&#;

 

New advances in ocular testing equipment present an opportunity for primary care providers to reduce severe vision loss, especially those cases caused by diabetic retinopathy or macular edema. By bringing effective diagnostic eye care to non-eyecare specialists, the latest retinal screening tools make early detection affordable and accessible for both patients and providers. New, innovative eye exam equipment also offers more mobility and enriched capabilities for providers to leverage, including easier travel to retinal exam sites and handheld imaging. 

Choosing the best retinal imaging camera for your practice can be overwhelming, but it&#;s critical to effectively delivering quality care. Here are a few considerations to keep in mind as you select the best camera to fit your practice&#;s unique needs:

Types of Cameras

There are two common types of eye exam equipment used for retinal imaging: tabletop cameras and handheld cameras.

Tabletop Cameras

We use the term &#;tabletop&#; camera to describe cameras that sit on top of a medical instrument table. The two pieces of fully automated retinal exam equipment work hand in hand to deliver the best possible experience for both the camera operator and the patient.

Tabletop cameras tend to be more expensive than portable cameras. However, they do allow operators to take higher-quality images more consistently. Most tabletop cameras offer very high image quality and fully automatic image-capturing capabilities, contributing to ease of use and high user satisfaction.

 

Handheld Cameras

A handheld camera is a smaller, more portable imaging device. This tool is battery-operated and does not need a stand or table to operate. It is best suited for customers who need to be more mobile with their camera to complete their exams successfully, such as those performing fundus photography in patient homes.

Handheld cameras have come a long way in recent years. This type of imaging equipment tends to be more affordable than tabletop cameras, and it allows you to make retinal imaging more accessible to your patients. Handheld cameras are used in homes, mobile clinics, and health fairs and are often shared between remote location

s. A handheld camera also requires a smaller footprint for your clinic, allowing for increased flexibility in space.

Both handheld and tabletop cameras have been proven to be effective eye exam tools for retinal imaging. Most handheld cameras are manual, which requires a bit more practice to achieve optimal image quality. This is not a reason to forgo handheld cameras; instead, it&#;s a reminder to select the right tool based on the needs of your patient population and to provide your personnel with the training they need to use either camera with accuracy and efficiency. 

 

 

In conclusion, handheld cameras are often best for health risk assessment companies or payors looking to provide more complete at-home care services, and tabletop cameras are better suited for healthcare provider offices, as they don&#;t travel well. We see comparable image quality from both solutions; the difference is the type of solution that best fits the needs of your organization. Here&#;s our latest webinar which teaches providers how to use both types of cameras to reach underserved patients:

 

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The Importance of Fundus Image Quality

While price is an important consideration for selecting any imaging equipment, image quality is paramount. Being able to easily capture a high-quality image using the right equipment is critical to the effectiveness of your program. 

IRIS offers a unique solution that includes proprietary image enhancement technology that helps optimize gradability. Couple this with IRIS&#; historic readability rates of approximately 95% and the chance of success is very high. Once the image is captured, a licensed eye care provider can then evaluate the health of a patient&#;s retinas.

Staff training is also critical to ensuring high image quality. Select a service provider that offers training for your staff to ensure that your team can effectively use the camera you choose. IRIS prides itself on providing both onsite and virtual training for all camera types. Not to mention, we know that superior image quality can be achieved with each camera compatible with our software platform. At IRIS, we have a team of training experts that are ready to assist our clients whenever they need it.

The IRIS Partnership with Health Risk Assessments

These days, more and more private organizations are partnering with payor and provider clients participating in value-based care programs that perform in-home health evaluations to evaluate whole-health needs of plan members. These organizations, commonly referred to as HRAs, or Health Risk Assessment companies, find IRIS technology to be useful in improving the accessibility of patient care. Because of the ease, reliability, and portability of the IRIS solution, preventative diabetic retinopathy testing can be done as a part of an at-home care check. The fundus image is taken by the healthcare worker with a handheld portable camera and is uploaded to the IRIS cloud technology platform. It is then automatically enhanced with our proprietary enhancement technology to create a more detailed view of the retinal image. It is then sent through the cloud to the IRIS Reading Center or other licensed eye care providers, and after examination, the results are made available to the HRA. 

Doing preventative testing for diabetic retinopathy straight from a patient&#;s home is a game changer for HRAs in their quest to close the care gap with these types of preventative screenings. It means an additional screening measure can be offered to the HRA&#;s health plan customers as part of the routine check an HRA provider already performs.

