Posted on Tue, Jan 05, 2010
A recently discovered OCT artifact proves enormously predictive. By Jerry Sherman, OD
 | "We now have a simple test which
in seconds can differentiate between
maculopathy and optic neuropathy!" |
The ophthalmoscope has served vision care well for 150 years, but in light of recent advancements, its primacy has become outdated. We wrongly assume that if a retina looks normal via ophthalmoscopy it is healthy. In fact, we now know the earliest stages of virtually all posterior ocular diseases are invisible to ophthalmoscopy. Further, many such conditions can be diagnosed using new technologies, such as ocular coherence tomography (OCT).
Ocular coherence tomography has revolutionized eye care by imaging detailed cross-sections of the retina, revealing what previously was hidden (in vivo, at least); while at the same time OCT software technology allows us to measure quantitative parameters that otherwise couldn't be measured-for example, the exact thickness of the macula and the retinal nerve fiber layer (RNFL).
There are many remarkable applications for this technology, but I'll focus here on one so recent it hasn't received much attention in the literature.
We were taught that the retina consists of 10 layers, the lower nine of which are invisible to ophthalmoscopy. Much of this area contains photoreceptors (rods and cones). The advent of OCT has revealed these structures, and better still, we've found a bio-marker of photoreceptor health unique to Spectral Domain OCT images that appears never to fail.
Located at the border between the outer and inner segments of the photoreceptors, this bio-marker is a line which looks like the retina's "11th layer." It does not appear on histologies, but only on OCT images, probably due to the intense change in light refraction between the inner and outer segments. Astoundingly, this line is present in every single normal patient we have studied (a total of about 1,500) and is broken or abnormal in every single patient with outer retinal disease. [[art suggestion: image comparing histology to OCT image, 13:50 on presentation, illustrating PIL]]
Additionally, the nature of the line-which we've named the photoreceptor integrity line (PIL)-corresponds to the type of disease. Once basics like media opacity are ruled out, patients with reduced acuity and a PIL that is healthy under the fovea, where most cones are located, are probably suffering from rod degeneration around the disk. Conversely, patients with normal PILs near the RNFL likely have cone degeneration.
(Although the photoreceptor integrity line, or the PIL (defined as the junction between the inner and outer segments) is barely visible in most histological sections, it is highly prominent in normal SD OCTs. The PIL, as shown above, should be continuous throughout the entire scan in normal eyes. The PIL is considered by some as a mere artifact that is due to the difference in the index of refraction of the inner and outer segments but this artifact is remarkably useful in SD OCT interpretation.)In essence, we now have a simple test which in seconds can differentiate between maculopathy and optic neuropathy!
The clinical value of the PIL is enormous-just one factor which leads me to believe the retina represents the new frontier for optometry. For more information about how OCT can help provide optimal patient care, visit www.retinarevealed.com, where I present and discuss new case studies every week.
Dr. Sherman is President of the Optometric Retina Society.
-end-
Posted on Wed, Dec 23, 2009
One practice’s experience with the EyeRoute® System.By Frank Celia, contributing writer | Dr. Joseph B. Harlan, Retinal Specialist, and Dr. Donna Booth, review the tests of a patient she referred to him for retinal consultation, using their Topcon EyeRoute® Image Management System. |
The Katzen Eye Group had been up and running with its electronic medical records (EMR) system for about five years. They were very happy with it, having realized substantial efficiencies in manpower and cost. But as patient volume grew, and greater numbers of digital diagnostic images began to accumulate on the server, the staff noticed an impact on the computer system's speed.
"It is never fun to hear 'It's too slow,' or 'When it was on paper, I had it right away,'" says Janna Mullaney, Practice Administrator for the Towson, MD group, which employs eight ophthalmologists and eight optometrists. “The seconds really add up by the end of the day."
Seeking a way to streamline the system and enhance its speed, the practice this summer installed the EyeRoute Ophthalmic Image Management System, which stores all the patients' digital images at a single, secure, web-based location. EyeRoute frees the EMR system from having to download and store these bulky image files, while at the same allowing them to be viewed instantly by anyone in the practice authorized to do so.
