Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Retina Evaluation With Nonmydriatic Ultrawide-Field Color Imaging After Cataract Extraction Surgeries in Asymptomatic Patients

Shulamit Schwartz, MD; Carmen Luz Gonzalez, MD; Ramanath Bhandari, MD; Scott N. Oliver, MD; Naresh Mandava, MD; Hugo Quiroz-Mercado, MD

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the role of nonmydriatic ultrawide-field (UWF) color retinal imaging as a screening tool in the follow-up of asymptomatic patients after cataract extraction surgeries.

PATIENTS AND METHODS:

A retrospective, observational case series. A review of electronic medical records identified patients after cataract extraction followed with UWF retinal imaging (Optos 200Tx; Optos, Dunfermline, Scotland). Images were graded and reviewed by a retina specialist. Outcome measures included image quality, the detection of peripheral lesions, and association with perioperative risk factors.

RESULTS:

Seventy-six eyes of 58 consecutive patients were enrolled. A good visualization of the peripheral retina was accomplished in more than 90% of patients. Peripheral lesions were identified in 40 eyes (52.6%) with no surgery-related retinal breaks and/or detachments. Additional pathologies were found in 35 eyes (46.1%).

CONCLUSION:

Nonmydriatic UWF color retinal imaging was found to be a useful screening tool in the follow-up of asymptomatic patients after cataract extraction in this series.

[Ophthalmic Surg Lasers Imaging Retina. 2015;46:50–55.]

From the Ophthalmology Department, Denver Health Medical Center, affiliated with University of Colorado, Denver, Colorado (SS, CLG, HQ-M); and Ophthalmology Department, Rocky Mountain Lion Eye Institute, University of Colorado, Aurora, Colorado (RB, SNO, NM).

The authors have no financial or propriety interest in the materials presented herein.

Address correspondence to Shulamit Schwartz, MD, Ophthalmology Department, Denver Health Medical Center, Affiliated with University of Colorado, 777 Bannock Street, Denver, CO 80204-4507; email: schwartz330@gmail.com.

Received: January 19, 2014
Accepted: October 06, 2014

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the role of nonmydriatic ultrawide-field (UWF) color retinal imaging as a screening tool in the follow-up of asymptomatic patients after cataract extraction surgeries.

PATIENTS AND METHODS:

A retrospective, observational case series. A review of electronic medical records identified patients after cataract extraction followed with UWF retinal imaging (Optos 200Tx; Optos, Dunfermline, Scotland). Images were graded and reviewed by a retina specialist. Outcome measures included image quality, the detection of peripheral lesions, and association with perioperative risk factors.

RESULTS:

Seventy-six eyes of 58 consecutive patients were enrolled. A good visualization of the peripheral retina was accomplished in more than 90% of patients. Peripheral lesions were identified in 40 eyes (52.6%) with no surgery-related retinal breaks and/or detachments. Additional pathologies were found in 35 eyes (46.1%).

CONCLUSION:

Nonmydriatic UWF color retinal imaging was found to be a useful screening tool in the follow-up of asymptomatic patients after cataract extraction in this series.

[Ophthalmic Surg Lasers Imaging Retina. 2015;46:50–55.]

From the Ophthalmology Department, Denver Health Medical Center, affiliated with University of Colorado, Denver, Colorado (SS, CLG, HQ-M); and Ophthalmology Department, Rocky Mountain Lion Eye Institute, University of Colorado, Aurora, Colorado (RB, SNO, NM).

The authors have no financial or propriety interest in the materials presented herein.

Address correspondence to Shulamit Schwartz, MD, Ophthalmology Department, Denver Health Medical Center, Affiliated with University of Colorado, 777 Bannock Street, Denver, CO 80204-4507; email: schwartz330@gmail.com.

Received: January 19, 2014
Accepted: October 06, 2014

Introduction

Peripheral retinal pathologies including tears and rhegmatogenous detachments (RDs) are well-known vision-threatening complications after cataract extraction surgeries despite progress in surgical techniques.1,2 The gold standard for their detection is a dilated fundus examination with scleral indentation performed by a retina specialist.