Furthermore, it is of paramount importance for these fundus images to have high image quality. If the images taken by a fundus camera are upgradeable, it wastes both time and money. Thus, in order for HRAs to avoid sunken costs, it is important to make image quality a priority in your quest to pick a retinal imaging camera.

Why Ease of Use is so Important

Multiple members of your staff can use new retinal screening tools, but it&#;s important to shorten the learning curve for them as much as possible to mitigate the go-to-market timeline. It is critically important to pick a camera that your staff will be comfortable using. Introducing a new tool can add frustration for your employees, which can ultimately counteract the effectiveness of your program. However, if they can use the tool(s) confidently, it will lead to high satisfaction and engagement in the program, quality retinal imaging, and an increase in early diagnoses of diseases that cause preventable blindness. 

Tabletop cameras are typically much easier to use than handheld devices because tabletop cameras generally are fully automatic, which usually leads to more consistent quality images. A handheld camera gives users more control and portability but requires more manual effort. Because the camera needs to be aligned and focused manually, there is a steeper learning curve. However, with the help of IRIS trainers, this learning curve is lowered drastically.

In addition to the actual camera itself, software and hardware integration must be easy for users. The more proficient your staff is, the more efficiently you can incorporate retinal screening into your practice and provide high-quality results to your patients. 

 

 

There are many factors to consider when choosing to invest in a retinal camera. Your selection will have a lasting impact on your organization and your patients. Leverage these considerations above to make confident decisions as you pick retinal screening tools for your camera operators and patients.

Want to learn more about what kind of eye exam equipment may fit best with your practice? Contact us to learn more!

Interested in learning more about how IRIS is innovating diabetic retinal exams? Check out our blog!

 

Retinal Imaging FAQs

How much are digital retinal cameras?

Retinal (fundus) cameras range dramatically in price depending on a variety of factors including field of visibility, size, and portability. Determining what your practice needs will be key in choosing a camera that meets your needs while remaining within your budget. Our team can help you choose the right camera that meets your practice&#;s needs &#; connect with us today to learn more. 

 

What can retinal imaging detect?

Currently, retinal imaging, done by an eye care professional, has the ability to detect a host of pathologies that affect the eye, such as diabetic retinopathy, HIV retinopathy, hypertension, macular edema, epiretinal, glaucoma, cataracts, wet/dry AMD, macular hole, vein occlusion, etc.  There is ongoing research exploring the possibility of using retinal screenings to detect other issues like Alzheimer&#;s disease.

 

 

SM036 RevB 

Clinical Update

Retinal Imaging: Choosing the Right Method

Retina/Vitreous

Download PDF

"It&#;s just going to keep getting better.&#; That&#;s how K. Bailey Freund, MD, summed up the state of retinal imaging. Perhaps Hermann von Helmholtz said something similar when he introduced the ophthalmoscope in . But he could not have imagined all that his Augenspiegel (eye mirror) has spawned.

Today&#;s devices can reveal all the layers of the retina. Several optical coherence tomography (OCT) devices include color fundus photography capability. And there&#;s a device that takes images and lasers the eye. &#;All the manufacturers are going in the direction of multiple capabilities in one device,&#; said Dr. Freund, at Vitreous-Retina-Macula Consultants of New York. He called retinal imaging &#;a hot field, with a lot of advances occurring very quickly.&#;

Though Dr. Freund is not worried yet about being replaced by a machine, he and other retina specialists agree that imaging has changed the way they identify pathology and monitor response to therapy. It has expanded their view, as well as their understanding, of disease mechanisms and manifestations.

&#;Imaging has revolutionized the management of patients with retinal disease,&#; said Jay S. Duker, MD, at Tufts University. Although OCT may come first to mind, he said, other modalities in the armamentarium keep retina specialists busy debating the relative merits of each.

Optical Coherence Tomography 

OCT has changed clinical practice and opened new areas of understanding.

