1. Healthcare

Applications of Wide-field
Imaging
SriniVas
•  Research Grant Recipient: Allergan,
Genentech, Carl Zeiss Meditec, Optovue,
Optos
Sadda, MD
Professor of Ophthalmology
Director,
Medical Retina Unit
Ophthalmic Imaging Unit
Doheny Image Reading Center
Doheny Eye Institute
David Geffen School of Medicine
University of California – Los Angeles
Disclosure
•  Consultant: Allergan, Genentech, Regeneron,
Carl Zeiss Meditec, Optos
RETINAL UPDATE 2015
January 31, 2015
What is widefield imaging?
•  DSMC: e-ROP study (NEI)
Technology for multimodal widefield imaging
Optomap P200Tx
Ø  Multi-wavelength Scanning Laser
Ophthalmoscope
Widefield
•  Red (633), green (532), and blue (488)
Scanning Lasers
•  Virtual Point™ SLO Technology
50 degree mode
Traditional Fundus Camera
–  Optical path allows images to be
captured from a point that is “virtually”
in the eye
Ø  Permits “color”, FA, and autoflourescence
Ø  Scans up to 200° of the Retina
Ø  Image capture in 0.25 seconds
DRCR.net definition:
Widefield = >100 degrees
Ø  Non-mydriatic colour and AF imaging (>
2.0mm pupil size)
Technology for multimodal widefield imaging
Technology for multimodal widefield imaging
•  Heidelberg non-contact widefield angiography
module
•  Staurenghi contact widefield lens
–  150 degrees
–  ?100 degrees
Clinical Ophthalmology
Dovepress
open access to scientific and medical research
ORIGINAL RESEARCH
Open Access Full Text Article
Comparison of ultra-widefield fluorescein
angiography with the Heidelberg Spectralis®
noncontact ultra-widefield module versus
the Optos® Optomap®
Matthew T Witmer
George Parlitsis
Sarju Patel
Szilárd Kiss
Department of Ophthalmology, Weill
Cornell Medical College, New York,
NY, USA
Correspondence: Szilárd Kiss; Matthew
T Witmer
Weill Cornell Medical College,
Department of Ophthalmology,
1305 York Ave, 11th Floor, New York,
NY 10021, USA
Tel 1 646 962 2020
Fax 1 646 962 0602
Email [email protected];
[email protected]
submit your manuscript | www.dovepress.com
Dovepress
http://dx.doi.org/10.2147/OPTH.S41731
Purpose: To compare ultra-widefield fluorescein angiography imaging using the Optos®
Optomap® and the Heidelberg Spectralis® noncontact ultra-widefield module.
Methods: Five patients (ten eyes) underwent ultra-widefield fluorescein angiography using the
Optos® panoramic P200Tx imaging system and the noncontact ultra-widefield module in the
Heidelberg Spectralis® HRAOCT system. The images were obtained as a single, nonsteered
shot centered on the macula. The area of imaged retina was outlined and quantified using Adobe®
Photoshop® C5 software. The total area and area within each of four visualized quadrants was
calculated and compared between the two imaging modalities. Three masked reviewers also
evaluated each quadrant per eye (40 total quadrants) to determine which modality imaged the
retinal vasculature most peripherally.
Results: Optos® imaging captured a total retinal area averaging 151,362 pixels, ranging
from 116,998 to 205,833 pixels, while the area captured using the Heidelberg Spectralis® was
101,786 pixels, ranging from 73,424 to 116,319 (P 0.0002). The average area per individual quadrant imaged by Optos® versus the Heidelberg Spectralis® superiorly was 32,373 vs 32,789 pixels,
respectively (P 0.91), inferiorly was 24,665 vs 26,117 pixels, respectively (P 0.71), temporally
was 47,948 vs 20,645 pixels, respectively (P 0.0001), and nasally was 46,374 vs 22,234 pixels,
respectively (P 0.0001). The Heidelberg Spectralis® was able to image the superior and inferior retinal vasculature to a more distal point than was the Optos®, in nine of ten eyes (18 of
20 quadrants). The Optos® was able to image the nasal and temporal retinal vasculature to a more
distal point than was the Heidelberg Spectralis®, in ten of ten eyes (20 of 20 quadrants).
Conclusion: The ultra-widefield fluorescein angiography obtained with the Optos® and Heidelberg Spectralis® ultra-widefield imaging systems are both excellent modalities that provide
views of the peripheral retina. On a single nonsteered image, the Optos® Optomap® covered
a significantly larger total retinal surface area, with greater image variability, than did the
Heidelberg Spectralis® ultra-widefield module. The Optos® captured an appreciably wider view
of the retina temporally and nasally, albeit with peripheral distortion, while the ultra-widefield
Heidelberg Spectralis® module was able to image the superior and inferior retinal vasculature
more peripherally. The clinical significance of these findings as well as the area imaged on
steered montaged images remains to be determined.
