This article was reviewed by Sherif R. El-Defrawy, MD, PhD, FRCSC

 and Canada-wide lockdown, Canadian ophthalmologists have moved to screening patients by phone, triaging the need for in-person visits and attempting to treat emergent and urgent cases in general ophthalmology, as well as 

On May 15, 2020, the University of Toronto’s Department of Ophthalmology and Vision Sciences held a roundtable webinar discussion to update ophthalmologists across Canada about best practices they should implement during the 

As health care comes under provincial jurisdiction, it will be up to individual provinces to decide on plans to reschedule elective surgeries. 



COVID-19: Should ophthalmologists prepare for a second surge?



In Ontario, Canada’s largest province, nearly 53,000 surgeries were cancelled or unscheduled, and there is currently no specific timeline for when the procedures are expected to resume.

“We do not anticipate elective surgery to open until late June,” said Sherif R. El-Defrawy, MD, PhD, FRCSC, Nanji Family Chair in Ophthalmology and Vision Sciences, professor and chair of the Department of Ophthalmology and Vision Sciences at the University of Toronto, and the ophthalmologist-in-chief at Kensington Eye Institute in Toronto. “I anticipate we will be seeing a large backlog in cases.”

El-Defrawy suggested plans such as operating on Saturdays and having 12-hour operating days, with 2 surgeons working in 6-hour shifts, to help address the backlog when elective surgery resumes.

When community ophthalmology practices do resume operating, it is vital that ophthalmologists wear personal protective equipment and minimize their verbal interaction with patients, according to Abdu Sharkawy, MD, FRCPC, internal medicine and infectious diseases consultant and assistant professor of medicine, University of Toronto.

“Even through speaking, if you are within 6 feet of someone who has tested positive for COVID-19, there is a risk of transmission through the droplets,” Sharkawy said. “You want to minimize the amount of talking you are doing and tell the patient to do likewise during your examination.”

COVID-19 mutations: A more efficient virus 

Moreover, Sharkawy discussed how ophthalmologists can mitigate risk, noting that there is clear evidence that 

 can be detected in tears and conjunctival secretions.

“This is problematic because the type of follicular conjunctivitis that presents as part of COVID-19 may be completely indistinguishable from that caused by a lot of other benign, viral etiologies,” Sharkawy said. “It really behooves the ophthalmologist to have a very high index of suspicion when they are seeing someone who has conjunctivitis [to be aware] that they may be dealing with a patient who has COVID-19.”

Because it is an aerosol type of transmission that can occur, an ophthalmologist should ideally be wearing an N95 mask and a face shield when examining a patient with a conjunctival issue, according to Sharkawy. 

A routine surgical mask, however, is adequate for basic assessments such as tonometry and slit-lamp examinations if the patient does not have a conjunctival issue, he added.



The dropless future: SLT as a first-line treatment for glaucoma

Yvonne Buys, MD, FRCSC, a professor in theDepartment of Ophthalmology and Vision Sciences, University of Toronto, and codirector of the Glaucoma Unit at the University Health Network, noted that the Canadian Ophthalmological Society put out a statement in late March outlining how 

cases can be triaged, such that only urgent and emergent cases are seen.

“You can do assessments on issues with drops by phone,” said Buys, noting prescription refills can be faxed to pharmacies to avoid a patient visit. “In the glaucoma area, drug shortages and discontinuation (of medications) is really a problem.”

Pharmacies are sometimes writing back to Canadian ophthalmologists treating patients with glaucoma, letting them know about the lack of medical therapies.

“There are no topical β-blockers (available in Canada),” Buys noted. “This is a made-in-Canada problem. It is not a problem south of the border (in the United States).”



Glaucoma treatment alternatives: Thinking outside the box

Buys speculated that the lack of availability of topical β-blockers is related to drug benefit plans and pricing and companies may not be choosing to stock pharmacy shelves.

To respond to the dearth of topical β-blockers in Canada, Buys suggested ophthalmologists consider looking to other sources for obtaining these medications.

“Don’t forget about compounding companies,” she told fellow ophthalmologists. “We should probably be using those more than we are.”



