International Conference on Ophthalmic Photography

Organized by
Australian Institute of Medical and Biological Illustration
Japanese Ophthalmic Photographers' Society
Ophthalmic Imaging Association
Ophthalmic Photographers' Society

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Saturday, 20 May 2006
Plenary Session 7
Autofluorescence Imaging
2.33 OPS Continuing Education Credits
10:10 Introduction By Moderator
Alison J Farrow
Aberdeen, Scotland, UK
10:15 Attenuated Autofluorescence Imaging - A New Screening Method For ARMD
Paula F. Morris
John Moran Eye Center, University of Utah
Salt Lake City, Utah, USA
Purpose: To review current techniques of measuring lipofuscin using autofluorescence imaging, and report on a new method of autofluorescence measurement which indirectly shows the distribution of macular pigments in patients with Age Related Macular Degeneration (ARMD).
Design: Literature review and experience at the John Moran Eye Center, University of Utah, USA.
Methods: Short reviews of autofluorescence imaging using scanning laser ophthalmoscopes and modified fundus cameras, followed by a report on a new imaging method which indirectly quantifies macular pigment distribution based on attenuated autofluorescence of lipofuscin.
Results: Autofluorescence imaging has become an important modality for documenting the presence of lipofuscin in the retinal pigment epithelium (RPE), as it indicates degenerative changes and injury due to tissue oxidation in patients with exudative ARMD. Currently, SLOs and modified fundus cameras are being used clinically to document the presence of lipofuscin. Detecting and imaging lipofuscin autofluorescence requires excitation and emission filters of different wavelengths, depending on the instrument used to make the measurements, since each of those instruments measure at different planes in the eye.
The John Moran Eye Center, and the Department of Physics, University of Utah, are collaborating on a new ARMD screening method based on autofluorescence imaging. Lipofuscin autofluorescence has reduced intensity where the carotenoid pigments lutein and zeaxanthin are present. These macular pigments are thought to contribute to the prevention or delay of the onset of ARMD, and their relative concentrations can indicate the amount of risk a patient faces of developing the disease.
An instrument has been produced to indirectly quantify macular pigments by measuring the reduction of lipofuscin autofluroescence, using different excitation and emission wavelengths than the techniques mentioned above.
Conclusions: Indirect quantification of macular pigments using attenuated lipofuscin autofluorescence is being developed as a valuable, non-invasive screening tool for Age Related Macular Degeneration.

10:30 Comparison Of Autofluorescence Images From Digital Fundus Camera And cSLO
Dennis A Orlock¹, J.Slakter², L.Yannuzzi², R. Curtin¹, C. Novalis¹, C. Eandi³
Digital Angiographic Reading Center¹
Vitreous-Retina-Macula Consultants²
New York, New York, USA
Topcon Research and Development³
Japan
Purpose: To describe the differences between fundus autofluorescence (FAF) using retinal images of eyes with a digital fundus camera and a confocal scanning laser ophthalmoscope.
Methods: Images were obtained using HRA2 (Heidelberg Engineering Heidelberg Germany,) and a Topcon 50 IX fundus camera equipped with autofluorescent filters (580nm excitation and 695 nm barrier filters), digital camera (Kodak Megaplus 1.4i) and ImageNet software (Topcon USA, Paramus, N.J.). Images were taken and a mean image was computed using the Heidelberg Version 1.4.1.0 software. Two autofluorescent fundus camera images were taken using a 50-degree field. All the images were evaluated by the authors for differences in hypofluorescent and hyperfluorescent areas and autofluorescence patterns.
Results: When the images between the two systems were compared, The HRA2 images showed higher contrast than the fundus camera images. The contrast in the fundus camera images was slightly enhanced to compensate for this difference.
Conclusions: Clinically useful autofluorescence imaging can be performed with either the confocal scanning laser ophthalmoscope or a modified digital fundus camera. Autofluorescence Imaging may play an important role in the evaluation of retinal pathology in both investigational as well as clinical practice settings.

10:45 An Unusual Pattern Of Increased Retinal Brightness During Fundus Autofluorescence Using A cSLO
Denise Cunningham
National Eye Institute
Bethesda, Maryland, USA
Purpose: Fundus autofluorescence (FAF) is an imaging technique that uses the fluorescent properties of lipofuscin to study retinal disease in vivo. Fifteen months after the first FAF was performed at the National Eye Institute (NEI) using a confocal scanning laser ophthalmoscope (cSLO), an unusual pattern of increased retinal brightness was observed and recorded in a patient with bilateral optic nerve drusen. The configuration of this bright area corresponded exactly with the shape of the internal mask seen when looking directly into the objective tube of the camera. Discovery of this bright area prompted a review of all previous FAF studies. A careful frame-by-frame examination of these images demonstrated the presence of this bright phenomenon on other pictures.
Materials and Methods: The cSLO Heidelberg Retina Angiograph 2 (HRA2) was is used to record FAF using a 488 nm solid state laser in combination with a 500nm barrier filter. Fundus Autofluorescence with the HRA2 is acquired using a standard protocol. The NEI parameters for image acquisition require a 30 degree angle of view with the detector set to a sensitivity of 90%, and the laser power at the default setting of 100%. Using the high speed resolution mode, a series of 15 frames are captured at a rate of 8.8 frames per second. Once acquired and saved, the mean of the images is computed using the software. After the averaging procedure is performed, a single image is produced from the 15 originally acquired frames.
Results: Unsatisfactory FAF results were obtained using the NEI standard protocol in the patient’s left eye because vitreous floaters obscured parts of the fundus. Instead of shooting another 2” movie using the 15 frame mean at 8.8 frames per second, a longer movie was obtained with the hope that the vitreous debris would float out of the way if given the chance, allowing the fovea to be visualized. Thirteen frames into the movie, the peculiar bright area was noticed and followed and recorded using swings and tilts of the camera head. After 30” of recording, the entire shape of the bright area was revealed and the movie was stopped.
Conclusions: The appearance of this pattern of brightness on the fundus during FAF is worrisome if the intensity of the autofluorescence is to be judged.

