Raising the Bar in Ocular Imaging

Learn how posterior and anterior segment specialists are using ultra-widefield imaging to better diagnose and manage disease.

BY JUDITH RIDDLE, SENIOR EDITOR

Imagine this: You just took high-definition, digital images of the majority of a patient's retina in a single image capture. You notice pathology in the periphery that would go undetected with your conventional fundus camera. Because of your discovery with this imaging system, you accurately document your patient's pathology, make an earlier and precise treatment decision and produce a favorable visual outcome.

Welcome to the world of ultra-widefield digital imaging.

The advent of ultra-widefield imaging has virtually revolutionized the diagnosis, treatment and management of retinal disease and glaucoma. Furthermore, it has changed the way eyecare practitioners provide preoperative and postoperative care for cataract and refractive surgery patients.

Unlike conventional fundus photography that enables physicians to view up to 30°–50° of the retina at any one time, ultra-widefield imaging, specifically with the Optomap P200 Series (Optos, Marlborough, Mass.), allows ophthalmologists to view up to 200° of the retina in a single image capture — with or without mydriasis. Most often, doctors use this system as an ancillary device to help diagnose pathology in the peripheral retina that may have been missed with standard fundus cameras. The system not only allows doctors to more accurately document pathology, it also enables them to assess disease progression, monitor response to therapy and clearly detect systemic diseases, such as diabetes, hypertension and even certain types of cancers.

Because the ultra-widefield images are digital, physicians can manipulate them by magnifying, reducing, adding or subtracting color, adjusting brightness or changing contrast to zoom in on suspicious pathology.

"[Ultra-widefield imaging technology] is in the process of revolutionizing posterior segment imaging," says Douglas C. Anderson, founder of Optos, Edinburgh, Scotland. "Physicians are making substantial discoveries about the amount of proliferative disease and nonperfusion present in the eye. They're realizing the eye is much sicker than they previously thought, and they're able to treat patients sooner."

According to Sanjeev Nath, MD, a general ophthalmologist and retinal surgeon at The Eye Institute and Laser Center in New York City, ultra-widefield imaging "has markedly improved my approach to diagnosis and disease management. It enables me to see a much larger area of the retina, and I can easily obtain images that point me to pathology much more quickly."

Read on to learn how retina specialists and general ophthalmologists are using the Optomap ultra-widefield digital imaging system, which they believe is enhancing patient care and helping them build their practices.

Rave Reviews in Retina

Because retinal imaging is essential in disease detection and management of the posterior segment, many retina specialists are using the Optos P200MA device — a novel scanning laser ophthalmoscope that features ultra-widefield angiography — to aid in the diagnosis and monitoring of diabetic retinopathy, diabetic macular edema, inflammatory disease, cytomegalovirus and retinal detachment (Figure 1). The device provides simultaneous views of the macula and periphery, as well as a zoom mode for macular angiography. Retina specialists say the technology has greatly affected patient care and treatment in their practices.

Figure 1. Ultra-widefield angiography aids in the diagnosis and monitoring of retinal detachment (shown here), diabetic retinopathy, diabetic macular edema, inflammatory disease and cytomegalovirus.

"Ultra-widefield angiography certainly has changed and refined the way I care for patients," says John W. Kitchens, MD, a retina specialist and partner at Retina Associates of Kentucky. "I've developed a better understanding of the patho genesis of disease, and I can detect and treat disease earlier."

Says Mathew W. MacCumber, MD, PhD, a private practitioner at Illinois Retina Associates, and associate professor and associate chair for research in the department of ophthalmology at Rush University Medical Center, "Because of this technology, we can appreciate pathology in the peripheral retina that we couldn't before. We can image through an undilated pupil or a smaller pupil, which conventional fundus photography doesn't allow us to do. The technology provides excellent images of the posterior pole, so you don't need a second camera to look at the macula. You can use it as your primary camera even in a small practice setting."