COVID-19: Smart thermometer shows real-time changes in fever levels

Patients should definitely be seen if intraocular pressure is very elevated (more than 38 mm Hg), if there are symptoms of acute angle closure, bleb-related endophthalmitis, bleb leaks, and hypotony with a high risk of vision loss.

 and has had surgery in the past few months, and the threshold should be lower for a monocular patient (then a patient should be seen in person),” Buys added.

Tonometry should continue to be performed with alternatives such as the Tono-Pen (Reichert Technologies) or Icare tonometers (Icare USA) with disposable tips that allow for greater spacing between the patient and the examiner.


Glaucoma 360: Decision-making in surgical glaucoma

management can be triaged, to ensure more urgent care is seen. 

Visits to see patients with diabetic macular edema and retinal vein occlusion can be delayed, whereas premature babies who require screening and treatment for retinopathy of prematurity should be seen, according to Radha Kohly, MD, PhD, FRCSC, of Sunnybrook Health Sciences Centre in Toronto and an assistant professor in the Department of Ophthalmology and Vision Sciences at the University of Toronto.

Patients who undergo regular intravitreal injections may choose to continue to come to clinic, to ensure that they can continue to drive and get their groceries, explained Kohly.

“These are patients who are undergoing a lot of stress and feel that they have to choose between their vision and their life,” Kohly added. “We need them to know that we understand the predicament that they are in, and we are here for them.”


p: 416/978-7931 
e:seldefrawy@kensingtonhealth.org


Dr. El-Defrawy has no financial disclosures related to this content.

Articles

Canadian ophthalmologists receive updates on best practices amid coronavirus outbreak


Pearls for managing COVID-19 pandemic north of the border

This article was reviewed by Danny Haddad, MD.



The sudden influx of refugees into southeast Bangladesh from Myanmar in 2017 was instrumental in creating a settlement of Rohingya, members of a Muslim minority sect, that is larger than some major international populations and their surroundings, and with all the inherent difficulties. 

In 2018, the Qatar Fund for Development reached out to Orbis International based on its recognition of the mounting need for eye care in this settlement, which is the largest such in the world. Orbis is an international organization with the mission of preventing and treating avoidable blindness. 

Upon that request for a helping hand, according to Danny Haddad, MD, Orbis began assessing the timing of the introduction of eye care to the camp based on the living status of the refugees regarding their safety, hygiene, and the basic needs being met first.

“Based on discussions with the World Health Organization (WHO), we saw that this was the right time to start building the resilience of this population, which appeared to be going to remain static for the foreseeable future,” Haddad said. “Ascertaining that the non-communicable diseases were addressed as well was an important issue.”

The organization’s assessment of the camp’s status is one of the largest published datasets on refugee eye health, and it underscored the high degree of eye disease among the members of this displaced population. 



Visual impairment high among Rohingya refugees


The study, which indicated the urgent need for eye care among the refugees, was published in 

https://doi.org/10.1371/journal.pmed.1003096

A noteworthy aspect of the eye-care program was that the care that was extended was not limited to the refugee population but also included the host population. This decision took into consideration the huge resource drain from the host population that accompanied bolstering of the refugee camps, Haddad noted.   

“It was important that their health care needs also were addressed,” he said.

A major observation of Orbis’ assessment was that 

-related blindness developed at a much earlier age in the refugee population than in other scenarios.

“This likely reflected the poor living conditions in combination with ultraviolet light exposure, malnutrition, and episodes of severe diarrhea, under which these patients were living,” he said. “Many of these patients who were blinded by cataracts were in their early 40s, about 10 years earlier than in other low-income countries. This was shocking to me.”

-related blindness was profound when considering the obstacles encountered by the refugees as they fled Myanmar, that is, the need to cross rivers to safety and the difficulty of navigating life in a camp with the prospect of monsoon season approaching with the resultant mud slides and flooded roadways.

“Being able to see again after surgery and establish social connections was incredible for these patients,” Haddad commented. 



Surgeon brings cataract care to underserved patients in the Caribbean

Orbis has set up a vision center in one camp that also serves surrounding camps. Vision screening takes place in this center and patients with refractive errors are provided with glasses free of charge. When surgery is needed, patients are transported to a partner hospital, the Cox’s Bazar Baitush Sharaf Hospital.

