Application on Digital
Infrared Thermal Imaging
Presented by: Rubie F. Viñas, 方如玉
Adviser: Dr. Shih-Chung Chen, 陳世中
LOGO
Date: October 16, 2008
Determining Inflammatory State and
Follow-up Effect
of Methylprednisolone Pulse Therapy
in Patients
with Graves’ Ophthalmopathy
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Abstract
What is the aim of this study?
 Elucidate the feasibility of DITI
• Biomedical Field
 Subjects
• Patients with GO
 Objectives
• Determine
– Inflammatory state
– Follow-up effect of treatment
» Methylprednisolone Pulse Therapy
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Author
 T.-C. Chang, Y.-L. Hsiao
 Department of Internal Medicine, National Taiwan
University
 Hospital and College of Medicine, National Taiwan
University
 Address: 7 Chung-Shan South Road, Taipei, Taiwan
 E-mail: tienchunchang@ntu.edu.tw
 S.-L. Liao
 Department of Ophthalmology, National Taiwan
University
 Hospital and College of Medicine, National Taiwan
University
 Address: 7 Chung-Shan South Road, Taipei, Taiwan
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Outline
I.
II.
Introduction
Patients and Methods
A. Patients
B. Methods
III. Statistical Analysis
IV. Results
V. Discussion
A. Conclusion
B. Recommendation
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I.
Introduction
 DITI - Digital Infrared Thermal Imaging
 Diagnostic technique
• Non-invasive
• No exposure to radiation
 Applications
 Evaluation of dry eye in the Ophthalmological field
X Evaluation of the Clinical Activity of GO
– Monitor the temperature distribution of the human skin
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DITI CAMERA
THERMOGRAMS
Capture images called thermograms
Thermographic Images
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I.
Introduction (cont.)
 Inflammation
 Latin:
Inflamatio
 English:
To set on fire
 Is the complex biological response of vascular tissues
to harmful stimuli, such as pathogens, damaged cells,
or irritants.
 It is a protective attempt by the organism to remove
the injurious stimuli as well as initiate the healing
process for the tissue.
 Cause
• Local increase in temperature
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I.
Introduction (cont.)
 GO - Graves’ Ophthalmopathy
• Other Names
– Graves' Thyroid-associated
– Dysthyroid Orbitopathy
– Exophthalmos
• Autoimmune inflammatory disorder
– Cause
» Inflammation of the eyes
– Affects
» Orbit of the eye, with or without thyroid disorder
• Patients Treatment
– Use Immunosuppressive Agents
» Graves’ Ophthalmopathy is in an inflammatory or so-called
active state.
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I.
Introduction (cont.)
 To assess the activity of GO
1. CAS - Clinical Activity Score
•
Origin
– Introduced
» Mourits
– Revised
» International Ad Hoc Committee (1992) Classification of eye
changes of Graves’ disease. Thyroid 2:235–236
•
Measure
– One Point
» Mild/Severe Conjunctival Injections
– Problem
1. Not sensitive enough  Detect the effect of treatment clearly
2. Very subjective in nature  In the assessment of pain with eye
movement
– Solution
» Objective assessment of disease activity
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II.
A.
Patients and Methods
Patients
Group I:
1.
14 patients with GO
•
Gender
–
–
•
Mean Age = 39.0±11.4 (standard deviation)
–
•
Age Range  19–55
Mean CAS = 2.5±1.0 (
–
2.
3 men
11 women
Range  0–4
16 normal controls
•
Gender
–
–
•
Mean Age = 34.4± 11.6
–

7 men
9 women
Age Range  25–65
Methods
•
GO
–
–
•
Orbital computed tomography
History of hyperthyroidism
CAS
–
Calculated from seven items with one point given for each item present:
1.
Pain with Eye Movement
2.
Spontaneous Retrobulbar Pain
3.
Eyelid Erythema
4.
Eyelid Edema or Swelling
5.
Conjunctival Injection
6.
Chemosis
7.
Caruncle Swelling
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II.
Patients and Methods (cont.)
Group II:
1.
11 patients with GO  includes 5 patients from the first group

Gender
•
•

4 men
7 women
Mean Age = 47.5±11.0 years (standard deviation)
•

Age Range  26–60M
Mean CAS = 2.8±0.8
•

Range  2–4
No history
•
•

Methylprednisolone Pulse Therapy
Radiation Therapy of the orbits
Method

Intravenously infused Methylprednisolone
•
•
Amount  500 mg
Frequency  daily
–

3 Consecutive days
Procedure
•
WHEN



Before treatment
24 hour after completion of treatment
Measure
1.
2.
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Temperatures and CAS
Thermal density plots of the eyes
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II.
B.
Patients and Methods (cont.)
Methods

