There’s a lot to think about when faced with a progressing myope. Is their script up to date? Is the treatment arresting axial length growth? And, most importantly, how can you be sure the retina hasn’t been compromised out in the periphery?
Sydney optometrist Dr Susan Ang could be considered an early adopter in myopia management, but it wasn’t necessarily pursued out of interest.
It was 2004, and her Eyestore practice, an independent located in the western Sydney suburb of Bankstown, had a big focus on paediatric eyecare and a patient-base that was around 95% Asian descent.
With myopes streaming into her consulting room, she needed to offer more than single vision spectacles; the emerging evidence demanded it. So starting out with orthokeratology (orthok), bifocal and multifocal ophthalmic lenses, she got to work expanding her treatment repertoire over the years to include atropine and more precise interventions like specially designed soft lenses and myopia-specific spectacle lenses.
But by 2019, there was a nagging feeling her approach wasn’t complete.
The International Myopia Institute (IMI) was putting out white papers documenting best practice. A biometer for axial length was necessary, but so was an ultra-widefield retinal imaging device if she to was pick up pathologic myopia or other related complications.
“We wanted to go up a notch, just to ensure we were following the IMI papers, obtaining a strong baseline and giving the best level of care to our children,” says Dr Ang, who has certification with the International Academy of Children’s Myopia Management and is an Orthokeratology Society of Oceania member in fellowship training.
“As soon as we installed the Optos Daytona, we began noticing how many retinal holes and tears we were missing, because we usually waited for a symptom or a sign to appear.”
The Daytona is the most common Optos technology found in the optometry setting and in Australia has become a feature of independents looking to step up and differentiate their service. It produces a 200° single-capture retinal image (optomap) – up to 82% of the retina – in less than half a second while offering other functionality like autofluorescence.
For Dr Ang, whose practice sees a high volume of progressing myopes weekly, it’s allowing her to pick up peripheral retinal pathology she couldn’t see otherwise through fundoscopy or biomicroscopy, or to document lesions that would have been recorded with written notes.
“It also removes any doubt or question marks over whether something might have been missed by the optometrist on the day, which is vital from a medico liability point of view, especially when we’re treating so many children – a picture tells 1,000 words,” she says.
“Now we’ve spotted a child as young as 10 with a retinal hole and 14 is the youngest I’ve seen with an asymptomatic tear, so we see great value of using optomap imaging as a screening tool.”
In such cases, they are promptly referred to the vitreoretinal surgeon across the road, Dr Thomas Pham, where several options are on the table like prophylactic barrier laser treatment. He also uses an Optos system, making data sharing seamless.
Every patient starting myopia treatment in Dr Ang’s practice has an optomap taken to obtain a baseline. Others who are -4.00 D or more – regardless of their condition or age – are also recommended, as well as those presenting with flashes and/or floaters.
She’s scanned children as young as three on the device, gaining an insight into the child’s retinal health that would have been extremely difficult otherwise.
In cases of high myopia – a refractive error of at least -6.00D or an axial length of 26.5mm or more – it’s allowed her to check for signs of myopic maculopathy that can impact people in their most productive years.
But Optos technology has also challenged many long-held beliefs.
“We always think that you’ve got to have very long eyeballs to get a tear or a hole – and I think the Optos has prompted us to not follow that misnomer as strictly. ‘It’s not rare, unless it’s in your chair’, kind of thing. It’s shown us they can happen to anybody.”
When describing the value of Optos imaging to her practice, Dr Ang uses words like “failsafe”, “armour guard”, “clinical confidence”. It’s an indisputable, time-stamped record of the patient’s retinal health. It’s vital in a condition like myopia that can progress rapidly, and when other optometrists work under you autonomously.
Plus, with a certain number of scans per week, she’s pretty sure the return on investment (ROI), in monetary terms, has probably been met.
But it’s something she hasn’t thought about much; it’s the hard-to-measure stuff – like loyalty, word-of-mouth-referrals and the patient’s ongoing contribution to society – that reminds her it was an investment worth making.
Getting myopes invested in their plan
Two cases spring to mind for Victorian optometrist Mr Jason Teh when asked when an optomap image has influenced his myopia clinic.
