Implementation of Ultra-Widefield Retina Imaging

Doctors familiar with the technology discuss practice logistics

Dr. Hariprasad: To begin the discussion, do any of the panel members have any tips or advice for retina specialists who are thinking about implementing ultra-widefield imaging in their practices?

Dr. Kitchens: In general, I like to have the image captured before I see each patient. That way, when I’m sitting down and talking to them about why they are seeing me, whether it’s to evaluate a nevus, rule out diabetic retinopathy, repair a retinal detachment, or something else, I can show them what’s going on in their eye. It gives them a whole new understanding not only of what’s going on but also the severity of it. Patients really appreciate that insight.

Dr. Hariprasad: In terms of clinic flow, that’s a great idea. I’ve told our residents and fellows to use their judgment. If they think a patient needs imaging, they should complete it before I come in, which allows me to perform a comprehensive exam with all of the data that I need in front of me.

Dr. Kiss: When I think about implementing any new piece of equipment in the office, I look at three aspects. The first aspect is the physical space. You may think the Optos 200Tx has a big footprint, but it doesn’t. It’s actually smaller than some of the other equipment and patients can easily settle into the proper position for us to obtain readings. The second aspect I consider is workflow, how I see patients and how the photographer moves patients through the photography or imaging suite. Along with the right physical spot, I thought about where to put this particular machine because it’s used for color photos, fluorescein angiography and autofluorescence.

The third consideration is how an instrument will be tied into the electronic medical records. I like to work paperlessly and call up images right in the exam room. Optos has made it easy to use its images with any image management system.

I would venture to say that we can’t diagnose, treat or follow what we can’t see, and those are the three things we need to be doing every day. OCT technology provides a good analogy. How much more valuable to us are spectral domain OCT systems? … We can detect fluid with both technologies but nobody would trade in their spectral domain OCT for a time domain device — Szilárd Kiss, MD

Dr. Hariprasad: Can you comment on the software platform of the Optos 200Tx?

Dr. Kiss: It’s great. The navigation is nice. I like the false color used in some of the software packages. It’s a bit more true to what we’re used to in traditional white light photography, and it makes some of the pathology look the way we’re used to seeing it. In terms of looking at two images and “registering” them, Optos has a nice feature there. Overall, the software is very user friendly. We can look at the pathology and zoom in on the macula or the periphery. Importantly, we can also show the pathology directly to patients as we ‘fly through’ their eyes using the 3D Wrap Software.

Dr. Hariprasad: I would say, in terms of photographer acceptability, training is crucial. The support we receive from Optos in training photographers to understand the new software, the new way images are obtained, and so on has been invaluable. If you have the buy-in of the photographer, you have less resistance to implementing new technology into the practice.

According to a satisfaction survey we used, patients preferred the ultra-widefield imaging over other modalities because it is more comfortable and takes less time. — Mathew MacCumber, MD, PhD

Dr. MacCumber: I’m impressed with the Optos commitment to technology. We’ve seen it improve to where it’s now a very smooth, easy-to-use system. Patients like it, too. We studied that in our patients with cytomegalovirus (CMV) retinitis.¹ According to the satisfaction survey we used, they preferred the ultra-widefield imaging over other modalities because it is more comfortable and takes less time. The image quality has also improved over the years. For example, early on, we had a problem with tilted discs that has since been corrected.

The viewing stations are easy to use. We have a wonderful zoom mode, and we can see the macula just as well as with a standard fundus camera. We can obtain so much more information in less time.

Dr. Hariprasad: Have you had any issues with patient acceptability?

Dr. MacCumber: I haven’t heard any complaints at all. Patients used to complain about the bright lights with other modalities, especially if we were going for peripheral sweeps. Optos is much faster, which pleases patients, and provides better quality images, which is great for physicians.

Dr. Hariprasad: Because of the widefield sweeps the Optos instruments take, eyelid artifact may come into play. We’ve found that using an external lid speculum is of tremendous value. Alternatively, a skilled photographer can hold the lid open.

Dr. Kitchens: Patients accept the Optos imaging much more readily than they do seven-field photography. With the seven fields, it wasn’t uncommon to have conflicts between patients and photographers, with the photographer saying “OK, look up, look up now, you’ve got to look farther up,” while the patient endures the bright light of the flash. I had almost given up on fluorescein angiography. OCT seemed to show me everything I needed to know, and the fluoresceins used to be so out of focus that I didn’t obtain any useful information from them. With the Optos 200Tx, I’m getting valuable information with greater frequency than with traditional platforms. This is the main reason I adopted the technology so readily.

Dr. Hariprasad: Should retina specialists consider ultra-widefield imaging a must-have technology for their offices?

Dr. Kiss: Every office is different, but I would venture to say that we can’t diagnose, treat or follow what we can’t see, and those are the three things we need to be doing every day. OCT technology provides a good analogy. How much more valuable to us are spectral domain OCT systems compared to the older time-domain machines? We can detect fluid with both technologies, but nobody would dare trade in their spectral domain OCT for a time domain device.

Patients accept the Optos imaging much more readily than they do seven-field photography. With seven fields, it wasn’t uncommon to have conflicts between patients and photographers, with photographers saying, “OK, look up, look up now, you’ve got to look farther up,” while the patient endures the bright light of the flash. — John W. Kitchens, MD

Dr. Kitchens: I’ve looked at many retinas, and I used to think I was seeing so much. For example, in diabetes, I felt like I knew exactly what was going on peripherally. When I got the Optos device and started using the UWFFA, it was like “my gosh, I’ve been missing so much important stuff!” RP