Ultra-widefield retinal imaging has become so crucial to the clinics that have adopted the technology, they can’t picture practising without it. Two Australian ophthalmologists discuss how their investments in Optos technology has transformed their care.
Regardless of how excellent an ophthalmologist might be at their craft, Canberra retinal subspecialist and cataract surgeon Dr Richard Barry struggles to see how any of his peers could practise today without an ultra-widefield (UWF) retinal camera. In fact, in the not-too-distant future, he believes physically looking into the back of an eye will become redundant in most cases.
As the principal of Blink Eye Clinic – specialising in premium cataract surgery, macular and vitreoretinal surgery and medical retina – Dr Barry says an ultra-widefield camera plays a central role in his practice from a disease diagnosis and management perspective.
But his most recent investment – Optos California – is also offering major advantages in terms of practice efficiency, patient education and documentation. He’s been so impressed with the technology that he’s now considering investing in Optos’ latest instrument – Silverstone, the only model with integrated swept-source OCT (SS-OCT) – which will allow his clinic to screen retinal pathology even more effectively in the periphery.
“From my point of view, it’s a standard of care to have an ultra-widefield device – and Optos is the gold standard in its field,” he says. “For any clinic that doesn’t use ultra-widefield imaging I believe it would be difficult to provide the same quality of service. Having ultra-widefield imaging for most patients on each visit to compare is necessary in my practice – it’s a lot of data to collect, but it’s incredibly useful and makes the consultation so much easier and faster.
“It doesn’t matter how experienced and skilled you are, you can’t consistently achieve this level of data by looking into someone’s eye through a lens or indirect ophthalmoscope and using written documentation.”
The reason Dr Barry, among an increasing number of Australian ophthalmologists and optometrists, has turned to California and other Optos devices (Monaco and Silverstone) comes down to their optomap images capturing approximately 82% and 200° of the retina – something the company says no other device can do in a single shot. Optos has expanded its technology now with nine imaging modalities available across all its platforms, including the recent addition of optomap colour red, green blue laser (rgb), natural colour and blue fundus autofluorescence.
Since acquiring the device, Dr Barry has noticed much greater use of fluorescein angiography (FA) especially in retinal vascular disease and uveitis. This is largely due to the ease that staff can acquire the image, as well as the quality and ultra-widefield obtained.
“We were performing FA on another device previously, and while it’s a great device, the image quality was sometimes poor and required me to search around in the periphery to show staff exactly what I wanted. Whereas now we utilise FA much more because it’s fast, efficient, ultra-widefield and provides an excellent quality image on the California,” he says.
Dr Barry says the technology is creating other efficiencies in the practice, especially when it comes to scan acquisition performed by triage staff – captured in less than 0.5 of a second – and documenting findings at scale over long periods.
“Some key benefits of having an ultra-widefield in your practice are legal and medical documentation and interaction with patients. It’s much more effective than having to draw diagrams and write extensive notes that can be difficult to re-interpret six months, 12 months or two years later versus an actual photograph,” he says.
“In terms of patients, it provides them insight and ownership into how they’re going to be managed, rather than providing a script for an eye drop and saying ‘I’ll see you in six months’ without an understanding of their disease. When you actually show them an optomap image, it’s more engaging and makes consulting that much more enjoyable. Plus, the patients are very impressed – they feel like they’re receiving a great service.”
Patients are happy for another reason too. California and other Optos devices eliminate the need for pupil dilation. This provides a more frictionless practice workflow – and a more convenient experience for those who may need to drive or return to work after the consultation.
Interestingly, when Blink Eye Clinic first trialled the California and compared it with its pre-existing ultra-widefield device, staff initially thought they would prefer what they were familiar with. But after adapting to a new process that requires the patient to position their head before a green circle appears to confirm the image can be captured, it didn’t take long before Optos became their technology of choice.
“It was an adjustment, but then over time staff found the Optos to be much better because it’s fast and convenient. We still have the previous ultra-widefield machine in our clinic, but the California is now used the majority of the time,” Barry adds.
Now that he’s had the chance to appreciate the impact the California on the clinic, Dr Barry says he is considering investing in the Silverstone that has the added functionality of SS-OCT that will be useful as a screening tool for lesions in the peripheral retina. For more detailed diagnostics, he has a separate, standalone OCT that he will continue to use.
“If you’re looking at breaks, schisis, detachments, choroidal nevi, or retinal lesions like CHRPE (congenital hypertrophy of the retinal pigment epithelium) for example, it’s useful to have the SS-OCT feature because currently we need to switch to a separate OCT device to then scan around in the periphery of the retina. So having this technology will create even more efficiencies,” he says.
Major workflow efficiencies
For Dr Simon Chen, the ability to diagnose before even seeing the patient in many cases is one of the great benefits of investing in Optos ultra-widefield technology.
As a retinal and cataract surgeon at Vision Eye Institute in Sydney (across Bondi Junction, Chatswood and Drummoyne) with a busy workload, being able to delegate image acquisition to orthoptic staff and have a large optomap image immediately available on his consulting room monitor is a major time saver.
“Just recently, I had a classic case of a patient presenting with flashing lights and floaters where the Optos clearly demonstrated a macula-on retinal detachment. So even before seeing the patient, I already knew the correct diagnosis and that the patient would require urgent retinal detachment surgery. This enabled me to focus the consultation on education and preparing the patient for surgery,” he says.
“And similarly, in patients with diabetic retinopathy, often we can see very clearly from the optomap image what’s occurring.”
Dr Chen was a relatively early adopter of Optos ultra-widefield and now has three California models installed. His first Optos unit was installed in 2012. “
This was early on when there wasn’t much of this technology around. I had no intention to acquire an Optos device but a company rep talked me into trialling one, which I did for a couple of weeks. I found it so useful, particularly for patients with small pupils that couldn’t dilate properly. There’s no question you can often get a better view with the optomap image than you can by examining the patient, especially when the view of the retina is obscured by conditions such as vitreous haemorrhage or cataract,” he says.
“By the end of the trial period, I had become spoiled by the benefits of using the Optos technology and it had become an important part of my routine clinical workflow so I have been using it ever since.”
From a clinical perspective, he says the California shines in enabling clinical monitoring of pathology in the peripheral retina such as choroidal nevi because these lesions would be very difficult to image otherwise.
“The Optos is often the best way to monitor patients with peripheral retinal pathology to see whether there have been any changes between visits,” he says.
“It’s also useful for assessing the peripheral retina for retinal tears, lattice degeneration and retinal detachments. This is particularly relevant in myopes who are at increased risk of retina detachment, so it facilitates discussions with the patient.”
Optos – and its autofluorescence imaging modality – has also found its place in monitoring geographic atrophy. It’s thought this could become even more relevant with the first approved therapies for this disease expected in the near future in Australia.
“The fundus autofluorescence feature is a great way to assess progression of this disease” Dr Chen says.
“It’s also a simple way of educating patients because it shows black patches where there’s atrophy in the macula, and over time, if those areas enlarge, it’s quite obvious on the optomap image. It makes it easy for patients to understand and visualise the progression of their condition.”
Echoing Dr Barry’s comments in terms of pathology documentation, Dr Chen says by performing optomap scans on each new patient, he can document evidence of the patient’s retinal health at various points in time.
“Even if someone is undergoing straight-forward cataract surgery and has no retinal problems, a baseline image is helpful because if problems arise post-surgery – for example a retinal detachment a few months later – patients can question whether something was missed earlier on,” he says.
“But if you’re able to bring up their optomap scan, you’re able to show they had normal-looking retinas beforehand, which allows them to understand what’s occurred is something new.”
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