Multimodal imaging with ultra-widefield (UWF) photography and OCT is bringing a new level of accuracy to retina diagnosis, treatment, and management. For example, in a recent case, a physician referred a 52-year-old woman to me for floaters, noting a suspected retinal tear in the superotemporal periphery.
Diagnosis: Standard clinical exam with ophthalmoscopy revealed a somewhat atypical appearing retinal tear. Given the atypical appearance, I obtained an ultra-widefield image, along with a peripheral OCT through the area of interest. Combining these two modalities allowed me to utilize the OCT overlay to map the cross-sectional OCT data with a specific location on the fundus. In this case, it revealed a retinoschisis cavity with both inner and outer leaflets visible. Scrolling through the area of interest, I was able to see holes in both the inner and outer leaflets, indicating this was an early retinoschisis-related detachment as opposed to a standard retinal tear or simple retinoschisis. Without the technology to combine these two imaging modalities, it would have been difficult to make this diagnosis clinically.
Management: Multimodal imaging (see related video below) not only accurately identified the specific pathology, it also provided key information to guide treatment. In this case, the ultra-widefield image with OCT overlay provided precise detail regarding the border of the outer retinal break, allowing me to carefully place the necessary laser retinopexy. During an in-clinic procedure, I was able to successfully barricade the localized area of schisis-related detachment with careful laser treatment.
Follow up: Knowing this patient was at a higher risk for progression to clinical detachment, I watched her very carefully. Monitoring was made much easier through the integrated ultra-widefield fundus image-peripheral OCT overlay, which could be compared “slice-for-slice” to the previous images to ensure no further progression occurred. With retinoschisis, in particular, clinical exam may reveal retinal elevation posterior to previously placed laser, which may represent progression of the retinoschisis (e.g. elevation of the inner leaflet only), or the development of frank retinal detachment. The latter scenario requires prompt surgery while the former is simply observed. Using this technology, I have anatomic information down to the micron level, allowing me to feel confident about whether progression has occurred or not.
Patient education: Combining these technologies also has a positive effect on workflow and patient education. I can access most or all of the imaging from a single visit on one screen, which saves time compared to opening different device interfaces to review and compare images. The multimodal display is also much easier for patients to view. In this case, I was able to show the patient her pathology, helping her clearly understand what was happening to her eye and how I planned to treat it.
Eric W. Schneider, MD, practices with Tennessee Retina in Nashville. He has published more than 15 peer-reviewed articles and book chapters on a wide-ranging array of medical and surgical retina topics.