62 The Journl of Ophthlmic Photogrphy Volume 35, Numer 2 Fll 2013 ORIGINAL ARTICLE Angel J Chppell B.App.Sci, CRA, OCT-C Jmie E Crig MBBS(hons), D.Phil., FRANZCO Ophthlmology Deprtment Flinders Medicl Centre Bedford Prk South Austrli, 5042 Angel.Chppell@flinders.edu.u 618 82044775 Phone Tles of the Unexpected: Incidentl Findings in Ophthlmic Imging Key Words Incidentl findings, ophthlmic imging, opticl coherence tomogrphy, screening scns I Introduction n the course of crrying out their work, ophthlmic photogrphers my come cross unusul or unexpected findings. An incidentl finding is defined s per chnce discovery in ptient which my wrrnt further investigtion. 1 This pper reports on series of eleven cses of ptients referred for ophthlmic imging in which incidentl findings were oserved y the photogrpher, with the im of determining; () the significnce for the ptient, () the fctors tht led to the photogrpher discovering them, nd (c) issues tht were rised in reporting the findings. Method The 11 cses were oserved y the photogrpher (AC) over period of 12 yers nd include photogrphic, opticl coherence tomogrphy (OCT), nd verl incidentl findings. Results Cse Report 1 An 83 yer old mle norml control ptient for glucom reserch study ws referred for optic disc imging. Disc photogrphy reveled retinl emolus, not previously noted (Figure 1). Study investigtors were emiled to ring it their ttention nd enquire out its significnce. The ptient ws investigted to evlute his crotid rteries with ultrsound. He ws lredy on spirin, nd interestingly he susequently hd cererovsculr ccident (stroke) pproximtely three months lter ut mde good recovery. Figure 1: (Cse 1) Optic Disc photo showing refrctile emolus lodged in rtery. This cse shows tht norml control ptients in n eye study my hve significnt pthologies detected t the time of routine imging. In this cse the incidentl finding wrrnted further investigtion nd ws significnt for the ptient s generl helth. One previously reported study of ptients with symptomtic retinl emolus found 22% rte of significnt crotid stenosis (>70% stenosis) on ultrsound, however the study popultion consisted entirely of dietic ptients. 2 In norml popultion it hs een shown tht the presence of n symptomtic retinl emolus is risk fctor for stroke. 3 Cse Report 2 An 81 yer old femle ptient in ctrct study ws referred for lens imging. Slit lmp photogrphy reveled peeling deposits on the nterior lens surfce round the pupil mrgin chrcteristic of pseudoexfolition (PEX) of the lens cpsule (Figure 2). PEX ws susequently confirmed y the study investigtor when
Tles of the Unexpected: Incidentl Findings in Ophthlmic Imging 63 he exmined the ptient fter imging hd een crried out. He explined tht PEX indicted this ptient ws t risk of secondry glucom nd would need regulr review, nd lso tht there would e incresed risks for ctrct surgery. This cse shows doctor workflow rrngements my men eye exmintion is completed fter ptient s pupils re dilted nd ophthlmic imging hs een performed. Cse Reports 3 nd 4 A 78 yer old femle ws referred for fundus fluorescein ngiogrm (FFA) to investigte the possiility of post-opertive cystoid mcul edem. An 88 yer old femle ws lso referred for FFA with ge-relted mculr degenertion nd distorted vision. Both ptients were oserved to hve the sme incidentl finding of disc drusen indicted y utofluorescence (Figures 3 nd 4). In cse 3 the drusen were ovious nd review of csenotes reveled drusen hd een previously noted, ut not cited on the imging request form. In cse 4, the utofluorescence ws more sutle, nd this ws rought to the ttention of the doctor since the photogrpher felt it could esily e overlooked, eing visile only on pre-injection nd very erly phse of the ngiogrm. The treting doctor explined tht this informtion regrding dignosis is useful, s in some cses disc drusen my e confused with disc swelling. Cse 3 illustrtes tht doctors do not lwys put ll the eye findings on the imging request, proly ecuse they re not considered to e of primry importnce. Cse 4 shows the importnce of tking the pre-injection or control photo on FFA which my e the only time sutle utofluorescence of disc drusen is reveled. Cse Report 5 An 81 yer old mle ws referred for FFA to investigte the possiility of perippillry choroidl neovsculristion. The distinctive ppernce of the disc in the ngiogrm reveled choroidl neovsculristion secondry to Angioid Streks (Figure 5). Pttern recognition of this rre condition occurred ecuse the photogrpher hd seen nother five exmples over period of twelve yers. Angioid Streks my e ssocited with connective tissue diseses nd hve systemic connottions. In this instnce the priority of the Figure 2: (Cse 2) Red reflex photo with rrows indicting previously undignosed PEX of the lens cpsule. Figure 3: (Cse 3) FFA 2-up view () showing ovious disc utofluorescence pre dye filling nd () erly phse of FFA. Figure 4: (Cse 4) FFA 2-up view () showing sutle disc utofluorescence pre dye filling nd () erly phse of FFA with no visile disc utofluorescence.