"Now with EyeRoute we are able to access our imaging studies much quicker, compare tests over time, and analyze and manipulate the captured images in a much more dynamic way," says Richard Edlow, OD, who in addition to treating patients functions as the group's CEO. "It also allows us to store the images via its web-based system, versus continually clogging up our image server."
Installation of the system at Katzen's main and satellite offices was handled almost entirely by Topcon, so there was little interruption in the practice's operation, according to Dr. Edlow. Once EyeRoute was tested and ready to go, Topcon provided three days of on-site training. "Their training staff was extremely knowledgeable and IT literate," Dr. Edlow adds.
So far, the staff has noticed a definite enhancement, says Ms. Mullaney. "Having images stored in another server makes them more accessible and speeds up the performance of the EMR system," she says. "Even in the satellite office, the system is readily available with just a click!"
EyeRoute also seamlessly fits in with the practice’s existing EMR system. Patient images can be viewed instantly, without having to open, close or toggle between different programs.
"There is so much more we can do with our diagnostic images now with regards to chronologic comparisons, manipulation of images and magnifying specific areas, as well as showing and explaining conditions to the patient in the exam room,” explains Dr. Edlow. Plus the extra speed will positively impact patient flow. "It will probably cut a couple of minutes off each exam, which in our practice really adds up," he says.
Posted on Wed, Nov 11, 2009
From Our Contributor
Since the financial crisis of 2007, there has been significant concern among private optometric practices trying to keep afloat. Having been established for over 20 years, the doctors at Perry Eye Care in Orlando, Florida have found that investing in Topcon Medical System's 3D OCT-1000 has contributed significantly to their battle against the recession, and has resulted in an increase in revenue.
Being in private practice, optometric physician Dr. Mark Perry and his colleagues at Perry Eye Care, Dr. Karen Perry and Dr. Juan Menjivar, had to refer patients out if they were dealing with medical disorders such as diabetic retinopathy, glaucoma or macular degeneration. But since investing in the 3D OCT-1000 in December 2008, they have been able to provide on-site care to these patients, opening new opportunities within the practice.
In a large metropolitan area populated with several optometric practices, competition has been fierce, and so Dr. Mark and his colleagues saw it necessary to differentiate their approach to eye care by promoting medical optometry and serving a larger segment of the population. Since purchasing the 3D OCT-1000, the Perry Eye Care team has been able to fulfil this by offering patients high-speed Fourier domain OCT imaging with an integrated digital fundus camera that has substantially improved diagnostic imaging.
There has since been an increase in the number of services available for patients at Perry Eye Care "Prior to having the OCT, we referred a lot of our patients out for analysis of diseases like age-related macular degeneration," says Dr. Mark. "But with the 3D OCT we no longer need to send patients away. There is an increased awareness that we offer more than just eyeglasses and contact lenses within our practice."
In addition to the significant clinical value, the 3D OCT-1000 is also useful for improving patient education and compliance as well as contributing to the image of the practice, says Dr. Karen. "With the introduction of the 3D OCT-1000 we noticed a significant difference in the standard of care we offer, which helped the staff gain confidence in knowing that we deliver a unique level of concern for our patients and how we differentiate ourselves from other practices. Patients now distinguish our practice from others at a higher level. Furthermore, this technology has been very valuable for the patient's understanding of ocular disease, in addition to their perception of our practice," she says.
The clinical and financial value of the 3D OCT-1000 for private optometric practices can be multifaceted. According to Dr Menjivar, at Perry Eye Care the 3D OCT-1000 has contributed significantly to increased revenue, by enhancing the public image of the practice, as one that provides a high standard of care with state-of-the-art technology that is effective, efficient and comprehensive: "Patients that come into our practice see that we're on the cutting edge, and that we're trying to do the best we can to take care of our patients - and they show their appreciation for this."
Perry Eye Care's Top Tips to Stay Afloat
- Technology: invest in new devices that help to improve the level of care and reinforce positive perceptions of your practice
- Demographics: Understand the dynamics of the trends in the population - what do they need?
- Billing: Find out more about medical plans and billing procedures, particularly on billing for OCT and fundus images, to provide an additional stream of revenue
- Education: Make a commitment to your staff and patients so that they are well-informed and aware of what the practice does