In practice. OCT is very good at measuring thickness of the retina, so it&#;s helpful for diseases that cause fluid buildup, such as retinal vein occlusion (RVO) and diabetic macular edema (DME), said Dr. Duker. &#;In , you can&#;t treat diabetic macular edema or wet age-related macular degeneration (AMD) without an OCT. It&#;s standard of care for treatment of those diseases.&#;

OCT allows evaluation of different levels of macular ischemia not previously seen with prior imaging modalities. &#;Traditionally, we appreciated only superficial capillary ischemia. But newer OCT and high-resolution systems (resolution down to 3 µm from 10 µm) have revealed an intermediate and a deeper plexus that can also be ischemic. We never appreciated that clinically,&#; said David Sarraf, MD, at Jules Stein Eye Institute, UCLA.

A new window on disease processes. OCT has revealed previously unknown pathology, said Dr. Freund. For example, &#;OCT really helped us understand how macular holes occurred. It made us realize that we were not very good at determining whether fluid was in or beneath the retina. It&#;s helped me understand wet macular degeneration by pinpointing the location of the abnormal new vessels.&#; Are they beneath the RPE, in the subretinal space, or proliferating in the retina itself? This delineation of anatomic subtypes of neovascularization, known as types 1, 2, and 3, respectively, has influenced Dr. Freund&#;s treatment choices.

OCT has revealed the following:

• Subretinal fluid (serous retinal detachment) in RVO and DME

• Vitreomacular traction as the cause of primary (formerly called idiopathic) full-thickness macular hole

• Macular schisis as a manifestation of vitreomacular interface disease (epiretinal membrane and vitreomacular traction)

• Macular schisis as a manifestation of optic nerve disease (acquired optic pits)

Advantages. OCT is noninvasive, reproducible, and easy to interpret, Dr. Duker said. Dr. Sarraf added that it requires neither dye injection nor the bright lights used for color fundus photography, so it&#;s easy on patients.

Downside. OCT doesn&#;t identify blood well, so it won&#;t document or measure a disease with bleeding in the retina, Dr. Duker said.

On the horizon. Most U.S. practices use spectral-domain OCT, said Dr. Freund, noting that the next wave will include swept source OCT (SS-OCT), which is commercially available outside the United States. SS-OCT allows deeper penetration of tissue and faster acquisition. By capturing enhanced depth images of the choroid, SS-OCT deepens our understanding of central serous chorioretinopathy, which is characterized by a thicker-than-normal choroid, he said. Beyond that, Dr. Freund foresees that adaptive optics will be incorporated into OCT.

In addition, OCT is being studied as a possible tool for large-scale screening of asymptomatic patients for conditions including glaucoma and DME.

Ultra-widefield Cameras Expand the Image

A typical fundus camera delivers a 50-degree field of view, but now ultra-widefield imaging systems can deliver 100 degrees or more. Dr. Freund said two systems are now commercially available in the United States that do ultra-widefield imaging.

Optos 200Tx. Using scanning laser ophthalmoscopy, the Optos 200Tx can image the peripheral retina to 200 degrees with single capture. And because it can produce both FA and FAF images, it&#;s becoming more popular among retina specialists, Dr. Freund said. Dr. Sarraf added that it requires no special lenses or dilation.

However, both doctors noted a caveat: The image is created by red and green scanning lasers that produce inaccurate color (pseudocolor), which may limit its interpretation. Further, said Dr. Sarraf, various artifacts may be present, including those caused by the eyelashes or the nose. He said that it&#;s possible to digitally match peripheral images to create a color montage for greater resolution and a better appreciation of the true nature of the disease.

Spectralis. Heidelberg Engineering offers an add-on lens for the Spectralis camera to capture an ultra-widefield view. The add-on is interchangeable with the existing lenses. It has FA and ICGA capability, but not FAF. It is designed to detect and monitor clinically relevant peripheral changes such as microaneurysms, neovascularization, perivascular leakage, or areas of nonperfusion, said Dr. Freund.

Fundus Photography

Color fundus photography captures 30- to 50-degree views of the retina and optic nerve. &#;Virtually every ophthalmologist in the country has a fundus camera,&#; Dr. Duker said. &#;It&#;s widely available, easy to use, and is very good at documenting the appearance of the optic nerve and existence of blood buildup in the eye.&#; But, he added, &#;We rarely make treatment decisions based on the photos.&#;

What&#;s new? Although today&#;s cameras deliver high resolution, color fundus photography hasn&#;t undergone any major transformations since the s, Dr. Sarraf said. More recent developments include enhanced capabilities for creating color montage photographs of the posterior pole and periphery with automated software.