Keywords: peripheral, retina, wide-angle, widefield, ultra-widefield
Introduction
As the site of considerable pathology, visualization of the peripheral retina has become
essential to the screening, diagnosis, monitoring, and treatment of many visionthreatening eye diseases, including diabetic retinopathy.
Clinical Ophthalmology 2013:7 389–394
389
© 2013 Witmer et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
which permits unrestricted noncommercial use, provided the original work is properly cited.
From http://www.revophth.com/content/d/retina/c/35992/`
1
Technology for multimodal widefield imaging
Applications of widefield imaging
Other contact methods
(100-120 degrees)
Panoret 1000
RetCam 3
•  Angiography
•  Color
Transcleral illumination
•  Autofluorescence
Applications of widefield imaging
•  Angiography
Applications of widefield imaging
•  Angiography
–  Peripheral Neovascularization
–  Peripheral Neovascularization
–  Peripheral Non-perfusion
–  Peripheral Non-perfusion
–  Peripheral Vasculitis
–  Peripheral Vasculitis
Why widefield angiography?
Why widefield angiography?
ETDRS: 7 Standard Fields
Traditional Photography: 30 Degrees
•  Still only a relatively
small portion of the
retina is sampled
•  Is this enough for
managing this
patient?
Image courtesy of Szilárd Kiss, MD
Image courtesy of Szilárd Kiss, MD
2
Why widefield angiography?
Ultra-widefield FA (Optos)
ETDRS: 7 Standard Fields
Why widefield angiography?
ETDRS: 7 Standard Fields
•  Is this an unusual case?
•  How frequently are we understaging diabetic retinopathy or
potentially missing lesions that
would affect management?
Image courtesy of Szilárd Kiss, MD
Clinical importance of widefield
imaging for diabetic retinopathy
Kiss et al, Retina 2011
 
 
 
Clinical importance of widefield
imaging for diabetic retinopathy
Kiss et al, Retina 2011
Retrospective review of
diabetic patients who
underwent diagnostic Optos
UW fluorescein angiography
•  UWFA showed 3.2X more total
retinal surface area than 7SF.
•  Compared to 7SF, UWFA also
showed:
–  3.9x more nonperfusion (p<0.001)
–  1.9x more NV (p=0.036)
The respective areas
identified on UWFA were
compared to a modified
ETDRS 7SF image as
–  3.8x more PRP (p=0.001)
•  In 22 eyes (10%), UWFA
demonstrated retinal pathology
(including nonperfusion (n=13) and
neovascularization (n=9)) not
evident in an 7SF overly.
218 eyes of 118 diabetic
patients were included.
Clinical importance of widefield
imaging for diabetic retinpathy
Kiss et al, Retina 2011
Image courtesy of Szilárd Kiss, MD
Several distinct patterns observed
Case: Peripheral PDR
Asymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU
Peripheral Non-perfusion and NV
3
Clinical importance of widefield
imaging for diabetic retinopathy
Case: Peripheral PDR
Asymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU
Several distinct patterns observed
Kiss et al, Retina 2011
Peripheral Retina Relatively Spared
Clinical importance of widefield
imaging for diabetic retinopathy
Several distinct patterns observed
Kiss et al, Retina 2011
Clinical importance of widefield
imaging for diabetic retinopathy
Kiss et al, Retina 2011
Conclusions:
 
 
 
Peripheral Ischemia, mid-peripheral NV
Benefits of widefield
angiography
•  Flourescein Angiography
Compared to conventional imaging,
UWFA demonstrates significantly more
pathology in patients with diabetic
retinopathy.
Improved visualization can alter the
classification of retinopathy; may
influence follow-up and treatment of
these patients.
Clinical significance - targeted peripheral
treatment and effect of anti-VEGF
therapy - currently under investigation
for both diabetic retinopathy and venous
occlusive disease.
Upcoming DRCR.net protocols
Benefits of widefield
angiography
•  Flourescein Angiography
–  Peripheral Neovascularization
–  Peripheral Neovascularization
–  Peripheral Non-perfusion
–  Peripheral Non-perfusion
–  Peripheral Vasculitis
–  Peripheral Vasculitis
4
Case: Re(nal Vein Occlusion Case: Re(nal Vein Occlusion 52 y/o Diabe(c F w/ glaucoma presents with rapid loss of superior visual field ↓ vision OS and NVI Diagnosis: HRVO, background DR
Patient needs PRP (+/- anti-VEGF), but do they need an FA?
Widefield imaging for venous
occlusive disease
Tsui et al,
•  Developed an ischemic index (ISI), based on
the percent of retina that was non-perfused on
UWFA.
•  ISI was correlated with development of
anterior and posterior segment NV.
•  Mean ISI in eves with NV was 75% compared
with 6% in eyes without NV.
•  Ischemic index was significantly correlated to
neovascularization (P <0.0001).
