Taking Retinal Imaging to the Next Level

Consider ultra-widefield imaging as a practice enhancer.

By Mark R. Kapperman, OD

Our four-doctor optometric practice is one of the leading primary eye care providers in the Chattanooga community, offering comprehensive vision care services and products to patients of all ages and working closely with other health care providers in the area through integrated care and referral relationships. We have focused on building a reputation for the highest quality, reliability and value with both our patients and our eye care partners and are always looking for ways to enhance this image. Our team’s stated daily objective is to hear our patients say, unsolicited, “That’s the best eye exam I’ve ever had.”

We did not anticipate, however, that the addition of a single piece of technology would support this ongoing effort in so many different ways. About 2 years ago, we acquired a Daytona ultra-widefield (UWF) retinal imaging system (Optos). In the intervening period, it has helped improve our clinical practice, enhance collaboration with our colleagues in the community, strengthen patients’ experiences, and even increase our eye wear business. Whether or not we employ a dilated examination, today about 60% of our patients elect to receive a routine Optomap, the ultra-high resolution, digital image produced by the Daytona, during their visit. This number approaches 75% for elderly patients and 100% for patients with known retinal pathology that we are monitoring. Most choose this additional service because they understand that there is no other way for us to evaluate their retinal health as quickly, effortlessly, and thoroughly.

The Daytona is a scanning laser ophthalmoscope that provides the widest view of the retina, approximately 200 degrees or 82%, of any available imaging system.1 Using this tabletop device, our technicians can obtain the Optomap image in a single, noncontact, often nonmydriatic autocapture lasting less than 1 second. This image is immediately available on a monitor for our review with the patient in the exam room. The optical technology in the Daytona, incorporating two low-power red (635 nm) and green (532 nm) lasers that scan the retina simultaneously, provides multimodal imaging to better visualize different layers of the retinal anatomy and permits image capture through a pupil as small as 2 mm and most cataracts. In addition to the color and red-free Optomap modalities that image the sensory retina, retinal pigment epithelium, and the choroid, the Daytona also offers UWF autofluorescence (AF) that highlights lipofuscin in the retinal pigment epithelium associated with geographic atrophy related to age-related macular degeneration or choroidal neovascularization (Figures 1 and 2). Full cross-registration allows us to switch back and forth to examine the same lesion or area of interest with these different modalities to provide a very comprehensive evaluation. Prior to the device, we did not have access to AF imaging but now we review AF for every patient who gets an Optomap. We have found this modality to be very useful in detecting retinal neoplasms and nevi, as well as small hemorrhages or branch vein retinal occlusions in the retinal periphery. It is also helpful in the central pole, allowing us to pick up optic nerve drusen we might otherwise have overlooked.

Figure 1. Color (A) and AF (B) UWF images demonstrating the peripheral extent of retinal changes associated with age-related macular edema. Adding AF to the diagnostic imaging suite allows for a functional assessment of the metabolic status of the retina.

Figure 2. Daytona UWF retinal imaging system.

RECOGNIZED FOR CLINICAL EXCELLENCE

In fact, adopting UWF retinal imaging has dramatically improved our ability to identify and monitor retinal disease. Our doctors are in unanimous agreement that we detect more ocular pathology with Optomap than we would using only a dilated exam. For example, we are able to visualize small retinal tears on UWF and refer patients for appropriate treatment before they become symptomatic. This experience is supported by a number of published papers that demonstrate that UWF imaging identifies more retinal disease and facilitates earlier diagnosis.2-4 One study concluded that UWF imaging could increase disease detection rates by an average of 30% compared with standard ophthalmoscopy.5

We have found UWF imaging particularly useful in detecting and evaluating diabetic retinopathy (DR) and we use UWF retinal imaging routinely with all of our patients with diabetes. The diagnostic and prognostic importance of UWF imaging for DR is increasingly well-documented. Investigators at the Beetham Eye Institute of the Joslin Diabetes Center have published results from a prospective 4-year study that found patients with predominantly peripheral lesions, lying largely outside the range of conventional fundus photography, were at three times greater risk for DR progression and nearly five times more likely to develop proliferative DR.6 This same group has also demonstrated the utility of Optomap imaging in an ocular telehealth setting, reporting that it reduced evaluation time by 28% and the ungradable rate by 70%.7 Such increases in efficiency and precision can be critical in a busy practice and make primary eye care providers even more valuable in an integrated eye care setting.

