Image from the Optos Silverstone RGB ultra-widefield retinal imaging device.
Examining a frightened toddler’s retinal periphery can test the patience of even the most experienced clinician. Sydney paediatric ophthalmologist Dr Caroline Catt explains how Optos ultra-widefield (UWF) imaging is changing what she can see, and what she can do about it.
For many children, the fundus examination is the hardest part of an eye appointment. Bright lights, dilating drops, and an unfamiliar clinician can be enough to bring a consultation to a halt, leaving the retinal periphery – where conditions such as complications from retinopathy of prematurity (ROP) first declare themselves – unexamined.
Ultra-widefield imaging offers a way around the problem. Optos optomap devices capture more than 80%, or 200°, of the retina in a single, rapid image, often without the need for pupil dilation. For Dr Caroline Catt, a paediatric ophthalmologist and strabismus surgeon who completed her fellowship at Toronto’s Hospital for Sick Children, that combination of speed and coverage has done more than improve image capture rates. In the case of infants treated for ROP, it has helped keep some children out of the operating theatre altogether.
mivision spoke to Dr Catt about how UWF imaging fits into a busy paediatric practice, from ROP follow-up to documenting the myopic optic disc.
Q. What is the main clinical advantage of ultra-widefield imaging?
It captures both the posterior pole and the retinal periphery in a single image, so you’re more likely to capture pathologies that you might miss on standard imaging, and it’s a still image that can be stored and used for comparisons in the future.
Q. How has this capability improved the way you detect and manage paediatric eye disease?
An ultra-widefield image improves our ability to detect and manage paediatric eye disease in a number of ways, including cases where we can’t examine the fundus because the child is frightened or unable to cooperate with the examination. Also, in cases where there is peripheral retinal disease, you’re more likely to capture those on an image than to see them on a binocular indirect examination in some instances. It can be quite difficult to identify peripheral retinal disease in a child who’s unable to cooperate with the assessment and in whom you can’t do an indented examination.
Q. How does optomap imaging help detect paediatric eye disease?
Ultra-widefield imaging helps us detect paediatric eye disease by giving us a picture of the posterior pole and the retinal periphery in one image. Fundus autofluorescence is particularly helpful when we’re considering optic disc pathologies or retinal dystrophies. It’s a really powerful tool when we’re looking for peripheral retinal diseases in children such as retinopathy of prematurity.
Q. How do findings from optomap imaging contribute to your treatment planning?
The most powerful way that optomap has contributed to or adjusted my clinical practice is in babies who’ve received anti-VEGF therapy for their retinopathy of prematurity. We can use oral fluorescein angiography to determine if there is any ongoing vascular leak. Ongoing vascular leak requires laser treatment in the operating theatre. And sometimes, if we can determine that there’s an absence of leak by using optomap, then we can avoid the need to take that child to theatre, which also means we can avoid unnecessary general anaesthesia. It’s not only a great relief for the parents, but it also means that we’re not overusing valuable and precious operating theatre resources.
Q. How valuable is optomap in monitoring treatment responses and long-term disease progression?
Imaging is highly valuable for monitoring disease progression and treatment because you can save the images and track changes over time.
Q. Have you observed improvements in clinical decision making or outcomes when integrating ultra-widefield imaging into your workflow?
Because the images can be captured in quite a speedy way, and often without pupil dilation, we’re more likely to capture a quality image in more children. So, if we have a good quality fundus image, we can be more confident in making a diagnosis in more cases.
Q. What do you believe to be the biggest clinical advantage of ultra-widefield imaging in myopia control?
I think there are two main clinical advantages in using ultra-widefield imaging in children with myopia. Firstly, it can be used to assess for fundus features of syndromic myopia. You can use colour imaging to look for retinal dystrophic changes, or the fundus autofluorescence mode to look for autofluorescence abnormalities – features of, say, an inherited retinal dystrophy. Secondly, it can be used to document the optic disc, macula, and retinal periphery to assess for pathologies associated with myopia. And if those pathologies can be identified and treated in a timely manner, then that’s a clinical benefit.
Any changes identified can also be documented and tracked over time. In terms of the optic disc, there is an important relationship between myopia and glaucoma, and it is very difficult to identify glaucomatous optic neuropathy in a myopic disc. So having baseline optic disc clinical photography can be really helpful when trying to tease those diagnoses apart in the future.
Dr Caroline Catt BMBS MMed BMedSci (Hons I) FRANZCO specialises in paediatric and general ophthalmology and strabismus, including cataract and strabismus surgery. Dr Catt consults in Sydney, is a Clinical Senior Lecturer with the University of Sydney Department of Ophthalmology, and a CASA-certified Designated Aviation Ophthalmologist.