Children undergo vision screening at the schools in the camp and the host schools for strabismus, congenital 

, and refractive error. Children who need surgery are transported outside of the camp to a larger hospital where general anesthesia can be induced.

Thus far, about 68,000 people have undergone screening; most visual loss has been the result of refractive errors and cataracts.

Haddad reported that the prevalence of operable cataracts was 3- to 6-fold higher among working-age Rohingya (age range, 18-59 years) than in the host population.

He noted that a random sampling of the Rohingya who had cataracts removed showed excellent surgical outcomes when benchmarked against a large online database of other global users.

 is having a huge impact on this settlement. A big fear is that the virus will run rampant in a living situation such as this. In light of this, some projects currently have been suspended temporarily.

“Great precautions have been put in place by the government of Bangladesh, WHO, and the United Nations High Commissioner for Refugees to protect the camps from outbreaks. In this event, the focus is on providing emergency care. We are working on a lower scale than previously to provide our partners with the opportunity to deal with the pandemic,” Haddad explained. 

The global emergency need for personal protective equipment, masks, swabs, and test kits also extends to Bangladesh. While social distancing is difficult, attempts to control exposure include limiting the number of people who can enter the camps.

 website provides additional information about the organization, which includes Cybersight, a telemedicine platform, the Flying Eye Hospital, and opportunities for donation.




Dr. Haddad has no financial interest in this subject matter. Dr Haddad is chief of programs, Orbis International, New York.

One company is providing urgent eye care to patients in a refugee camp settlement of Rohingya. 

Stepping up to meet visual needs of refugees in Bangladesh


In a study carried out by investigators at Duke University’s Vision, Imaging and Performance Laboratory,

 Atalie C. Thompson, MD, MPH, and colleagues developed a segmentation-free deep learning (DL) algorithm using the entire circle B-scan image from 

. 

The aim of the investigators was to determine if such an algorithm would be better at detecting glaucomatous damage than using the 

l nerve fiber layer (RNFL) value provided by the machine’s automated segmentation software.



OCT: Illuminating the retina layer by layer

is usually diagnosed by a combined analysis of clinical parameters and risk factors such as age and IOP, tests for the evaluation of structural damage to the optic nerve, and visual function assessment with perimetry.



Spectral-domain OCT (SD-OCT) is the most commonly used test for structural evaluation. It provides objective quantification of damage that has occurred to the optic nerve head and RNFL. 

To obtain quantitative thickness measurements, conventional SD-OCT software applies segmentation algorithms to delineate the RNFL and extract its thickness.

Although this is generally accurate for diagnosing 

, the algorithms may fail in the presence of segmentation errors (reported in 20% to 40% of scans). 

Even without segmentation errors, interpreting conventional SD-OCT RNFL information can be difficult, due to a large number of summary parameters in addition to maps and plots.



Assessing quality of OCT scans affects clinical-decision process 


Deep learning for segmentation-free analysis

Recent advances in artificial intelligence have led to the development of DL algorithms, which can be trained to accurately detect complex patterns in images.

These algorithms can learn to analyze information across an entire SD-OCT image rather than just a segment, and may potentially provide more information about the presence of glaucomatous damage than individual SD-OCT parameters from segmentation. 

Interpreting the whole image may minimize false positives that arise when clinicians assess multiple individual parameters.



AI screening: Allowing physicians to see physicians more clearly from afar

This was a cross-sectional study of 1154 eyes in 635 individuals, and was undertaken to develop a segmentation-free DL algorithm to assess glaucomatous structural damage, using the whole peripapillary SD-OCT B-scan.

According to Thompson, the algorithm’s performance was compared with that of conventional RNFL thickness parameters.


Macular OCT: A must for treating glaucoma patients

A convolutional neural network was trained to discriminate glaucomatous from normal eyes using the SD-OCT circle B-scan without segmentation lines.

The research team found the DL algorithm had a greater area under the receiver operating characteristic curve than RNFL global and sector parameters, and it was more sensitive at 80% and 95% specificity. This appeared to be even more likely in early disease.