Ultrawild-field (UWF) retinal imaging is a relatively new technology that allows for the visualization of nearly the entire retina (200°) in one frame. It can be performed in nonmydriatic patients to evaluate, diagnose, and document central and peripheral retinal pathologies.3,4 The advantages of using UWF technology were already described for a variety of retinal pathologies.5–7 However, there are no well-defined indications or guidelines for its usage yet. Only a few case reports and small studies on the use of UWF imaging in retinal tears or detachments were found in the literature.8–11

The purpose of the present study was to evaluate the possible benefits of nonmydriatic UWF fundus color imaging as a screening tool in the follow-up of asymptomatic patients after cataract extraction surgeries.

Patients and Methods

We conducted a retrospective, observational case series that was approved by the institutional review board of Denver Health Medical Center and performed in accordance with the ethical standards of the Declaration of Helsinki. We reviewed the electronic medical records to identify patients who underwent elective cataract extraction surgery using phacoemulsification as a primary procedure performed by a single anterior segment surgeon between January and August 2012. Patients were included in the study if they had no postoperative new visual symptoms including flashing lights, floaters, or decreased vision and were sent by their physician for nonmydriatic retinal imaging with the Optos Optomap Panoramic 200Tx UWF retinal imaging system (Optos, Dunfermine, Scotland) in the postoperative period. This imaging system is a scanning laser ophthalmoscope that can produce up to a 200° wide-field panoramic image of the fundus in a single capture. One or two images were taken in the primary gaze position for each eye. This was performed by several trained ophthalmic technicians and reviewed by one retina specialist. The goal was to identify possible retinal lesions, emphasizing on the periphery, that require further referral to a retina specialist for definitive diagnosis and/or treatment. The reviewer was allowed to enhance the images by using the smoothing function and the optimization function by adjusting contrast, brightness, gamma, and zooming.

Images were graded according to the largest field of view and image clarity. Poor-quality images were defined as those with no view anterior to the equator or low clarity.

All imaging findings were recorded and compared with any documented preoperative fundus evaluations. Data were collected for each patient including demographic characteristics, known preoperative retinal pathologies, cataract stage, biometric measurements, and intraoperative complications.

The primary outcome was the detection of peripheral retinal lesions including retinal tears and detachments using the UWF retinal imaging system. Secondary outcomes were image quality and the association between retinal findings that require treatment and perioperative risk factors.

Results

Seventy-six eyes of 58 consecutive patients (35 women and 23 men) were enrolled in the study. The mean age was 66.6 ± 12.3 years; 46.9% of the eyes were myopic with an axial length of at least 24 mm, and 16.1% of them had pathological myopia with an axial length of 26.5 mm or more. Thirty-six percent of patients (21) had diabetes mellitus, with six eyes known to have diabetic retinopathy preoperatively. Fifteen eyes (19.7%) had advanced cataracts, six of them (40%) with no preoperative visualization of the retina. Two eyes (2.6%) had complicated surgeries with posterior capsule rupture. On average, retinal imaging was performed 4.2 ± 3.2 weeks (range: 1.1–12.6 weeks) after surgery at the surgeon’s discretion.

Seven images (9.2%) were considered poor quality as defined by the reviewer. This could be explained by records of poor patient positioning compliance, very small pupils, deep-set eyes, and dermatochalasis.

Twenty eyes did not have any retinal pathologies. Peripheral lesions were identified in 40 eyes (52.6%) and included (Table) chorioretinal atrophy, lattice degeneration, white without pressure areas, scars from previous laser/cryo-treatment, scleral buckle, pigment changes, nevus, vessel sclerosis, and drusens (Figures 1 and 2). We did not find any new retinal breaks and/or detachments related to the cataract extractions that required a referral to a retina specialist for further evaluation and diagnosis. One diabetic patient was diagnosed with tractional RD (Figure 3).

