More is Better: Wide-Field

Rajeev K. Seth, MD

RVSCNY Historical Perspective

•! 1926: first reliable 20o fundus camera

•! 1961: fluorescein angiography developed

•! 1970s: rudimentary wide-field camera with scleral transillumination and contact

•! 1980s: •! peripheral sweeps, creating montage (pioneered with ETDRS 7 standard fields (7SF)) •! scanning laser ophthalmoscope (SLO) technology

•! 1990s o •! specialized contact lenses and non-contact lenses for up to ~100 field of viewRVSCNY 7SF and Montage

•! Approximately 75o •! Limitations •! patient alignment problems •! focus irregularities •! marginal corneal •! poor fixation •! light reflex artifacts •! error of image alignment with montage creation

RVSCNY RVSCNY RVSCNY Current Technology

•! Using a special lens adapter with small-angle camera

•! Dedicated wide-angle camera

RVSCNY Current Technology

•! Image renderings

•! Fluorescein angiography

•! ICG

•! Fundus Autofluorescence

RVSCNY Current Technology

•! RetCam •! Utilizes contact lens system with coaxial illumination •! Provides 130o field of view •! Best suited for neonates and infants •! Being used in ROP telemedicine programs

RVSCNY Current Technology

•! Heidelberg Spectralis •! 55o or up to 150o field of view •! Capable of FA, ICG, FAF

RVSCNY RVSCNY Current Technology

•! Optos OptoMap •! 200o field of view w/ non-contact lens •! Capable of FA, ICG, FAF

RVSCNY Role of Wide-Field Angiography

•! Dynamic with true temporal reference imaging

•! Better visualization of peripheral pathology

•! Peripheral pathology might play an even more significant role in the pathophysiology and management of retinal disease

•! Document peripheral findings and response to treatment

RVSCNY Role of Wide-Field Angiography

•! Retinal Vascular Disease – Diabetic , Retinal Vascular Occlusions, •! neovascularization •!

•! Posterior •! Vasculitis •! Choroiditis or

•! Pediatric Retinal Disease •! Hereditary Retinal Disease •! ROP RVSCNY

•! Studies regarding PRP are >30 yrs ago •! WFI shows 2x amount of nonperfusion and neovascularization than 7SF •! 10-15% of eyes, WFI shows nonperfusion and neovascularization that 7SF misses

RVSCNY DME

•! Mixed mechanism etiology •! localized vascular leakage •! inflammation •! vitreoretinal traction •! localized macular ischemia •! diffuse retinal ischemia

RVSCNY Diabetic Retinopathy

•! Correlation between amount of peripheral nonperfusion and DME •! role of peripheral laser in managing recalcitrant DME •! RaSCAL trial

•! Peripheral perivascular leakage associated with n.v. and DME

RVSCNY RVSCNY Diabetic Retinopathy

•! Targeted Retinal Photocoagulation (TRP) for PDR •! laser to areas of capillary non-perfusion seen on WFI •! decreases side effects (peripheral visual field defects, decreased night vision, etc)

•! Earlier PRP? •! quantifying extent of peripheral ischemia

•! How much PRP is enough? •! monitoring treatment response and disease progression

RVSCNY RVSCNY Retinal Venous Occlusions

•! More accurate classification of ischemic vs non-ischemic •! Visualize peripheral nonperfusion, vascular leakage or n.v. otherwise missed by traditional imaging •! ischemic index: area of nonperfusion / area of visualized

RVSCNY Retinal Venous Occlusions

•! TRP for patients with macular edema refractory to anti-VEGF or steroids

RVSCNY Peripheral Retinal Vascular Disease

•! Sickle Cell Disease •! Improved screening •! Monitor increasing nonperfusion •! Earlier detection of neovascularization prior to or traction

•! Coats Disease

RVSCNY Retinopathy of Prematurity

•! Good correlation between RetCam images and indirect

•! Telemedicine for ROP

•! Documentation of findings

RVSCNY RVSCNY Pediatric Retinal Diseases

RVSCNY Pediatric Retinal Diseases

RVSCNY RVSCNY Limitations

•! Peripheral aberrations •! 3-D structure on 2-D image

•! SLO “color” image •! Rendering from 2 wavelength lasers •! Not same quality as traditional light based images

•! Contact lenses •! Learning curve •! Corneal irritation/abrasions

•! Entire area of retina not imaged •! Does not replace indirect ophthalmoscopy with scleral depression RVSCNY Future Directions

•! Research on effects of peripheral ischemia on posterior disease •! improved treatment paradigms

•! Telemedicine protocols

•! Prospective trials for TRP

•! Race to get to the ora

RVSCNY References

• Kaines A, Oliver S, Reddy S, Schwartz SD. Ultrawide angle angiography for the detection and management of diabetic retinopathy. Int ! Ophthalmol Clin. 2009;49:53-59. •! Wessel MM, Aaker GD, Parlitsis G, et al. Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy. Retina. 2012;32:785-791. •! Wessel MM, Nair N, Aaker GD, et al. Peripheral retinal ischaemia, as evaluated by ultra-widefield fluorescein angiography, is associated with diabetic macular oedema. Br J Ophthalmol. 2012;96:694-698. •! Oliver SC, Schwartz SD. Peripheral vessel leakage (PVL): a new angiographic finding in diabetic retinopathy identified with ultra wide-field fluorescein angiography. Semin Ophthalmol. 2010;25:27-33. •! Pahor D. Visual field loss after argon laser panretinal photocoagulation in diabetic retinopathy: full-versus mild-scatter coagulation. Int Ophthalmol. 1998;22: 313-319. •! Reddy S, Hu A, Schwartz SD. Ultra wide field fluorescein angiography guided targeted retinal photocoagulation (TRP). Semin Ophthalmol. 2009;24:9-14. • Muqit MM, Marcellino GR, Henson DB, et al. Optos-guided pattern scan laser (Pascal)-targeted retinal photocoagulation in proliferative ! diabetic retinopathy. Acta Ophthalmol. 2011 Dec 16. [Epub ahead of print] •! Prasad PS, Oliver SC, Coffee RE, et al. Ultra wide-field angiographic characteristics of branch retinal and hemicentral retinal vein occlusion. . 2010;117:780-784. •! Tsui I, Kaines A, Havunjian MA, et al. Ischemic index and neovascularization in central retinal vein occlusion. Retina. 2011;31:105-110. •! Chiang MF, Wang L, Busuioc M, et al. Telemedical retinopathy of prematurity diagnosis: Accuracy, reliability, and image quality. Arch Ophthalmol. 2007; 125:1531-1538. •! Photographic Screening for Retinopathy of Prematurity (Photo-ROP) Cooperative Group. The photographic screening for retinopathy of prematurity study (photo-ROP). Primary outcomes. Retina. 2008;28(Suppl 3):S47-S54. •! Dhaliwal C, Wright E, Graham C, et al. Wide-field digital retinal imaging versus binocular indirect ophthalmoscopy for retinopathy of prematurity screening: A two-observer prospective, randomised comparison. Br J Ophthalmol. 2009;93:355-359. •! Dai S, Chow K, Vincent A. Efficacy of wide-field digital retinal imaging for retinopathy of prematurity screening. Clin Experiment Ophthalmol. 2011;39: 23-29. • Cho M, Kiss S. Detection and monitoring of sickle cell retinopathy using ultra wide-field color photography and fluorescein angiography. RVSCNY ! Retina. 2011;31: 738-747.