applications of widefield imaging894acfa90051d7a2a27e-8978d0c3c4c8cb744d658542db70335f.r59.… ·...
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Applications of WidefieldImaging
SriniVas Sadda, MDProfessor of OphthalmologyDirector, Medical Retina Unit Ophthalmic Imaging UnitUniversity of Southern CaliforniaLos Angeles, California, USA
Retina 2014
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Disclosure
Consulting Fee: Allergan; Carl Zeiss Meditec;Genentech; Optos; Regeneron
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What is widefield imaging?
Widefield
50 degree mode
Traditional Fundus Camera
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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
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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
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Technology for multimodal widefield imaging• Heidelberg non-contact widefield angiography
module–
m
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Technology for multimodal widefield imaging• Staurenghi contact widefield lens
– 150 degrees
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Applications of widefield imaging
• Angiography
• Color
• Autofluorescence
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• Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
Applications of widefield imaging
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• Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
Applications of widefield imaging
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Why widefield angiography?Traditional Photography: 30
Degrees
Image courtesy of Szilárd Kiss, MD
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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?
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ETDRS: 7 Standard FieldsUltra-widefield FA (Optos)Why widefield angiography?
Image courtesy of Szilárd Kiss, MD
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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
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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
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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
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Case: Peripheral PDRAsymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU
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Case: Peripheral PDRAsymptomatic 64 y/o HM for routine DM2 exam: 20/25 OU
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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
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Benefits of widefieldangiography
• Flourescein Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
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Benefits of widefieldangiography
• Flourescein Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
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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
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Case: Retinal Vein Occlusion
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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
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Case: Venous Occlusive Disease
67 y/o HF with BRVO OS; Va = 20/80CMENVITx’d with anti-VEGF + PRP
Is VMT a concern here?
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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)
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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
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Case: Venous Occlusive Disease
67 y/o HF with BRVO OS;After supplemental PRP1 month laterEdema further reduced, Va = 20/30
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• Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
Applications of widefield imaging
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• Angiography– Peripheral Neovascularization
– Peripheral Non-perfusion
– Peripheral Vasculitis
Applications of widefield imaging
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62 y/o Asian Female: complained of some �fogginess� ofperipheral vision in both eyes, Va =20/25 OU20/25 OU
Case
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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
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67 y/o CF with flashinglights and floaters ODVa: 20/20 OU+ occludable angles
Miotic pupils: limitedview
Does patient need anurgent PI?
Case
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• Angiography
• Color
• Autofluorescence
Applications of widefield imaging
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• Angiography
• Color– Visualization through small pupils or media
opacity
Applications of widefield imaging
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• Angiography
• Color– Visualization through small pupils or media
opacity– Long Axial Length
Applications of widefield imaging
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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
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• Angiography
• Color– Visualization through small pupils or media
opacity– Long Axial Length
Applications of widefield imaging
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• Angiography
• Color– Visualization through small pupils or media
opacity– Long Axial Length– Documentation
Applications of widefield imaging
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• Angiography
• Color– Visualization through small pupils or media
opacity– Long Axial Length– Documentation– Diabetic retinopathy screening
Applications of widefield imaging
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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
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• Angiography
• Color
• Autofluorescence
Applications of widefield imaging
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• Angiography
• Color
• Autofluorescence
Applications of widefield imaging
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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?
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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%)
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Age-related maculardegeneration
? Prognostic Significance …… To BeDetermined (AREDS2)
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
79%
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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)
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70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative
Case
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70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative
Case
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70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative
Case
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70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative
Case
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70 y/o Vietnamese male with vision OU x2Y20/400 OUPMHx: Asthma, o/w negative
Case
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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)
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83 y/o Caucasian male with vision OS (20/80)
Case
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s/p PDT (full fluence) 20/50+2 OS
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Ocular Tumors
• Choroidal melanoma, striking FAF changes
% of Eyes withPeripheral FAFAbnormalities
82%
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
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Inflammatory/Infectious diseases
• Chronic Vogt-Koyanagi-Harada syndrome
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
71%
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Inflammatory/Infectious diseases
• Chronic Vogt-Koyanagi-Harada syndrome
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
71%
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Inflammatory/Infectious diseases
• Chronic Vogt-Koyanagi-Harada syndrome
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
71%gt-Koyaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaannnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii--------------------------------------------HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaarrrrrrrrrrrrraaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyynnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnndddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrooooooooooooooooooooooooooooooooooooooooooooooooommmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee
% of Eyes wiPeripheral FAAbnonnnnnnnnnnnnnnnnnnn rmalitie
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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%
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61 y/o M with nyctalopia+anti-retinal auto-Ab against 23-kDa protein
20/80 20/60
Case
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61 y/o M with nyctalopia+anti-retinal auto-Ab against 23-kDa protein
20/80 20/60
Case
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Retinal dystrophies
• Stargardt’s disease
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
82%
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41 y/o CM with progressively vision OU, 0/14 Ishihara platesNo family history of retinal degenerationVa: 20/200 OU
Case
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Case41 y/o CM with progressively vision OU, 0/14 Ishihara platesNo family history of retinal degenerationVa: 20/200 OU
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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
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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
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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
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Diagnosis: Oculo-cutaneous Albinisim: Hermansky Pudlak
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25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU
Case
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25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU
Case
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25 y/o CF with peripheral vision OUh/o strabismusno Fam Hx of eye disease20/25 OU
Case
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Retinal dystrophies
• Rod/Cone degeneration(?PPRCA/ CRB1mutation)
AMD
CSCR
Ocular tumors
Inflammatory
Degenerations
% of Eyes withPeripheral FAFAbnormalities
82%
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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)
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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
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Thank You