64 The Journl of Ophthlmic Photogrphy Volume 35, Numer 2 Fll 2013 doctor ws to tret the ptient s uncontrolled glucom, which required urgent surgery. This cse shows how doctors trige clinicl tretment of their ptient, nd tret the most importnt eye condition first. It lso shows tht experienced photogrphers my redily recognise some rre eye conditions. Cse Report 6 A 38 yer old mle with n herpetic eye infection ws referred for slit lmp photogrphy of single dendritic ulcer. Photogrphy nd ppliction of fluorescein stin reveled second ulcer (Figure 6) which ws then rought to the doctor s ttention. Although the mngement for the condition is the sme for one or multiple ulcers, it could hve confused the doctor into thinking the infection ws getting worse on the ptient s next visit. Cse Report 7 A 74 yer old femle with previous retinl detchment surgery nd n incidentl choroidl nevus ws referred for fundus photogrphy of the nevus. The photogrpher ws unle to locte the nevus in the c peripherl retin, even fter reviewing digrms in the ptient csenotes. The treting doctor then provided new digrm showing the correct loction, llowing the photogrpher to finlly imge the nevus (Figure 7). The explntion for this incidentl finding of Migrting Nevus (Figure 7) ws tht registrrs (trinee ophthlmologists) on the two previous ptient visits were still lerning how to doule-invert (ie. turn upside-down nd ck-to-front) the view of the retin s seen on slit lmp or indirect ophthlmoscope nd hence hd presented Figure 5: (Cse 5) () Angiogrm imge (lte phse) compred to ngiogrm imges of 3 other ptients (, c, d) with Angioid Streks, showing the distinctive stining pttern round the optic disc. d Figure 6: (Cse 6) () Sclerl sctter illumintion with rrows showing dendritic ulcers in the superior nd inferior corne. () Colt lue illumintion with yellow rrier filter clerly showing fluorescein stining of the two dendritic ulcers.
Tles of the Unexpected: Incidentl Findings in Ophthlmic Imging 65 Figure 7: (Cse 7) Digrms of the retin showing loction of the choroidl nevus on 3 successive ptient visits. Figure 7: Arrows show the pth of the so-clled Migrting Nevus. Figure 8: (Cse 8) () OCT plot of left optic disc showing nerve fire loss. () OCT line scn showing left mculr hole. misleding digrms to the photogrpher out the true loction of the pthology. Cse Report 8 A 61 yer old mle with suspected non-rteritic nterior ischemic optic neuropthy ws referred for opticl coherence tomogrphy (OCT) of the optic disc (Figure 8). Mculr OCT reveled full thickness mculr hole (Figure 8) not previously noted, nd explined the ptient s chronic poor visul cuity in the left eye. This mculr hole my hve een suitle for surgery hd it een picked up erlier. This cse gin shows tht doctor workflow rrngements my men tht n eye exmintion is completed fter ptient s pupils re dilted nd ophthlmic imging hs een performed. Secondly, it illustrtes tht OCT screening scns of the mcul or disc or even the other eye cn esily revel incidentl findings. Thirdly, it shows OCT my e more sensitive thn cursory fundus exmintion, since this ptient ws referred from n externl ophthlmologist without reference to the mculr pthology. Cse Report 9 An 83 yer old mle glucom suspect ws referred for opticl coherence tomogrphy (OCT) of the optic disc. Mculr OCT ws performed using time domin OCT device (Figure 9) nd newer spectrl domin (Figure 9) device. The ltter reveled cyst, not seen clerly with the former device. When rought to the doctor s ttention he jokingly complined the new OCT showed him more thn he wnted to see nd tht his ptient hd too mny eye prolems. Lter he cknowledged the OCT scn confirmed clinicl finding of microneurysm in tht loction, nd tht this ws possily the strt of new disese process. This cse shows tht spectrl domin OCT cn detect findings not esily seen
66 The Journl of Ophthlmic Photogrphy Volume 35, Numer 2 Fll 2013 on time domin OCT, ecuse of the higher resolution imge produced. Secondly, it shows tht incidentl findings re not lwys immeditely welcomed y the doctor. Cse Report 10 An 84 yer old femle with mculr degenertion nd treted choroidl neovsculristion ws referred for mculr OCT. The monochrome fundus imge (Figure 10) on the OCT reveled well-defined drk ptch which ws initilly thought to e n rtefct. However when compred to previous colour fundus photo (Figure 10) the re ws shown to e choroidl nevus. Enquiries to the mnufcturer of the OCT device (Zeiss Strtus OCT3) reveled the illumintion used on the freeze without flsh setting is in the ner infr-red region of the electromgnetic spectrum, which is idel for detecting nevi nd tumours. This cse