UK-trained ophthalmologist DR OLIVER COMYN made it a priority to install a state-of-the-art imaging device when he joined a well-known private hospital in New Zealand as its sole retinal specialist. Now that piece of equipment has become an essential part of the clinic.
When St George’s Eye Care appointed Dr Oliver Comyn as its first dedicated medical retina specialist, it did so with the intention of expanding its suite of services beyond cataract and glaucoma care.
Comyn arrived at his new post in Christchurch, New Zealand, in 2018 having completed vitreoretinal fellowships at the Sussex Eye Hospital and the world-renowned Moorfields Eye Hospital in London, in addition to internationally published works on diabetic eye disease and retinal imaging.
For St George’s – the first private hospital in New Zealand to invest in fulltime ophthalmologists – it was an important appointment because it meant medical and surgical retinal treatment would become a significant component of the clinic, with Comyn complementing the practice’s other consultant ophthalmologist Dr Paul Baddeley, whom he trained under in West Sussex in 2013-14.
Imaging equipment is a key tool in the repertoire of any medical retinal specialist, so upon his arrival Comyn was determined to advocate for investment in a state-of-the-art instrument that would offer superior results and usability than the existing fundus camera.
That device was the Optos California FA ultra-widefield (UWF) retinal imaging device with optomap. After stating his case, the instrument was swiftly installed and has now cemented its place as a key piece of equipment.
“The hospital recognised in order to have a comprehensive and credible retinal practice we needed something to capture images and conduct fluorescein angiography, without the need to employ a retinal photographer who could use a fundus camera effectively. We also didn’t want to risk acquiring poorer images with the existing camera,” he says.
“Ultra-widefield images are essential to managing retinal disease today, and widefield angiograms and the ability to do targeted laser treatment based on identifying vascular changes in the peripheral retina is part of modern retina care, so my argument was if they were serious about having a retinal specialist who could treat all patients coming through the door then this was the piece of equipment to do that.”
Easy acquisition
Optos California has been available to the Australasian market for five years and remains the company’s premium offering to optometry and ophthalmology practices.
It comes in three versions, with up to six imaging modalities including three-in-one colour depth imaging (colour, red-free and choroidal in a single image), as well as autofluorescence (AF), fluorescein angiography (FA) and indocyanine green angiography (ICG).
According to Optos, the California RG version has been popular among general ophthalmologists because it allows for high resolution 200° ultra-wide field (UWF) colour and AF images of the retina, without the need for dilation, in as little as 0.1 seconds.
The mid-range California FA has the added benefit of UWF angiography to provide diagnostic information of the mid and far periphery for general ophthalmologists and retinal specialists.
California ICG incorporates the technology of the other two models plus interweaved ICG. This added feature is for retinal specialists to optimise management of AMD, uveitic conditions and other choroidal pathology.
According to Optos, up to 82% of the retina is captured in one image, allowing eyecare professionals to see 50% more compared with conventional imaging devices such as the slit lamp, indirect ophthalmascope (30°) and fundus camera (45°).
Since arriving at St George’s, Comyn has grown the retinal patient cohort to fill one clinic out of four each week, with up to 14 patients. Many visit on a regular basis for injection treatments and he also performs retinal surgery at the hospital too.
In addition to the imaging benefits, Comyn says an important factor in choosing Optos California was its usability. It meant the clinic avoided the need for heavy investment in the upskilling of the existing ophthalmic technicians and clinic nurse.
In turn, the instrument could be used to its full capability soon after installation and removed the need for pupil dilation as is necessary in traditional imaging techniques.
“The fundus camera was rarely used before I arrived, and the staff weren’t particularly confident using it; they didn’t understand all the features and hadn’t had formal training as retinal photographers. I wanted the clinic to have a machine that enabled rapid and easy acquisition of images by the technical staff without the need for complicated training or further qualifications,” he says.
“Our staff have been impressed with how quick it is, it doesn’t have any complicated settings, it’s easy to use and acquires really good images. Patients also like seeing images of their eye.”
Further, Comyn says the review software is simple to use. It’s browser- based so images can be reviewed on any computer within the
practice network.
From a disease management perspective, Comyn says the 200° field- of-view is one of California’s greatest strengths, making it possible to view almost the entire peripheral retina with steered views.
“I think it’s important to understand that optomap images don’t replace clinical examination, but they complement it. It’s good for identifying peripheral retinal pathology, such as a small retinal tear you may have otherwise missed. It’s great for assessing how well you’ve applied laser. Sometimes patients can be difficult to examine, they can be light sensitive, blink a lot or they can struggle to get into the right position on the slit lamp for a detailed examination,” he says.
“It also combines photography, fluorescein angiography and autofluorescence imaging in a single machine. Autofluorescence is useful for looking at patients with retinal dystrophies, age-related macular degeneration and pachychoroid disorders like central serous retinopathy.”
As an example of its ability to expose hard-to-spot pathology, Comyn points to a case where an optometrist contacted him about their inability to perform an OCT scan on a patient. The optometrist sent an optomap image and it became clear why the OCT wasn’t functioning.
“The patient had a retinal detachment the optometrist hadn’t noticed on the Optos image. This one was quite shallow and the patient had lots of other changes in their retina that were distracting,” he says.
“It’s a great tool for communicating with optometrists and trying to identify whether the patients need to be referred to an ophthalmologist.”
Due to its ability to show the peripheral retina, Comyn says California is also useful for retinal vascular disease.
“For a case of branch retinal vein occlusion, it can show what you thought was perhaps a fairly small occlusion involving the posterior pole may actually involve quite an extensive amount of the peripheral retina, and you can demonstrate that by normal colour imaging or angiography, which shows a lot more than a fundus camera. This can improve patient care by allowing you to do targeted laser to areas of retinal ischemia.”
Also impressive, Comyn says, is California’s zoom function allowing detailed inspection of the macula, optic nerve head and small pathology. The sophistication of this technology includes a feature where the eyecare professional can take a portion of a historical scan and overlay that with the patient’s latest scan.
He says this had benefits in monitoring disease progression including retinal lesions and choroidal nevi.
“It allows for multi-modal imaging where you can drag a colour image over a fluorescein angiogram image; this allows you to localise angiographic changes such as leaking vessels with actual retinal landmarks,” he says.
Educating patients
The ability to produce clear and detailed images is also said to be a powerful tool to educate patients.
This includes cataract patients, who make up a significant proportion of cases within St George’s Eye Care. Due to the swift image acquisition of California, retinal imaging has become a standard part of the cataract work up – a measure that would be unviable if a fundus camera was the primary imaging tool.
“We use the images educationally to show the effect the cataract might be having on the view of the retina and to show when there’s co-existing pathology – as there frequently is,” Comyn says.
“For example, if they have macular degeneration you can show them the features of the disease on the Optos image and explain how that might have an impact on the final outcome. We find patients really understand what we are talking about when we show them the actual changes in their eye, it makes it much more real rather than being a theoretical idea that they can’t visualise.”
Mr Anton Tesoriero, account manager at Optos Australia, says with three different versions, California has gone from being perceived as a retina specialist product to “must have” for eyecare professionals looking to enhance diagnostic capabilities, practice efficiency and patient experience.
“More than 900 published and ongoing clinical trials, as well as thousands of case studies and testimonials, show the long-term value of optomap imaging in diagnosis, treatment planning, and patient engagement.”