Clinical importance of widefield
imaging for macular edema
Kiss et al, BJO 2012
 
 
 
Case: Venous Occlusive Disease
67 y/o HF with BRVO OS; Va = 20/80
CME
NVI
Tx’d with anti-VEGF + PRP
Studied relationship between peripheral
ischemia and presence of DME
Patients with peripheral retinal ischemia
had a 3.75 times increased odds of
having macular compared to those
without retinal ischemia (p<0.02).
Clinical significance - targeted peripheral
treatment for persistent macular edema
(e.g. in patients undergoing anti-VEGF
therapy) is currently under investigation
for eyes with retinal vascular disease
Case: Venous Occlusive Disease
67 y/o HF with BRVO OS;
After PRP à NVI resolved
Despite 8 monthly anti-VEGF injections and grid laser….
VMT resolved, CME improved but persisted (Va=20/60)
Is VMT a concern here?
5
Case: Venous Occlusive Disease
67 y/o HF with BRVO OS;
After PRP à NVI resolved
Despite 8 monthly anti-VEGF injections and grid laser….
CME improved but persisted (Va=20/60)
Case: Venous Occlusive Disease
67 y/o HF with BRVO OS;
After supplemental PRP
1 month later
Edema further reduced, Va = 20/30
PRP added through this area of non-perfusion
Applications of widefield imaging
•  Angiography
Applications of widefield imaging
•  Angiography
–  Peripheral Neovascularization
–  Peripheral Neovascularization
–  Peripheral Non-perfusion
–  Peripheral Non-perfusion
–  Peripheral Vasculitis
–  Peripheral Vasculitis
Case
62 y/o Asian Female: complained of some “fogginess” of peripheral vision in both eyes, Va =20/25 OU Case
62 y/o Asian Female: complained of some “fogginess” of peripheral vision in both eyes, Va =20/25 OU20/25 OU Dx: Peripheral Vasculi(s OU (only OD shown) Labs: ANA+ 1: 160 (Speckled) Follow-­‐up: mixed connec(ve (ssue disease 6
Next evolution of widefield angiography
Ultrawidefield ICGA
Optos ICG
prototype
Central Serous Chorioretinopathy
Advanced Choroidal
Neovascularization
Courtesy: K. Bailey Freund
Case
Ultrawidefield ICGA
Polypoidal Choroidal Vasculopathy
Courtesy: K. Bailey Freund
Applications of widefield imaging
67 y/o CF with flashing lights and floaters OD Va: 20/20 OU + occludable angles Mio(c pupils: limited view Does pa(ent need an urgent PI? Image captured through undilated pupil
Dx: Macula-on RD with multiple breaks
Applications of widefield imaging
•  Angiography
•  Angiography
•  Color
•  Color
•  Autofluorescence
Answer: Yes
–  Visualization through small pupils or media
opacity
7
Applications of widefield imaging
•  Angiography
74 y/o CM with poor vision OU for his whole life LP
HM •  Color
–  Visualization through small pupils or media
opacity
–  Long Axial Length
Diagnosis: Pathologic myopia with deep staphyloma (axial length: 33mm)
Virtual Point Benefit: Note base of staphyloma and peripheral
retina are both in focus à due to large depth of field
Applications of widefield imaging
Applications of widefield imaging
•  Angiography
•  Angiography
•  Color
•  Color
–  Visualization through small pupils or media
opacity
–  Long Axial Length
Documentation of DR severity
–  Visualization through small pupils or media
opacity
–  Long Axial Length
–  Documentation
Predominantly Peripheral Lesions
Aiello et al, Joslin Diabetes Center
Peripheral Lesions Identified by Mydriatic
Ultrawide Field Imaging: Distribution and
Potential Impact on Diabetic Retinopathy
Severity
Paolo S. Silva, MD,1,2 Jerry D. Cavallerano, OD, PhD,1,2 Jennifer K. Sun, MD, MPH,1,2
Ahmed Z. Soliman, MD,1,2 Lloyd M. Aiello, MD,1,2 Lloyd Paul Aiello, MD, PhD1,2
Objective: To assess diabetic retinopathy (DR) as determined by lesions identified using mydriatic ultrawide
field imaging (DiSLO200; Optos plc, Scotland, UK) compared with Early Treatment Diabetic Retinopathy Study
(ETDRS) 7-standard field film photography.
Design: Prospective comparative study of DiSLO200, ETDRS 7-standard field film photographs, and dilated
fundus examination (DFE).
Participants: A total of 206 eyes of 103 diabetic patients selected to represent all levels of DR.
Methods: Subjects had DiSLO200, ETDRS 7-standard field film photographs, and DFE. Images were graded
for severity and distribution of DR lesions. Discrepancies were adjudicated, and images were compared side by
side.
Main Outcome Measures: Distribution of hemorrhage and/or microaneurysm (H/Ma), venous beading (VB),
intraretinal microvascular abnormality (IRMA), and new vessels elsewhere (NVE). Kappa (k) and weighted
k statistics for agreement.