Number of Retinal Pathologies Identified With Ultrawide-Field Retinal Color Imaging

Table:

Number of Retinal Pathologies Identified With Ultrawide-Field Retinal Color Imaging

UWF retinal color imaging (Optos 200Tx) demonstrating peripheral lesions. (A) Patient 20 (left eye), a 66-year-old man with a history of retinal detachment treated with a primary scleral buckle and cryotherapy. The Optos image was taken 39 days after uneventful cataract extraction surgery. Note buckle impression with extensive cryotherapy (white arrow) and lattice (black arrow). No new retinal breaks or detachment were found. (B) Patient 7 (left eye), a 64-year-old woman with high myopia (axial length = 30.5 mm). The Optos image was taken 8 days after uneventful cataract extraction surgery. Note posterior vitreous detachment in the periphery (black arrow), Weiss ring floater (black arrowhead), peripheral pigmentary changes (white arrowheads), and a choroidal pigmentary lesion (white arrow). No new retinal breaks or detachment were found. (C) Patient 23 (left eye), a 56-year-old woman. The Optos image was taken 34 days after uneventful cataract extraction surgery. Note the wide area of white without pressure (black arrow). No new retinal breaks or detachment were found. (D) Patient 48 (left eye), a 71-year-old with diabetic retinopathy known preoperatively. The Optos image was taken 11 days after uneventful cataract extraction surgery. Note the partial pan retinal photocoagulation (black arrows) and very peripheral retinal hemorrhages (white arrowheads). No new retinal breaks or detachment were found.

Figure 1.

UWF retinal color imaging (Optos 200Tx) demonstrating peripheral lesions. (A) Patient 20 (left eye), a 66-year-old man with a history of retinal detachment treated with a primary scleral buckle and cryotherapy. The Optos image was taken 39 days after uneventful cataract extraction surgery. Note buckle impression with extensive cryotherapy (white arrow) and lattice (black arrow). No new retinal breaks or detachment were found. (B) Patient 7 (left eye), a 64-year-old woman with high myopia (axial length = 30.5 mm). The Optos image was taken 8 days after uneventful cataract extraction surgery. Note posterior vitreous detachment in the periphery (black arrow), Weiss ring floater (black arrowhead), peripheral pigmentary changes (white arrowheads), and a choroidal pigmentary lesion (white arrow). No new retinal breaks or detachment were found. (C) Patient 23 (left eye), a 56-year-old woman. The Optos image was taken 34 days after uneventful cataract extraction surgery. Note the wide area of white without pressure (black arrow). No new retinal breaks or detachment were found. (D) Patient 48 (left eye), a 71-year-old with diabetic retinopathy known preoperatively. The Optos image was taken 11 days after uneventful cataract extraction surgery. Note the partial pan retinal photocoagulation (black arrows) and very peripheral retinal hemorrhages (white arrowheads). No new retinal breaks or detachment were found.

UWF retinal color imaging (Optos 200Tx) demonstrating peripheral lesions using the zooming function of the imaging system. (A) Patient 65 (right eye), a 57-year-old man with a history of retinal tear treated with retinopexy. The Optos image was taken 29 days after uneventful cataract extraction surgery. Note the laser scars (black arrow). No new retinal breaks or detachment were found. (B) Patient 14 (left eye), a 69-year-old man. The Optos image was taken 8 days after uneventful cataract extraction surgery. Note chorioretinal atrophy at the temporal far periphery (black arrow). No new retinal breaks or detachment were found.

Figure 2.

UWF retinal color imaging (Optos 200Tx) demonstrating peripheral lesions using the zooming function of the imaging system. (A) Patient 65 (right eye), a 57-year-old man with a history of retinal tear treated with retinopexy. The Optos image was taken 29 days after uneventful cataract extraction surgery. Note the laser scars (black arrow). No new retinal breaks or detachment were found. (B) Patient 14 (left eye), a 69-year-old man. The Optos image was taken 8 days after uneventful cataract extraction surgery. Note chorioretinal atrophy at the temporal far periphery (black arrow). No new retinal breaks or detachment were found.

