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- Success With Challenging Patients
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One of the many advantages of fully integrated eye care is the potential to identify ocular pathology early and begin effective intervention quickly. Using ultra-widefield (UWF) retinal imaging as part of routine eye exams supports these overarching goals. Patients can be referred efficiently to specialists if new problems are identified. Once a course of treatment has been initiated, the patient’s primary eye doctor can resume monitoring to evaluate therapeutic success. The same type of efficient care can be provided to patients who are found to have previously undetected pathology during evaluations for cataract or refractive surgery and other procedures.
In our practices, the use of optomap (Optos) UWF imaging supports this team-based approach. These systems facilitates early detection and interdisciplinary evaluation of posterior pole pathology. The detailed, high-resolution, multimodal optomap images enhance retinal examinations and support patient engagement. Since implementing optomap-guided retinal exams, we have noted improved patient flow and, as a result, additional revenue from increased patient throughput.
USE IN INTEGRATED EYE CARE MODEL
Our care model is centered around a comprehensive eye care practice, Harvard Eye Associates, with three offices in Orange County, California. From this practice, a multispecialty team, led by 10 ophthalmologists (including specialists in anterior segment surgery, oculoplastics, glaucoma, and medical retina), three optometrists, an aesthetic plastic surgeon, and a hearing instrument specialist, delivers a full spectrum of vision, medical, surgical, and aesthetic services. Patients are referred to these offices by a community eye care network comprising several prominent optometric practices. This hub-and-spoke model allows us to address the eye care needs of thousands of patients in our area each year with the most appropriate care delivered in a timely and cost-efficient manner.
UWF retinal imaging fits this integrated eye care model well. The specially designed scanning laser ophthalmoscope in Optos’ device captures approximately 200°, or 82% of the retina, in a single image. This is the widest angle single-capture image available from any imaging system.1 Because dilation is not required, the noncontact high-resolution image can be obtained in less than a minute. The image is then immediately available for physician evaluation, patient education, and collaboration with colleagues.
In these systems, low powered red (635 nm) and green (532 nm) lasers scan the retina simultaneously and provide multimodal images that allow more comprehensive visualization of different layers of the retina. The color and red-free optomap modalities highlight the sensory retina, retinal pigment epithelium, and choroid, and green light UWF autofluorescence shows the metabolic status of the retinal pigment epithelium and can highlight signs of retinal degeneration. Devices with OptosAdvance software enable panmodal cross-registration to instantaneously compare or overlay these different views. Some models also offer UWF fluorescein angiography and UWF indocyanine green angiography.
UWF retinal imaging has other advantages across different examination and evaluation settings. The optomap technology permits detailed image capture through a pupil as small as 2 mm and often yields valuable information even through media opacities including cataract, vitreous hemorrhage, corneal scarring, and gas bubbles or silicone oil used in retinal surgery.
Because mydriasis is not required, imaging can be performed successfully in eyes that cannot be dilated, such as those with anatomic narrow angles, and those that do not dilate well, as in patients with pseudoexfoliation, iris trauma, or uveitis. Generally, image capture tends to be easier, faster, and more patient-friendly with a nonmydriatic camera than with a camera that requires mydriasis. Together, these advantages translate into efficient referral and patient flow, allowing more patients to be seen while also improving patient satisfaction with the visit.
LEARNING TO SEE
As our use of UWF imaging has grown, our collective ability to identify and evaluate retinal pathology has markedly improved. There was a learning curve, however. We needed to be able to identify the inherent differences in the optomap laser color images compared with the colors typically seen in images captured with traditional fundus cameras. We would often see anomalies on screening images that were not seen on dilated fundus examination. As the team’s experience with this modality grew, our confidence in identifying imaging artifacts improved, and this issue resolved.
This learning curve was reminiscent of the early days of optical coherence tomography use, when ophthalmologists suddenly were able to see ocular anatomy and pathology in an entirely new way. Optical coherence tomography is now an indispensable technology in many practices.
UWF imaging has increased the diagnostic sensitivity of our examinations and made us all more sophisticated image readers. From a clinical perspective, we would rather evaluate and dismiss a suspected problem than miss it altogether. Our experience is consistent with published studies showing that UWF imaging can identify more retinal disease and facilitate earlier diagnosis than standard seven-field photography.2-4 In one study, use of UWF imaging improved detection of retinal pathology by an average 30% over standard ophthalmoscopy.5
We estimate that our implementation of UWF imaging and our increased sophistication in interpreting the multimodal optomap images have improved our detection of retinal pathology. We find peripheral retinal anomalies in approximately two-thirds of our screening images. This correlates well with the findings of more than 200 peer-reviewed studies confirming the importance of peripheral imaging and showing that approximately 68% of retinal pathology is located outside the central 60° field.2,3,6-9
To help with the learning curve, Optos has produced a number of useful retina atlas tools, visible in each modality, that present montages of a variety of peripheral pathologies. These tools are helpful for both clinician and patient education.
WIDER VIEW FOR BETTER CARE
The ability to capture high-resolution digital images of the retinal periphery easily is as important for managing chronic retinal disease as it is for early detection. For example, we use UWF retinal imaging routinely for all of our patients with diabetes. Previously, diabetic retinal photographs required a series of seven standard 45° views, usually obtained by a skilled ophthalmic photographer. Now we can see a larger area with one image, the acquisition of which is more comfortable for the patient.
