Image analytical techniques have been extensively developed to evaluate complex microbial aggregates such as sludge flocs and biofilms. This review covers the latest contributions concerning the application of image analysis to the activated sludge systems with respect to the most frequently used morphological parameters and relations between them and traditional wastewater treatment parameters. Recent developments have indicated that image analysis can be successfully used for the quantification of flocs and filamentous bacteria in the operating wastewater treatment plants, which enables prediction of bulking events and pinpoint flocs formation.