The authors noted some limitations. Although they used an independent test dataset for the final assessment of diagnostic accuracy, external validation in populations from other clinical settings is desirable.

In addition, it should be noted that the diagnosis of 

 is not based on the results of a single test but rather on a combined interpretation of information on risk factors, such as age and intraocular pressure, and results of structural and functional tests. 

Therefore, it remains to be seen how incorporating such an algorithm would affect clinical diagnosis when combined with these other pieces of information acquired in clinical practice, as well as for assessing change over time.

Technology assisting surgeons in capturing spectral-domain OCT



The authors concluded that the segmentation-free DL algorithm they developed performed better than global and sectoral RNFL thickness parameters for discriminating glaucomatous from control eyes, especially in cases of preperimetric or early perimetric glaucoma.

They believe that using this DL algorithm in a clinical setting may improve the accuracy and sensitivity of SD-OCT for diagnosing 

, while obviating the need for error-prone segmentation of 

Future studies should investigate how such an approach contributes to diagnostic decisions when combined with other relevant clinical information, such as risk factors and perimetry results. 


e:atalie.thompson@duke.edu
Dr. Thompson is a senior resident in ophthalmology at Duke Eye Center in Durham, North Carolina.


1. Thompson AC, Jammal AA, Berchuck SI, Mariottoni EB, Medeiros FA. Assessment of a segmentation-free deep learning algorithm for diagnosing glaucoma from optical coherence tomography scans. 

 2020;138(4):333-339. doi:10.1001/jamaophthalmol.2019.5983

Research finds automated segmentation software examines OCT scans

Investigators target algorithm for diagnosing glaucoma

A sight for sore eyes

 pandemic and the search for effective therapies and vaccines have consumed much of the world’s attention during the first half of the year. 

Results of recent reports from the University of Oxford indicate that dexamethasone, an inexpensive generic drug, significantly reduced deaths when used in very sick patients with 

Echoes of history: COVID-19 pandemic stirs memories, tests our mettle



The drug reduced deaths by a third in patients on ventilators and less severelyaffected patients receiving supplemental oxygen. Presumably the drug works by blunting the exuberant inflammatory response (the so-called cytokine storm) that the immune system mounts in some patients.

Dexamethasone is not the first drug with claims to be effective against the coronavirus. Remdesivir, in a study of 1063 patients funded by the National Institute of Allergy and Infectious Diseases, was shown to reduce median recovery time from 15 to 11 days. 

I can assure you that in academic medical centers like mine, where many were worried this spring that they would be overwhelmed by severely ill patients, a one-third reduction in the time these patients needed to be on a ventilator in our intensive care units was a very big deal.

As far as I can tell, 1 drug—hydroxychloroquine—has received an inordinate amount of attention in the lay press. Some described it as very risky, but we ophthalmologists are very familiar with hydroxychloroquine because we use it to treat patients with lupus, who generally tolerate it well, and we follow these individuals for signs of retina toxicity.

My view is that the truth will win out. Medicine is a science, I have always believed, and the truth will always become clear as additional research is performed and published. 

So I was confident that the issue surrounding hydroxychloroquine’s efficacy would become clear.

As such, when the almost 200-year-old prestigious British medical journal the 

published a paper reporting that hydroxychloroquine both was ineffective at treating the coronavirus and caused cardiac complications, my initial reaction was that we seemed to have had our answer: The drug is apparently not helpful. Science is science, after all.

Imagine my disappointment upon learning the following:

> The data used to reach the conclusion in the published paper may not exist. The Harvard professor who was lead author, Mandeep R. Mehra, MD, reported via a hospital spokesperson that “he never saw any of the data.” According to newsreports, the small company Surgisphere generated the data.

> Surgisphere claimed that it had access to enormous patient databases from health-care systems and electronic health records providers. But news organizations have reported that they cannot find any such organizations that are sharing their data, and Surgisphere declined to name any. Aneesh Chopra, former President Barack Obama’s chief technology officer, said he doubted the existence of the database. Jerome Kassirer, former editor of the 

, called the publication of the paper “a serious failure of peer review.”

published the paper based on questionable, unverified, or nonexistent data, it also published an unsigned editorial criticizing an elected American politician who had expressed his belief that hydroxychloroquine was likely effective. The 

, reporting on the editorial, made this understatement: “Rarely do publications with the 

’s influence use [their] full weight … to call for a president to be voted out of office.”