Measure
•
Local temperatures
A.
B.
C.
D.
E.
F.
G.
•
Instrument
–


Lateral orbit (reference point)
Upper eyelid
Caruncle
Medial Conjunctiva
Lateral Conjunctiva
Lower Eyelid
Cornea
Digital Infrared Thermal Image System
»
Spectrum 9000 MB Series (United Integrated Service, Taipei Hsien, Taiwan)
Room Temperature ~ 23°C.
Reference Black Plate
•
•
Reflected the room temperature
Place
–
–
•
In front of the system
Above and Lateral to the eyebrow
Purpose
–
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Ensure accurate temperature calculation
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II.
Patients and Methods (cont.)
Reference Plate
Ensure accurate
temperature calculation
Upper Eyelid
Reference Point
Lateral Orbit
Lateral Conjunctiva
Caruncle
Medial Conjunctiva
Cornea
Lower Eyelid
Filter 1 : Blue
Colors
Filter 2 : Red
Black
Temperature Degree : Lowest  Highest
Bar Length = 1 cm
Violet
Blue
Green
Yellow Orange
Red
Grayish
White
Histogram
Local Temperature Thermal Density
Plot
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II.
1.
Patients and Methods (cont.)
System calibration
– Each examination
– Procedure
1. Place Thermometer Sensor on the focus of
measurement target
2. Opening the icon “Fever Test Setup”
–
FOCUS
OPEN ICON
“Fever Test Setup”
“Thermal Reference Source” will appear
3. Select “Manual” icon
4. Key in temperature value
–
START
From thermometer
5. System in now ready for the patient test
MANUAL ICON
KEY IN
TEMPERATURE
VALUE
SYSTEM IS NOW
READY
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II.
2.
Patients and Methods (cont.)
Check if the Following Rules are Implemented
 Patients
•
•
•
•
Not allowed to wear make-up
Not allowed to Drink hot or cold water
Not allowed to smoke
Requirement
–
Sit in the room and rest for 5 min before the examination.
3.
4.
Patient sat before the camera
Picture of each eye was captured
 Left and Right Eye
5. Measure the temperatures of the target areas
•
Computer
6. Computation
A. Difference between Temperature
•
Lateral Temperature – Target Area
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II.
Patients and Methods (cont.)
B. Coefficient of Variation (CV)
A. Intra-assay
•
•
Healthy Person  Local Temperature
0.3% (31.6±0.1°C, n=5)
–
–
•
Temperature = 31.6°C
lateral orbit, reference point
0.7% (33.7±0.2°C)
–
–
Temperature = 33.7°C
Caruncle)
B. Inter-assay
•
2.5% (31.0±0.8°C, n=5)
–
–
•
Temperature = 31.0°C
lateral orbit, reference point
2.0% (33.6±0.7°C)
–
–
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Temperature = 33.6°C
Caruncle
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II.
7.
Assessments
 DITI and CAS
•
8.
Masked manner
Study
 Ethical standards
•
9.
Patients and Methods (cont.)
Declaration of Helsinki
Informed Consent
 Obtained from the participants
•
After explanation of the nature and possible consequences
of the study
10. Approval
 Institutional Review Board of National Taiwan
University Hospital
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III. Statistical Analysis
1.
Temperature Difference

Data
•
Patients VS. Normal Controls
–

Temperature
•
Before and After Methylprednisolone Pulse Therapy
–
2.
3.
Student’s t test  Statistically Analyzed
» Data failed to pass the normality test  Perform Mann–Whitney
rank sum test
Student’s paired test  Analyzed
» Data failed to pass the normality test  Perform Wilcoxon
signed rank test
Correlation Coefficient

Temperature Variation and Change in Clinical Activity Score
•
•
After Methylprednisolone Pulse Therapy
Spearman Rank Order Correlation  Analyzed
•
Calculation
Coefficient of Variation