Results: The distribution of DR severity by ETDRS 7-standard field film photographs was no DR 12.5%;
nonproliferative DR mild 22.5%, moderate 30%, and severe/very severe 8%; and proliferative DR 27%. Diabetic
retinopathy severity between DiSLO200 and ETDRS film photographs matched in 80% of eyes (weighted k ¼
0.74,k ¼ 0.84) and was within 1 level in 94.5% of eyes. DiSLO200 and DFE matched in 58.8% of eyes (weighted
k ¼ 0.69,k ¼ 0.47) and were within 1 level in 91.2% of eyes. Forty eyes (20%) had DR severity discrepancies
between DiSLO200 and ETDRS film photographs. The retinal lesions causing discrepancies were H/Ma 52%,
IRMA 26%, NVE 17%, and VB 4%. Approximately one-third of H/Ma, IRMA, and NVE were predominantly outside
ETDRS fields. Lesions identified on DiSLO200 but not ETDRS film photographs suggested a more severe DR level
in 10% of eyes. Distribution in the temporal, superotemporal, inferotemporal, superonasal, and inferonasal fields
was 77%, 72%, 61%, 65%, and 59% for H/Ma, respectively (P < 0.0001); 22%, 24%, 21%, 28%, and 22% for
VB, respectively (P ¼ 0.009); 52%, 40%, 29%, 47%, and 36% for IRMA, respectively (P < 0.0001), and 8%, 4%,
4%, 8%, and 5% for NVE, respectively (P ¼ 0.03). All lesions were more frequent in the temporal fields compared
with the nasal fields (P < 0.0001).
Conclusions: DiSLO200 images had substantial agreement with ETDRS film photographs and DFE in
determining DR severity. On the basis of DiSLO200 images, significant nonuniform distribution of DR lesions was
evident across the retina. The additional peripheral lesions identified by DiSLO200 in this cohort suggested
a more severe assessment of DR in 10% of eyes than was suggested by the lesions within the ETDRS fields.
However, the implications of peripheral lesions on DR progression within a specific ETDRS severity level over time
are unknown and need to be evaluated prospectively.
Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. Ophthalmology 2013;120:2587e2595 ª 2013 by the American Academy of Ophthalmology.
Management of diabetic eye disease is guided by landmark
clinical trials conducted during the past 40 years.1e10 These
clinical trials established treatment modalities and elucidated the risk for progression, visual loss, and response
to treatment on the basis of the severity level of diabetic
retinopathy (DR). In these trials, DR was evaluated using
! 2013 by the American Academy of Ophthalmology
Published by Elsevier Inc.
• 
Non-mydriatic Optos images have excellent agreement with
dilated ETDRS photos and dilated fundus examination in
determining severity of DR and DME.
mydriatic stereoscopic 30-degree 35-mm retinal photography obtained using a defined protocol of 7-standard retinal
fields in what is referred to as “Early Treatment Diabetic
Retinopathy Study (ETDRS) protocol fundus photography.”
This method of retinal evaluation has been widely adopted
and has generally remained the gold standard for evaluation
ISSN 0161-6420/13/$ - see front matter
http://dx.doi.org/10.1016/j.ophtha.2013.05.004
2587
10% of time
peripheral lesions
suggested a more
severe assessment
than EDTRS 7 fields
Any HMA, IRMA or NVE distributed
>60% outside ETDRS fields
8
Aiello et al, Joslin Diabetes Center
Aiello et al, Joslin Diabetes Center
Key Study Question
•  To determine if the distribution of DR lesions
outside as compared to within the ETDRS 7
standard fields is associated with differences in
DR progression over 4 years.
•  Study approach:
–  ETDRS photos at baseline to determine baseline DR severity
–  UWF imaging at baseline to assess baseline posterior and peripheral
lesion distribution
–  ETDRS photos ~4 years later to assess DR severity change
Posterior vs Peripheral Lesions
•  Total eyes = 109
•  Eyes with any predominantly peripheral lesion
type
•  55 (50%)
•  Eyes without a predominantly peripheral lesion
type
•  54 (50%)
–  Compare DR severity change by posterior and peripheral lesion
distribution at baseline
Predominantly peripheral
retinopathy in diabetes
Aiello et al, Joslin Diabetes Center
Baseline Peripheral Lesion Effect on PDR Onset at 4
Years in Eyes with No DR or NPDR at Baseline (by
ETDRS photos at baseline and followup, N=109)
PDR
Onset
Eyes WITHOUT
Predominantly
Peripheral Lesions
at baseline (N=54)
Eyes WITH
Predominantly
Peripheral Lesions
at baseline (N=55)
Yes
6% (3)
4.2 fold increased
risk
25% (14)
P value*
P value†
0.0069
0.0816
Implications
•  If these findings are confirmed in larger trials
across each DR severity group, careful peripheral
retinal evaluation or peripheral imaging may
become essential in clinical, research and
teleophthalmology settings to more accurately
determine risk of DR progression.
