Applications of WidefieldImaging

SriniVas Sadda, MDProfessor of OphthalmologyDirector, Medical Retina Unit Ophthalmic Imaging UnitUniversity of Southern CaliforniaLos Angeles, California, USA

Retina 2014

Disclosure

Consulting Fee: Allergan; Carl Zeiss Meditec;Genentech; Optos; Regeneron

What is widefield imaging?

Widefield

50 degree mode

Traditional Fundus Camera

Optomap P200Tx

Multi-wavelength Scanning LaserOphthalmoscope

• Red (633), green (532), and blue (488)Scanning Lasers

• Virtual Point SLO Technology– Optical path allows images to be

captured from a point that is “virtually”in the eye

Permits “color”, FA, and autoflourescence

Scans up to “200 ” of the Retina

Image capture in 0.25 seconds

Non-mydriatic colour and AF imaging (>2.0mm pupil size)

Technology for multimodal widefield imaging

Optomap P200Tx

Multi-wavelength Scanning LaserOphthalmoscope

• Red (633), green (532), and blue (488)Scanning Lasers

• Virtual Point SLO Technology– Optical path allows images to be

captured from a point that is “virtually”in the eye

Permits “color”, FA, and autoflourescence

Scans up to “200 ” of the Retina

Image capture in 0.25 seconds

Non-mydriatic colour and AF imaging (>2.0mm pupil size)

Technology for multimodal widefield imaging

Technology for multimodal widefield imaging• Heidelberg non-contact widefield angiography

module–

m

Technology for multimodal widefield imaging• Staurenghi contact widefield lens

– 150 degrees

Applications of widefield imaging

• Angiography

• Color

• Autofluorescence

• Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Applications of widefield imaging

• Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Applications of widefield imaging

Why widefield angiography?Traditional Photography: 30

Degrees

Image courtesy of Szilárd Kiss, MD

Why widefield angiography?

Image courtesy of Szilárd Kiss, MD

ETDRS: 7 Standard Fields

• Still only a relativelysmall portion of theretina is sampled

• Is this enough formanaging thispatient?

ETDRS: 7 Standard FieldsUltra-widefield FA (Optos)Why widefield angiography?

Image courtesy of Szilárd Kiss, MD

ETDRS: 7 Standard Fields

• Is this an unusual case?

• How frequently are weunder-staging diabeticretinopathy or potentiallymissing lesions that wouldaffect management?

Why widefield angiography?

Image courtesy of Szilárd Kiss, MD

Clinical importance of widefieldimaging for diabetic retinopathy

Kiss et al, Retina 2011

Retrospective review ofdiabetic patients whounderwent diagnostic OptosUW fluorescein angiography

The respective areasidentified on UWFA werecompared to a modifiedETDRS 7SF image as

218 eyes of 118 diabeticpatients were included.

R

Clinical importance of widefieldimaging for diabetic retinopathy

Kiss et al, Retina 2011

• UWFA showed 3.2X more totalretinal surface area than 7SF.

• Compared to 7SF, UWFA alsoshowed:– 3.9x more nonperfusion (p<0.001)– 1.9x more NV (p=0.036)– 3.8x more PRP (p=0.001)

• In 22 eyes (10%), UWFAdemonstrated retinal pathology(including nonperfusion (n=13) andneovascularization (n=9)) notevident in an 7SF overly.

UW

Case: Peripheral PDRAsymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU

Case: Peripheral PDRAsymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU

Clinical importance of widefieldimaging for diabetic retinopathy

Kiss et al, Retina 2011Conclusions:

Compared to conventional imaging,UWFA demonstrates significantly morepathology in patients with diabeticretinopathy.

Improved visualization can alter theclassification of retinopathy; mayinfluence follow-up and treatment ofthese patients.

Clinical significance - targetedperipheral treatment and effect of anti-VEGF therapy - currently underinvestigation for both diabeticretinopathy and venous occlusivedisease.

Upcoming DRCR.net protocols

nc

Benefits of widefieldangiography

• Flourescein Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Benefits of widefieldangiography

• Flourescein Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Case: Retinal Vein Occlusion52 y/o Diabetic F w/ glaucoma presents with rapid loss of superior visualfield vision OS and NVI

Patient needs PRP (+/- anti-VEGF), but do they need an FA?

