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Technology update: is the equipment market maturing?

By Coleby Nicholson
Following recent launches of new imaging equipment along with significant software and technology enhancements, COLEBY NICHOLSON asks whether the market is beginning to mature.

In today’s fast-moving world major technology advances that are initially considered groundbreaking and revolutionary, often soon become viewed as a necessity.

This trend seems to be taking hold in imaging equipment. OCT, for example, has changed the face of many practices and is now considered part of the ‘standard of care’ by most optometrists.

Increasingly, independent optometrists regard the latest equipment as an essential part of their practice and patient offering, which is making even the most advanced technology become commonplace. It has also helps them to differentiate their business from the corporate chains.

However, the issue for the equipment suppliers and ultimately, optometrists and ophthalmologists, is whether the market has matured.

Mr Mark Altman, business manager of ophthalmics at Device Technologies is adamant that while the technology will continue to offer advancements, it might not be in areas first expected.

“I don’t think the market for optometry equipment has matured, in fact I think it’s only going to expand. There will be development aimed at improved efficiencies with more devices being developed, which will incorporate more functionality. The future is heading towards combined diagnostic and treatment devices, particularly in the ophthalmology area,” Altman said.

“The whole area will be expanded and in particular I have no doubt there will be more diagnostics and therapy-type devices, especially in areas of Dry Eye, glaucoma and macula disease. Traditionally most equipment is either standalone diagnostic tools or treatment devices, so down the track we’ll see more combinations of both – diagnostics and treatment combined into one system.”

National sales manager of BOC Instruments Mr Robin Lanesman agrees: “Manufacturers will endeavour to combine more functions into single instruments. For some products this path has matured, but surprising future prospects for other devices are yet to be seen.”

Mr Jason Martone, managing director of Optos, is another who doesn't believe the market has matured.

"In the future most optometrists will be focused more on disease detection – they’ll be doing a lot more with imaging devices and diagnostic tools"
Mark Altman, business manager of ophthalmics at Device Technologies

“Technology is always changing, especially within this market and we believe it will continue to expand in the years to come. To thrive in this ophthalmic profession independent practices need to demonstrate that they are serious about ocular health. We see a continued focus in the improvement of patient care, and ultra-widefield imaging being the standard of care for all independent practices,” he said.

Optos launched its newest device in Australia, the Daytona Plus, in July and Martone says, “The response so far has been overwhelmingly positive.”

There’s no doubt that the ultra-widefield (UWF) equipment area is set to expand given that Zeiss entered the UWF category in October with the release of the Clarus 500 and Zeiss medical division manager Mr Dane Moloney sees the increasing importance of ‘combined’ equipment.

“With a growing need for primary eyecare pathology screening and management, the Clarus 500 has been viewed as a diagnostic tool to address both peripheral fundus needs and posterior pole assessment. It’s a 2-in-1 proposition for the cost and space conscious independent practice owner seeking to provide superior patient care from a premium optometric brand,” he said.

Altman echoes Moloney’s point about optometrists needing to consider clinical space requirements within their practice.

“Optometrists have two major costs – time and practice location, rent. As they adopt more imaging modalities and OCT, with increased access to new technology, prices will reduce. That means ‘combined’ equipment will offer space savings with smaller-sized desk areas, and it will help reduce tenancy costs such as rent and overheads,” Altman said.

Other efficiencies are derived from the fact that new instrumentation will better reflect the service needs of the optometrists, which Moloney points out is especially important because “with an increasing ageing population and proliferation of certain chronic diseases, the load on optometrists is likely to increase from a front line ocular pathology diagnosis and management perspective.

“As a result, it is likely that imaging and patient data management software will take on greater importance. Centralisation and the ability to securely transmit data in a co-management environment will be key to continued quality patient care,” Moloney added.

Meanwhile, Altman says in a broader sense, the medical area will see greater progress around genetics, which he expects to be a big driver in healthcare.

“As an equipment company it makes it a little hard to forecast where that will head, however it will open up a whole new area of market. Artificial intelligence will also start to impact in many areas of medicine. Of course, it’s already started but AI will certainly herald some major changes in the ophthalmic professions over the next 5–10 years. This will become a big area.”

Martone shares the opinion that diagnosis will continue to take on a more significant role and says ultra-widefield imaging in particular is regarded as an increasingly important diagnostic tool among optometrists.

“The ability to diagnose and digitally document existing, new and potentially asymptomatic pathology aids in building patient loyalty and trust,” he said, adding that the new Daytona Plus provides a 200 degree field of view in a single image.

