The basic design of the
fundus camera remains unchanged going on several decades now. Its utility is manifold — the fundus image, the external photograph, paired optic disk images,
fluorescein angiography, stereo-angiography, and the occasional anterior segment image. From time immemorial to the mid-90’s, the major advance was transition from film-based camera systems to digital image capture system. The community’s embrace of the new digital technology was slow and shallow, akin to the European cheek kissing routine—pro-forma, but not intimate. However, once digital storage became cheaper and processing routines became blazingly fast, the advantages of digital-based camera systems declared themselves. Chief among them was near-simultaneous interpretation of the images coincident within the patient’s visit with the physician.
Historically, photographs would be taken, film would be sent out at the end of the day, returned the next day, and then interpreted at the physician’s leisure. The lack of effective treatment strategies did little to hasten this process along, and the whole community accepted this strategy. Many argued for the superiority of the film quality, and early on this argument held sway. Additionally, the ease of stereoscopic fundus and angiographic photography was useful. The limitations were clear—cost, delay, lack of back-up, inability to easily transfer images to other physicians, and a propensity for lost images.
As a fellow, I had a pathologic disregard for my task of reading directly from the negatives and complained loudly, clearly, and persistently such that within 12 months of arrival we had our first digital fundus photography system. Lo and behold, it was secretly loved and utilized. At first, only for “emergent” cases, and then for everything. The advantages are also straightforward—cost-effectiveness, ease of use, simultaneous interpretation, accurate filing, and ability to share. The advent of photodynamic therapy and non-destructive therapy for age-related macular degeneration probably served to facilitate the wide-spread transition from film-based to digital-based photography systems. Today, digital systems rule and there is no substitute for the fundus camera on the horizon. Presently available systems include Topcon, Nidek, Nikon, Zeiss, OIS. Each camera has its idiosyncrasies, but, by and large differ only in their supported software and imaging. I would largely categorize fundus cameras as a commodity that should be purchased on price or software preference.
The next evolution of the fundus camera is the non-mydriatic camera. Perhaps no procedure is more vilified by patients that ocular dilation. The first question is “do I need it?” The second is “how long will it last?” The third is “do you have reversing drops?” The same questions may be posited for the non-mydriatic camera. Having chatted with my friends in the private practice world, I was recently informed that more and more new, fancy, cool, “must-have” equipment is coming on the market but it always fails the fundamental question—“Will it make me more money?” This question hasn’t been answered to anyone’s satisfaction. Typically, this means “No.” This, in particular, applies to the non-mydriatic cameras.
The camera John Kitchens, M.D. profiled, the optomap®, does not offer the resolution or color that we in the retina world have come to demand for fundus photography. Having said that, it offers unparalleled, wicked-cool wide-field angiography images. Can you make more money with it—no. Are they cheap—no. But the wicked-cool factor is off the charts. From my vantage point, the non-mydriatic camera is strictly a luxury. Nice to have, hard to justify. The typical argument in their favor is that a technician can be deployed to take photographs of every incoming patient prior to work up, screening can be performed based on these photographs, and then dilation offered to those who really need it. These cameras are not cheap, do not yet offer separate coding, and to get the wicked-cool feature of wide-field angiography, dilation is routinely applied. But for the retina specialist who has to have everything, check out the angiography on the Optos.
What about specialty cameras? Glad you asked. I serve on the Scientific Advisory Board for Clarity Medical Systems, Inc., the maker of the RetCam. For those of you involved in retinopathy of prematurity or retinoblastoma, you probably know what you need to. For the rest of you rushing for the exits, Clarity is touting the ability of the RetCam ROP hand-piece to perform gonioscopic photography in the office on adults. This is a billable procedure with existing codes. If you already have a camera, try it out. I was taught to focus on the little “Intel Inside” sticker on the laptop computer that is associated with my RetCam Shuttle. Apply some Genteal or Goniosol, some topical anesthetic, recline the patient and then place the hand-piece on the cornea. Aim for the angles and be sure to decrease the light, as most patients find the fiber-optic light to be a wee bit annoying. I find it useful for tracking my CRVO patients monthly for the first 6 months to document the angle status photographically.
RetCam Shuttle, Clarity Medical Systems, Inc.
We have a microperimetry unit in our office. Typically, we send a patient with advanced macular changes or subtle macular changes on over to Mike Marmor, M.D., who evaluates the patient for dystrophies with ERGs/EOGs/VEPs/ABCs/etc. Oftentimes, he sends back these microperimetry reports and tells me what is wrong. Good thing he does, because I don’t have the foggiest clue. Usually, my patient has such advanced macular pathology that mapping out where they can and cannot see is merely an academic exercise or they have such subtle pathology (coupled with pretty good visual acuity) that the test doesn’t help me either way. And it surely doesn’t help the patient. In their favor, they might be useful for toxic maculopathies.
For fluorescein angiography, I usually revert to my choices for fundus camera imaging above. Being in an academic setting, we have a wide variety of choices. The one that I find the most useful and interesting, but ironically use the least, is our HRA 2 device. For those of you who have not been submerged by the tidal wave of literature that they put out, HRA 2 stands for Heidelberg Retinal Angiograph (the 2 I think is still 2.) This unit suffers only from its inability to take a true color fundus photograph—it offers an infrared. It is probably this that limits our usage of this otherwise remarkable device. We only have one photographer, and it is much simpler to take the photographs and angiogram at one device without having to reposition the patient at a different camera. This minor deficiency is more than compensated for by its numerous attributes—fluorescein, indocyanine green, and autofluorescence in one compact unit. The video features are key, but again cannot be utilized yet on the image management software systems currently available. I like this machine a lot and have started requesting more autofluorescence images, now that we have a photographer who is experienced in taking them. We recently demoed a Spectralis unit, which includes their version of the OCT, and I was IMPRESSED.
I would urge you to make an economic argument for every piece of equipment that you are intending to purchase. At the end of the day, the office is a business, and it will not do to buy equipment that is not used.
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