Purpose
To determine whether the use of ultra wide-field imaging changes the management or determination of disease activity in patients with noninfectious posterior uveitis.
Design
Prospective, observational case series.
Methods
setting: Divisions of Retina and Ocular Immunology at single academic medical center. patient population: Total of 43 patients with noninfectious posterior uveitis seen by 4 investigators at the Wilmer Eye Institute. procedures: Each patient underwent standard clinical examination, followed by ultra wide-field scanning laser ophthalmoscope (SLO) imaging and angiography. Investigators successively determined disease activity and management decisions based on clinical examination, examination plus simulated 30- or 60-degree fluorescein angiography (FA) (obtained by physically narrowing the field of view of the wide-field images), examination plus ultra wide-field SLO images, and examination plus wide-field FA. main outcome measures: The primary outcome was the percentage of patients whose management changed based on the availability of wide-field imaging, compared with standard examination and imaging. The secondary outcome was detection of disease activity with and without wide-angle imaging.
Results
Management was altered in 7 of 43 patients (16%) based on examination and limited FA, whereas 21 of 43 patients (48%) had management change with the use of the ultra wide-field imaging and angiography ( P < .001). Disease activity was detected in 22 of 43 patients (51%) based on examination and simulated conventional imaging, and in 27 of 43 (63%) with wide-field imaging ( P = .27).
Conclusions
The index study, with several design limitations, has suggested that ultra wide-field imaging may alter management decisions compared to standard-of-care imaging and clinical examination. Additional studies, including longitudinal evaluations, are needed to determine whether these findings, or the subsequent management alterations, may improve patient outcomes.
Posterior uveitis can be challenging to diagnose and treat. Diagnosis often requires careful clinical examination of the peripheral retina. Management decision algorithms often hinge on the clinical appearance and angiographic behavior of retinal lesions. In common clinical practice, there is no technology available that simultaneously images the posterior pole and peripheral retina, limiting chronological comparisons to clinician memory, drawings, montage photography (where available), and peripheral sweeps during mid-late angiography.
Conventional fundus photography and fluorescein angiography (FA) are limited by their narrow fields of view. Ultra-wide-field scanning laser ophthalmoscope (SLO) imaging has been recently introduced and provides 200 degrees of photographic and angiographic views of the fundus, which may be helpful in the clinical management and treatment of posterior uveitis. Early reports suggest that the imaging modality, which provides pseudo-color images and wide-field FA, is well tolerated by patients, and can image through undilated pupils. There may be imaging artifacts. Ongoing research is being conducted to enhance the quality of macular angiographic resolution.
There have been several reports of the use of this technology in the management of patients with a wide variety of retinal and choroidal disorders including diabetic retinopathy, vein occlusion, retinal detachment, cytomegalovirus (CMV) retinitis, retinal and choroidal tumors, and uveitis; however, most of the reports have been retrospective case reports or series. Kaines and associates reviewed 5 cases of posterior uveitis seen at their institution and identified several attributes of the SLO wide-field imaging system that aided in the diagnosis and management of their patients. They noted that the high-resolution images allowed clear documentation of peripheral retinal lesions and greatly simplified longitudinal comparisons for disease activity and progression. Areas of neovascularization and nonperfusion were easily identified, aiding targeted panretinal photocoagulation. In several patients, they also noted peripheral angiographic findings that suggested disease activity in the absence of clinical evidence of disease.
The index study aims to employ the use of this imaging modality prospectively in the management of patients with posterior uveitis to determine whether the added information provided by the wide-field images would alter management compared with standard examination and simulated conventional (30- or 60-degree) imaging.
Methods
In this prospective, observational study of patients with noninfectious posterior uveitis, disease activity and changes in management were assessed based on clinical examination with and without simulated (30- or 60-degree) FA, and then with the addition of wide-field pseudo-color SLO images and FA using the Optos ultra-wide-field SLO (Optos Panoramic 200MA; Optos PLC, Dunfermline, Scotland, United Kingdom). New and established patients in the Divisions of Retina and Ocular Immunology at the Wilmer Eye Institute were recruited by 5 co-investigators (H.A.L., T.G., J.P.D., D.D., and Q.D.N.). A standardized questionnaire was completed by each investigator at the time of the clinical evaluation. An algorithmic approach was used that forced the investigators to determine a) whether the disease was active and b) whether they would change their current management based on examination alone, examination plus simulated conventional FA (see below), examination plus wide-field SLO photography, and examination plus wide-field angiography. Thus, each clinical encounter generated 4 “yes” or “no” responses for each of the examination technique combinations.
For practical and ethical reasons, we were unable to perform both the standard FA and the wide-field FA at the same visit. Thus, to determine disease activity and management based on examination and “conventional” (30- or 60-degree) FA, investigators were asked to limit their assessment to the central 30 or 60 degrees (based on preference) of the wide-field images (simulated conventional FA). Simulated peripheral sweeps were permitted if the investigator indicated that based on the clinical examination, peripheral sweeps were needed.
The primary outcome was the percentage of patients whose management was changed by clinical examination and “simulated conventional” FA, compared with examination plus wide-field imaging. The secondary outcome was percentage of patients whose disease was determined to be active with each modality. The primary and secondary outcome measures were analyzed in terms of proportions (ie, proportion of patients whose disease was determined to be active based on wide-field imaging compared with examination and “simulated conventional” FA) using the prtest function in Stata v11.0 (StataCorp, College Station, Texas, USA).
Results
Forty-three patients were enrolled in the index study. All patients received wide-field imaging and angiography following their clinical examination. The Table depicts the percentage of patients who demonstrated disease activity and whether management was changed based on the 4 possible combinations of examination and imaging.
| Disease Activity (n = 43) | P | Management Change (n = 43) | P | |
|---|---|---|---|---|
| Examination | 44% (29%-60%) | 14% (3%-25%) | ||
| Plus simulated conventional fluorescein angiogram | 51% (36%-67%) | .51 a | 16% (5%-28%) | .76 a |
| Plus wide-field photograph | 56% (40%-71%) | .28 a | 35% (20%-50%) | .02 a |
| Plus wide-field fluorescein angiogram | 63% (48%-78%) | .08 a .27 b | 48% (33%-64%) | <.001 a .001 b |
b vs examination and simulated conventional fluorescein angiogram.
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