The eye and COVID-19: Providing fact, not fears

At a minimum, the juxtaposition of a political editorial with a subsequently retracted article allegedly based on nonexistent data is a black eye for the notion that politics and biomedical science are 2 different disciplines. 

reputation, built over 2 centuries, is now tarnished.

There is another old saying that when you mix medicine with politics, you end up with politics. This sad episode speaks to the truth of that shibboleth. 

The value of a reputation: Mixing medicine, politics a bitter pill 

This article was reviewed by Suber S. Huang, MD, MBA



“You make the weather. Own your outcome. Create the culture.” These are 3 big tasks that Suber S. Huang, MD, MBA, assigned that were perhaps previously unrecognized by ophthalmologists.

There are 3 important ingredients in this recipe, according to Huang, president and CEO, Retina Center of Ohio, voluntary assistant clinical professor, University of Miami, Bascom Palmer Eye Institute.

“The physician has a critical role in developing and leading the professional culture of the organization,” he said. “Collaborative partnering approaches between the physician team and the patient are important in fostering efficient and effective care, and patient satisfaction and retention of patients is the most important metric for financial success and the cornerstone of organizational sustainability.”



Setting up shop: Three common real estate errors physicians make 

Upon entering the office, physician leaders, administrative leaders, and technician leaders must thoroughly believe in what they are doing. These individuals set the tone in the office, which is a major factor in making the office operate more efficiently.

“There is no substitute for leadership, organization, discipline, and the professional will to follow through on a desired plan of action,” Huang said.

If a physician is trying to implement a new office system that will result in more efficiency and productivity and be more helpful to people, that plan must be believable to every person in the office, and the physician must partner with his or her patients, according to Huang.


Huang advised physicians to determine what the real goal is from greater office efficiency, such as adopting a lean strategy. Are the goals increased income and/or time savings? 

But, importantly, what are the effects on each physician, patients, and staff members. “Faster” and “more” are not necessarily better.

According to Huang, physicians must understand that their missions, that which they divined in their heads, is not necessarily everyone’s mission.

“They need to articulate exactly the physician’s vision, the mission, and the best possible outcome,” he said.



Navigating office management during crisis no easy task

Asking everyone from the new technician to the senior partner to describe the perfect day should reflect the same vision as the physician so that the avenue to the goal is clear. 

Although that perfect outcome may not be readily attainable, redirection can be undertaken, he emphasized. Huang also advised that doing it right the first time is the best route. Time is wasted when a mistake is made and the situation is revisited.

“For example, if endophthalmitis develops in a patient, but the physician performed the surgery 15% faster, he or she is going backward,” he said.

Being lean does not work in a vacuum. Huang explained that everyone in the office is involved in creating an efficient environment.

“The sobering statistic is that 65% to 92% of lean programs fail,” he pointed out.

The reasons for the failures include the following: lack of management support and no idea how to actuate support; incorrect strategy deployment, with the focus on saving seconds versus achieving a better outcome and greater satisfaction for patients; choosing an incorrect project to achieve more efficiency within an individualized environment and not attempting to emulate the unattainable; inappropriate team members, including those who are simply unable to embrace the system; incorrect scope, such as a project that may be too all-encompassing considering all the individuals involved in a large practice; incorrect measurement system; and incorrect implementation.



Returning to the new 'norm' of ophthalmic practice

Huang highlighted 2 important trends of economic forecasting. The first, the broken-arrow era, is defined as the time when physicians are about to be overrun and slaughtered and financial austerity is important.

“The current financial system is in the broken-arrow era,” he said. “Of all the factors that play into the total cost of health care, the rate and unit cost of injections is the fastest-growing health care cost, and it isappropriate to look at.”

The second trend is the concept that as more is learned about how to care for patients, the recognition is that medicine is less art and more protocol, a trend that merits attention, Huang pointed out.

“The trend is between consumer-driven and patient-driven and between physician/patient teaming,” he said. “The patient has to appreciate what the physician is doing, for example, keeping appointment times and delivering perfect health care.”