“That is done in under .25 of a second and this has allowed our customers to see more patients throughout the day, increasing practice flow and has resulted in the detection of more pathology.”

"There is a good case for optometrists who choose to differentiate themselves and to be recognised as offering much more advanced eyecare."
Robin Lanesman, National sales manager of BOC Instruments

Business efficiency is always important and that’s no different for healthcare professionals, but equipment size should not be the sole focus. While combined devices will certainly be a major focus of equipment suppliers in the future, Moloney points to other issues as well.

“With space a premium in most optometric settings this is a logical pathway, however all optometric device manufacturers would be conscious of potential bottlenecks to clinic workflow. We have worked hard to balance the two and with Clarus 500 the true colour imaging rendered negates the need for a traditional 45 degree digital camera for quality imaging at the posterior pole,” Moloney said.

Lanesman says that the most recent advances with OCT technology has been in OCT Angiography (OCTA) capabilities and enhancements, however, “Many ophthalmic practitioners not yet utilising OCTA are yet to come to terms with the clinical benefits and different ways to view, understand and interpret these highly detailed 3D Angiography images, which significantly differs from traditional 2D Fluorescein Angiography requiring dye injection and dilation.”

Altman believes artificial intelligence (AI) will not only play a larger role for all medical and healthcare categories, but he foresees a time where independent optometrists are truly connected to the digital world via their equipment. 

“It’s not that far off reality where devices will be connected into AI databases which will capture the data and anonymously send it to another database with a broader structure that looks at and analyses all data, and advises on treatment paths as a result,” he predicted.

“We already have data feeding into this AI technology, so I see that as an area with big advancements, along with further understanding of epigenitcs. Genetic testing adds further accessibility to the type of tests that will become more readily available and can decrease healthcare costs in the long term through early detection and intervention.”

To some extent it’s a case of Amara’s Law: We tend to overestimate the effect of a technology in the short run and underestimate the effect in the longrun.

That is, there’s a propensity to overestimate the change that will occur say in the next two years and underestimate major technological advances in the next decade – the future arrives quicker than expected – and if true, the impact of AI on optometry practices might happen sooner rather than later.

“While not diluting the key role optometrists play in treating significant incidence of refractive error in our community, future independent optometrists will have an increasingly crucial role in the management of certain chronic ocular pathology. Ophthalmology will continue to provide significant surgical and procedure based treatment intervention, but will likely need additional support from their optometric partners in the medical management of ocular disease,” Moloney predicts.

Altman agrees: “In the future most optometrists will be focused more on disease detection – they’ll be doing a lot more with imaging devices and diagnostic tools, rather than traditionally being focused on refractions. We have seen in recent years the rapid uptake of OCT technology and although not yet in every practice, it is now commonplace and will become considered standard of care.

“The adoption of new technology by optometrists will become paramount to the focus on disease detection and diagnosis, and thus lead to working more closely with ophthalmologists through referrals to achieve early detection and therefore earlier intervention. ”

Martone points to a recent example: “We installed a new Daytona Plus into a Victorian practice and the owner said, ‘We detected a whole range of retinal diseases and anomalies that we otherwise might not have diagnosed, which means we can will build our practice through patient and GP referral.’”

In essence, the advent of AI at a more local level could further widen the possibilities for optometry in terms of their co-management of diseases.

“These sorts of things open up additional channels and you might start to see markers for a particular disease, such as glaucoma, which means a treatment intervention can take place sooner – even down to one day where certain genes can be switched on or off,” Altman explains.

Lanesman reinforces the view that independent practice owners need to consider the fast changing market: “There is of course a broad range of optometrists practicing on diverse sides of the spectrum. You have those more interested in ocular pathology who aim to provide the most advanced and sophisticated diagnostic clinical care, and those who choose to mostly do refractions and dispensing, as is the case with some chain stores.

“There is a good case for optometrists who choose to differentiate themselves away from that, and to be recognised as offering much more advanced eyecare. However, while we should not forget that advances like AI may be the future, the ultimate responsibility lies with the practitioner to interpret all test results and images for an educated diagnosis.

Test reports and AI have limitations especially in borderline conditions but are often essential, providing the practitioner with necessary information to differentiate pathology from normal and correctly diagnose.”

Equipment comes at a price, however, even more costly losses can result from underestimating its impact and being left behind. Therefore, it's important for optometrists and ophthalmologists to keep pace with technical advances as they emerge, because the ever-increasing speed and significance of evolving technologies means that the market is unlikely to mature in the foreseeable future.


