OCT images (using Spectralis SD-OCT) of 277 consecutive patients who had a diagnosis of glaucoma of any stage or had suspected glaucoma. Retinal nerve fiber layer (RNFL) and macular thickness scans were included. For each scan, the final printout and the source images that generated the final printout were examined. If present, artifacts were classified as evident on the final printout or not and were categorized as to the primary source of the artifact (eg, ocular pathologic features or technician errors). Examples of common artifacts are provided.

Main Outcomes and Measures  The presence of imaging artifacts.

Results  In 277 consecutive patients, 131 macular thickness scans were obtained, and 277 RNFL scans were obtained. Of the macular thickness scans, 37 (28.2%; 95% CI, 20.8%-36.1%) had imaging artifacts. Six of these artifacts were not obvious on the final printout. Of the RNFL scans, 55 (19.9%; 95% CI, 15.2%-24.6%) contained artifacts. Seven of these artifacts were not evident on the final printout. The most common cause of artifacts for macular thickness and RNFL scans was ocular pathologic features, primarily the presence of an epiretinal membrane.

Conclusions and Relevance  It is likely that SD-OCT–related imaging artifacts occur in 15.2% to 36.1% of scans obtained in patients being evaluated for glaucoma. Some of these artifacts may not be evident on the final printout. Physicians should be alert to the possibility of artifacts, particularly in patients with ocular pathologic features such as an epiretinal membrane.

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Figure 1.
The Epiretinal Membrane in the Superotemporal Quadrant Prevents Collapse of a Degenerated and Thinned Retinal Nerve Fiber Layer (RNFL) (Arrowhead)

The spectral-domain optical coherence tomography software algorithm has misidentified the boundary of the epiretinal membrane as the upper edge of the RNFL, leading to an erroneously elevated measure of the RNFL in that region. G indicates global mean thickness; ILM, internal limiting membrane; INF, inferior; NAS, nasal; NI, inferonasal; NS, superonasal; SUP, superior; T, temporal; TI, inferotemporal; TMP, temporal; and TS, superotemporal.

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Figure 2.
A Common Ocular Cause of Artifact Is the Natural Evolution of a Posterior Vitreous Detachment, Which Results in Traction on the Inner Limiting Membrane

The upper scan demonstrates a retinal nerve fiber layer (RNFL) in the nasal region (black arrowhead) that is thicker than normal. The lower scan 18 months later demonstrates thinning of the RNFL (pink area in the bottom right measurement graph). A closer examination of the scans reveals released vitreous adherence from the retina. The edge of the vitreous is now clearly identifiable following release of vitreous–internal limiting membrane adhesions (red arrowhead). G indicates global mean thickness; ILM, internal limiting membrane; INF, inferior; NAS, nasal; NI, inferonasal; NS, superonasal; SUP, superior; T, temporal; TI, inferotemporal; TMP, temporal; and TS, superotemporal.

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Figure 3.
Operator-Dependent Artifacts Included Truncation of the Acquired Spectral-Domain Optical Coherence Tomography (SD-OCT) Image (ie, All Edges of the Image Were Not Within the Acquisition Window)

A, The retinal nerve fiber layer (RNFL) was outside of the acquisition window in a portion of this scan. B, The corresponding final printout, showing a severely thin RNFL in the temporal and superotemporal quadrants. In the final printout, the SD-OCT scan is centered, making the truncated portion less obvious. C, The same patient’s RNFL scan repeated, with the entire RNFL in the acquisition window. D, The final printout, showing a normal RNFL in all quadrants. G indicates global mean thickness; ILM, internal limiting membrane; INF, inferior; NAS, nasal; NI, inferonasal; NS, superonasal; SUP, superior; T, temporal; TI, inferotemporal; TMP, temporal; and TS, superotemporal.

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Figure 4.
An Example of a Retinal Nerve Fiber Layer (RNFL) Scan of a Patient With High Myopia

Several areas of schisis exist within the RNFL (arrowhead), making interpretation of thickness results difficult.

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