Five-step leadership system supports patient workflow, staff efficiency 


“The physician has to create a culture that everyone can live with,” Huang said. Patient satisfaction seems to be the key, and many factors drive the patient experience in a practice. A few deserve special attention.

One, as noted in the Accenture Global Customer Satisfaction Report 2008, is that price is not the main reason for customer churn, but rather overall poor quality of customer service.

“A physician may perform examinations faster, but if he or she is perceived as rushing patients through a production line, that patient will not be happy,” he said.

A second observation by Bain & Company, an American management consultancy headquartered in Boston, Massachusetts, is that a customer is 4 times more likely to move to a competitor in the face of a service-related and not a price- or product-related problem.

 is that the probability of selling to an existing customer is 60% to 70% but selling to a new prospect is 5% to 20%.

“This means that your patients are incredibly valuable to your practice,” Huang said. “Physicians must keep their patients happy, and must understand what they fear, what they have, and what they will appreciate.”



Small practices can success with a patient-first focus 

Lee Resource reported that for every customer complaint, there are 26 other unhappy customers who have remained silent.

“Physicians must pay attention to even a single complaint,” Huang noted.

In line with this, 1st Financial Training Services reported that 96% of unhappy customers do not complain; however, 91% of those will simply leave and never return. In support of this, the White House Office of Consumer Affairs found that a customer who is dissatisfied will relate their dissatisfaction to 9 to 15 patients; about 13% of dissatisfied customers tell more than 20 people.

“It makes sense to keep patients happy. As the practices are becoming more efficient, they should not trade off decades of good will,” he said.

The White House Office of Consumer Affairs also reported another interesting statistic, namely, that patients who have their issue resolved will relate that to 4 to 6 people; 70% of buying experiences are based on how the customer feels they are being treated, according to McKinsey. 

The ideal scenario is avoidance of negative experience, because 12 subsequent positive experiences are needed to make up for that 1 bad experience.

 Emmet Murphy and Mark Murphy pointed out that a 2% increase in customers has the same effect as decreasing cost by 10%, which is a profound effect on the bottom line.

“There is almost nothing we can do to increase our bottom line by 10%; making sure our patients are happy accomplishes that,” Huang pointed out.

Productivity may be key factor for a successful practice


To foster an environment for success, Huang also advised creating a can-do culture. This can lead to success in the office.

“All technicians and staff should feel that they have a part in improving the process and the experience in the office,” Huang explained. “Everyone’s experience should be better. If they are happy, everything flows better.”

In addition, he urges physicians to encourage innovation and discovery by patients and staff and promote physician/patient teaming. 

e:DrHuang.RCO@gmail.com
Dr. Huang has no financial interest in any aspect of this report.

Murphy EC, Murphy MA. Leading on the Edge of Chaos: The 10 Critical Elements for Success in Volatile Times. Prentice Hall Press; 2002.

Physicians must play a critical role in setting the tone in an ophthalmology facility 

Optimizing practice environment, outcomes, and patient satisfaction 

Like most physicians, I am always interested in technology that can elevate patient care. 

However, as a solo practitioner in a competitive market, I must be sure that any new technology I consider will have a reasonable financial return. 

The optomap ultra-widefield (UWF) imaging devices (Optos) are an example of technology that can simultaneously improve patient care and help grow the practice.

UWF retinal imaging, as defined by the International Wide Field Study Group, refers to a single-capture image encompassing retinal anatomy anterior to the vortex vein ampullae in all 4 quadrants.

Studies show that UWF imaging helps doctors discover, diagnose, document, and treat pathology that might go undetected using traditional exams and equipment.

 These clinical advantages can save vision. 



Ultra-widefield imaging adding depth to pediatric ophthalmology 

A less-obvious benefit to UWF imaging is that these clinical applications equate to quantifiable practice efficiencies. 

Since adding UWF imaging to the practice, we have enjoyed faster patient throughput, as well as increases in referrals and patient satisfaction, resulting in significant practice growth.

Before acquiring our Optos UWF imaging device, we used a digital fundus camera, which meant investing significant time and effort to obtain quality images.

