Eventual obsolescence of the indirect ophthalmoscopes exam with OCT/retinal imaging?

[noflag]

With OCT getting greater use yearly and new innovations such as wide field retinal cams like the Optos, do you ever see the indirect exam becoming irrelevant and/or less accurate than imaging each patient?

Could you today ‘get away’ with imaging all of your retina patients in lieu of an indirect exam?

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[Slide]

With OCT getting greater use yearly and new innovations such as wide field retinal cams like the Optos, do you ever see the indirect exam becoming irrelevant and/or less accurate than imaging each patient?

Could you today ‘get away’ with imaging all of your retina patients in lieu of an indirect exam?

Absolutely not; if anything it’s still as important if not more. As early as fellowship I got referrals for OCT and Optos findings for incorrect diagnoses all the time that required an exam. I’ve caught melanomas, retinal detachments, and other life/sight threatening things because they were brushed off as other diagnoses on OCT or Optos. The opposite is just as true; Ive been referred “retinal detachments“ that turned out to be as benign as white without pressure, to toxocariasis.

I tell my residents that imaging is no different as using a computer; it’s no smarter than the person using it. Ancillary imaging is a powerful tool but you have to know its limitations.

 

[TheLesPaul]

It's not often in medicine we get to see pathology with our own eyes, in three dimensions and microscopic detail, with living color. It's beautiful

 

[dantt]

As early as fellowship I got referrals for OCT and Optos findings for incorrect diagnoses all the time that required an exam.

As a resident, our supervising retina fellow advised us what to do based solely on the OCT.

 

[MstaKing10]

As a resident, our supervising retina fellow advised us what to do based solely on the OCT.

For every single retina condition including PVD, detachments, lattice etc? That’s a poor fellow if so.

Our current tech isn’t as good as an exam. At least for peripheral pathology. And OCT often fails to demonstrate subtle macular heme and other findings only visible by exam. Worse yet, as Slide mentioned, pictures can oftentimes be misleading. That said the next iteration may indeed reduce the need (not eliminate altogether) the need for more intense examination techniques. For current residents and fellows I strongly suggest you learn how to perform a solid retina exam including scleral depression.

 

[Slide]

As a resident, our supervising retina fellow advised us what to do based solely on the OCT.

Not going to rehash what MstaKing10 said above (I agree 100%); if you know a patient well and see that patient regularly, you can use OCT only to intermittently guide treatment, but it still doesn’t supplant an exam. If your fellow knew the patient history well and the patient was coming monthly, I can justify that. For every visit and all patients? That is inexcusable and lazy of that fellow. Even if the patients come regularly, they need to have periodic exams because new things can occur, whether related or not.

Also, to all of those who are reading, if you are only using OCT or Optos photos to evaluate the retina, or if you cannot make sense of the imaging findings along with exam, you need to refer out instead of trying to take care of it yourself. Using the excuse that you used imaging in lieu of a dilated fundus exam is indefensible in court if there is a vision or life-threatening issue and it wasn't done.

Sources:

Malpractice Risk: Retinal Detachments

There’s a new surge in lawsuits related to diagnostic errors, and much of it is being driven by a common condition: retinal detachment. What’s behind these errors—and what can you do to prevent them?

www.aao.org

Re: Antonio Ribeiro v. The Rhode Island Eye Institute, et al
Though an old lawsuit, this one definitely comes to mind because the initial management was mainly based on OCT.

 

[Dusn]

My personal opinion is that if you can get the pathology imaged on the OCT, then the OCT is way more important than the exam. Yes, the exam can clarify some OCT findings, like heme. But the majority of the information is coming from the OCT with the exam complemented it. Unfortunately the OCT cannot easily capture many areas of the eye yet.

The caveat I'll make is that OCT interpretation is a true art. One that I've never seen a non-retina specialist perform well and I think even some retina specialists could do better.

 

[dantt]

There are many many many doctors (most) who get a better examination from a wide field fundus photo than a physical dilated exam. Everybody likes to think they're better than average but the sad truth is they're not.

 

[MstaKing10]

A lot of the above holds true for the macular exam. But as it stands today, there is no wide field OCT (I know, it’s on the horizon). And the distortion at the periphery with devices such as the optos really limits its abilities to image micro breaks and tears, not to mention artifact which can hide findings or make ones appear that aren’t real. Back to the OPs question regarding indirect I don’t see this tech supplanting indirect ophthalmoscopy any time soon.

Still impresses me the old greats like Don Gass who saw what OCT sees and predicted findings that decades later proved correct solely based on his exam. It’s a dying art, but I think still a critical one.

 

[optamologistz]

You are talking about imaging only? What to say about using the indirect to apply barrier laser in the office? You would need those skills in order to see a peripheral tear, depress, and apply laser. Unless future laser systems will be able to do this. I may be naive, maybe there is a laser that can do this already?

 

[dantt]

And the distortion at the periphery with devices such as the optos really limits its abilities to image micro breaks and tears, not to mention artifact which can hide findings or make ones appear that aren’t real.

True. Unfortunately those micro breaks/tears are not appreciated by the vast majority of non retina specialists anyway.