Article Date: 9/1/2008

Get the Upper Hand on Retinal Disease

Get the Upper Hand on Retinal Disease

Cutting-edge digital imaging technology allows you to examine the retina without pupil dilation — a benefit for you and your patients.

By David Way, O.D., Houston

A thorough retinal examination is essential to any comprehensive eye exam, but patients often are reluctant to have their pupils dilated. However, with the Optomap Retinal Examinations (Optos, Malborough, Mass.), I can acquire digital 200-degree images of the retina without having to dilate my patients' pupils, enabling me to detect disease early and keep my patients happy. By providing this cutting-edge technology, I've set my practice apart from the competition, which is a huge plus for someone who's been in practice only 5 years in a large metropolitan city.

In this article, I'll share how you can use this digital retinal imaging system to improve patient care and build your practice.

Understand the Benefits of Screening

We recommend an Optomap Retinal Exam to every patient who comes in for a routine eye exam. We explain the importance of examining the entire retina in detail, and we assure patients that this important screening often requires no dilation unless I detect pathology. Although Optomap screening exams typically aren't covered by medical or vision insurance, patients often will pay the out-of-pocket fee to take advantage of the technology. The system's second track, called the Optomap Plus Medical Retinal Exam, is used for reimbursable procedures, such as fundus photography, when documenting and monitoring disease.

Initially, I was hesitant to supplement my traditional fundus exam with an Optomap image until I realized the Optos system allows me to view nearly the entire retina of both eyes simultaneously, and it provides useful photo-documentation. In contrast, a dilated exam with a binocular indirect ophthalmoscope and handheld lens limits you to examining only a small fraction of the retina at a time. You have to work your way around the retina section by section. Because the binocular indirect ophthalmoscope is very bright and patients don't like to hold their eyes open for too long, you can miss small sections of the retina and risk not making an accurate diagnosis.

Furthermore, with a traditional exam, you must maintain a mental composite of what you see and then draw it on paper for the patient's records. But the Optomap provides a complete file history of digital images that you can compare from year to year. I believe this is one of the best features of the Optomap. It also allows you to scrutinize the entire retina in more detail — and in less time — than a traditional exam.

Because you can split the layers of the retina using the Optos software features, you can differentiate whether a lesion penetrates all retinal layers (like a retinal hole) or if it's localized below the retinal pigment epithelium (like a benign choroidal nevus). This feature allows you to diagnose retinal disease more efficiently and accurately.

Learn to Use the System to Monitor Disease

Although the Optomap images don't substitute for dilation when monitoring eye disease, the Optos software is versatile, allowing you to use the system as a fundus camera to track disease progression. If I'm monitoring a specific condition, such as glaucoma, diabetic retinopathy or macular degeneration, I perform a dilated exam and then order a fundus photograph, using the system's Optomap Plus feature. The Optomap Plus Medical Retinal Exam has software that prompts me to make notes, draw on the photo, comment on the exam and attach a diagnosis code, which allows me to bill the patient's medical insurance for the photograph (fundus photography: 92250). In addition, software tools allow you to evaluate changes in the optic nerve and monitor progression in diabetic retinopathy, for instance, over time.

The Optomap Fa Dynamic Ultra-widefield Angiography program provides fluorescein angiography, and this functionality further demonstrates the versatility of the equipment. You can use one instrument as a screening tool, for fundus photographs and for fluorescein angiography.

Bring Your Staff On Board

When you introduce this technology in your practice, it's important for your staff to understand your philosophy regarding the system. They must be trained to clearly and accurately explain the advantages of the Optomap to patients. My technicians discuss the benefits up front, explaining that I need to examine the entire retina for a complete eye exam. They add that this new technology allows me to view the inside of the eye without dilation and keep their photos on file. Even though they explain that there's an additional fee that isn't covered by insurance, most patients believe the exam is worthwhile.

It's also important to train your technicians carefully to recognize that eye structure varies from patient to patient, which affects the quality of your images. Rather than blindly following the alignment instructions provided by the system, technicians may need to position deeper set eyes closer to the machine than suggested to obtain an adequate, complete image. Conversely, shallow-set eyes may need to be farther from the machine to obtain the best images possible.

