17

CHAPTER 2

THE HEIDELBERG RETINA TOMOGRAPH

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).

Fig. 2.1 Fig. 2.2

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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2.2 Equipment description.

The HRT is essentially composed of a light source that generates the laser beam, an
optic system, a scanning system and a detector. Other parts include a power source, a
control panel, a computer with the pertinent peripherals, and a monitor that is used to
view the examined object as well as for analysis of information and display of results.
The light source of this machine is a laser diode with a wavelength of 670 nanome-
ters. It emits a beam of 0.5 mW/cm2 intensity for 10 degree images, which is 100 times
lower than that used by a regular retinograph when a flash photograph of the fundus is
taken.
The laser camera is supported by a mounting system similar to that of a slit lamp,
with a chinrest and a forehead strap for the patient. The whole optics system, the laser
source, the diaphragms, and two electrically controlled mirrors responsible for the scan-
ning effect, are contained in this camera.
The computer contains the software used for analyzing the information obtained. It
has a hard disk of 1000 or more megabytes to store the data and allow quick access to it.
It also has a large optical drive for archiving patient images for future access. A super
multifrequency VGA monitor produces high resolution images. Finally, a printer is used
to print out results, which in our opinion, have a better quality if printed in black and
white with a 600 dpi resolution.
The control panel has 6 switches and three buttons. The switches adjust the inten-
sity of the emitted laser, the detector’s sensitivity, the size of the field to be examined in
degrees (10,15 or 20 degrees), the depth of the retinal examination in millimeters (0.5 to
4.0 mm) and the refraction in diopters or quarter diopters. The two most frequently used
buttons are: the one that activates laser emission and the one that records the image which
is on the screen. The third button is used only to reset the equipment under certain cir-
cumstances (figure 2.3).

Fig. 2.3
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2.3 Imaging technique

Once the laser is emitted, it is reflected on the patient’s retina at the level of the ves-
sel coming into the optic nerve. It then returns to the camera, where it goes through a pin-
hole diaphragm that eliminates the light reflected at the planes located anteriorly and
posteriorly to the one under examination. The detector then captures the beam. This is
one of the most important components of this system since it is the one that gathers all
the information. The detector measures the existing reflectivity differences between
the light projected to the retina and the light reflected by it towards the detector.
Now that we have reviewed the beam’s route through the system, we shall discuss
the right way of performing tomographies for the acquisition of high resolution images.
To start the examination, the patient’s head is rested on the chinrest and the eye not
to be examined is staring at a fixed point. The laser activation button, located on the right
of the central row of the panel, must then be pressed.
To focus well on the area to be examined, the laser light must enter the center of the
pupil. To achieve this, the stand on which the camera is mounted can be moved either
vertically or horizontally. Once the laser beam is centered on the pupil, the system must
be set in this position, and only then should the vertical and horizontal circular move-
ments begin so as to find the area to be studied on the retina. The equipment should now
be set again in this area.
The detector’s sensitivity should be set to almost maximum, and the diopter control
should be adjusted until the monitor turns bright white, and there is no image. (This oc-
curs because the retina is being focused on and the image is saturated.) Then, the detec-
tor’s sensitivity should be decreased and the first images of the retina will appear on
screen.
Should any of the edges or angles of the screen become dark, the laser camera must
be moved vertically and horizontally to center the beam on the pupil again.
Then, sensitivity should be decreased as much as possible without losing the lumi-
nosity of the image on the screen, but making sure that there are no white areas with
black spots, which are signs of saturation. The quarter diopter switch should then be
moved for greater resolution, achieved by reaching the retina plane of the optic disc sur-
face perpendicularly.
It should be kept in mind that with this control, the focus must be placed at the level
of the vessels’ reflection when they emerge from the optic disc. This is very important
since the focusing plane is the eleventh out of a 32 plane series, which means that there
are 10 anterior planes and 21 posterior planes to this plane position.
The patient should now be asked to keep fixation at the luminous point and not to
blink. The image record button, on the bottom right of the control panel, should now be
pressed. In approximately 1.6 seconds the 32 planes are scanned and an original series
image is obtained. [3].
The 32 images will now appear on screen. From left to right and from top to bottom
they are the 32 planes scanned in an anterior to posterior direction. The first thing to ver-
ify is that the patient did not lose fixation during the examination. This can be done with
the movie option: the 32 images are displayed one after the other like in a movie. If the
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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.

2.4 Understanding the 32 planes

As previously mentioned, when a series is taken, the retina is scanned within a cho-
sen study depth. This is done in 32 planes that are displayed anteroposteriorly. The sec-
tions start at the vitreous, before the retina and end behind it (figure 2.6). The 32 planes
are always equidistant, but the distance between each one depends exclusively on the
chosen study depth. For instance, if the study depth is 0.5 mm, the planes are very close
to each other, resulting in a high definition retina study. On the other hand, if the study
depth is 4.0 mm, the planes are farther apart and definition is decreased (figure 2.7).
When the image is taken, 32 confocal, two-dimensional and sequence images are
produced. Each image corresponds to an individual focal plane scan. This single plane is,
in turn, scanned in 256 horizontal lines and in 256 vertical lines. A movable mirror that

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].

2.5 Information Processing

Once a series is obtained, and "Save Series" has been pressed, it is saved on the
computer hard disk with the S option (S stands for Original Series). When we have saved
the three series, we will have 3 S (series) on the hard disk, which means we have three
non-aligned series of the same eye.
The next step is to align each series to obtain the topographic information, which
will later produce the final images for optic disc analysis [3]. This is done with the Batch
Topography option. As a result we obtain three pieces of information for each series:

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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images, can be displayed on the screen (figure 2.9).

Whenever the mean is obtained (M), only this data can be stored on the hard disk,
and the S, A and T data of each tomography can then be deleted. In this case the original
32 images cannot be displayed, unless they are retrieved from the optical disk. Even
though only the mean (M) is stored, it is advisable to save a copy on the optical disk.
Information processing is shown in figures 2.8 and 2.9.
A back-up of the Database file (which contains necessary information on each pa-
tient as well as each image) should be made every 50 to 100 examinations. It too can be
backed up to an optical disk.
If the hard disk is erased and there is no back-up of the database file, it will be im-
possible to recover any information, even if the patients’ files were saved on the optical
discs [3].
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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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