Advancing Eye Care with Retinal Imaging
The need for periodic retinal evaluations is a factor that can draw patients to practices. While a sizable portion of patients may be chiefly interested in eyewear or contact lenses, most individuals will admit that receiving a clean bill of health after a thorough ocular examination gives them peace of mind regarding what is arguably their most precious sense.
Ocular health examinations have been improved with ultra-widefield (UWF™) optomap retinal imaging over the past 25 years. UWF captures retinal anatomical features anterior to the vortex vein ampullae in all four quadrants.1 Optos invented this technology and remains the leader in UWF market share, with retinal visualization of up to 200°, or 875mm2 of the total retinal surface area through an undilated pupil.2,3 (Figure 1)
Figure 1. Comparison of field-of-view capture potential with Optos technology vs. conventional fundus photography.
Image courtesy of Optos
optomap when used alone, or as a complementary tool to dilated fundus examination (DFE), can improve the detection of retinal abnormalities, by up to 30%, with the potential to detect subtle retina changes. optomap imaging can also increase practice efficiency in cases of diabetic retinopathy due to the reduced time required to capture images compared to dilated ETDRS imaging.4
Increased capabilities with Optos
Optos UWF technology is an extremely valuable tool in healthcare settings and can improve practice efficiency, clinical efficacy, and patient care.5,6 Optos technology provides simultaneous, non-contact, pole-to-periphery views in a single image capture via a series of low-powered lasers with an ellipsoidal mirror.7,8 With multiple imaging modalities available, eye and other healthcare providers may find that they have a greater perspective regarding underlying pathology than is possible with conventional photography. Current Optos devices provide the ability to view these retinal substructures within their laser separations in the following fashion (Figure 2 and Figure 3):
- Green laser (532 nm) - this laser yields scans from the superficial sensory retina down to the level of the retinal pigment epithelium (RPE);
- Red laser (635 nm) - the red laser scans deeper retinal tissues, from the RPE to the choroid;
- Blue laser (488 nm)- the blue laser yields the most superficial scans, allowing clinicians to capture natural color optomap rgb images and to perform UWF angiography with intravenous fluorescein dye (note: not available on all Optos models);
- Infrared laser (802 nm) - this is used with an excitation filter to obtain UWF angiography using intravenous indocyanine green dye (note: not available on all Optos models).9
Figure 2. Demonstrating optical penetration of the various laser wavelengths.9
Figure 3. Summary of Optos products and features.
Through its use of advanced imaging modes across devices, optomap enhances visualization of retinal structures while optimizing the detection of pigment choroidal lesions and improving visualization of the optic nerve peripheral retinal abnormalities, ischemic changes, and macular health.7,10,11,12
Improved clinical efficiency with Optos
Drs. Crooker, Walrath, and Rafieetary all leverage Optos technology in practice and have found it permits greater clinical efficiency as a result of improved identification and diagnosis of retinal pathology than could be anticipated with ophthalmoscopy and fundus photography in isolation. Their experience is consistent with the findings of a study in 2017, which demonstrated that ~50% more lesions were seen on UWF imaging than the “gold standard,” i.e., the Early Treatment Diabetic Retinopathy Study (ETDRS) seven-standard fields.13 (Figure 4) Additional imaging modalities have been added to the Optos technology over 30 years to include Optical Coherence Tomography (OCT) and angiography12 and are widely accepted throughout optometry, ophthalmology, retina, and point-of-care communities.
Figure 4. The ETDRS 7-standard fields are shown in comparison to optomap.
Image courtesy of Optos
One of the most beneficial attributes of Optos technology is its ability to gather information with diminished chair time and patient fatigue. Drs. Crooker, Walrath, and Rafieetary leverage Optos technology on every appropriate and consenting patient in their practices. The subsequent benefits of this reduced chair time include increased patient volume and greater time to review findings and initiate proactive discussions with patients, which may help improve patient satisfaction and increase practice profitability.
optomap images can be of tremendous benefit to those clinicians in multi-doctor offices as a beneficial strategy for maintaining continuity of care. As experienced by those that have inherited a new patient from another physician, it can be extremely challenging to gauge a patient's progress or response to therapy simply by reviewing chart notes and drawings. Optos devices provide high-resolution images with exquisite detail that serve as a chronological marker in disease management. Also, in such practices, obtaining a “second opinion” from a staff colleague on a captured optomap image is more convenient than subjecting the patient to an additional ophthalmoscopic exam.
A great application of the resident software is the magnification and enhancement of optomap images using the various laser channels, which can optimize levels of differentiation and improve efficiency and accuracy in clinical decision-making. For less experienced clinicians, this can be an appealing feature and a great professional confidence booster.