2 year average HbA1c prior to baseline*Fisher’s exact test
†Corrected for baseline DR severity, diabetes duration, diabetes type and
Applications of widefield imaging
ARIA
Assessing diabetic RetInopAthy
Study Objectives:
Ø Longitudinal Prediction of Progression: Patients
will be followed for 5 years to determine the
predictive factor of peripheral lesions on the
progression of diabetic eye disease.
Ø Will look to confirm/corroborate results of the
Joslin ETDRS 7 standard field validation study
Ø  40 sites
Ø  n= 350, FPI – Winter 2014
•  Angiography
•  Color
–  Visualization through small pupils or media
opacity
–  Long Axial Length
–  Documentation
–  Retinopathy screening
53
9
New gold standard for diabetic
retinopathy telescreening
Remote ROP screening
Research
Original Investigation
Validity of a Telemedicine System for the Evaluation
of Acute-Phase Retinopathy of Prematurity
Graham E. Quinn, MD, MSCE; Gui-shuang Ying, PhD; Ebenezer Daniel, MBBS, MS, PhD; P. Lloyd Hildebrand, MD;
Anna Ells, MD, FRCS; Agnieshka Baumritter, MS; Alex R. Kemper, MD, MPH, MS; Eleanor B. Schron, PhD, RN;
Kelly Wade, MD, PhD, MSCE; for the e-ROP Cooperative Group
IMPORTANCE The present strategy to identify infants needing treatment for retinopathy of
prematurity (ROP) requires repeated examinations of at-risk infants by physicians. However,
less than 10% ultimately require treatment. Retinal imaging by nonphysicians with remote
image interpretation by nonphysicians may provide a more efficient strategy.
Supplemental content at
jamaophthalmology.com
OBJECTIVE To evaluate the validity of a telemedicine system to identify infants who have
sufficiently severe ROP to require evaluation by an ophthalmologist.
DESIGN, SETTING, AND PARTICIPANTS An observational study of premature infants starting at
32 weeks’ postmenstrual age was conducted. This study involved 1257 infants with birth
weight less than 1251 g in neonatal intensive care units in 13 North American centers enrolled
from May 25, 2011, through October 31, 2013.
INTERVENTIONS Infants underwent regularly scheduled diagnostic examinations by an
ophthalmologist and digital imaging by nonphysician staff using a wide-field digital camera.
Ophthalmologists documented findings consistent with referral-warranted (RW) ROP (ie,
zone I ROP, stage 3 ROP or worse, or plus disease). A standard 6-image set per eye was sent
to a central server and graded by 2 trained, masked, nonphysician readers. A reading
supervisor adjudicated disagreements.
•  Assessment of diabetic retinopathy
severity from non-myd UWF images
showed excellent agreement with
gold standard screening methods
MAIN OUTCOMES AND MEASURES The validity of grading retinal image sets was based on the
sensitivity and specificity for detecting RW-ROP compared with the criterion standard
diagnostic examination.
RESULTS A total of 1257 infants (mean birth weight, 864 g; mean gestational age, 27 weeks)
underwent a median of 3 sessions of examinations and imaging. Diagnostic examination
identified characteristics of RW-ROP in 18.2% of eyes (19.4% of infants). Remote grading of
images of an eye at a single session had sensitivity of 81.9% (95% CI, 77.4-85.6) and
specificity of 90.1% (95% CI, 87.9-91.8). When both eyes were considered for the presence of
RW-ROP, as would routinely be done in a screening, the sensitivity was 90.0% (95% CI,
85.4-93.5), with specificity of 87.0% (95% CI, 84.0-89.5), negative predictive value of 97.3%,
and positive predictive value of 62.5% at the observed RW-ROP rate of 19.4%.
•  Lower rate of ungradable images
compared to conventional
photographic screening
Retcam 3
CONCLUSIONS AND RELEVANCE When compared with the criterion standard diagnostic
examination, these results provide strong support for the validity of remote evaluation by
trained nonphysician readers of digital retinal images taken by trained nonphysician imagers
from infants at risk for RW-ROP.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01264276
•  Media opacity benefits
JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2014.1604
Published online June 26, 2014.
Author Affiliations: Author
affiliations are listed at the end of this
article.
Group Information: The e-ROP
Cooperative Group members are
listed at the end of the article.
Corresponding Author: Graham E.
Quinn, MD, MSCE, Division of
Ophthalmology, The Children’s
Hospital of Philadelphia, Wood
Center, 1st Floor, Philadelphia, PA
19104 ([email protected]).