Diagnosis: HRVO, background DR

Case: Retinal Vein Occlusion

Clinical importance of widefieldimaging for macular edema

Kiss et al, BJO 2012Studied relationship betweenperipheral ischemia and presenceof DME

Patients with peripheral retinalischemia had a 3.75 timesincreased odds of having macularcompared to those without retinalischemia (p<0.02).

Clinical significance - targetedperipheral treatment for persistentmacular edema (e.g. in patientsundergoing anti-VEGF therapy) iscurrently under investigation foreyes with retinal vascular disease

Stpe

Case: Venous Occlusive Disease

67 y/o HF with BRVO OS; Va = 20/80CMENVITx’d with anti-VEGF + PRP

Is VMT a concern here?

Case: Venous Occlusive Disease

67 y/o HF with BRVO OS;After PRP NVI resolvedDespite 8 monthly anti-VEGF injections and grid laser….VMT resolved, CME improved but persisted (Va=20/60)

Case: Venous Occlusive Disease

67 y/o HF with BRVO OS;After PRP NVI resolvedDespite 8 monthly anti-VEGF injections and grid laser….CME improved but persisted (Va=20/60)

PRP added through this area of non-perfusion

Case: Venous Occlusive Disease

67 y/o HF with BRVO OS;After supplemental PRP1 month laterEdema further reduced, Va = 20/30

• Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Applications of widefield imaging

• Angiography– Peripheral Neovascularization

– Peripheral Non-perfusion

– Peripheral Vasculitis

Applications of widefield imaging

62 y/o Asian Female: complained of some �fogginess� ofperipheral vision in both eyes, Va =20/25 OU20/25 OU

Case

Labs: ANA+ 1: 160 (Speckled)Dx: Peripheral Vasculitis OU (only OD shown)

Follow-up:mixed connective tissue disease

62 y/o Asian Female: complained of some �fogginess� ofperipheral vision in both eyes, Va =20/25 OU20/25 OU

Case

67 y/o CF with flashinglights and floaters ODVa: 20/20 OU+ occludable angles

Miotic pupils: limitedview

Does patient need anurgent PI?

Case

• Angiography

• Color

• Autofluorescence

Applications of widefield imaging

• Angiography

• Color– Visualization through small pupils or media

opacity

Applications of widefield imaging

• Angiography

• Color– Visualization through small pupils or media

opacity– Long Axial Length

Applications of widefield imaging

74 y/o CM with poor vision OU for his whole life

LP HM

Diagnosis: Pathologic myopia with deep staphyloma (axial length: 33mm)Virtual Point Benefit: Note base of staphyloma and peripheralretina are both in focus due to large depth of field

• Angiography

• Color– Visualization through small pupils or media

opacity– Long Axial Length

Applications of widefield imaging

• Angiography

• Color– Visualization through small pupils or media

opacity– Long Axial Length– Documentation

Applications of widefield imaging

• Angiography

• Color– Visualization through small pupils or media

opacity– Long Axial Length– Documentation– Diabetic retinopathy screening

Applications of widefield imaging

New gold standard for diabeticretinopathy telescreening

• Assessment of diabetic retinopathyseverity from non-myd UWF imagesshowed excellent agreement withgold standard screening methods

• Lower rate of ungradable imagescompared to conventionalphotographic screening

• Media opacity benefits

• Angiography

• Color

• Autofluorescence

Applications of widefield imaging

• Angiography

• Color

• Autofluorescence

Applications of widefield imaging

200

50

Potential Limitation of Typical FAFEvaluations

Focused on the posterior poleEven wider angle fundus camera lens or sweeping

with the SLO covers a modest territory

Is there moreuseful

informationout there in

theperiphery?