Angiography

Fluorescein angiography. FA has been around since the s. It&#;s good at finding focal lesions to laser. But ever since anti-VEGF therapy supplanted focal laser treatment, &#;focal identification of the lesion is not as important as it once was,&#; Dr. Duker said. &#;Many of us still use fluorescein when first making the diagnosis of wet AMD.&#;

Dr. Sarraf agreed that standard FA is a good baseline tool for fine-tuning the diagnosis of choroidal disorders and neovascular macular degeneration.

A wider view. Ultra-widefield angiography captures 100 to 200 degrees to the periphery and beyond the equator, revealing pathology such as neovascular proliferation or ischemia that can&#;t be identified with standard angiography, Dr. Sarraf said. He uses it to guide laser treatment in diabetic retinopathy and RVO, where lesions extend beyond the macula to the periphery. Other uses include imaging tumors, choroidal melanoma, and some hereditary diseases.

Indocyanine green angiography. ICGA has a more limited role than FA in the clinic, said Dr. Sarraf, noting some of the differences between the methods: In ICGA, the dye is much more protein bound than fluorescein, so less leakage is visible on the angiogram. In addition, the longer wavelength can better penetrate the RPE and blood. As a result, ICGA complements FA, which captures images of retinal circulation above the level of the RPE.

Uses of ICGA include the following:

• Diagnosing polypoidal choroidal vasculopathy (PCV) and certain choroidal tumors, such as choroidal hemangioma

• Refining diagnoses, such as the finding of choroidal vascular hyperpermeability associated with central serous chorioretinopathy

• Assessing choroidal circulation below the RPE and identifying choroidal neovascular membranes associated with retinal pigment epithelial detachments or obscured by blood

Fundus autofluorescence. FAF is not yet in widespread use, although it has gained traction over the last decade and, in some cases, may replace the more invasive fluorescein angiography, said Dr. Sarraf. If you&#;re using FAF, Dr. Freund noted, it&#;s important to know that different systems employ different wavelengths. Heidelberg uses a short blue wavelength; the Optos a longer green wavelength.

Uses include the following:

• Revealing the health of the RPE and buildup of lipofuscin, which is intensely autofluorescent. One such application is in Best disease, which is characterized by lipofuscin deposition and, thus, is easy to diagnose with FAF, Dr. Duker said.

• Seeing where areas of disease have occurred in the back of the eye. &#;It&#;s useful in hereditary macular diseases because they have specific patterns. It&#;s also good at detecting and monitoring drug toxicities, for example, in patients on hydroxychloroquine (Plaquenil),&#; Dr. Freund said.

• Monitoring progression of geographic atrophy in clinical trials.

Pearls

Dr. Sarraf. In a patient who has transitioned from dry to wet macular degeneration, my practice guideline is to obtain a baseline color fundus photo and baseline fluorescein angiogram, along with SD-OCT, to determine if the neovascularization is type 1, 2, or 3, which can influence the prognosis and the aggressiveness of the therapy. Going forward, I use only OCT to judge response to therapy.

Dr. Freund. Don&#;t rely exclusively on OCT printouts. Sometimes you&#;ve acquired hundreds of scans, but the printout shows maybe two. You need to understand the limitations of the automated algorithms. You may misinterpret the results if you don&#;t look at individual scans on the monitor

Dr. Duker. OCT is going to become increasingly important in the practice of ophthalmology from front to back. Angiography will become increasingly less important because OCT will be able to do some&#;or perhaps all&#;of the things that angiography does. Finally, there&#;s a place for autofluorescence in a referral practice.

Better and Better

Regardless of the advances in imaging, the experience of a skilled clinician is still essential in fundus examination, for example, in assessing the health of the disc and identifying peripheral retinal tears and detachments, Dr. Sarraf said. And unlike the exam, no machine can &#;give a sense of comfort and satisfaction to the patient.&#;

But these sophisticated systems have enhanced clinical practice. &#;Our understanding of retinal and macular disease is much more clearly defined,&#; Dr. Sarraf said. And there&#;s more to discover. &#;There&#;s always mystery involved in the retina.&#; 

___________________________

Jay S. Duker, MD, is director of New England Eye Center and professor and chairman of ophthalmology at Tufts Medical Center, Tufts University School of Medicine. Financial disclosure: Receives research support from Carl Zeiss Meditec; is a consultant to Alcon/Novartis, Allergan, EMD Serono, Optos, Regeneron, and Thrombogenics; and holds stock in Eye-Netra, Hemera Biosciences, and Ophthotech.