Diabetes Care

Ultra-widefield angiography is especially effective in the diagnosis and management of retinal disease associated with diabetes.

"The technology has had the most impact in diagnosing and treating diabetic retinopathy and retinal vein occlusions," Dr. MacCumber says. "These diseases affect the peripheral retina as well as the posterior pole. Ultra-widefield photography helps us to better appreciate the extent of these diseases in the periphery."

Thomas Stone, MD, a retina specialist and partner with Dr. Kitchens at Retina Associates of Kentucky, says ultra-widefield angiography, using the Optos P200MA, has changed the way he treats diabetic macular edema. Before ultra-widefield angiography, he'd initiate treatment with a focal laser. If unsuccessful, he'd administer an intravitreal injection of off-label bevacizumab (Avastin, Genentech) or triamcinolone acetonide (Kenalog, Bristol-Myers Squibb). If this didn't resolve the edema, he'd consider vitrectomy surgery. "With this new technology, I'm able to look at the peripheral retina," Dr. Stone says. "If the patient has significant peripheral nonperfusion, I'll perform panretinal photocoagulation to the nonperfused areas. This reduces macular edema (Figure 2). It's less invasive than vitrectomy and may help prevent vitrectomy in the future."

Figure 2. Ultra-widefield technology has changed the way many retina specialists treat diabetic macular edema, because they're able to target treatment more precisely to produce better visual outcomes.

Dr. Kitchens says, "If a patient has diffuse edema with poor perfusion, I'll treat him with an intravitreal injection of off-label bevacizumab. If a patient has diffuse edema with good perfusion, I'll treat him with an intravitreal corticosteroid and consider focal or grid laser photocoagulation. Before ultra-widefield angiography, my treatment decisions were almost based on trial and error. This new technology enables me to treat patients much more precisely."

What's unique about ultra-widefield angiography is that it gives physicians the ability to deliver treatment that's targeted only to the areas of the retina that need it, therefore sparing healthy tissue.

"You can take digital images of the peripheral retina in a patient with moderate-to-severe proliferative diabetic retinopathy and conclude that he'd benefit precisely from panretinal photocoagulation," Dr. Stone says. "You can miss an opportunity to make an early diagnosis and a more targeted treatment decision if you use fluorescein angiography with conventional camera systems."

Dr. Kitchens agrees. "By having the ability to determine more accurately where the problems are in the retina, you can treat the areas that need it and avoid the healthy areas that don't."

Says Dr. MacCumber, "I can direct my laser more precisely in diabetes patients who have early proliferative diabetic retinopathy. In some cases, I can avoid performing a complete panretinal photocoagulation treatment, which is something I've done routinely in the past when using conventional camera systems."

A Boon in General Ophthalmology

While ultra-widefield imaging has significance in diagnosing and treating retinal disease, it also has important applications in the general ophthalmology practice.

Thomas Henderson, MD, a cataract and refractive surgeon in private practice at Eye Clinic of Austin in Austin, Texas, uses the Optos P200C primarily to document and monitor pathology. The optometrist in his practice uses ultra-widefield imaging as a basic screening tool for 20% to 30% of healthy, well-vision patients.

"We perform basic screenings for patients who are healthy and for their convenience," Dr. Henderson says. "With one ultra-widefield image, you can see most of what you'd see with a full dilated exam. But instead of allocating 30 minutes to dilate a patient, 5 minutes to examine him and then 4 hours for the patient to recover, you spend 2 minutes taking the image and 2 minutes reviewing it with the patient. Plus, it takes 100 views with a direct ophthalmoscope to cover the area you see in one ultra-widefield image. Even then, you couldn't cover the same area with the direct ophthalmoscope — even in a dilated eye."

Figure 3. Ophthalmologists use ultra-widefield imaging to find and document abnormalities, such as wet AMD (shown here), that might identify certain patients as being poor candidates for cataract and refractive surgery.