SEEN AS A MORE VALUABLE REFERRAL PARTNER

As it happens, we are among the first eye care practices in our area to be utilizing UWF retinal imaging. This capability has enhanced our relationships with the retinal specialists to whom we refer patients because the digital Optomap images are easily shared, even if the receiving practice does not have an Optos UWF system (Daytona is DICOM compatible), and provide an objective record of each patient’s retinal pathology over time. Importantly, our ability to rapidly detect retinal disease in a patient-friendly manner is increasing referrals to our practice from primary care physicians in situations when eye disease is suspected. The device has helped cement our role at the center of the eye care delivery continuum from general practitioners to retinal specialists.

VIEWED VERY FAVORABLY BY OUR PATIENTS

We simply have never had a more useful tool for educating our patients about eye health than the Optomap. Patients are fascinated to see these detailed pictures of their actual retinas, as soon as they come into the exam room, and will listen intently as we describe anatomical features and clinical findings. We explain that imaging the retina gives us an opportunity to examine the health of their vasculature more clearly—and less invasively—than anywhere else in the body. Patients who have had retinal pathology identified are very motivated to adhere to treatment and follow-up instructions, even lifestyle changes, and always want to see how a new Optomap compares with previous images to determine if they have improved. We definitely feel that UWF technology has given our patients a better experience in the office, better understanding about their disease, and better clinical outcomes. We have also noticed an additional unexpected benefit. Because more of our patients are being imaged without dilation and the process is completed so quickly, they are able to enjoy time after their exam browsing in our high-fashion retail optical shop. We have literally seen an uptick in our eyewear sales since we began offering UWF.

CONCLUSION

In our setting, UWF retinal imaging is a win-win-win, for our patients, our medical colleagues, and our practice. By facilitating earlier diagnosis, better monitoring, more productive interactions with our referral partners, and greater patient empowerment, Daytona has made us better optometric physicians and burnished the image we’ve built so painstakingly in our market of providing the best eye care possible. We can foresee a day when Optomap will be a standard of care across the field as it has rapidly become in our practice. n

 

1. Witmer MT, Parlitsis G, Patel S, Kiss S. Comparison of ultra-widefield fluorescein angiography with the Heidelberg Spectralis noncontact ultra-widefield module versus the Optos Optomap. Clin Ophthalmol. 2013;7:389-394.

2. Kernt M, Hadi I, Pinter F, et al. Assessment of diabetic retinopathy using nonmydriatic ultra-widefield scanning laser ophthalmoscopy (optomap) compared with ETDRS 7-field stereo photography. Diabetes Care. 2012;35(12):2459-2463.

3. Silva PS, Cavallerano JD, Sun JK, et al. Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy. Am J Ophthalmol. 2012;154(3):549-559.e2.

4. Silva PS, Cavallerano JD, Sun JK, et al. Peripheral lesions identified by mydriatic ultrawide field imaging: distribution and potential impact on diabetic retinopathy severity. Ophthalmology. 2013;120(12):2587-2595.

5. Brown K, Sewell JM, Trempe C, Peto T, Travison TG. Comparison of Image-assisted versus Traditional Fundus Examination. Eye and Brain. 2013; 2013(5):1-8.

6. Silva PS, Cavallerano JD, Haddad NMN, et al. Peripheral lesions identified on ultrawide field imaging predict increased risk of diabetic retinopathy progression over 4 years. Ophthalmology. 2015;122(5):949-956.

7. Silva PS, Cavallerano JD, Tolls D, et al. Potential efficacy benefits of nonmydriatic ultrawide field retinal imaging in an ocular telehealth diabetic retinopathy program. Diabetes Care. 2014;37:50-55.

Mark R. Kapperman, OD
• Founding Partner and President, Kapperman and White Eyecare, Chattanooga, Tennessee
marankapp@aol.com
• Financial interest: none acknowledged