K. Bailey Freund, MD, is a member of Vitreous-Retina-Macula Consultants of New York and clinical associate professor of ophthalmology at New York University School of Medicine. Financial disclosure: Consults for Bayer HealthCare, Genentech, Heidelberg Engineering, and Regeneron.

David Sarraf, MD, is clinical professor of ophthalmology in the Retinal Disorders and Ophthalmic Genetics Division at Jules Stein Eye Institute, University of California, Los Angeles. Financial disclosure: Is a speaker for Heidelberg and has an investigator grant with Regeneron.

Informed Consent

Video is an effective and versatile tool in the informed consent process. Concise informed consent videos save you time, increase practice efficiency, and bolster patient understanding.

The Academy&#;s downloadable Retina Informed Consent Video Collection (#V) includes 21 short videos&#;each about five minutes long&#;on specific, common retinal conditions. OMIC-reviewed, each video clearly explains risks and benefits to enhance patient understanding, encourage consent, improve compliance, and set realistic expectations to mitigate malpractice risk.

The collection of 21 retina topics (provided in both English and Spanish) is $545 for Academy members, $709 for nonmembers. Choose from a variety of file formats.

 

 

SM036 RevB 

Clinical Update

Retinal Imaging: Choosing the Right Method

Retina/Vitreous

Download PDF

"It&#;s just going to keep getting better.&#; That&#;s how K. Bailey Freund, MD, summed up the state of retinal imaging. Perhaps Hermann von Helmholtz said something similar when he introduced the ophthalmoscope in . But he could not have imagined all that his Augenspiegel (eye mirror) has spawned.

Today&#;s devices can reveal all the layers of the retina. Several optical coherence tomography (OCT) devices include color fundus photography capability. And there&#;s a device that takes images and lasers the eye. &#;All the manufacturers are going in the direction of multiple capabilities in one device,&#; said Dr. Freund, at Vitreous-Retina-Macula Consultants of New York. He called retinal imaging &#;a hot field, with a lot of advances occurring very quickly.&#;

Though Dr. Freund is not worried yet about being replaced by a machine, he and other retina specialists agree that imaging has changed the way they identify pathology and monitor response to therapy. It has expanded their view, as well as their understanding, of disease mechanisms and manifestations.

&#;Imaging has revolutionized the management of patients with retinal disease,&#; said Jay S. Duker, MD, at Tufts University. Although OCT may come first to mind, he said, other modalities in the armamentarium keep retina specialists busy debating the relative merits of each.

Optical Coherence Tomography 

OCT has changed clinical practice and opened new areas of understanding.

In practice. OCT is very good at measuring thickness of the retina, so it&#;s helpful for diseases that cause fluid buildup, such as retinal vein occlusion (RVO) and diabetic macular edema (DME), said Dr. Duker. &#;In , you can&#;t treat diabetic macular edema or wet age-related macular degeneration (AMD) without an OCT. It&#;s standard of care for treatment of those diseases.&#;

OCT allows evaluation of different levels of macular ischemia not previously seen with prior imaging modalities. &#;Traditionally, we appreciated only superficial capillary ischemia. But newer OCT and high-resolution systems (resolution down to 3 µm from 10 µm) have revealed an intermediate and a deeper plexus that can also be ischemic. We never appreciated that clinically,&#; said David Sarraf, MD, at Jules Stein Eye Institute, UCLA.

A new window on disease processes. OCT has revealed previously unknown pathology, said Dr. Freund. For example, &#;OCT really helped us understand how macular holes occurred. It made us realize that we were not very good at determining whether fluid was in or beneath the retina. It&#;s helped me understand wet macular degeneration by pinpointing the location of the abnormal new vessels.&#; Are they beneath the RPE, in the subretinal space, or proliferating in the retina itself? This delineation of anatomic subtypes of neovascularization, known as types 1, 2, and 3, respectively, has influenced Dr. Freund&#;s treatment choices.

OCT has revealed the following:

• Subretinal fluid (serous retinal detachment) in RVO and DME

• Vitreomacular traction as the cause of primary (formerly called idiopathic) full-thickness macular hole

• Macular schisis as a manifestation of vitreomacular interface disease (epiretinal membrane and vitreomacular traction)

• Macular schisis as a manifestation of optic nerve disease (acquired optic pits)

Advantages. OCT is noninvasive, reproducible, and easy to interpret, Dr. Duker said. Dr. Sarraf added that it requires neither dye injection nor the bright lights used for color fundus photography, so it&#;s easy on patients.

