|The Nonmyd 8 retinal camera from Kowa
features 24 megapixel color and FAF
(Fundus Autofluorescence) images.
|ZEISS AngioPlex OCT allows practices to easily integrate advanced vascular imaging into their routine OCT diagnostic exams.|
|The Diopsys NOVA ERG and VEP Vision Testing System can detect early physiologic changes
at the cellular level in the macula at a much
earlier stage than visualization of retinopathy.
The latest developments to treat and manage patients with diabetic retinopathy.
From a practical perspective, there is no better investment a clinician can make than a high quality fundus camera system. The versatility and ease of use allow for rapid integration into clinical care protocols, while at the same time providing image quality that is unparalleled with results that can challenge viewing the retina with a biomicroscope and 78D condensing lens. The elevation of the technology is related to both the quality of the camera systems as well as new applications that are available for reviewing and managing diabetic retinopathy. Software that allows for progression analysis of retinopathy is available as is the capacity for excellent stereo photography that provides enhanced assessment of macular edema, cotton wool spots and other pathologies.
Optical Coherence Tomography
What was once a luxury has now become a remarkable new tool for the assessment and long-term management of patients with diabetes. Optical Coherence Tomography (OCT) has catapulted itself into the mainstream of clinical practice, making it difficult to imagine how we, as clinicians, have dealt with the disease state prior to its development.
The essential application is the imaging of the macular region to determine the presence or absence of diabetic macular edema, one of the primary causes of vision loss in patients with diabetes. The technology can be applied as a screening tool, or as a definitive diagnostic assessment in patients who have reductions in visual acuity. In one of its more elegant applications, OCT can be utilized in conjunction with the co-managing retinal specialist to monitor the success of interventional therapy, such as anti-VEGF, steroids and more as patients are treated through the course of their diabetic disease state. Traditional OCT has to a large degree replaced the use of fluorescein angiography in assessment of macular edema, especially once therapy has been initiated. An advancement that has recently been introduced is the ZEISS AngioPlex OCT Angiography (available on the CIRRUS 5000 HD-OCT platform). This is a new technology that produces FFA level examination of the underlying vascular architecture without the need to inject venous dye. One of its best software programs is the ability to analyze change between visits in relation to macular edema and assess the success or failure of therapy.
Another important aspect of OCT is the ability to document the ONH, RNFL and ganglion cell complex. This is crucial in the body of patients with diabetes who are either ocular hypertensives and/or glaucoma suspects and at greater risk for progression. Recent advances such as Glaucoma Progression Analysis (GPA) and Ganglion Cell Analysis (GCA) give the clinician the ability to identify the transition to glaucoma at the earliest possible moment and also aid in the long term management of the disease.
One of the complex issues in managing the diabetic patient is interpreting data following either panretinal laser photocoagulation or focal laser photocoagulation as it relates to glaucoma. Visual fields can be complex to analyze and unreliable, but the OCT can provide accurate and repeatable information.
Another modality that has concurrently developed along with OCT is the use of electrophysiology to identify early diabetic changes at the physiologic level. While other devices are typically directed toward anatomic analysis, such as OCTs and fundus photography, the use of office-based electroretinography (ERG), such as Diopsys NOVA or Diopsys ARGOS systems, is a relatively newer tool to identify early physiologic changes at the cellular level that can identify the impact of diabetes in the macula at a much earlier stage than the visualization of retinopathy. The current use of electrophysiology has been notably enhanced by the reduction of the complexity of the device, the remarkable decrease in cost and the minimal footprint of the instrumentation. Another major advance in the technology is the software programs that provide change analysis.
Ocular Surface Disease Testing
Another technology in the ophthalmic diabetic space is the use of ocular surface diagnostic systems to identify abnormalities of tear film production and the presence of inflammatory-induced ocular surface disease. In the diabetic population, as with so many ophthalmic issues, the rate and intensity of ocular surface disease state is notably greater than in a healthy population of the same age. As a result, the measurement of tear osmolarity and matrix metalloproteinase-9 (MMP-9) inflammatory assessments have become an integrated component of our day-to-day management. Tear osmolarity (as measured by TearLab technology) is a critical biomarker of the performance of the ocular surface and has a significant role in understanding both the patients’ symptoms and the clinical signs associated with ocular surface disease. This gives the clinician a valuable tool to not only identify ocular surface disease but to quantify its management.
InflammaDry by RPS Diagnostics detects elevated levels of MMP-9 to assess the ocular surface. It is invaluable in its ability to allow clinicians to understand the role of inflammation and construct appropriate clinical intervention as a result of identification of this biomarker.
Office Laboratory Testing
A final thought on new technologies is the integration of laboratory testing within the modern optometric practice. An additional technology that can be integrated into a primary care optometric practice is the ability to assist the patients in understanding their disease state by assessing fasting blood glucose in the office. This allows for rapid information acquisition and the ability to better integrate with primary care physicians and endocrinologists who are the global managers of the patients’ diabetic disease state.
The technologies that have arisen in the past decade have markedly altered the playing field with respect to the role of the ECP in the diagnosis and management of the diabetic patient. It is clear that new diagnostic technologies will continue to produce greater and more improved systems permitting us to provide higher levels of care to our diabetic patients of the future.
J. James Thimons, OD, FAAO, ABO, is founding partner/ophthalmic medical director of Ophthalmic Consultants of Connecticut.
WHERE TO FIND IT:
Carl Zeiss Meditec, Inc.
800.341.6968 | Meditec.Zeiss.com/USA
973-244-0622 | Diopsys.com
Kowa American Corporation
800-966-5692 | Kowa-USA.com
877.921.0080 | RPSDetectors.com
855.TEARLAB | TearLab.com