Moreover, ultra-widefield imaging plays an important role in anterior segment patient care. The technology doesn't allow doctors to examine the anatomy of the anterior segment, such as the crystalline lens or cornea, but it enables them to use it in presurgical and postsurgical applications in cataract and refractive surgery patients.

"Ultra-widefield imaging is a competent way of detecting presurgical risk factors and postsurgical complications because you can view nearly the whole retina," Mr. Anderson says. "For example, if a patient had peripheral retinal breaks, you'd want to know this before cataract surgery. If the patient doesn't have retinal breaks, you'd want to know if he developed them after surgery. The Optos technology enables you to image the majority of the retina and even see through cataracts."

Peyton Neatrour, MD, a cataract and refractive surgeon at Beach Eye Care/Neatrour Eye Institute in Virginia Beach, Va., says he uses the Optos P200C to find and document abnormalities that would identify certain patients as being poor candidates for cataract and refractive surgery. "Ultra-widefield imaging enables me to image and document pathology in the retina that may limit a patient's return of vision following cataract surgery. It also gives me a more targeted prognosis of a patient's visual outcomes post cataract surgery," he says. In potential cataract surgery patients, he looks for retinal pathology such as macular holes, AMD, epiretinal membrane and macular puckering. "The ability of the technology to detect subtle choroidal nevi with the green filtered view is impressive as well," he adds.

Dr. Neatrour also uses the technology for presurgical evaluations in LASIK, CK, ICL and PRK candidates. "Patients who have myopia greater than –5 are at a higher risk for peripheral retinal pathology. Using ultra-widefield technology provides a thorough view of their eyes, which complements the dilated indirect exam," he says.

Utility in Glaucoma

Physicians also use ultra-widefield imaging to more accurately diagnose and manage glaucoma. Doctors can get a clear view of the optic nerve, measure it and examine it in both eyes side by side. In addition, clinicians can measure the ISNT rule and examine the remaining fundus to determine if any retinal pathology exists well into the periphery that might be affecting the optic nerve. These views help confirm whether or not a patient is a glaucoma suspect. "Our technology enables you to pinpoint glaucoma indicators, such as defects in the superior arcade and breaks in the retinal nerve fiber layer, which are linked to an early indication of glaucoma risk," Mr. Anderson says. "Looking at the optic discs on screen side by side is the fastest way to find asymmetry, which is one of the biggest risk factors in determining a glaucoma suspect. You can zoom in on the discs so they take up 90% of the screen."

According to Dr. Neatrour, ultra-widefield imaging enables him to see the optic nerve more clearly and document damage that occurs over time due to glaucoma progression (Figure 4).

Figure 4. With ultra-widefield imaging, physicians can pinpoint glaucoma indicators, such as defects in the retinal nerve fiber layer (shown here), which are linked to an early indication of glaucoma risk. They can view optic discs on screen side by side to find asymmetries — one of the biggest risk factors in determining a glaucoma suspect.

Pictures Worth a Million Words

Because of the clarity of the digital images that show the posterior segment in great detail, doctors have the ability to educate patients about their eyes and eye disease like never before.

"Patients are blown away by the images," Dr. Henderson says. "You can paint a picture with your words and sometimes patients will understand. You can draw a picture with your pen, and patients may understand a little better," he says. "But when you take a picture of their eyes and show them exactly what's going on, there's no doubt they understand what's right or wrong with their eyes. This helps me forge a better therapeutic bond with my patients. I can't emphasize strongly enough how much this technology reinforces the doctor-patient relationship."

Dr. Stone has had and continues to have similar experiences. "Patients are fascinated with the technology. They can see their eyes in a way they've never seen them before," he says. "When I show patients before and after treatment photos, their reactions are positive. I give them confidence about how I take care of them, and it means a lot to them."