UWF retinal color imaging (Optos 200Tx) of patient 26 (left eye), a 73-year-old woman. Diabetic retinopathy known preoperatively. The Optos image was taken 40 days after uneventful cataract extraction surgery. Note the extensive tractional retinal detachment (black arrow). The patient was send for further evaluation and treatment by a retina specialist.

Figure 3.

UWF retinal color imaging (Optos 200Tx) of patient 26 (left eye), a 73-year-old woman. Diabetic retinopathy known preoperatively. The Optos image was taken 40 days after uneventful cataract extraction surgery. Note the extensive tractional retinal detachment (black arrow). The patient was send for further evaluation and treatment by a retina specialist.

The UWF retinal imaging allowed for the detection of additional posterior pathologies in 35 eyes (46.1%) that included (Table) age-related macular degeneration, macular holes, retinal dystrophy, myopic changes, and vascular abnormalities related to diabetic and/or hypertensive retinopathy (Figure 4). Three patients were sent for further evaluation by a retina specialist.

UWF retinal color imaging (Optos 200Tx) of patient 32 (right eye), a 61-year-old woman. The Optos image was taken 41 days after an uneventful cataract extraction surgery. Note the macular dystrophy (black arrow). A similar symmetric pathology was found in the fellow eye. The patient was referred for further evaluation by a retina specialist.

Figure 4.

UWF retinal color imaging (Optos 200Tx) of patient 32 (right eye), a 61-year-old woman. The Optos image was taken 41 days after an uneventful cataract extraction surgery. Note the macular dystrophy (black arrow). A similar symmetric pathology was found in the fellow eye. The patient was referred for further evaluation by a retina specialist.

When compared with recorded preoperative fundus examination, only two patients had known peripheral lesions, one with laser retinopexy for a retinal tear and another with a scleral buckle for RD. Another 10 patients had other retinal pathologies preoperatively, including diabetic retinopathy and age-related macular degeneration.

Discussion

Overall published rates of pseudophakic RDs range from 0.26% to 4.0%, which is higher than would be expected in the normal population.1,12 Although it may be an uncommon complication, the absolute number of RDs is substantial given the large and growing number of cataract extractions annually performed in the United States.13 Population-based cohort studies demonstrated an increased risk of RDs after cataract extractions. In 2006, Erie et al14 reported a nearly linear increase in the cumulative probability of RD observed over a 25-year study period. At 1, 5, 10, 15, and 20 years after cataract extractions, cumulative probabilities of RD were 0.27%, 0.71%, 1.23%, 1.58%, and 1.79%, respectively. The expected cumulative probability of RDs in age- and sex-matched populations not undergoing cataract extraction was 0.03% and 0.44% at 1 and 20 years, respectively. Male sex, younger age, myopia, increased axial length (> 23 mm), posterior capsular tear, RD in the fellow eye, and postoperative posterior vitreous detachment were found to be significantly associated with RD.15,16

A preoperative dilated examination of the retina is recommended in any patient who undergoes cataract extraction for the evaluation of any existing retinal pathologies that might reflect on their postoperative course.17 Moreover, attention should be given to the development of retinal tears and/or RDs in the follow-up period. According to the Preferred Practice Pattern Guidelines of the American Academy of Ophthalmology, a postoperative dilated fundus examination is indicated only if there is a reasonable suspicion or higher risk of posterior segment problems. The timing and frequency of the follow-up visits are at the surgeon’s discretion. In the absence of symptoms or surgical complications, no study has demonstrated that a dilated fundus examination results in earlier detection of RD. Batchelder et al18 evaluated the cost-effectiveness of routine dilated fundus examination in improving visual outcomes. They found that most peripheral retinal diseases could not be prevented by routine dilated fundus examination in asymptomatic patients.

The rationale behind our study was to evaluate the role of a UWF imaging system that provides a large angle view of the retina in the follow-up of patients who underwent cataract extractions. All patients were asymptomatic, and, therefore, they did not require a dilated examination during the study period. This imaging system was previously reported to be a better diagnostic tool than undilated fundoscopy alone, especially in patients who would not be normally considered for dilatation.19 UWF imaging allowed for a good visualization of the peripheral retina in more than 90% of our patients. Poor images were mainly related with low patient compliance and eyelid artifacts. We found it to be an easy and short procedure that can be used even in patients with marginal compliance. It should be mentioned that this technique does not necessarily provide a whole view of the retina (from ora to ora) in the primary gaze position in one frame in every patient.