The first, a -3.00 D 14-year-old who visited his In2Eyes practice in Surrey Hills, in Melbourne’s east, had several retinal holes in the extreme periphery.
It was a surprise finding, and after some monitoring he was referred for prophylactic barrier laser treatment.
He recalls another case of a young child who came in earlier than expected for an orthok review due to blurred vision they thought was related to the treatment.
“It turned out to be a retinal detachment. Unfortunately, he had to be referred straightaway to undergo major surgery, a scleral buckle.
“If you’ve got a full-blown retinal detachment, any quick view into the retina will show you that. But with the Optos, it’s nice to be able to see the before and after photos, to see if there were any early signs. In this case, unfortunately, there weren’t any, so it was probably a very acute event.”
Teh picks up lacquer cracks that appear in extremely long eyes, as well as chorioretinal atrophy.
“But that’s very rare. I think I’ve seen that once in 20 years, so it’s main uses are for peripheral degeneration and detecting early retinal detachment for myopic patients. But it images the optic nerve as well, allowing you to see the myopic presence, or any nerve peripapillary atrophy that you can track over time.”
In his practice, his protocol is to monitor young myopic patients every six months, with optomap scans obtained annually.
At the first visit, a montage of scans (central, up, down, left and right), is captured for a baseline. It’s a vital moment to educate patients on myopia, using a 3D eye model the Optos system generates.
He demonstrates how, when the eye elongates, it creates strain on the delicate retinal tissues. It gets the patient invested in their care, to take treatment compliance seriously, and creates an air of professionalism for the optometrist.
Another key feature of the Optos Daytona is fundus autofluorescence, which has proved its worth in extreme cases like myopic maculopathy.
“Depending on what you’re looking for, what structure you’re looking at, the hyperfluorescence will show up as metabolic stress in the RPE, for example, or it might suggest your RPE is undergoing atrophy.
“It allows you to also see chorioretinal changes, which are rare, but the autofluorescence function is quite helpful for assessing the impact of the myopia at different retinal layers.”
It’s the goodwill that counts
Heading back to Sydney, businessman Mr Paul Lee operates three boutique-style practices under The Eye Piece banner. Since 2020, he has been keen to make Optos ultra-widefield imaging standard in the patient journey, realising it was imperative to remain at the “forefront of independent practice”.
“And from a business perspective, I thought it could attract and bring in more patients, but the optometry team has seen huge clinical benefits with it too,” he says.
“The way you take the photo, the way it’s displayed and how the information is relayed helps to elevate the experience too.”
Lee’s optometrists, Ms Patricia Tsong and Ms Adeline Wong, say retinal imaging has become more common in optometry, so it’s becoming easier to encourage most patients to take it up and pay the additional fee.
An Optos Daytona is installed at Lee’s Sydney CBD and Balmain locations. The third practice, in Wahroonga, is surrounded by schools and sees the majority of their myopia patients – but it hasn’t quite got the floor space, so patients are sent to the other locations when a retinal scan is necessary.
In Wong’s experience, she’s typically picking up retinal pathology in high myopes in their 60-70s, and while OCT detects most of myopic maculopathy, optomap imaging has made her job easier to visualise and record peripheral lesions.
For Tsong, she recently picked up a temporal retinal hole in a 16-year-old borderline high myope.
Naturally, patients like this are thankful and relieved. It galvanises the patient-practitioner bond, which is a bonus in progressing myopes early in their eye health journey.
“When we pick something up, the patients are so grateful,” Lee says. “Often Patricia and Adeline get chocolates and flowers as a thank you for preventing something more sinister happening to their vision, so it’s a great outcome for everyone.”
Across town, Dr Ang has had the same experience in her Sydney store. The investment has been more than been justified in monetary terms, but she’s equally happy with the good will it has generated.
“Sometimes you can’t measure impact financially, because when you’ve picked something up and referred that patient, you’ve got them for life,” she says.
“And they’ll start sending their friends and their family along to you too.”
More reading
Why these two Australian optometrists invested in Optos ultra-widefield imaging
A strong business case for Optos ultra widefield imaging
How these Australian ophthalmologists maximise Optos ultra-widefield retinal imaging