E1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - Los Angeles User on 07/29/2014
Non-contact ultra-widefield imaging of ROP
CK Patel et al
592
Table 1 Clinical characteristics of the ROP cases
GA BW PNA
Case (weeks) (g) (weeks) Race
Sex
24
25
785
590
34
70
Caucasian M
Mixed race M
3
4
5
30
24
27
1540
755
1045
34
46
38
Caucasian M
Mixed race F
Caucasian F
6
27
1150
34
Asian
7
8
9
24
23
28
550
590
1120
43
42
351
M
Caucasian F
Mixed race F
Caucasian F
APROP
S3, Z1
Pre-plus
S1, Z3
S2, Z2
S3, Z2
Pre-plus
S3, Z2
Plus
S4b
S4a, Z2
S3, Z1
APROP
S3, Z1
Pre-plus
No ROP
S2, Z2
S3, Z2
Pre-plus
S3, Z2
Plus
S4a
S4a, Z2
S3, Z1
imaging of ROP
591
Applications of widefield imaging
Remote ROP screening
Abbreviations: BW, birth weight; F, female; GA, gestational age; M, male;
PNA, postnatal age; S1–S5, stages 1–5; Z1–Z3, zones 1–3 and plus disease
according to the ICROP classification of ROP.
respectively (Figures 3e and f). The left eye had skip
areas nasally that were treated with additional laser, and
the right eye was managed conservatively.
NC-UWFI in the right eye showed fibrous tissue
associated with a tractional retinal detachment involving
the macula (white arrows in Figure 3e), with the optic
disc indicated by the yellow arrow in Figure 3e. There
was a peripheral retinal detachment seen inferotemporally in the left eye, which is not convincingly
visualised in the Optos image.
“flying baby position”
Case 8: Stage-4a ROP in zone 2
A baby was referred after developing bilateral, threshold
ROP in zone 2 (Figure 4a). Confluent bilateral laser
photocoagulation was performed at 39 weeks PNA and
the baby discharged for ophthalmic review elsewhere.
She developed bilateral stage-4a retinal detachment and
a heavy circumferential cicatrix 5 weeks later. The baby
was re-admitted to our hospital, and treated with
bilateral encirclement and left-sided lens sparing
vitrectomy.
The NC-UWFI from the left eye shows a double ridge
of stage 3 before laser treatment (Figure 4a; white
arrows). Following initial laser treatment, cicatrisation of
the ridge developed, with a subsequent extra-foveal
retinal detachment in the infero-temporal quadrant
(Figure 4b; blue arrow). Lens-sparing vitrectomy to
partially release traction has resulted in the resolution of
retinal detachment, and it is possible to visualise the
residual circular cicatrix that required support with an
encircling band (Figure 4c).
Fast Track Paper
Eye (2013) 27, 589–596
& 2013 Macmillan Publishers Limited All rights reserved 0950-222X/13
www.nature.com/eye
Non-contact
ultra-widefield
imaging of
retinopathy of
prematurity using
the Optos dual
wavelength
scanning laser
ophthalmoscope
Abstract
CK Patel1 , THM Fung1 , MMK Muqit1 , DJ Mordant1 ,
J Brett1 , L Smith1 and E Adams2
CLINICAL STUDY
1
2
Non-contact
ultra-widefield
Grade (S1–S5)
Grade (S1–S5)
Zone (Z1–Z3)
Zoneet
(Z1–Z3)
CK Patel
al
Right eye
Left eye
•  Color
Optos
Aims The purpose of this report is to
demonstrate that a non-contact ultrawidefield dual wavelength laser camera
(Optos) is able to capture high-quality
images in retinopathy of prematurity (ROP).
Materials and methods We conducted a
retrospective review of patients attending the
Oxford Eye Hospital with ROP between
1 August 2012 and 16 November 2012 that
underwent standard clinical assessment.
Anterior segment imaging, where relevant,
was performed with Retcam. Retinal imaging
was then performed with Optos, using a
modified ‘flying baby position’.
Results The Optos scanning laser
ophthalmoscope was able to acquire
ultra-widefield fundal images in nine ROP
subjects. The images obtained show clear
views of the different stages of ROP features
at the posterior pole and peripheral retina.
Regression of ROP features were identified,
following laser and intravitreal bevacizumab
treatment. Additionally, ‘skip areas’ missed
by initial laser treatment could be identified
in the peripheral retina.
Conclusion The Optos ultra-widefield
scanning laser ophthalmoscope is capable of
acquiring clinically useful high-quality
images of the fundus in ROP subjects. The
imaging technique could potentially be used in
monitoring ROP progression and documenting
ROP regression following treatment.