New releases for optovue OCTs

BOC Instrument’s Optovue range of OCTs received a boost in October when the Optovue Avanti-based AngioVue Essential OCTA (Angiography) upgrade was released. The rate of evolution of the technology was underlined further with the announcement of the pending release this month of an expansion of the device’s features through additional software, the AngioVue Comprehensive upgrade package.

The AngioVue Essential is an affordable OCTA upgrade that targets primary eyecare practices. One of its stated aims is to assist the primary care practitioner with decisions related to if, and when, a patient should be referred for specialist care. The rapid, non-invasive imaging of the retinal vasculature offered by OCTA (the imaging is blood-flow based), assists such decision making.

Further, the AngioVue Essential upgrade offers easy OCTA that provides an interpreted, single-page report showing high definition individual layers of the retinal vasculature. Especially for high-risk cases, the Essential enhances a practitioner’s ability to manage patients with ocular disease, as well as any decision-making pursuant to quality eyecare subsequently.

The OCTA Comprehensive upgrade package includes AngioAnalytics, a feature that assesses and quantifies areas of blood flow, areas lacking blood circulation, and vessel density in the retina and optic nerve head. Meanwhile, the AngioVue HD Automatic Montage feature offers a high resolution, panoramic rendering of the retinal vasculature at the macula and optic disc.

Its depth-resolving ability images individual retinal layers as well as enabling the isolation of specific areas of interest and revealing microvasculature in fine detail not seen with conventional FA/ICG.

The OCTA Comprehensive software’s new data-tracking features enable disease timelines and trends to be tracked objectively, along with quantitative data relating to the Superficial and Deep Plexuses, and the Foveal Avascular Zone (FAZ) including area, perimeter, A-circularity, and vessel density.

Optos - Daytona plus

The Australian launch of Optos’ Daytona Plus ultra-widefield imaging instrument in July was the latest offering in a long line of successful products, and helped create and define a new product category.

It provides eyecare professionals with ultra-widefield (UWF) digital images of up to 82% of the human retina, which can be recorded in a single, non-contact Optomap image at high resolution (Optomap 20 microns, Optomap plus 14 microns).

The Optomap images provide optometrists with a trilogy of colour views – the sensory view, the choroidal view, and a composite colour image. With a simple setting change, the Daytona Plus can also provide an autofluorescence (FAF) image.

The Optos Advance software provided with all Daytona Plus models offers auto-montage, a measurement tool, eye steering, and a 3D stereo rendition. Daytona Plus is also available in three optional instrument colour schemes, black with red trim, white with red trim, and white with silver trim.

Enhance practice benefits:

Clinical studies show that Optomap imaging provides faster captures, easier reviewing, and reveals more pathology than traditional fundal examination techniques. The company claims that the routine use of Optomap imaging as part of a comprehensive eye exam can also improve patient flow and increase patient throughput by up to 1.5 patients per working day.

Optomap shows pathology not always visible using only conventional technology. Early signs of many ocular diseases start in the retinal periphery, which is the retinal area most difficult to view using traditional examination techniques and equipment.

That difficulty can mean the early signs go unnoticed, a scenario that can be detrimental to the long-term outcome of the condition due to late detection. Over 500 peer-reviewed studies show the value of Optomap imaging in diagnosis, treatment planning, and patient engagement.

Other features of the Daytona Plus include; the ability to capture non-mydriatic, high-resolution images through pupils as small as 2 mm; eye-steering that further extends the field-of-view, in some cases past the vortex vessels;

Autofluorescence imaging with green laser-light, which displays lipofuscin (brown-yellow in colour) in the RPE; 3D wrap for patient education, and; innovative software tools that enhance image evaluation.

New IOL calculation system

Device Technolgies recently launched an upgrade for the Haag Streit Lenstar Biometer, which addresses one of the great challenges in cataract surgery; that of IOL calculation and the plethora of formulae available to assist that process.

Over time, that process has been refined and now the challenge is not so much avoiding the occasional refractive ‘surprise’, as it is how close to the target Rx one can get. Although having quality biometry measurements is important, something the Haag Streit Lenstar series has provided for many years, the company is also aware of the importance of IOL power calculation.

All previous IOL formulae are based on a theoretical model of the human eye. The Hill-RBF Calculator takes a different approach (Dr Warren Hill, Norfolk, VA) in that it is 100% data-driven, using results from thousands of previous ocular surgeries. RBF (radial basis function) is akin to a neural network, specialised to feature extraction and feature recognition, while capable of handling multiple factors and non-linear relationships.