Clinical Utilization and Implementation
There are many ways that Optos can be incorporated into the office workflow. Regardless of the setting, this technology can be incorporated proactively in either select cases or as a universal part of the examination procedure. Some private practices elect to screen all patients with Optos as part of their preliminary examination procedures, along with other devices such as an autorefractor, corneal topographer, and visual field analyzer. Others will utilize the technology as ancillary testing for medical examinations (i.e., CPT 92002 - 92014), billing separately under fundus photography (CPT 92250) for the procedure and accompanying report.
Patient and Clinical Impact
Optos can greatly improve clinical decision-making and patient education. Whether screening asymptomatic patients with unexpected peripheral lesions or targeting those with chronic medical conditions, such as diabetic retinopathy, optomap images provide a more detailed inspection of the retinal anatomy than conventional funduscopic examination alone. With the resident software, doctors can isolate, magnify, measure, filter, and enhance areas of concern in the peripheral or central retina, and additionally can use previously captured images saved locally or in the cloud for direct comparisons to determine the likely course and prognosis for a given condition.
Some Optos devices include integrated OCT and/or angiography along with the ultra-widefield retinal imaging capabilities which present a significant advancement in ophthalmic imaging, expanding the capabilities and clinical decision-making of doctors. Studies have shown:
- optomap-guided OCT imaging influences clinical decision-making in 84% of cases.14
- In 38% of cases, the optomap-guided SS-OCT directly contributed to patient management plans, including laser treatments, injections, or surgical procedures.15
Drs. Crooker, Walrath, and Rafieetary have all experienced improved pathology detection, most notably peripheral retinal lesions such as holes, tears, detachments, hemorrhages, choroidal nevi, and other suspicious lesions with Optos technology. In addition, they have benefited from greater diagnostic capabilities facilitating earlier referrals for treatment in cases of diabetic retinopathy and AMD, and have found utility in employing Optos to track other progressive disorders, such as glaucoma and other proliferative disorders.
Studies show that optomap has an ~89% sensitivity in detecting peripheral retinal lesions.16 optomap-guided SS-OCT can help identify common findings such as chorioretinal scars, tears, holes, retinoschisis, and even peripheral retinal traction seen in sickle cell retinopathy patients.14,17 97% of practices using optomap report finding unexpected pathology in the eyes of patients with no visual complaints.18
UWF imaging grading has high reproducibility for evaluating vertical cup-to-disc ratios and aligns well with stereoscopic optic disc imaging, making it suitable for glaucoma diagnosis when cup-to-disc ratios are not available.19
optomap is an excellent tool for managing ocular diseases linked to systemic conditions. In a retrospective study, a decreased nasal-annular arteriole-to-venule ratio was found to be associated with hypertension. This finding suggests that it could be useful for screening individuals for hypertension during routine comprehensive eye examinations.20 Additionally, for Retinopathy of Prematurity (ROP), UWF imaging is advantageous for screening, diagnosing, and managing the condition in infants.21
Optos also facilitates better patient communication, education, and compliance. As the adage goes, “A picture is worth a thousand words.” Having the capability of showing the patient precisely what and where the problem is located and how it deviates from the norm is an incredibly powerful and motivational tool. Raising awareness about the condition and explaining the treatment options helps patients take a more active role in their health care. Even in situations where no pathology is identified, patients often marvel at the technological advancements. This can help to distinguish a practice as being more progressive or cutting-edge than its competitors. It also creates an inherent sense of loyalty, knowing that the doctor monitors their ocular health at each successive visit.
Bottom-line benefits
As with any capital expenditure, practice owners considering the acquisition of Optos technology are often concerned with return on investment. While this is always a very individualized and complex calculation, it is nonetheless an important topic for discussion. Any technology that improves patient care essentially pays for itself in the long term, whether fees are passed along to patients directly or indirectly.
There are multiple models by which practitioners can recoup their investment in Optos technology. Some employ the device as part of the routine screening of patients, helping to expedite the examination process in hopes of decreasing chair time and increasing potential patient volume. Others follow the model of offering UWF imaging as an additional, non-covered service to enhance their quality of care, provide unique insight regarding potential ocular disease, and improve documentation and continuity of care within their practice. Additionally, offices can certainly bill for the various features (i.e., photography and/or OCT) to 3rd party insurers when medically indicated and appropriate, provided they include an interpretive report in their record. This capability also permits offices to grow the medical aspect of their practices, facilitating better disease detection and management as well as earlier, more accurate referrals.
Understand and calculate the potential return on investment (ROI) when bringing Optos technology into your practice and hear from your colleagues on their first-hand experiences with the return on investment from incorporating Optos into their practices.
