Article Date: 12/1/2010

Image is Everything
retinal imaging

Image is Everything

Follow these 10 steps to ensure your staff obtains accurate, reliable and consistent results with retinal imaging devices.

S. Steven Chander, O.D., Chicago, Ill.

Although much of today's retinal imaging devices are comprised of automated features, the accuracy, reliability and consistency of these devices remains contingent on the operator. Because we, as optometrists, simply don't have the time to operate these important instruments on each and every patient, we must provide thorough staff training on them to ensure the most appropriate management for our patients and accurate third-party reimbursement.

Here are several steps I've followed to accomplish this in my own practice.


Regardless of whether you purchase an ocular coherence tomographer (OCT), spectral-domain OCT or digital retinal camera, don't rely on the manuals of these devices to provide adequate staff training. While the manual alone may enable you to quickly learn how to best use these instruments, keep in mind that your staff members don't share your eyecare educational background.

Therefore, schedule one or more educational sessions with the device manufacturer's sales rep. These sales reps are very knowledgeable in the clinical didactics of the “art” in acquiring retinal images. In addition, many of these manufacturers offer training via videos and the Internet to facilitate the learning curve.


Produce your own video of the appearance of the pathology of retinal diseases (e.g. age-related macular degeneration, diabetic retinopathy, glaucoma, etc.) and the specific techniques to use to identify this pathology.

Currently, my practice has video training modules on four retinal imaging devices. All videos have proven very successful in enabling my staff to obtain accurate, reliable and consistent results.


Invest time and money in sending staff to trade shows locally and abroad. You'll be very pleased with the return on these investments. As I'm writing this, our staff just returned from International Vision Expo West, where they learned a great deal about retinal imaging, among other eyecare-related topics.


The 35mm cameras and Polaroid imaging systems we use to employ made this a less-than-an-ideal training method due film costs. Thanks to today's digital technology, however, no such costs are involved. As a result, encourage your staff to practice using retinal imaging devices on each other. As the old idiom goes, “practice makes perfect.”


Once a month, I meet with my staff to troubleshoot and discuss quality control issues. These meetings are comprised of anonymous critiques on patient flow, office cleanliness and issues staff may be experiencing with each other, patients or operating equipment. We collectively troubleshoot these issues and work to prevent them from re-occurring — time very well spent.


This provides an incentive for your staff members to acquire high-quality images. And in the process of attempting to win that free lunch, movie passes, or whatever you decide to offer as the prize, they'll improve their skills to the point of achieving accurate, reliable and consistent results on your retinal imaging devices.


To ensure you get full reimbursement and in a timely fashion, educate your staff that digital photos require a bilateral code that must be billed with the “RT” or “LT” modifier if you're not billing for both eyes. Also, let them know that OCT scans, among other devices that require unilateral codes, must be billed with “RT” and “LT” modifiers.

Finally, to ensure the photos submitted receive immediate reimbursement, have staff employ an artificial tear to patients prior to obtaining the image. The reason: Blurred mires affect photo quality.


To enable your staff to obtain digital photographs of a retinal abnormality or pathology, as you saw it through extended ophthalmoscopy, instruct the staff member to hold her right or left palm facing toward her and to form her fingers as if she's grasping a baseball. Tell the staff member: “This is the eye as you are looking inward.” Then, have the staff member bend her thumb inward, and tell her: “The tip of your thumb represents the location of the optic nerve.” Next, simply point to the staff member's finger that represents the location of the lesion, as seen through extended ophthalmoscopy. This technique enables the staff member to best “steer” the camera.


The flash of non-mydriatic digital imaging causes pupil miosis. This makes image acquisition of the fellow eye challenging, especially in patients who have small pupils. To solve this problem, have your staff members place one drop of 2.5% phenylephrine in patients’ eyes. This amount will create enough mydriasis to allow for an optimal image, while also minimizing the patient's accommodative loss. In my experience, the accommodative effect isn't too grand to throw the patient's refraction off. Zero accommodation provides the best distance refraction, which is why I refract at a ratio of 20 feet. Although it may take time to work, I've found that the medication's effect to stop the fellow pupil from constricting after the first eye experiences the flash works in about five to six minutes.

Something else to consider: Pupils in patients younger than age 35 react faster to bright light than pupils in older patients, and their retinal photoreceptor cells regenerate with rhodopsin quicker than older retinas. Therefore, acquiring images on the younger pupil isn't as challenging as doing so on the older patient because their pupil size returns to normal after the flash faster than older pupils. If your staff member is dealing with a younger patient, have her photograph one eye immediately and then conduct other testing, such as the intraocular pressure measurement. This allows time for the fellow eye's pupil to regulate after the intense flash. Then, have the staff member wrap up pre-testing imaging on the fellow eye.


A typical OCT performs roughly 400 A-scans per second, with the typical scan occurring between four to seven seconds. Spectral domain (SD) OCT scans perform between 18,000 to 40,000 A-scans per second. Although the advent of the SDOCT and devices that have head straps have made motion artifact, or patient eye movement during testing less of an issue, it can still occur, rendering inconsistent results.

For an unknown reason, patients tend to stretch their mouths open during scans. This makes them less stable in the chin and forehead rests, causing motion artifact. As a result, instruct the patient to keep his mouth closed with his teeth together during scanning. Doing so stabilizes the head.

Another method of preventing motion artifact: Tell patients to find the target (e.g. a cross, green light, etc.) and just stare or daydream through it.

Despite the fact that retinal imaging devices are comprised of various automated features, these devices are only as good as their operator, in terms of providing accurate, reliable and consistent results. Because we don't have time to operate these devices ourselves, yet we rely on their results to guide our management decisions and afford us accurate third-party reimbursement, it's crucial we provide our staff with thorough training on them. Through my experience, the aforementioned steps have enabled me to accomplish this. OM

Dr. Chander is in private group practice with Primary Eye Care Associates in Chicago, Ill. where he serves as the clinical director, specializing in refractive therapy and surgical comanagement. E-mail him at, or send comments to

Optometric Management, Issue: December 2010