The UWF device images more than 80% of the retina in a single capture in less than half a second, and it is always in focus.

These UWF imaging devices use cSLO technology, which means they can image effectively through an undilated pupil (and even through most cataracts), contributing significantly to practice efficiency. 

By reducing the waiting and patient flow issues incurred during the dilation process, we are able to get patients in and out of the office much more quickly.

The UWF imaging device also enhances efficiency by enabling me to delegate the imaging function to our technicians. All staff members are trained to operate the device. 

The learning curve is short and is much easier to use than our previous fundus camera, so staff quickly became adept at capturing and previewing the images.


Coming to terms with 'ultra-widefield' and 'widefield' imaging 

As a result of their involvement, staff members often recognize situations when I might require further testing. 

When a patient presents with new- onset floaters, I walk into the exam room already knowing where the tear is located because my technician has already captured an optomap image.

Our patients appreciate the benefits this technology offers. Those who are 20/20 uncorrected postoperatively are delighted to be imaged and out the door quickly rather than being dilated and dealing with the associated discomfort and blurred vision for hours afterward.

Of course, dilated fundus exams are still the standard of care. We dilate virtually every patient on their first visit, but if things are stable on follow-up, we may utilize the UWF device to visualize the posterior segment.

For patients who refuse to be dilated, a UWF image that shows no pathology helps me feel more comfortable letting the patient go without dilation. 

When the UWF shows peripheral pathology, such as a choroidal mass or a possible tear, I show the optomap image to help the patient understand the need.



UWF imaging contributes to earlier disease detection

Although patient care is always our top priority, a healthy bottom line is key to growth and longevity, and we have realized several financial benefits by adopting UWF.

First, it enables us to see more patients. In addition, because peripheral imaging allows us to detect more pathology, we submit more image claims for reimbursement. 

We are billing approximately 5 additional images per day because of the increased patient volume, field of view, anddetail achieved with this technology. 

A final benefit is that we have increased patient volume specifically via word-of-mouth referrals from patients who appreciate the UWF exam.

The UWF device has design features that contribute to better patient interactions, better care, and practice efficiency.

For example, the ability to compare images taken at various points in time either side by side or with the overlaying feature is invaluable. Sometimes, I will see a nevus and wonder, “I did not comment on this last year, is it something new that I should be more concerned about?” 

To be able to look back and confirm the status of pathology at the previous visit is helpful.

Historical images saved in patients’ files are an important medicolegal backup. In many cases, the crux of a lawsuit is whether the physician missed something (a tear, tumor etc).



Ultra-widefield OCT 'may be the only imaging needed' to manage PDR

Relying on our UWF imaging device enables me to finish my busy clinic work on time—which is appreciated by my family, my staff, and my patients. Dilating only the patients who require it and locating pathology rapidly allows me to operate more efficiently and provide better patient care.

UWF is fast becoming standard-of-care testing in comprehensive ophthalmology. Research in the management of diabetic retinopathy has shown that peripheral lesions identified with UWF imaging are associated with increased risk of disease progression, and identifying these lesions often affects diabetic retinopathy severity grading.

This should convince ophthalmologists to consider adding UWF to their practice. 



Dr. Goldman is founder and CEO of GoldmanEye, Palm Beach Gardens. He is a speaker and consultant for Optos.

1. Choudhry N. Classification & guidelines for wide field imaging: recommendations from the International Wide Field Imaging Study Group. Poster session presented at: 51st Annual Retina Society Meeting; 2018 Sept 12-15; San Francisco, CA.

Physicians can discover, diagnose, document, treat diseases that might go undetected

Ophthalmology Times: July 1, 2020

Pearls for managing COVID-19 pandemic north of the border

Stepping up to meet visual needs of refugees in Bangladesh

Investigators target algorithm for diagnosing glaucoma

A sight for sore eyes

The value of a reputation: Mixing medicine, politics a bitter pill

Optimizing practice environment, outcomes, and patient satisfaction

Ultra-widefield imaging can enhance efficiency for practices

Study targets results of MIGS device versus trabeculectomy

Getting it right: There is no magic bullet for IOL calculations

Surgeons discuss MIPS, impact of pass-through medications

For IOL placement, location is key