11:00 Use Of Fundus Autofluorescence Imaging For Non-Invasive Diagnoses Of Retinal Diseases
Ethan R. Priel
MOR Institute
Bnei-Brak, ISRAEL
Purpose: To describe the technique and results associated with fundus autofluorescence (FAF) imaging – a non-invasive photographic method of documenting pathological findings and processes in the retina. Hyper- or hypofluorescence patterns generated by different areas and conditions in the retinal pigment epithelium (RPE) were evaluated.
Materials and Methods: As the amount of fluorescent light (at approx. 500 nm) emitted by the RPE is extremely low, an SLO (HRA 2 ) was used with both exciter illumination and barrier filters in place. Patients were dilated prior to photography. Color photos, fluorescein angiography (FA) and an OCT exam were performed as well.
A built-in option of the software was used in order to evaluate multiple images averaged, and compared to the single images, as well as to the FA, OCT and color images. Pathologies imaged included AMD in all stages, BDR, CSR, CME and atrophic entities.
Results: Using the FAF technique, distinct patterns of RPE changes were noted, depending on the amount of light emitted by the lipofuscin accumulated in the RPE, adding important information to findings seen in the other imaging modalities. It was possible to obtain informative images from a variety of patients / diagnoses without the need for angiography.
Conclusions: FAF is a promising ophthalmic imaging modality, complementing others already in use. It is especially helpful in outlining changes to the RPE before they become evident clinically or even angiographically

11:15 Panel Discussion On Autofluorescence
Invited Lecture
11:30 Introduction
Paul R. Montague
University of Iowa
Iowa City, Iowa, USA
11:35 Auto-Fluorescence Imaging 2006
Lawrence Yannuzzi, MD
Vitreous-Retina-Macula Consultants
New York, New York, USA