Intra-Assay or Inter-Assay
–
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(Standard Deviation / Mean) × 100%
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Whole System
START
SYSTEM
CALIBRATION
CHECK:
RULES ARE
IMPLIMENTED
POSITION
PATIENT
TAKE PICTURE:
LEFT EYE
RIGHT EYE
ASSESSMENT
STUDY
INFORMED
CONSENT
APPROVAL
END
SOFTWARE:
MEASURE TEMPERATURE OF
TARGET AREAS
STATISTICAL ANALYSIS:
TEMPERATURE DIFFERENCE
CORRELATION COEFFICIENT
COEFFICIENT OF VARIATOIN
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IV.
Difference
 Temperature
• Patient Parts
–
–
–
–
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Caruncle
Medial Conjunctiva
Lateral Conjunctiva
Lower Eyelid


Results
Statistically significantly
 Higher than those of normal controls
No Difference
 Temperature
•
Patient Parts
–
–
–

Upper Eyelid
Cornea
Lateral Orbit (reference point)
Patients and Normal Controls
Data are presented as mean ± standard deviation
*p<0.05 vs. normal controls
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IV.

Results (cont.)
11 GO patients
 Treatment
•

Methylprednisolone Pulse Therapy
Temperatures
•
Parts
–
–
–
•

Significantly decreased after treatment
Sum of the Temperatures
•
Parts
–
–
–
–
–
–
•
201.9±7.0°C vs. 196.9±9.2°C, p<0.05
CAS
•
Significantly decreased after Methylprednisolone Pulse Therapy.
–

Upper Eyelid
Caruncle
Medial Conjunctiva
Lateral Conjunctiva
Lower Eyelid
Cornea
Significantly decreased after treatment
–

Caruncle
Medial Conjunctiva
Lower Eyelid
2.8±0.8  2.2±1.0 (p<0.05)
Difference
•
•
Sum of the Temperatures before and after treatment
Significantly and Positively correlated
–
Change in clinical activity score (correlation coefficient=0.8, n=22, p=0.000).
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IV.
Results (cont.)
Data are presented as mean ± standard deviation
Lateral orbit is a reference point
*p<0.05 vs. after treatment
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IV.
Results (cont.)
METHYLPREDNISOLONE PULSE THERAPY
Patient with GO
BEFORE
NORMAL CONTROL
AFTER
Thermal Density Plots of the Right Eye
Notes:
Conditions of the filters are the same for these three pictures.
Bar length=1 cm
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IV.
Results (cont.)
METHYLPREDNISOLONE PULSE THERAPY
Patient with GO
BEFORE
AFTER
Thermal Density Plots of the Left Eye
Notes:
Conditions of the filters are the same for these three pictures.
Bar length=1 cm
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V.
Discussion
Study
 DITI
• Objectively Measure Temperature
– Patients with GO
» Various areas of the eyes
» Adnexa
– Reflecting the degree of inflammation
• Thermal Density Plot
– Clearly shows which area of the eye has most severe
inflammation.
• Follow-up the Effects
– Methylprednisolone Pulse Therapy
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V.
Discussion (cont.)
 Study
 Comparison
• Sum
– Local Temperatures of various areas of the eye
– Thermal density plots before and after treatment
• Indicate
– Condition of GO is improved after Methylprednisolone Pulse
Therapy.
– Change in temperature  Well correlated with the change in
CAS.
» Decreased temperature was caused by a decrease in CAS
» Improvement in inflammation of GO
 Detect change in inflammation
 Show detailed improvement of inflammatory signs
• Eyes of patients with GO
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V.
Temperature
 Highest  Caruncle
 Lowest  Cornea
Why?
 Cornea is Vascular
Discussion (cont.)
Cornea
Caruncle
• During inflammation
– Significant differences are more easily seen in the
caruncle than in the cornea
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V.
Discussion (cont.)
 DITI - Digital Infrared Thermal Imaging
 Non-invasive examination that is already used
• Rheumatological field
 Recent Studies
 Temperature differences between the hands in complex regional
pain syndrome patients increased significantly when the
sympathetic system was provoked
 Temperature changes in the plantar surface correlated with
lower back pain intensity
 Relationship between plantar skin temperature and diabetic
neuropathy,
• Identifying small fiber neuropathy
 Identify Breast Cancer
• Heat generated  Angiogenesis
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V.
Discussion (cont.)
Present Study
 DITI
– Objectively determine clinical activity and effect of
Methylprednisolone Pulse Therapy in patients with GO.
» Depends on the heat generated in the inflammation
of GO
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V.
Discussion (cont.)
Conclusion
 Digital Infrared Thermal Imaging
• Evaluate the inflammatory state of GO
• Follow-up Effect
– Methylprednisolone Pulse Therapy
Recommendation
 A large scale study and further research are
therefore merited
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THANK YOU!!!
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