Eye (2013) 27, 589–596; doi:10.1038/eye.2013.45;
published online 22 March 2013
Keywords: retinopathy of prematurity;
ultra-widefield imaging; Optos
Introduction
Our centre uses Retcam (Clarity Medical
Systems, Pleasanton, CA, USA) to monitor
objectively the response to laser treatment of
advanced retinopathy of prematurity (ROP) that
is identified by indirect ophthalmoscopy during
screening. Retcam imaging is useful for teaching
and permits the detection of ‘skip areas’, which
can be dealt with as a top-up treatment. As
Retcam requires contact with the eye, we
became concerned about increased infection
risk when using it in the early postoperative
period, following intravitreal injection of
bevacizumab (Avastin; Roche, Grenzach,
Germany) for high-risk posterior ROP.1 We had
successfully obtained an oral fluorescein
angiogram using a non-contact ultra-widefield
scanning laser ophthalmoscope system in an
infant referred for the management of
incontinentia pigmenti and decided to use the
ophthalmoscope to monitor the therapeutic
response to intravitreal injection of
bevacizumab.2 We felt that the quality of noncontact ultra-widefield imaging (NC-UWFI)
was superior to Retcam in many ways. On the
1
Paediatric Vitreoretinal
Service, Oxford Eye Hospital,
John Radcliffe Hospital,
Oxford, UK
•  Autofluorescence
2
Neonatal Unit, John
Radcliffe Hospital, Oxford,
UK
Correspondence:
CK Patel, Oxford Eye
Hospital, John Radcliffe
Hospital, Oxford OX3 9DU,
UK.
Tel: þ 44 (0)1865 741166;
Fax: þ 44 (0)1865 234515.
E-mail: ckpatel@
btinternet.com
Received: 22 November
2012
Accepted in revised form:
28 February 2013
Published online: 22 March
2013
Applications of widefield imaging
•  Angiography
•  Angiography
Frequency of peripheral FAF
abnormalities in retinal disease
Figure 2 (a) Pseudo-colour fundal Optos image of a baby’s right
eye with stage 1, zone-3 ROP (white arrows). (b) Pseudo-colour
fundal Optos image of a baby’s right eye with stage 2, zone-2 ROP
(white arrows). (c) Pseudo-colour fundal Optos image of a baby’s
left with stage 3, zone-2 ROP and multifocal retinal haemorrhages. Extra-retinal neovascularisation was seen (white arrows).
•  Consecutive series of
patients referred to the
Doheny/USC imaging unit
for FAF imaging
lens-sparing vitrectomies and encirclement with silicone
oil tamponade as a baby. Further surgery involved
division of the buckle and removal of oil for a stage-4b
•  Both 30 degree and UWF
FAF images were obtained
Case 9: Treated stage-3 ROP in zone 1
•  Color
A pseudo-colour fundal image of the left eye has been
acquired through small bound-down pupil (Figure 4d)
and cataract at 7 years of age. The child had had two
Eye
•  Autofluorescence
•  Graded for presence of FAF
abornmalities outside
posterior pole
‘flying baby position’. (b) Pseudo-colour fundal Optos images of a CPAP baby’s right eye with APROP before
inent plus disease with circumferential neovascular proliferation in zone 1 (white arrows) was noted. The
arrow). (c) Pseudo-colour fundal Optos images of a CPAP baby’s right eye with APROP after Avastin injection:
isease was noted (d, e). Pseudo-colour fundal Optos images of a baby with resolved stage 3, zone-1 ROP.
e right eye and zone 3 of the left eye was noted (white arrows).
hages. NC-UWFI of the left eye
3 ROP with pre-plus disease,
w. The extra-retinal neovascularisation
white arrows in Figure 2c.
in zone 2 with plus disease
the retinal images (Figure 3a). Diode laser treatment was
applied to both eyes, and we recorded the disease
activity 1 week later (Figures 3c and d). Skip areas were
seen supero-temporally in the right eye (yellow arrows in
Figure 3c). The plus disease had however improved
bilaterally.
