Retinal ultra wide field imaging is an interesting tool in diagnosis, documentation and teaching of different retinal pathologies

1. Wide Field Imaging : impact on managing retinal
pathologies
Dr Manmath Kumar Das
Consultant VR surgeon
Department of Ophthalmology
Kalinga Institute of Medical Sciences (KIMS)
Institute of Eminence

2. Financial Disclosure
• NIL

3. What is UWF Retinal
Imaging
In 2019, the International Widefield Imaging Study Group published
definitions and descriptions for widefield and ultra-widefield imaging.*
The terms for visible retina for imaging are:
• Posterior Pole – area of retina within the major temporal vascular arcades and
slightly, just beyond
• Widefield – centered on the fovea and includes the retina in all four quadrants
posterior to and including the vortex vein ampullae
• Ultra-widefield – images showing retinal anatomy anterior to the vortex vein
ampullae in all four quadrants
*Classification & Guidelines for Widefield Imaging Recommendations from the International Widefield Imaging Study Group.
Choudhry, Duker, Freund, Kiss, Querques, Rosen, Sarraf, Souied, Stanga, Staurenghi, Sadda. Ophthalmology Retina 2019.

4. ETDRS 7 field vs WF/UWF

5. ◦

6. Field of view matters !!!
• Only disc, macula visible:30 degree
• ETDRS 7 field montage: 75 degree
• Spectralis UWF: 105 degree
• Clarus UWF: 133 (single image),200 (two
images), 267 degree (montage)
• Optos UWF: 200 degree
• Mirante UWF: 163 degree ( single image)
• RetCam: 130 degree

7. Limitations of current UWF system
• Inability to capture ora to ora in a single frame
• Media opacities : degrades the quality
• Peripheral distortion: nasal & temporal images
appear bigger than actual

8. Spectralis UWF lens

9. Spectralis field of view

10. Standard 30 degree vs UWF

11. 55 degree Vs UWF (102 degree)

12. Which one to choose from ???
• Spectralis UWF : sup. & inf. periphery
• Optos UWF : temporal & nasal periphery
• Comparison of ultra-widefield fluorescein angiography with the Heidelberg Spectralis® noncontact ultra-widefield module
versus the Optos® Optomap®. Witmore MW et al. Clin Cophthal 2013: 7: 389-94

13. Normal UWF-FA in Spectralis (105◦)

14. Optos UWF imaging

15. Wide field imaging in various retinal
diseases
• Diabetic Retinopathy
• CRVO/BRVO
• VHL
• TAKAYASU
• Coats’ disease
• Rheg RD,HST

16. UWF imaging in Takayasu retinopathy
Ultra-widefield imaging in Takayasu arteritis. Manmath K Das, Ridhima Pokharna, Debashis Maikap , Sangram Panda. Ind J
Ophthal 2022; Feb

17. UWF imaging in Takayasu retinopathy

18. UWF imaging in D.R.
VBHC- 15th October 2019, Mumbai

19. UWF imaging in D.R.

20. UWF imaging in Diabetic Retinopathy
Advantages :
 Severity level higher than Standard ETDRS 7 fields
 Detection of CNP areas and NVEs more than NON-uwf images
 25% more peripheral neovascularization than standard images
 Manjunath et al detected more PDR & severe NPDR eyes than
conventional images
 UWF images detected 50% more PPL lesions in DR eyes
Price L.D., Au S., Chong N.V. Optomap ultrawide field imaging identifies additional retinal abnormalities in patients with diabetic retinopathy. Clin Ophthalmol.2015;9:527–531.
Wessel M.M., Aaker G.D., Parlitsis G., Cho M., D'Amico D.J., Kiss S. Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy. Retina. 2012;32:785–791.
Talks S.J., Manjunath V., Steel D.H., Peto T., Taylor R. New vessels detected on wide-field imaging compared to two-field and seven-field imaging: implications for diabetic retinopathy screening image analysis. Br J Ophthalmol.2015;99:1606–1609.
Silva P.S., Cavallerano J.D., Sun J.K., Soliman A.Z., Aiello L.M., Aiello L.P. Peripheral lesions identified by mydriatic ultrawide field imaging: distribution and potential impact on diabetic retinopathy severity. Ophthalmology.2013;120:2587–2595.

21. UWF imaging in DME
• Recalcitrant DME is assoc. with large areas of
peripheral ischemia
M.M. Wessel, N. Nair, G.D. Aaker, J.R. Ehrlich, D.J. D’Amico, S. KissPeripheral retinal ischaemia, as evaluated by ultra-
widefield fluorescein angiography, is associated with diabetic macular oedema. British Journal of
Ophthalmology, 96 (5) (2012), pp. 694-698

22. Role of UWF imaging in TRP
• Targeted Retinal photocoagulation (TRP) refers to
selective laser application to CNP areas detected
by FA leads to reduction in VEGF → DME
reduction & PDR regression
S. Reddy, A. Hu, S.D. Schwartz. Ultra Wide Field Fluorescein Angiography Guided Targeted Retinal Photocoagulation (TRP)
Seminars in Ophthalmology, 24 (1) (2009), pp. 9-14

23. Conclusions in D.R.
• Almost all possible studies indicate UWF
imaging plays a major role in diagnosis,
classification and management
• Role of UWF – guided TRPs : still unclear
• DRCR.net protocol AA – trial is underway to
address many queries in UWF imaging in D.R.

24. UWF imaging in CRVO

25. UWF imaging in BRVO

26. Advantages: UWF imaging in RVOs
• Ability to capture a wider area in a single image
• Measurement of peripheral non-perfusion areas : risk
factor of NV
• Peripheral non-perfusion areas : key driver in VEGF levels,
hence macular edema
• Calculation of Ischemic index
• Ischemic index more in CRVO ( 0 TO 99%) than BRVO (0.1%
to 61.3%)
Colin S Tan, Kelvin Z Li , S R Sadda. Wide-field angiography in retinal vein occlusions. Int J Ret Vitreous 2019 Dec

27. UWF imaging in VHL syndrome

28. UWF imaging in PCV
Courtesy : Dr Nishant Radke

29. UWF imaging in Rheg RD
Courtesy : Dr Nishant Radke

30. UWF imaging in Rheg RD
Courtesy : Dr Nishant Radke

31. UWF imaging in PDR + S/H H’GE
Courtesy : Dr Nishant Radke

32. UWF imaging in Coats’ disease
Courtesy : Dr Nishant Radke

33. UWF showing HST
Courtesy : Dr Nishant Radke

34. Conclusions
• Wide field/ Ultra wide field imaging helps us –
1. Diagnosis
2. Better documentation
3. Screening tool
4. Teaching tool

35. THANK YOU