Ultra-widefield imaging provides a big wow factor for patients, Dr. Neatrour says. He often uses the 3D Wrap Patient Orientation tool that creates a 3-D model of patients' eyes with the Optomap image in the correct position. The feature provides a virtual tour of patients' eyes to educate them about the anatomy of the eye. "The virtual tour takes patients through the cornea, pupil, the crystalline lens to the back of the eye. This helps them to understand how their condition is affecting their vision."

Another feature of the 3D Wrap is the modeling capability (Figure 5) that allows doctors to illustrate the details of IOL placement in cataract and refractive surgery patients. "Within this model, doctors can simulate the insertion of different types of lenses, while explaining the benefits of monofocal and multifocal IOLs. This is shown on screen in a very graphic and easy-to-understand manner. It's very exciting for patients," Mr. Anderson says.

Figure 5. The 3D Wrap modeling capability feature of the Optomap P200C imaging system creates a 3-D model of patients' eyes, enabling doctors to illustrate the details of IOL placement in cataract and refractive surgery candidates. Doctors can simulate the insertion of different types of lenses, while explaining the benefits of monofocal and multifocal IOLs.

Affordable, Profitable Investment

Despite the many invaluable features of the Optos ultra-widefield digital imaging systems, the technology is affordable for retina specialists and general ophthalmologists who have small, medium or large practices.

Unlike some of the more common financing options, such as monthly lease agreements or upfront cash purchases that manufacturers offer physicians to implement new technology, Optos provides an operating lease program called Access Technology NOW (ATN), which covers basic screenings, advanced imaging procedures and/or fundus photography and fluorescein angiography.

The company offers each ATN model with a monthly lease plan that includes service, upgrades and a pay-per-procedure payment plan. "Our most popular financing option is the operating lease model," says Thomas G. Daniells, global vice president of marketing at Optos. "The doctor pays for the Optomap service on a per-procedure pricing basis, so there's no capital outlay."

Once physicians introduce the technology, they soon realize its profit potential. However, slight differences exist between retina and general ophthalmology practices when it comes to profitability and sources of revenue.

• Retina. The primary source of revenue from the use of ultra-widefield imaging in retina practices comes from medically necessary reimbursable procedures, such as fundus photography and fluorescein angiography. "The financial benefit comes from the incremental use of the technology," Mr. Daniells says.

At Retina Associates of Kentucky, Drs. Kitchens and Stone perform approximately 27 fundus photography and 47 fluorescein angiography procedures per month, generating around $130,000 a year. Dr. Stone says that while high-quality patient care is the chief reason for implementing ultra-widefield technology, the system has increased revenue for certain procedures.

"Since we've had this technology, I've performed 30% more medically necessary fluorescein angiography exams and probably about 10% to 20% more Optomap fluorescein angiography-driven laser surgeries," he says.

• General ophthalmology. Revenue from the use of this technology in general ophthalmology practices comes from reimbursable procedures for diagnosing and monitoring retinal pathology and glaucoma, as well as from annual basic screenings that patients pay for out of pocket. This is the case in Dr. Henderson's practice. He performs approximately 86 fundus photography procedures and 80 basic screenings per month, averaging $109,000 a year.

"I do anywhere from two to 10 ultra-widefield imaging exams a day, so most busy comprehensive ophthalmologists will find this technology to be profitable and practice building," Dr. Henderson says.

Basic screenings are an important revenue stream for general ophthalmology practices, Mr. Daniells says. "Because basic screenings are done annually, physicians can compare images year after year," he adds. "If you can do 100 or more of these procedures and charge $50 to $100 a patient per month, you can bring in an additional $5,000 to $10,000 per month. Many practices can bring in an extra $100,000 per year."

Dr. Neatrour says his practice, which has three locations, expects to perform approximately 394 basic screenings per month, or 4,728 per year, and 297 fundus photography procedures per month, or 3,568 per year. As a result, projected annual revenue from the machine is $460,880.

"We believe the Optos technology provides a 4-to-1 return on investment to the practice," Dr. Neatrour says. "It's such an incredible technology for you and the patient. You'll ask yourself why you didn't introduce it sooner." OM