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Frequency of peripheral FAF
abnormalities in retinal disease
•  A total of 461 eyes of 248 patients consecutive patients
in a tertiary care retina practice undergoing FAF imaging
Heussen et al, IOVS, 2012
Disease
Number of Eyes
Age-related macular
degeneration
Inflammatory
Degenerations
•  Atrophy OU, fibrosis OS,
% of Eyes with
Peripheral FAF
Abnormalities
79%
Number with
Abnormal
Peripheral FAF
(%)
Age-related macular degeneration
134
106 (79%)
Central serous chorioretinopathy
17
9 (53%)
Ocular tumors
11
9 (82%)
Inflammatory/infectious diseases
104
74 (71%)
Retinal degenerations
90
74 (82%)
Miscellaneous (diabetic retinopathy,
105
47 (44%)
ALL
461
319 (69%)
retinal vascular occlusive disease,
ocular albinoidism, non-specific
pigmentary changes)
AMD
CSCR
Ocular tumors
Patterns of peripheral FAF in AMD
Patterns of peripheral FAF in AMD
Normal periphery
Granular increased
•  Characteristic
feature: foci of
increased FAF
•  “Color” correlate:
drusen
Patterns of Peripheral FAF in AMD
Pattern
Nonneovascular
AMD (%)
Neovascular
AMD (%)
Normal
27.2
14.0
Granular
51.8
52.3
Nummular
17.5
24.4
Mottled
34.2
48.8
Case
70 y/o Vietnamese male with ↓ vision OU x2Y
20/400 OU
PMHx: Asthma, o/w negative
“Granular Increased FAF”
•  100 consecutive AMD patients: Presence of any abnormal
FAF:
–  Neovascular vs. Non-neovascular AMD: 86.0% vs. 72.8%
(p=0.025)
“Mottled Decreased FAF”
“Nummular Decreased FAF”
11
Case
70 y/o Vietnamese male with ↓ vision OU x2Y
20/400 OU
PMHx: Asthma, o/w negative
Case
70 y/o Vietnamese male with ↓ vision OU x2Y
20/400 OU
PMHx: Asthma, o/w negative
Case
70 y/o Vietnamese male with ↓ vision OU x2Y
20/400 OU
PMHx: Asthma, o/w negative
AMD
AMD
CSCR
Ocular tumors
Inflammatory
Case
70 y/o Vietnamese male with ↓ vision OU x2Y
20/400 OU
PMHx: Asthma, o/w negative
CSCR
Central Serous Chorioretinopathy
Degenerations
•  Punctate areas of decreased FAF with broad
patches of increased FAF (corresponding to
old neurosensory detachment)
Ocular tumors
Inflammatory
Central Serous Chorioretinopathy
Degenerations
% of Eyes with
Peripheral FAF
Abnormalities
53%
•  Full extent of gutters extending from the
macula may be defined
% of Eyes with
Peripheral FAF
Abnormalities
53%
12
AMD
AMD
CSCR
CSCR
Ocular Tumors
Ocular tumors
Inflammatory
Degenerations
Ocular tumors
Inflammatory
Inflammatory/Infectious diseases
Degenerations
•  Choroidal melanoma, striking FAF changes
% of Eyes with
Peripheral FAF
Abnormalities
82%
•  Chronic Vogt-Koyanagi-Harada syndrome
% of Eyes with
Peripheral FAF
Abnormalities
71%
AMD
CSCR
Ocular tumors
Inflammatory
Inflammatory/Infectious diseases
Degenerations
•  Chronic Vogt-Koyanagi-Harada syndrome
% of Eyes with
Peripheral FAF
Abnormalities
71%
AMD
CSCR
Ocular tumors
Inflammatory
Inflammatory/Infectious diseases
Degenerations
•  Multiple chorioretinal scars with
spiraling pattern, etiology unknown
% of Eyes with
Peripheral FAF
Abnormalities
71%
13
AMD
CSCR
Ocular tumors
Inflammatory
Retinal
Degenerations
% of Eyes with
Peripheral FAF
Abnormalities
82%
Rod-cone degenerations
Degenerations
Retinitis Pigmentosa
Rod-cone degenerations
Retinitis Pigmentosa
Retinitis Pigmentosa
Rod-cone degenerations
Retinitis Pigmentosa
Rod-cone degenerations
42 y/o F referred from oculoplastics for unexplained vision loss
20/25 OU
Patient complains of superior field reduction – initially though to be due to ptosis
25 y/o CF with ↓ peripheral vision OU
h/o strabismus
no Fam Hx of eye disease
20/25 OU
Undilated FAF images OU
Optos California
14
Rod-cone degenerations
Stargardt’s disease
25 y/o CF with ↓ peripheral vision OU
h/o strabismus
no Fam Hx of eye disease
20/25 OU
Pigmented Paravenous Retinochoroidal Atrophy (PPRCA)
Stargardt’s disease
Atrophic macular lesions with surrounding hyperfluorescent flecks
No apparent peripeheral disease
Stargardt’s disease
41 y/o CM with progressively ↓ vision OU, 0/14 Ishihara plates No family history of re(nal degenera(on Va: 20/200 OU Extensive peripheral involvement
Stargardt’s disease
•  Hyperfluorescent pisciform lesions (? Peripapillary sparing)
Extension beyond arcades
Stargardt’s disease
41 y/o WM with progressively ↓ vision OU, 0/14 Ishihara plates No family history of re(nal degenera(on Va: 20/200 OU Hypofluorescent lesions
Extensive peripheral involvement
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What’s next?
Multimodal Ultrawidefield
What’s going
on?
•  Additional modalities (“wish list”)
–  OCT
–  Near Infrared Autofluorescence
–  Multicolor
•  Multimodal approach
Courtesy: Szilard Kiss
Conclusions
Multimodal Ultrawidefield
Birdshot
•  Widefield imaging provides important advantages
that are of significant clinical benefit
•  These include:
–  Identification of location and extent peripheral non-perfusion and NV
•  May alter disease staging and treatment strategy (RCT data still required)
–  Visualization through small pupils and media opacity
–  “Big picture” view to facilitate diagnosis
–  Pathognomonic/characteristic findings for many diseases
Courtesy: Szilard Kiss
•  Widefield imaging has become a critical component of our
clinical practice
Thank You
16