Dr. Walrath finds that making this unique technology available elevates the perception of one’s practice in the minds of patients – the “wow factor,” if you will – in terms of sophistication and professionalism. With few exceptions, patients appreciate these innovations and the educational considerations that are inherently linked to optomap imaging.
Interprofessional collaboration facilitated by Optos
Dr. Crooker has found that Optos technology provides unparalleled benefits to patients and practices. Beyond the diagnostic utility and improved confidence in decision-making, having optomap images at her disposal has provided a mechanism to communicate uniform and validated information across the primary care ECPs, retinal specialists, surgeons, and other healthcare professionals she collaborates with to improve and expedite patient care.
Case studies
A 39-year-old male presented for his initial visit to our office, complaining of “a purple circle at the center of my vision that just won’t go away”. He reported working in the financial industry and was currently involved in an intense and highly demanding project, which resulted in significant stress and a lack of sleep. His best corrected visual acuity was 20/20 OD and 20/25 OS. optomap color rg imaging (Figure 5) revealed a small but significant central serous chorioretinopathy affecting the left macula, which was more evident upon examination with optomap af (Figure 6).
Figure 5. optomap color rg images of the right (A) and left (B) eye, respectively. Note the loss of foveal detail OS and the subtle, circumscribed elevation within the macula.
Image courtesy of Jessica Crooker, OD
Figure 6. optomap blue autofluorescence (AF) images of the right (A) and left (B) eye, respectively. Note the improved delineation of the central serous lesion OS, with corresponding hyperfluorescence and loss of the normal architecture within the foveal pit.
Image courtesy of Jessica Crooker, OD
The images were captured using the Monaco system, which features integrated spectral domain Optical Coherence Tomography (OCT). These images were instrumental in educating the patient about his condition and providing reassurance that such disorders often resolve spontaneously over time. He was monitored closely with OCT and optomap examinations every 4 to 6 weeks, along with regular Amsler grid testing at home. Ultimately, after nearly five months, he achieved complete resolution without the need for medical or surgical intervention.
A 59-year-old male presented emergently with complaints of spots and streaks in his left eye “like paint strokes” that began suddenly the day before. He denied any trauma or significant ocular history. Best corrected visual acuity was 20/20 OD and OS. optomap color rg imaging (Figure 7) revealed a large but relatively shallow horseshoe-shaped retinal tear in the far temporal periphery, with several retinal hemorrhages along its edge.
Figure 7. optomap color rg image of the left eye showing a large, shallow horseshoe-shaped tear at the 3 o’clock position.
Image courtesy of Judy Walrath, OD
A dilated fundus examination was performed with scleral indentation, confirming the diagnosis of a retinal tear. The patient was promptly referred to a retinal specialist and underwent successful laser photocoagulation of the region within 24 hours of his initial visit. His symptoms ultimately subsided, and he maintained 20/20 vision in both eyes.
A 52-year-old African-American female was referred by a local optometrist for retinal consultation. She had presented with complaints of reduced vision in her left eye, as well as a medical history that included hypertension and sickle cell disease. The referring optometrist had noted a large hemorrhage in the temporal periphery OS.
As shown in the accompanying optomap color rg image (Figure 8), this patient displayed a large area of sea-fan neovascularization inferotemporally, with associated hemorrhage obscuring the underlying retinal detail. In addition, there is a substantial epiretinal membrane (ERM) involving the macula, which explains the diminished acuity.
Figure 8. optomap color rg image of the left eye showing an area of neovascularization with adjacent preretinal hemorrhage from the 3:30 to 5:30 position. Also, note the large epiretinal membrane extending nasally through the macular region.
Image courtesy of Mohammed Rafieetary, OD, FAAO
This case demonstrates the value of UWF imaging in identifying the full extent of retinal pathology, including both the central and peripheral regions. After reviewing the images with the patient for educational purposes, she was scheduled with the surgeon for interventional therapy.
This case demonstrates the value of UWF imaging in identifying the full extent of retinal pathology, including both the central and peripheral regions. After reviewing the images with the patient for educational purposes, she was scheduled with the surgeon for interventional therapy.
Conclusions:
UWF single-capture retinal imaging has become an essential tool in eye care. Whether in single-doctor practices or multi-specialty group settings, Optos technology has demonstrated its ability to enhance clinical efficiency and patient satisfaction while also creating additional revenue streams for practices of all sizes. Optos has also proven beneficial in diagnosing and managing systemic diseases such as diabetes, hypertension, and retinopathy of prematurity. It will remain an indispensable resource for the detection, diagnosis, treatment, and management of both ocular and systemic diseases throughout the global healthcare continuum.