Hill-RBF provides a significant step up in accuracy of cataract surgery outcomes. It is also the first IOL calculation system to know its limits.

Benchmark data suggests the average cataract surgeon gets within 0.5 D of their target refraction in 50–80% of cases. The top 1% of surgeons meet that goal in 90% or more of cases, no mean feat when all the issues in play are considered – not the least of which is the optical significance of even small physical changes. In a recent study (2016), all surgeons using the Hill-RBF on the Lenstar got 91% or more of their cases within 0.5 D of target, with the best getting over 96% to target Rx.

The new Hill-RBF IOL calculation system is driven by ‘big data’ based on previous cataract surgeries and artificial intelligence pattern recognition, making it a new way of looking at IOL calculation.

Additionally, the integration of toric IOL calculation (the IOL Toric Planner) into the Haag Streit EyeSuite software saves time and reduces the chance of errors. The company views such integration as the perfect combination for demanding toric IOL calculations.

Interestingly, the software ‘learns’ from its user, refining its calculations even further by accessing more data and possibly taking local factors into account.

The Hill-RBF Calculator is not a formula or a series of formulae per se and is claimed to be suitable for all axial lengths (some existing formulae work best in certain ranges of axial length, ie. shorter, normal, or longer). The Hill- RBF Calculator is licensed exclusively on the Haag Streit Lenstar with EyeSuite software.

Zeiss launches UWF retinal camera

Zeiss unveiled the Clarus 500, its newest imaging equipment released in Australia and New Zealand, at the RANZCO Congress in Perth.

The Clarus 500 is a next-generation ultra-widefield retinal camera that provides true colour and clarity in a single fundus image, from a single system.

The images closely resemble the fundus colour as seen during clinical examination, aiding in diagnosis and documentation of ocular disease, and giving confidence when evaluating the optic disc, nevi and other lesions, in which colour is important.

True colour is achieved by uniquely combining three broad spectrum LEDs and this technique also allows the Clarus 500 to separate the true colour image out to the red channel (to reveal the choroid in more detail), the green channel (to provide excellent contrast for the vasculature in particular) and the blue channel (allowing better visualisation of the RNFL).

By leveraging Zeiss optics, it also captures clear and accurate images from the macula to the far periphery and is the only retinal camera that captures a high-resolution ultra-widefield image down to 7μm.

This allows clinicians to use the same image to survey the ultra-widefield areas as well as to zoom into structures such as the optic nerve head and the macula, thereby mitigating the requirement for a second fundus camera for fine detail. This also allows it to be used for stereoscopic evaluation of the optic nerve head.

In addition, Zeiss’s latest device also offers Fundus Autofluorescence (FAF) in both blue and green modes to suit each situation, which allows clinicians to visualise lipofuscin fluorescence in the retinal pigment epithelium (RPE), an indicator of RPE health.

Simple, stable and intuitive, the Clarus 500 is purposefully designed to optimise each patient’s experience by bringing the optics to the patient and swivelling between the right and left eye like a traditional fundus camera.

This helps create an ergonomically comfortable and satisfying patient experience that facilitates images free of obstructions (such as lid and lashes); it also requires fewer recaptures due to the infrared live alignment image giving the operator the best chance of getting the correct image first time.

Additionally, due to the optical design high-resolution external eye images are also possible.

Software upgrade for topcon maestro

Device Technologies has released a major software upgrade for its popular Topcon 3D-OCT-1 Maestro. The upgrade was made available to customers during the third quarter of this year. The Maestro offers wide-field (12 mm x 9 mm), 3D scanning of both the macula and optic disc, all in a single take (single scan).

Adding to its popularity is its added ability to provide a true colour fundus photograph using its integrated fundus camera. The new software builds on these features and offers some significant improvements in patient examination efficiencies, as well as disease detection and monitoring.

It provides in-depth reporting for both retinal and glaucoma analyses, along with a correlation of the patient’s results with normative data. This is combined into a comprehensive analysis in one easy-to-read report on retinal thickness, the retinal nerve fibre layer (RNFL), and retinal ganglion cell layer analysis (RGCL).

The latest release also incorporates progression analaysis from scans taken at consecutive patient visits from the single wide scan. Having so much data available from a single scan is invaluable to any busy practice, improving patient throughput and enhancing practice efficiency.

New imaging equipment gallery


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