Set Your Practice Apart

The Optos system is a great patient education tool that gives my practice a wow factor. Patients see photos of the inside of their eyes, and it's something they've never seen before. Through word of mouth, new patients come to my practice and inquire about the new high-tech device that doesn't require dilation.

I sit down with patients and show them the parts of the eye on the Optomap images and tell them that I'll keep those photos on file for future reference. This drives home the point that I'm a different kind of eye doctor: I'm doing a very thorough exam; I'm spending time discussing it with them, and I'm educating them so they can be involved in their care.

An interactive approach is essential in today's medical environment and using technology like this helps you collaborate with your patients. Patients today are more educated; they research their conditions online. So you must be willing and able to work with them, share exam findings and discuss how you can approach their care together. nOD

Two Examples of How Optomap Retinal Exams Have Benefited My Patients:
Case 1
Patient history: A 20-year-old Caucasian man reporting no health problems, symptoms or visual complaints had a routine eye exam in April 2005.

The Optomap Retinal Exam shows a new retinal hole (reddish oval, far right) at the 9 o'clock position in the right eye, just posterior to the ora serrata.

Clinical summary: The patient chose to have an Optomap Retinal Exam that appeared to reveal two small retinal holes at approximately 8 o'clock in the right eye just posterior to the ora serrata. Because of this finding, I performed a dilated fundus exam (DFE) with scleral depression, confirming the diagnosis of two atrophic retinal holes in that location with no surrounding fluid cuff.
I referred him to a retinal specialist who confirmed the diagnosis. Because the patient had no symptoms, there was no fluid cuff around the holes, and prophylactic laser treatment could induce more retinal holes, we decided to carefully monitor the retina for new changes or symptoms every 6 months.
At the most recent routine eye examination, the patient hadn't had any retinal changes (as observed with DFE and scleral depression) for 3 years, so we chose an Optomap Exam in lieu of dilation. Unfortunately, the new Optomap image appeared to show a previously undiagnosed atrophic retinal hole at approximately 9 o'clock just posterior to the ora serrata. Because this was a new finding, we performed a DFE, confirming an atrophic retinal hole. Prior Optos images showed that this retinal hole wasn't present in past exams.
Patient outcome: This new retinal finding prompted me to refer the patient to a retinal specialist to reconsider prophylactic laser treatment for these retinal holes. We're awaiting the retinal surgeon's treatment decision.

Case 2
Patient history: A 21-year-old, slightly overweight Caucasian woman with no other reported health problems had a routine eye exam for contact lenses. She said her distance vision had been decreasing gradually in both eyes over the previous year, which she attributed to a normal prescription change over time.
Clinical summary: This patient chose to have an Optomap Retinal Exam just as she had done in the prior 2 years.
Her best-corrected acuity was 20/20 OD and 20/20-3 OS through a moderate compound myopic astigmatic spectacle prescription. Anterior segment biomicroscopy revealed no remarkable findings.
An undilated fundus exam with a superfield lens revealed slightly elevated and nondistinct optic discs in both eyes, with a cup-to-disc ratio of 0.2/0.2 in both eyes. There was a spontaneous venous pulse in both eyes. All other fundus findings were unremarkable.
On previous exam charts, her optic nerves had been recorded as distinct and flat and her cup-to-disc ratio had been recorded as 0.3/0.3 in both eyes. Because of these suspected changes in the optic nerves, I needed to rule out recent onset of papillitis. I reviewed the Optomap scans from the past 2 years.

An undilated fundus exam with a superficial lens revealed slightly elevated and nondistinct optic discs in both eyes, leading to a diagnosis of pseudo-tumor cerebri (idiopathic intracranial hypertension).

A review of images from the past 2 years confirmed a gradual change in the appearance of the optic nerves and a decrease in the cup-to-disc ratio over time, so I referred her to a neuro-ophthalmologist. The ultimate diagnosis was pseudotumor cerebri (idiopathic intracranial hypertension). This patient was treated with oral acetazolamide for 6 months.
Patient outcome: At her most recent routine exam 3 months ago, her optic nerves appeared normal, with a cup-to-disc ratio of 0.3/0.3 in both eyes.

Dr. Way practices at Spring Klein Vision Center in Houston, and is an adjunct attending faculty member at the University of Houston College of Optometry. You can reach him at drway@springkleinvision.com.


Optometric Management, Issue: September 2008