Prevalence of FAF abnormalitiesoutside posterior pole

• A total of 461 eyes of 248 patients with ultra-widefieldAF imaging were included in this analysis

Disease Number of Eyes Number withAbnormal

Peripheral FAF(%)

Age-related maculardegeneration

134 106 (79%)

Central serous chorioretinopathy 17 9 (53%)

Ocular tumors 11 9 (82%)

Inflammatory/infectious diseases 104 74 (71%)

Retinal degenerations 90 74 (82%)

Miscellaneous (diabeticretinopathy, retinal vascular occlusivedisease, ocular albinoidism, non-specific pigmentary changes)

105 47 (44%)

ALL 461 319 (69%)

Age-related maculardegeneration

? Prognostic Significance …… To BeDetermined (AREDS2)

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

79%

Patterns of Peripheral FAF in AMD

“Nummular Decreased FAF”“Mottled Decreased FAF”

“Granular Increased FAF”

Pattern Non-neovascularAMD (%)

NeovascularAMD (%)

Normal 27.2 14.0

Granular 51.8 52.3

Nummular 17.5 24.4

Mottled 34.2 48.8

• 100 consecutive AMD patients: Presence of any abnormalFAF:– Neovascular vs. Non-neovascular AMD: 86.0% vs. 72.8%

(p=0.025)

70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative

Case

70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative

Case

70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative

Case

70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative

Case

70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative

Case

Central Serous Chorioretinopathy% of Eyes withPeripheral FAFAbnormalities

53%

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

• Full extent of gutters extending from themacula may be defined

• Punctate areas of decreased FAF with broadpatches of increased FAF (corresponding toold neurosensory detachment)

83 y/o Caucasian male with vision OS (20/80)

Case

s/p PDT (full fluence) 20/50+2 OS

Ocular Tumors

• Choroidal melanoma, striking FAF changes

% of Eyes withPeripheral FAFAbnormalities

82%

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

Inflammatory/Infectious diseases

• Chronic Vogt-Koyanagi-Harada syndrome

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

71%

Inflammatory/Infectious diseases

• Chronic Vogt-Koyanagi-Harada syndrome

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

71%

Inflammatory/Infectious diseases

• Chronic Vogt-Koyanagi-Harada syndrome

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

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Inflammatory/Infectious diseases

• Multiple chorioretinal scars withspiraling pattern, etiology unknown

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

71%

61 y/o M with nyctalopia+anti-retinal auto-Ab against 23-kDa protein

20/80 20/60

Case

61 y/o M with nyctalopia+anti-retinal auto-Ab against 23-kDa protein

20/80 20/60

Case

Retinal dystrophies

• Stargardt’s disease

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

82%

41 y/o CM with progressively vision OU, 0/14 Ishihara platesNo family history of retinal degenerationVa: 20/200 OU

Case

Case41 y/o CM with progressively vision OU, 0/14 Ishihara platesNo family history of retinal degenerationVa: 20/200 OU

35 y/o CF with vision OU x1 yearh/o Strabismus (s/p EMS), +rotary nystagmus,ROS: +easy bruising

20/60 ph 20/40 20/25

Case

Case

35 y/o CF with vision OU x1 yearh/o Strabismus (s/p EMS), +rotary nystagmus,ROS: +easy bruising

20/60 ph 20/40 20/25

35 y/o CF with vision OU x1 yearh/o Strabismus (s/p EMS), +rotary nystagmus,ROS: +easy bruising

20/60 ph 20/40 20/25

Case

Diagnosis: Oculo-cutaneous Albinisim: Hermansky Pudlak

25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU

Case

25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU

Case

25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU

Case

Retinal dystrophies

• Rod/Cone degeneration(?PPRCA/ CRB1mutation)

AMD

CSCR

Ocular tumors

Inflammatory

Degenerations

% of Eyes withPeripheral FAFAbnormalities

82%

Widefield FAF Summary

• Peripheral FAF abnormalities were prevalent in thisseries of eyes with macular disease-- 69%(319/461) of eyes – esp. in eyes with retinaldegenerations, inflammations, and AMD

• Peripheral FAF abnormalities– Often correlate with areas of RPE disturbance – but not always– Even when they do correlate, they often appear more striking on

FAF than on the pseudocolor images (better contrast)– Exhibit characteristic patterns for certain diseases (particularly

dystrophies and inflammatory diseases)

Overall Widefield Imaging Conclusions

• Widefield imaging provides important advantagesthat are of significant clinical benefit

• These include:– Identification of location and extent peripheral non-perfusion and NV

• May alter disease staging and treatment strategy (RCT data still required)

– Visualization through small pupils and media opacity

– “Big picture” view to facilitate diagnosis

– Pathognomonic/characteristic findings for many diseases

• Widefield imaging has become a critical component of ourclinical practice

Thank You