A few studies evaluated the sensitivity and specificity of the UWF imaging system compared with clinical examination for the detection of symptomatic peripheral retinal lesions with inconsistent results. Bonnay et al9 found the UWF imaging system to be a satisfactory screening tool for the detection of retinal breaks and RDs in 56 symptomatic patients. Mackenzie et al20 studied 60 patients with known retinal pathologies. They showed an overall specificity of 85% and sensitivity of 45% to 74% of the UWF system depending on the location and treatment potential of the lesions. Most of the undetected lesions were small holes anterior to the equator. They related this finding to the relative low resolution and contrast of the very far periphery. We are unaware of any previous reports on peripheral retinal evaluation with UWF retinal imaging after cataract surgeries in asymptomatic patients.

More than 50% of the study eyes had peripheral retinal lesions, but only one patient was referred for further evaluation because of tractional RD unrelated to the cataract extraction. The lack of peripheral breaks or RDs related to cataract extraction in the present study can be attributed to the very low percentage of complicated operations, the relatively small number of men, the old patient population, and the absence of new visual symptoms. In addition, images were taken, on average, a month after surgery (maximum of 3 months). Cataract extractions are known to promote alterations in the vitreous humor structure related to the transmission of forces on the retina. They lead to an increased risk of posterior vitreous detachment (PVD) and an increased long-term risk of retinal breaks and RDs.21 Ivastinovic et al22 evaluated the onset of PVD after uneventful cataract extractions in nonmyopic eyes. Some degree of PVD was noted in 59.2% and 71.4% 1 and 3 months, respectively, after cataract extractions using OCT in patients with an intact vitreoretinal inter phase preoperatively. Because PVD is a continuous process, we hypothesize that performing the images later in the postoperative period might have subsequently revealed more lesions. The status of the vitreous before and after the time of cataract extraction in our series was unknown.

Furthermore, images were taken only in the primary gaze position. Perhaps if the steering of the eye technique was used, we might have found some undetected small and very peripheral breaks.23

Limitations of the study are mainly its retrospective nature and the inconsistent time interval between the cataract extractions and imaging.

UWF retinal imaging allowed for the detection of other retinal pathologies that were not recognized preoperatively, illustrating an additional benefit of this imaging modality.

Our study represents a supplementary step in the evaluation of a UWF retinal imaging system in peripheral retinal lesions. It shows that UWF imaging has a role as a screening tool in the follow-up of asymptomatic patients after cataract extractions, taking into account that the majority of ophthalmologists (except for retina specialists) do not routinely perform dilated fundus examination with scleral indentation to visualize the most peripheral retina. UWF imaging can be considered in cases with uneventful cataract extractions and minimal or no risk factors. This technique does not intend to replace dilated examination when indicated.

Wide-field technology is changing the way clinicians practice medicine and has gradually become a valuable clinical tool for diagnosis and monitoring. The advantage inherent to this nonmydriatic technique is patient comfort. The main practical challenges of using a UWF imaging system as a screening method are accessibility and interpretation capabilities. Remote interpretation in a regional retinal imaging reading facility is an easy and effective way to overcome this obstacle. We encourage further prospective large-scale studies on UWF retinal imaging.

References

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Number of Retinal Pathologies Identified With Ultrawide-Field Retinal Color Imaging

Peripheral Pathologies
  Pigment changes4
  Lattice degeneration2
  Chorioretinal atrophy2
  White without pressure area1
  Scars (laser/cryopexy)2
  Nevus1
  Drusen30
  Vessel sclerosis2
  Total*50
Posterior Pathologies
  Age-related macular degeneration12
  Retinal dystrophy3
  Myopic changes13
  Vascular abnormalities12
  Macular hole1
  Total*41

10.3928/23258160-20150101-08

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