Feature, Report

Retinal imaging with confidence

A market-leading retinal imaging device was the final instrument Western Australian optometrist ADRIAN ROSSITER needed to modernise his equipment suite. He discusses using the device in an optometry setting.

As a full scope optometry practice based in Fremantle, Western Australia, there are few areas of eyecare For Eyes Optometrist won’t venture. Myopia control, axial length measurement, vision therapy, dry eye and intense pulsed light therapy, diabetic retinal screenings, anterior eye imaging, OCT and orthokeratology make up just some of its services.

Principal optometrist Mr Adrian Rossiter, a therapeutically-endorsed Fellow of the Australasian College of Behavioural Optometrists with 40 years’ experience, acquired the independent practice six years ago. He describes himself as an eyecare enthusiast, hence his motivation to modernise his practice with the latest equipment.

Adrian Rossiter, For Eyes Optometrist.

The nature of For Eyes Optometrist means the bulk of its patient-base comprises paediatric patients – some only a few months old – middle-aged patients, and a significant older demographic often affected by the three major sight-threatening diseases: age-related macular degeneration, glaucoma and diabetic retinopathy.

When it came to retinal examinations, For Eyes Optometrist previously traditionally relied on traditional digital photography and, if indicated, a dilated fundus examination and binocular indirect ophthalmoscopy (BIO).

“We had a Canon 45-degree retinal imaging device which was great, however it wasn’t ideal for smaller pupils or a wide image capture,” Rossiter explains.

“Before acquiring our new Optos system, we were also required to use a reasonable amount of skill to capture a good quality image; either by dilation, changing exposures, getting someone to fixate off-centre etc, so it wasn’t necessarily a straight forward process. We were using this to primarily monitor the macula and changes to the optic nerve head in conjunction with OCT scans. For the peripheral retina we had to perform a dilated fundus examination.”

Rossiter was acutely aware of the need to upgrade his retinal imaging capability, particularly for capturing images of the peripheral retina, in what would be the final instrument to modernise his equipment suite. It was a decision he mulled over, running two week-trials with various imaging devices before settling on the Optos Daytona.

The device has been available in Australia for several years, but has undergone continuous hardware and software upgrades. According to Optos, the instrument produces a 200° single-capture optomap retinal image in less than 0.5 seconds. Its ultra-widefield (UWF) imaging technology has been designed for healthy eye screening and has been shown to improve practice flow and patient engagement.

Wanting to embed the Daytona as a screening tool, Rossiter says these features made it an ideal choice for his practice. He’s been able to use it for pupils as small as 2 mm and young children. And the 200° single capture often means he’s able to perform scans without the need to dilate pupils. If a wider field of view is required the instrument can also easily create an image montage, again without the need to dilate.

After installing the device a year ago, he has noticed improved communication with ophthalmologists, largely due to the clarity, scope of the images and easy-to-use software. He’s also found the scan to be a useful education tool, especially for the high number of diabetic patients under his care.

“The beauty of this Optos device is that it is very easy to capture a competent image – that is pretty much a given – and as an optometrist it adds familiarity with what is typically out there in the periphery, so you become adept at differentiating what is pathology versus normal aging changes,” Rossiter explains.

“The huge benefit is that some of the primary conditions optometrists would fear missing, such as a retinal tear, you have much greater confidence that you’re not going to miss routinely because you know you’re seeing 80% of the back of eye in one capture.”

Fitting into the workflow

When hunting for a new retinal imaging device, Rossiter was adamant that he wanted a system that would be used as a screening tool on every patient. In addition to its imaging capabilities, he was drawn to the Daytona due to its reasonable footprint (width: 425 mm, depth: 475 mm, height: 800 mm), speed of image acquisition, and the need to take just one image without pupil dilation.

When patients enter For Eyes Optometrist, they are taken to a pre-screening room where autorefraction, keratometry, intraocular pressure and pachymetry tests are performed. Next, they go into the pre-testing room where scans are taken with the Daytona.