Downside. OCT doesn&#;t identify blood well, so it won&#;t document or measure a disease with bleeding in the retina, Dr. Duker said.

On the horizon. Most U.S. practices use spectral-domain OCT, said Dr. Freund, noting that the next wave will include swept source OCT (SS-OCT), which is commercially available outside the United States. SS-OCT allows deeper penetration of tissue and faster acquisition. By capturing enhanced depth images of the choroid, SS-OCT deepens our understanding of central serous chorioretinopathy, which is characterized by a thicker-than-normal choroid, he said. Beyond that, Dr. Freund foresees that adaptive optics will be incorporated into OCT.

In addition, OCT is being studied as a possible tool for large-scale screening of asymptomatic patients for conditions including glaucoma and DME.

Ultra-widefield Cameras Expand the Image

A typical fundus camera delivers a 50-degree field of view, but now ultra-widefield imaging systems can deliver 100 degrees or more. Dr. Freund said two systems are now commercially available in the United States that do ultra-widefield imaging.

Optos 200Tx. Using scanning laser ophthalmoscopy, the Optos 200Tx can image the peripheral retina to 200 degrees with single capture. And because it can produce both FA and FAF images, it&#;s becoming more popular among retina specialists, Dr. Freund said. Dr. Sarraf added that it requires no special lenses or dilation.

However, both doctors noted a caveat: The image is created by red and green scanning lasers that produce inaccurate color (pseudocolor), which may limit its interpretation. Further, said Dr. Sarraf, various artifacts may be present, including those caused by the eyelashes or the nose. He said that it&#;s possible to digitally match peripheral images to create a color montage for greater resolution and a better appreciation of the true nature of the disease.

Spectralis. Heidelberg Engineering offers an add-on lens for the Spectralis camera to capture an ultra-widefield view. The add-on is interchangeable with the existing lenses. It has FA and ICGA capability, but not FAF. It is designed to detect and monitor clinically relevant peripheral changes such as microaneurysms, neovascularization, perivascular leakage, or areas of nonperfusion, said Dr. Freund.

Fundus Photography

Color fundus photography captures 30- to 50-degree views of the retina and optic nerve. &#;Virtually every ophthalmologist in the country has a fundus camera,&#; Dr. Duker said. &#;It&#;s widely available, easy to use, and is very good at documenting the appearance of the optic nerve and existence of blood buildup in the eye.&#; But, he added, &#;We rarely make treatment decisions based on the photos.&#;

What&#;s new? Although today&#;s cameras deliver high resolution, color fundus photography hasn&#;t undergone any major transformations since the s, Dr. Sarraf said. More recent developments include enhanced capabilities for creating color montage photographs of the posterior pole and periphery with automated software.

Angiography

Fluorescein angiography. FA has been around since the s. It&#;s good at finding focal lesions to laser. But ever since anti-VEGF therapy supplanted focal laser treatment, &#;focal identification of the lesion is not as important as it once was,&#; Dr. Duker said. &#;Many of us still use fluorescein when first making the diagnosis of wet AMD.&#;

Dr. Sarraf agreed that standard FA is a good baseline tool for fine-tuning the diagnosis of choroidal disorders and neovascular macular degeneration.

A wider view. Ultra-widefield angiography captures 100 to 200 degrees to the periphery and beyond the equator, revealing pathology such as neovascular proliferation or ischemia that can&#;t be identified with standard angiography, Dr. Sarraf said. He uses it to guide laser treatment in diabetic retinopathy and RVO, where lesions extend beyond the macula to the periphery. Other uses include imaging tumors, choroidal melanoma, and some hereditary diseases.

Indocyanine green angiography. ICGA has a more limited role than FA in the clinic, said Dr. Sarraf, noting some of the differences between the methods: In ICGA, the dye is much more protein bound than fluorescein, so less leakage is visible on the angiogram. In addition, the longer wavelength can better penetrate the RPE and blood. As a result, ICGA complements FA, which captures images of retinal circulation above the level of the RPE.

