Can we talk a few minutes about ultra-widefield imaging (UWF) without another kind of UWF (ultra-widespread fighting) breaking out?
I hope so.
But first a disclaimer: I have no industry ties—nor shirts, shoes, or pants. All my opinions are generic, straight off the rack, and steeply discounted. There are only a handful of people (mostly non-optometric, no organizations of any stripe on the list) who receive my unqualified endorsement and utter fealty. All others can expect nuance.
That said, I love all the options that I have available for viewing retinas these days. I remember the time I looked through my first 90 D, a small, amber jewel of a lens that I use to this day. I gasped like a slack-jawed 1950s kid in Keds and a coonskin cap staring into a GAF View-Master.
Going high tech
I eventually learned on my own that with a 90 D you can see all the way to the ora with a cooperative and well-dilated patient gazing eccentrically and that its view of the posterior pole through an undilated pupil is usually superior to that of a direct ophthalmoscope.
Fast forward a couple of decades, and I find myself in the middle of a high-tech makeover.
I’m confident with my clinical skills, but now everybody wants more in less time. I realize how easy it would be to miss something significant. I’m looking for every edge I can get to give my patients the best care possible and to reduce both my mental stress and the musculoskeletal pain that’s resulted from the repetitive motions of performing tens of thousands of eye exams.
I petitioned my organization to order:
• A new autorefractor/wavefront aberrometer and automated phoropter
• A tonometer that measures IOP and corneal hysteresis (40 percent of my practice is glaucoma)
• A combination fundus camera/OCT
• An Optos Daytona UWF imager.
Management approved my requests, and I’m both surprised and thrilled. But apparently not everyone.
I catch some flak from my peers when I tell them I have an Optos. And then I read the comments in some online optometry forums and discover that the instrument is as polarizing as a certain light beer was back in the day (“Tastes great!” “Less filling!”). Sometimes the shouting gets so loud that I can’t decide if it’s a battle between haves and have nots, technophobes and technophiles, or camps of religious zealots who dogmatically defend their views of what constitutes a comprehensive eye exam past the point of reason.
Pros and cons of UWF
So, as someone who’s integrated Optos and UWF into my practice, I’m going to cut through the din and give you two cents’ worth of that steeply discounted opinion I mentioned:
• A wide-angle, “bird’s eye” view of around 200 degrees or over 80 percent of the retina in most patients. “The whole is greater than the sum of the parts.” With UWF you don’t get the retina in piecemeal; you get the whole bolt of cloth.
I view my Optos as an extension and enhancement (not a replacement) of indirect ophthalmoscopy. Sometimes when I view a patient’s image prior to the fundus exam, I’m better able to target my ophthalmoscopy toward areas of interest.
• Better penetration of media opacities with Optos’s laser scanning than with the white light of typical fundus photography, even through small pupils. Plus, with poor dilators and uncooperative and/or photophobic patients, it’s very common to get a better view of the retina than with BIO or precorneal lenses.
• I see more choroidal nevi with Optos. I have a hard time with this because I’m deuteranomalous, and I think the bright light of the slit lamp and BIO washes out the contrast so that I have a harder time picking up the subtle gray of nevi.
• Red and green filters allow separate viewing of the choroidal and retinal layers. Fundus autofluorescence (FAF) highlights lipofuscin and subtle AMD-associated pigment changes that may be difficult to appreciate with traditional ophthalmoscopy.
UWF is an excellent way to screen for diabetic retinopathy, and when combined with fluorescein angiography, it can highlight peripheral diabetic lesions which might go unnoticed with traditional ophthalmoscopy.1
• The “Fly-Through” feature is just plain cool. Turning it this way and that makes me feel like Tom Cruise manipulating his gestural interface in Minority Report (see video).
• Lids and shadows partially block the superior and inferior views. With all the dermatochalasis and blepharoptosis in my patient demographic, I often see less than the lofty 200 degrees (but still more than with a 90 D undilated or with BIO and poor dilators and uncooperative and/or photohobic patients).
• Doesn’t replace dilated ophthalmoscopy as the standard of care. Doctors who are hyping Optos (and in some cases, charging extra) as a replacement for dilation should know (and in most cases, probably do) that they’re taking their chances medico-legally.
That said, if I were in a situation in which a patient either wouldn’t or couldn’t be dilated, I would strongly prefer UWF over 90 D through an undilated pupil alone. Standards of care evolve with time and technology, and we may be witnessing such an instance here, especially as optical coherence tomography is added and the color, resolution, and field of view improve over time.
• Less resolution and color, and no stereo. At this point in time, Optos is no replacement of precorneal lens evaluation of glaucomatous optic nerve changes and macula edema and less useful for documentation of optic nerve and posterior pole disorders than traditional fundus photography.
• High cost and spotty customer service. The pricing structure didn’t bother me because I wasn’t footing the bill, admittedly, but it can be a hurdle for many private practices. I can speak to the second one—my calls and emails to customer service have, at times, had the feeling of bureaucratic purgatory. More competition in the future should improve both problems.
• Optos Daytona isn’t the most patient or user-friendly device. Patients often have a hard time centering themselves and “finding the green” in the fixation target to optimize the image. Also, the user doesn’t have a direct view of the retina, and it does take lots of practice to learn how to maximize image quality, especially getting those patient lids out of the way.
I practice better with it
When you shake it all out, I’m still glad I have UWF in my practice. It gives me a valuable alternative view and increases my chances of a correct diagnosis.2 I could practice without it, but I practice better with it.
Oh, and that patient in the video? It was the first time he’d ever seen his retina and his laser repair. He was duly impressed.
But when I tried to do BIO immediately afterward, he was so photophobic that I barely got a glimpse of retina amid all the tearing and tugging.
“I don’t understand,” he protested. “Why are you trying to blind me with that bright light? I thought you already got a good look in the back!”
I started to spout all the dogma and shibboleths about dilation, stereo, and standards of care, but the words just wouldn’t come out. I stood there, slack-jawed, just like that first time I looked through a 90 D.
I had to admit—the man had a point.
1. Sun JK, Aiello, LP. The future of ultrawide field imaging for diabetic retinopathy. JAMA Ophthalmol. 2016 Mar;134(3):247-8.
2. Brown K, Sewell JM, Trempe C, Peto T, Travison TG. Comparison of image-assisted versus traditional fundus examination. J Eye and Brain. 2013;(5):1-8.