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Saturday, 20 May 2006 Plenary Session 7 Autofluorescence Imaging 2.33 OPS Continuing Education Credits
10:10	Introduction By Moderator Alison J Farrow Aberdeen, Scotland, UK
10:15	Attenuated Autofluorescence Imaging - A New Screening Method For ARMD Paula F. Morris John Moran Eye Center, University of Utah Salt Lake City, Utah, USA Purpose: To review current techniques of measuring lipofuscin using autofluorescence imaging, and report on a new method of autofluorescence measurement which indirectly shows the distribution of macular pigments in patients with Age Related Macular Degeneration (ARMD). Design: Literature review and experience at the John Moran Eye Center, University of Utah, USA. Methods: Short reviews of autofluorescence imaging using scanning laser ophthalmoscopes and modified fundus cameras, followed by a report on a new imaging method which indirectly quantifies macular pigment distribution based on attenuated autofluorescence of lipofuscin. Results: Autofluorescence imaging has become an important modality for documenting the presence of lipofuscin in the retinal pigment epithelium (RPE), as it indicates degenerative changes and injury due to tissue oxidation in patients with exudative ARMD. Currently, SLOs and modified fundus cameras are being used clinically to document the presence of lipofuscin. Detecting and imaging lipofuscin autofluorescence requires excitation and emission filters of different wavelengths, depending on the instrument used to make the measurements, since each of those instruments measure at different planes in the eye. The John Moran Eye Center, and the Department of Physics, University of Utah, are collaborating on a new ARMD screening method based on autofluorescence imaging. Lipofuscin autofluorescence has reduced intensity where the carotenoid pigments lutein and zeaxanthin are present. These macular pigments are thought to contribute to the prevention or delay of the onset of ARMD, and their relative concentrations can indicate the amount of risk a patient faces of developing the disease. An instrument has been produced to indirectly quantify macular pigments by measuring the reduction of lipofuscin autofluroescence, using different excitation and emission wavelengths than the techniques mentioned above. Conclusions: Indirect quantification of macular pigments using attenuated lipofuscin autofluorescence is being developed as a valuable, non-invasive screening tool for Age Related Macular Degeneration.
10:30	Comparison Of Autofluorescence Images From Digital Fundus Camera And cSLO Dennis A Orlock¹, J.Slakter², L.Yannuzzi², R. Curtin¹, C. Novalis¹, C. Eandi³ Digital Angiographic Reading Center¹ Vitreous-Retina-Macula Consultants² New York, New York, USA Topcon Research and Development³ Japan Purpose: To describe the differences between fundus autofluorescence (FAF) using retinal images of eyes with a digital fundus camera and a confocal scanning laser ophthalmoscope. Methods: Images were obtained using HRA2 (Heidelberg Engineering Heidelberg Germany,) and a Topcon 50 IX fundus camera equipped with autofluorescent filters (580nm excitation and 695 nm barrier filters), digital camera (Kodak Megaplus 1.4i) and ImageNet software (Topcon USA, Paramus, N.J.). Images were taken and a mean image was computed using the Heidelberg Version 1.4.1.0 software. Two autofluorescent fundus camera images were taken using a 50-degree field. All the images were evaluated by the authors for differences in hypofluorescent and hyperfluorescent areas and autofluorescence patterns. Results: When the images between the two systems were compared, The HRA2 images showed higher contrast than the fundus camera images. The contrast in the fundus camera images was slightly enhanced to compensate for this difference. Conclusions: Clinically useful autofluorescence imaging can be performed with either the confocal scanning laser ophthalmoscope or a modified digital fundus camera. Autofluorescence Imaging may play an important role in the evaluation of retinal pathology in both investigational as well as clinical practice settings.
10:45	An Unusual Pattern Of Increased Retinal Brightness During Fundus Autofluorescence Using A cSLO Denise Cunningham National Eye Institute Bethesda, Maryland, USA Purpose: Fundus autofluorescence (FAF) is an imaging technique that uses the fluorescent properties of lipofuscin to study retinal disease in vivo. Fifteen months after the first FAF was performed at the National Eye Institute (NEI) using a confocal scanning laser ophthalmoscope (cSLO), an unusual pattern of increased retinal brightness was observed and recorded in a patient with bilateral optic nerve drusen. The configuration of this bright area corresponded exactly with the shape of the internal mask seen when looking directly into the objective tube of the camera. Discovery of this bright area prompted a review of all previous FAF studies. A careful frame-by-frame examination of these images demonstrated the presence of this bright phenomenon on other pictures. Materials and Methods: The cSLO Heidelberg Retina Angiograph 2 (HRA2) was is used to record FAF using a 488 nm solid state laser in combination with a 500nm barrier filter. Fundus Autofluorescence with the HRA2 is acquired using a standard protocol. The NEI parameters for image acquisition require a 30 degree angle of view with the detector set to a sensitivity of 90%, and the laser power at the default setting of 100%. Using the high speed resolution mode, a series of 15 frames are captured at a rate of 8.8 frames per second. Once acquired and saved, the mean of the images is computed using the software. After the averaging procedure is performed, a single image is produced from the 15 originally acquired frames. Results: Unsatisfactory FAF results were obtained using the NEI standard protocol in the patient’s left eye because vitreous floaters obscured parts of the fundus. Instead of shooting another 2” movie using the 15 frame mean at 8.8 frames per second, a longer movie was obtained with the hope that the vitreous debris would float out of the way if given the chance, allowing the fovea to be visualized. Thirteen frames into the movie, the peculiar bright area was noticed and followed and recorded using swings and tilts of the camera head. After 30” of recording, the entire shape of the bright area was revealed and the movie was stopped. Conclusions: The appearance of this pattern of brightness on the fundus during FAF is worrisome if the intensity of the autofluorescence is to be judged.
11:00	Use Of Fundus Autofluorescence Imaging For Non-Invasive Diagnoses Of Retinal Diseases Ethan R. Priel MOR Institute Bnei-Brak, ISRAEL Purpose: To describe the technique and results associated with fundus autofluorescence (FAF) imaging – a non-invasive photographic method of documenting pathological findings and processes in the retina. Hyper- or hypofluorescence patterns generated by different areas and conditions in the retinal pigment epithelium (RPE) were evaluated. Materials and Methods: As the amount of fluorescent light (at approx. 500 nm) emitted by the RPE is extremely low, an SLO (HRA 2 ) was used with both exciter illumination and barrier filters in place. Patients were dilated prior to photography. Color photos, fluorescein angiography (FA) and an OCT exam were performed as well. A built-in option of the software was used in order to evaluate multiple images averaged, and compared to the single images, as well as to the FA, OCT and color images. Pathologies imaged included AMD in all stages, BDR, CSR, CME and atrophic entities. Results: Using the FAF technique, distinct patterns of RPE changes were noted, depending on the amount of light emitted by the lipofuscin accumulated in the RPE, adding important information to findings seen in the other imaging modalities. It was possible to obtain informative images from a variety of patients / diagnoses without the need for angiography. Conclusions: FAF is a promising ophthalmic imaging modality, complementing others already in use. It is especially helpful in outlining changes to the RPE before they become evident clinically or even angiographically
11:15	Panel Discussion On Autofluorescence
Invited Lecture
11:30	Introduction Paul R. Montague University of Iowa Iowa City, Iowa, USA
11:35	Auto-Fluorescence Imaging 2006 Lawrence Yannuzzi, MD Vitreous-Retina-Macula Consultants New York, New York, USA