Uses of ICGA include the following:

• Diagnosing polypoidal choroidal vasculopathy (PCV) and certain choroidal tumors, such as choroidal hemangioma

• Refining diagnoses, such as the finding of choroidal vascular hyperpermeability associated with central serous chorioretinopathy

• Assessing choroidal circulation below the RPE and identifying choroidal neovascular membranes associated with retinal pigment epithelial detachments or obscured by blood

Fundus autofluorescence. FAF is not yet in widespread use, although it has gained traction over the last decade and, in some cases, may replace the more invasive fluorescein angiography, said Dr. Sarraf. If you&#;re using FAF, Dr. Freund noted, it&#;s important to know that different systems employ different wavelengths. Heidelberg uses a short blue wavelength; the Optos a longer green wavelength.

Uses include the following:

• Revealing the health of the RPE and buildup of lipofuscin, which is intensely autofluorescent. One such application is in Best disease, which is characterized by lipofuscin deposition and, thus, is easy to diagnose with FAF, Dr. Duker said.

• Seeing where areas of disease have occurred in the back of the eye. &#;It&#;s useful in hereditary macular diseases because they have specific patterns. It&#;s also good at detecting and monitoring drug toxicities, for example, in patients on hydroxychloroquine (Plaquenil),&#; Dr. Freund said.

• Monitoring progression of geographic atrophy in clinical trials.

Pearls

Dr. Sarraf. In a patient who has transitioned from dry to wet macular degeneration, my practice guideline is to obtain a baseline color fundus photo and baseline fluorescein angiogram, along with SD-OCT, to determine if the neovascularization is type 1, 2, or 3, which can influence the prognosis and the aggressiveness of the therapy. Going forward, I use only OCT to judge response to therapy.

Dr. Freund. Don&#;t rely exclusively on OCT printouts. Sometimes you&#;ve acquired hundreds of scans, but the printout shows maybe two. You need to understand the limitations of the automated algorithms. You may misinterpret the results if you don&#;t look at individual scans on the monitor

Dr. Duker. OCT is going to become increasingly important in the practice of ophthalmology from front to back. Angiography will become increasingly less important because OCT will be able to do some&#;or perhaps all&#;of the things that angiography does. Finally, there&#;s a place for autofluorescence in a referral practice.

Better and Better

Regardless of the advances in imaging, the experience of a skilled clinician is still essential in fundus examination, for example, in assessing the health of the disc and identifying peripheral retinal tears and detachments, Dr. Sarraf said. And unlike the exam, no machine can &#;give a sense of comfort and satisfaction to the patient.&#;

But these sophisticated systems have enhanced clinical practice. &#;Our understanding of retinal and macular disease is much more clearly defined,&#; Dr. Sarraf said. And there&#;s more to discover. &#;There&#;s always mystery involved in the retina.&#; 

___________________________

Jay S. Duker, MD, is director of New England Eye Center and professor and chairman of ophthalmology at Tufts Medical Center, Tufts University School of Medicine. Financial disclosure: Receives research support from Carl Zeiss Meditec; is a consultant to Alcon/Novartis, Allergan, EMD Serono, Optos, Regeneron, and Thrombogenics; and holds stock in Eye-Netra, Hemera Biosciences, and Ophthotech.

K. Bailey Freund, MD, is a member of Vitreous-Retina-Macula Consultants of New York and clinical associate professor of ophthalmology at New York University School of Medicine. Financial disclosure: Consults for Bayer HealthCare, Genentech, Heidelberg Engineering, and Regeneron.

David Sarraf, MD, is clinical professor of ophthalmology in the Retinal Disorders and Ophthalmic Genetics Division at Jules Stein Eye Institute, University of California, Los Angeles. Financial disclosure: Is a speaker for Heidelberg and has an investigator grant with Regeneron.

Informed Consent

Video is an effective and versatile tool in the informed consent process. Concise informed consent videos save you time, increase practice efficiency, and bolster patient understanding.

The Academy&#;s downloadable Retina Informed Consent Video Collection (#V) includes 21 short videos&#;each about five minutes long&#;on specific, common retinal conditions. OMIC-reviewed, each video clearly explains risks and benefits to enhance patient understanding, encourage consent, improve compliance, and set realistic expectations to mitigate malpractice risk.

The collection of 21 retina topics (provided in both English and Spanish) is $545 for Academy members, $709 for nonmembers. Choose from a variety of file formats.

Want more information on Laser Retinal Imaging? Feel free to contact us.

To see video clips and order, visit the Academy Store.