With the introduction of widefield retinal imaging, optometrists say they can more easily identify degenerative conditions. This ability to view the peripheral and central retinal regions has not just led to advantages for the practice, they say, but for patients too.
In this article, three practicing optometrists — Jessica Haynes, OD, of Charles Retinal Institute in Germantown, Tenn.; Rachael Wruble, OD, of Belmont Eye in Belmont, N.C.; and Kevin L. Gee, OD, FAAO, of Gee Eye Care in Missouri City, Texas — discuss the practice benefits of widefield retinal imaging, the conditions widefield imaging can help detect and the value of such images.
PRACTICE BENEFITS OF WIDEFIELD IMAGING
When Dr. Haynes’ clinic obtained its first widefield device, she says she regarded it as merely a documentation tool but soon found its value as a diagnostic tool.
“I was also surprised to learn that the more I viewed the images and correlated findings with my clinical exam, the better I was able to accurately diagnose conditions based on the widefield imaging. We think of these as just ‘photographs,’ but there is a learning curve to reading these images, just like we have to learn to read an OCT,” she explains.
Over the first few months with the device, Dr. Wruble says she and her technicians mastered its intricacies. “We really learned how to compare photos side by side and utilize the different filters and tools to monitor pathology,” she says. “Our technicians became well-versed in implementing the device for each patient, educating them on the conditions that the doctors have found.”
“We are not there to ‘sell’ imaging, but we are providing an efficient way to provide care,” she continues. “...We can detect and medically manage conditions that may have been missed.”
Dr. Gee says he feels that peripheral retinal imaging has multiple benefits. He says, “With the new additions in eye care, from new tonometers, refractors, technology like OCT, the concept of dilating a patient is often viewed by patients as archaic and behind the times. To a certain extent it may be, which leads me to my second point: Peripheral retinal imaging allows us to complement dilation. More specifically, it allows for targeted ophthalmoscopy and better detection and evaluation of lesions in the retina.”
“Finally, for some practice[s], this can be an addition[al] revenue stream if they were to charge an additional fee for imaging,” he explains.
Dr. Gee says he also appreciates being able to filter out the “noise” of an image. “In the past, we would always fight through eyelashes and limited views,” he says. “Now, we are able to discern a true lesion/finding vs. ‘noise’ in the background. Oftentimes, I am able to detect the edge of a lesion, then using targeted ophthalmoscopy, dilate and see exactly where I need to scleral depress and examine.”
CONDITIONS WIDEFIELD IMAGING CAN HELP DETECT
Dr. Haynes says the new widefield retinal imaging devices enable more physicians to identify “more and more peripheral retinal degenerations via white without pressure (WWOP)/dark without pressure (DWOP), lattice degeneration, microcystoid degeneration, retinoschisis, and pavingstone.”
However, Dr. Haynes notes it’s important to correlate the widefield device’s findings with a peripheral exam before rushing to judgement. “In particular, WWOP/DWOP and microcystoid degeneration can appear more dramatic with widefield imaging than the clinical exam and can be alarming, as physicians first get comfortable utilizing the technology.”
“We want to properly identify and refer sight-threatening pathology, but we also want to avoid unnecessary referral and undue patient worry, if possible,” Dr. Haynes cautions.
Dr. Wruble says her most commonly seen peripheral retinal images are tears, holes, nevi, and hemes. “What is interesting is that patients may have had a dilated exam years prior, and a nevi may have been missed from overexposure of light from a binocular indirect ophthalmoscope.”
With peripheral imaging, “we are able to adjust filters to detect small and large nevi, tears, and holes,” Dr. Wruble explains.
For Dr. Gee, he says the peripheral retinal condition he most often sees with widefield imaging are small congenital hypertrophy of the retinal pigment epithelium (CHRPE) lesions.
“Albeit harmless and benign, you wonder to yourself, ‘would I have seen that with traditional ophthalmoscopy?’ Patients love seeing lesions like this, and it helps to further build confidence [in us as their primary eye care provider],” he explains.
THE WORTH OF A PICTURE
In addition to widefield imaging’s other benefits, Dr. Haynes says “the ability for a patient to see a picture, scan, or other depiction of their retinal pathology allows for a better understanding of their condition and increases patient compliance.”
Dr. Gee says he agrees this is a valuable feature. “Photo-documentation has always been under-utilized in our profession. I believe that documentation benefits the patient,” especially when a patient can follow the changes in a lesion over time, he says.
Dr. Wruble adds that the imaging “also leads into education with each patient when discussing the photos. [This brings] more awareness to ocular and systemic conditions that we check for at each annual eye exam. For example, when discussing the photos, I let patients know we are looking for conditions, such as diabetes, hypertension, cholesterol plaques, and holes/tears…We are even starting to see more vision care plans cover retinal imaging,” she remarks.
At Dr. Wruble’s office, she says they use widefield tests on medical conditions, such as holes, tears, nevi, and hemes. “The photos can help guide and focus the dilated exam,” she says. “[The device] also allows for side-by-side comparison of images, allowing for better monitoring over time. Sometimes, small holes/tears or nevi are seen on the photos that were not detected at previous exams with dilation, as the patient may have been sensitive to light, giving poor views,” she says.
CASES DEMONSTRATE THE VALUE OF WIDEFIELD IMAGING
Dr. Haynes says she recalls an especially memorable case in which widefield imaging proved key. The patient was referred for unexplained difficulty in nighttime driving, which had been going on for several years, she explains. The clinical exam showed mild pigmentary changes in the peripheral retina, but widefield FAF revealed a significant bilateral disruption of the RPE in a ‘bull’s eye’ pattern, consistent with an inherited retinal disease.
“The patient would later be diagnosed with retinitis pigmentosa, explaining his night vision complaints. The thing that stood out to me the most in this scenario was how much more disease was visible on the widefield FAF than could be detected in the clinical exam.”
Dr. Wruble also describes a case in which peripheral retinal imaging proved a game changer.
“We had a 52-year-old male patient in for a comprehensive eye exam. [Widefield imaging] aided in detecting bear tracking in the peripheral retina,” she notes. “After I asked him more questions, he stated there is a family history of colon cancer. We referred him for a colonoscopy, and he was later diagnosed with Stage 2 colon cancer. Had we completed an anterior examination only, we may have missed a life-threatening condition.”
LOOKING TO THE FUTURE
Dr. Haynes believes that peripheral retinal imaging technology will see increasingly common use and compares it to other advances in imaging.
“Consider how our understanding of peripheral retina pathology may change with the ability to perform testing, such as peripheral OCT. In addition, I foresee that these imaging strategies will only become better over time.”
Reflecting on his experiences in using widefield imaging, Dr. Gee says he’s enthusiastic about retinal imaging’s diagnostic ability.
“I see nothing but an upward trend with this technology,” he points out. “I believe it will soon be the accepted, preferred practice to utilize it alongside targeted ophthalmoscopy. I also see that the resolution will continue to improve and complement other technologies like the OCT.” OM
Editor's Note: As laws from state to state vary and are often revised, we strongly recommend you become familiar with your state’s current laws and requirements regarding comprehensive eye examinations and dilation.