Recent studies have demonstrated the prognostic significance of peripheral findings in DR. A prospective 4-year study found that patients with predominantly peripheral lesions, beyond the reach of conventional imaging, were at three times greater risk for DR progression and nearly five times more likely to develop PDR over the study period than patients who did not have such findings in the periphery.9 A separate paper by the same group described the efficiency of UWF imaging as deployed in a multistate ocular telehealth program, noting a nearly twofold increase in detection of DR and an 81% decrease in ungradable images, compared to standard photography.10 As in our setting, UWF in that study facilitated the exchange and accurate review of images among offices and clinicians.
Regular monitoring of patients with identified risk factors for retinal disease, such as diabetes, can identify unrelated pathology as well. In another ocular telehealth program, approximately 20% of the patients who did not have findings of DR were shown to have other retinal findings.11 UWF imaging increased the identification of problems in the retinal periphery and vitreous, including choroidal nevi and chorioretinal atrophy, compared to conventional fundus photography. Examination of optomap images resulted in the detection of pathologies that were not seen in traditional fundus photos, including retinal tears, lattice and peripheral degenerations, and vitreous detachments or floaters.11
These results suggest that, irrespective of the state of the disease being followed, an imaging modality that allows more complete inspection of the retinal periphery is helpful to identify or rule out any other problems (Figures 1 and 2).
We are finding value for UWF in a myriad of other applications. Perhaps the most common use, other than diabetes management and optimizing eye examinations as described, is in patients with acute vitreous detachments, when there is concern for retinal tears and detachments. Although optomap imaging does not replace a dilated exam, it can often provide confidence to the patient and provider that no imminent vision-threatening issue is present, and a referral can be made with less urgency.
Other important indications include retinal vascular occlusions and uveitis, both of which require specific documentation regarding the extent of disease at presentation and its subsequent course. On optomap imaging, we can find early peripheral changes that might otherwise be missed until the disease progressed further.
Because of the efficiency of image capture and multimodal capabilities with UWF imaging, we have also used it for monitoring rheumatology patients for hydroxychloroquine toxicity.12 These patients should be examined with fundus autofluorescence imaging annually to monitor for drug-related vision loss.
UWF also sometimes allows us to find the root cause of problems in patients with vague or unexplained symptoms who simply do not seem to be doing well. In a recent case, a patient reported an idiopathic decrease in vision quality; we found, on closer inspection with UWF, a shallow inferior retinal detachment.
Lastly, the nonmydriatic aspect of UWF technology has been helpful in evaluating trauma patients and those who might not be able to be safely dilated at their first visit (Figures 3-5).
As a result of this broad utility, UWF imaging has become a standard of care across our delivery system. Nearly all of our referring optometrists have UWF imaging technology in their offices. For example, at Woodbury Optometry, new patients are automatically given an information sheet describing UWF imaging at intake and offered the opportunity to opt in for the examination or to discuss its potential benefits with the staff. (The imaging involves a nominal out-of-pocket fee when used in screening.) At least 60% of new patients elect to have an optomap, providing a baseline image that will be an important component of their care moving forward.
With UWF imaging in both the central multispecialty office and the optometric partner offices throughout the community, eye care practitioners can readily share and discuss exactly what they are seeing and how it changes over time. Because optomap images can be downloaded and reviewed by all members of the team (even without a UWF system in the office), whether we are discussing retinal detachments, possible malignancies, or lesions associated with other retinal diseases, our referring primary eye care providers are looking at the same high-resolution color or AF images as the retina specialist. This way we can make efficient use of our time and the patient’s by determining whether referral or additional follow-up is necessary without a specialist office visit.
This “virtual referral” or “group diagnosis,” in which several members of the integrated eye care team can simultaneously review the same high-resolution digital image of a patient’s retina, increases the speed and accuracy of assessment and determination of next steps.
Because it facilitates patient-friendly capture and immediate exchange of high-resolution, multimodal digital images of a wide expanse of the retina, UWF has become a cornerstone of our ability to identify and manage retinal disease more efficiently across our integrated eye care model. With this common platform in use along the continuum of care, from our community optometry referral partners to our retina specialists, we are better positioned to deliver complete, advanced eye care in a cost-effective way that fits our shared commitment to the long-term collaborative management of our patients.
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, et al. Comparison of image-assisted versus traditional fundus examination. Eye and Brain. 2013;5(1):1-8.
6. Witmer MT, Kiss S. Wide-field imaging of the retina. Surv Ophthalmol. 2013;58:143-154.
7. Wessel MM, Aaker GD, Parlitsis G, et al. Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy. Retina. 2012;32:785-791.
8. Kong M, Lee MY, Ham DI. Ultrawide-field fluorescein angiography for evaluation of diabetic retinopathy. Korean J Ophthalmol. 2012;26(6):428-431.
9. 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.
10. Silva PS, Horton MB, Clary D, et al. Identification of diabetic retinopathy and ungradable image rate with ultrawide field imaging in a national teleophthalmology program. Ophthalmology. 2016;123(6):1360-1367.
11. Silva PS, Cavallerano JD, Haddad NMN, et al. Comparison of nondiabetic retinal findings identified with nonmydriatic fundus photography vs ultrawide field imaging in an ocular telehealth program. JAMA Ophthalmol. 2016;134(3):330-334.
12. Wolfe F, Marmor MF: Rates and predictors of hydroxychloroquine retinal toxicity in patients with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2010;62(6):775-784.
Brian Kim, MD
• Harvard Eye Associates, Laguna Hills, California
• Financial disclosure: none acknowledged
Kenneth A. Fukuda, OD
• Woodbury Family Optometry
• Financial interest: none acknowledged
Karen P. Skvarna, OD
• Harvard Eye Associates, Laguna Hills, California
• Financial disclosure: none acknowledged