“I still have the original Canon 45-degree camera because I was convinced I would need it to continue following optic nerve imaging, but I’ve been very happy with the image quality provided by the Daytona in this respect, so the Canon has become redundant,” Rossiter explains, noting that it is also easy to compare a time series of images with the Daytona so that subtle retinal changes can be detected.

Optos Daytona.

The Daytona was a big investment the practice didn’t take lightly. But because Rossiter was keen to use it in a screening capacity, he was able to justify the ROI by charging a small incremental fee ($10) across the board, with costs communicated to patients before they visit. Screening a few selected patients didn’t make sense from a clinical or financial perspective.

“And from the experience I have had I am very comfortable we made that decision as well,” he adds.

As an optometrist, Rossiter has been surprised by how much more he can see in the periphery and the clinical confidence this provides. The Daytona’s imaging modalities include colour view, sensory view (red-free), choroid view, and autofluorescence.

“Having the added benefit of autofluorescence is amazing. You not only instantaneously see where something is – whether it’s the choroid layer – but you see things that you would not have a hope of seeing with a red/green image. For example, angoid streaks, changes to Bruch’s membrane, are easily detectable with autofluorescence,” he explains.

“You can also scan the anterior vascular layer right down to the deeper retinal layers, so for simple things we see often, like choroidal nevus, you can quickly determine where it is and whether it has characteristics that are more sinister.”

In patients with cataracts, he’s able to show the obstructive effects of their cataract, impacting the fidelity of the image. He can also clearly spot cuneiform cataracts that sometimes wouldn’t appear without dilation.

“But they show up very clearly in the peripheral retina and it’s something that you might otherwise not have detected,” he says.

Although he could delegate Daytona image acquisition to support staff, Rossiter chooses to capture the image himself, creating important opportunities to educate patients about their conditions and form stronger relationships.

An autofluorescence image of a middle aged male with central serous retinopathy. Image: Adrian Rossiter.

If he spots obvious pathology, he can immediately start thinking about how this will change the nature of the upcoming exam. For diabetic retinopathy patients, the optomap allows Rossiter to demonstrate the impact of leaky blood vessels, seeing patients become more engaged in their treatment. In one recent example, he saw a woman who had been living with diabetes for 14 years. She hadn’t had an eye examination in four years because she was coming to grips with a cancer diagnosis, but thought her prescription needed updating due to deteriorating eyesight.

“I took the first image of the right eye with the Daytona and was taken aback by the number of diabetic retinal haemorrhages. Although not severe, they were spread across her entire posterior pole, and I could also see changes to the macula, so we hadn’t even got to the consulting room and I’m looking at the picture saying this isn’t a glasses problem, it’s a diabetes problem,” he says.

“An OCT scan then confirmed diabetic macula oedema which was reducing the quality of her vision, so I didn’t even get to the traditional eye test because the whole process was short-circuited by the fact I had the relevant information in front of me.”

In another interesting case, Rossiter saw a man who had been bounced between optometrists, unhappy with his clarity of vision. Once he was screened on the Optos Daytona, Rossiter saw he had been treated for a retinal detachment in both eyes, sparking a conversation about his ocular troubles.

“It gave the patient confidence in the practitioner that he immediately understood his eye condition,” he explains.

“Without having ultra-widefield imaging, I wouldn’t have seen those previous retinal changes, or had a sense of the health of his macula and indication of visual acuity this person ultimately is going to have in a pair of specs. It then became an easy conversation to discuss his needs, and then coming up with a solution.

“That was one instance where the machine wasn’t detecting anything new, but it gave the patient a sense of being somewhere where the technology and the eyecare professional is current and up-to-date.”

Finally, when his patients are referred to an ophthalmologist, Rossiter feels the optomap adds quality information, bringing clarity around his referral decision.

“The device and software make it so easy to export images and send off as a PDF to an ophthalmologist. I wouldn’t say the installation of the Daytona has increased my number of referrals, but certainly it has improved practice efficiency and communications with ophthalmologists because we can specifically say this is what I am concerned about, and back it up with the images we have sent via the Oculo system.”

More reading

A new precedent in peripheral pathology detection

Full view: Enhancing retinal pathology detection

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