illustrtes tht OCT devices which utilise ner infr-red illumintion on the fundus picture cn help to detect nevi nd tumours, s these re more distinctive thn on colour fundus photogrphy which utilises flsh illumintion from the visile region of the electromgnetic spectrum. Cse Report 11 A 23 yer old visily distressed femle with thyroid eye disese cusing ptosis nd diplopi ws referred for nine positions of gze photogrphy. The photogrpher enquired symptheticlly out her prolems, nd relized she relly needed some kind of help. Nursing stff were lerted nd the doctor gve permission to rrnge for the ptient to see socil worker. Four dys lter she ws dmitted to the psychitric wrd with mjor depression. This ws n extreme cse of unreported ptient symptoms. In some instnces when ptients communicte symptoms to the photogrpher not reported to the doctor, the photogrpher my need to remind the ptient to discuss these concerns with the doctor. However, this cse illustrtes the need for potentilly lifethretening unreported symptoms to e rought to the doctor s ttention y the photogrpher directly. Discussion Significnce for Ptient The 11 cse reports highlight wide rnge in the level of significnce of incidentl findings for the ptients involved. At the lower end of the scle re the cses in which the findings were lredy known, or out to Figure 9: (Cse 9) () Time domin OCT colour scn of left mcul with no ovious normlity. () Spectrl domin OCT monochrome scn showing cyst t left mcul. Figure 10: (Cse 10) () Monochrome fundus imge tken on freeze without flsh setting on the Zeiss Strtus OCT3 device, showing distinctive drk re on the left. () Colour fundus imge showing choroidl nevus on the left. A mculr hemorrhge in the centre shows the re of choroidl neovsculristion prior to tretment.
Tles of the Unexpected: Incidentl Findings in Ophthlmic Imging 67 e discovered y the treting doctor. In the mjority of other cses the findings, lthough curious to the photogrpher, were not significnt for the ptient s little or no chnge of ptient mngement ws required. However, in prticulr, the first nd lst cses reported incidentl findings which were significnt for the ptients, nd emphsise the importnce of ringing them to the ttention of the treting doctor. In Cse 1 the finding of retinl emolus led to crdiovsculr investigtion, nd preceded stroke. In Cse 11 the finding of distrught ptient led to hospitlistion for mjor depression. Fctors Leding to Discovery It would seem tht the photogrpher is more likely to discover incidentl findings when the ptient referred for imging hs not yet hd complete nd thorough eye exmintion. Resons for this not eing crried out might e; (1) inexperience or eing focused on one prticulr prt of the eye exmintion; (2) the ptient is enrolled s norml control in study in which there is no perceived need for it; or (3) workflow which dicttes the ptient hs their dilting drops instilled nd is referred for imging prior to the doctor crrying out exmintion of the posterior segment (s imging such s OCT does not require fully dilted pupil). In other instnces ptients my mention some symptoms to the photogrpher ut not the doctor, not ll the eye findings/dignoses re written on the imging request, the photogrpher hs enough experience to recognise something unusul, or if not, to show unusul findings to doctor with specilised expertise for identifiction. A common reson for incidentl findings coming to light in OCT is the speed nd ese of doing extr scns. OCT Screening Scns OCT hs revolutionised eye imging nd ecome the most common imging modlity requested in the modern dy eye clinic. With its fst nd esily cquired detiled sections of the retin, most photogrphers cn point to incidentl findings discovered in scns not specificlly requested y the doctor. So clled screening scns hve populrly een ccepted s good prctice y mny ophthlmic photogrphers. Greg Hoffmeyer, former Director of Reserch Imging t Duke University, is respected s leder in the field of OCT nd dvoctes screening scns. He mde the following comment on the Optiml internet discussion forum: With ANY ptient I would do mculr Eye Condition Age-relted mculr degenertion Brnch retinl vein occlusion Centrl retinl vein occlusion Cliniclly significnt mculr edem Post-opertive cystoid mcul edem Mcul hole Epiretinl memrne Vitreo-mculr trction Centrl serous retinopthy Glucom / Glucom suspect Disc swelling Plquenil (Hydroxycholoroquinolone) screening AND optic disk cue, it tkes few more seconds, why wouldn t you?. 4 The ophthlmic photogrpher (AC) ccepted this philosophy nd hd no cuse to question it until discussion with doctors t Flinders Eye Clinic unexpectedly reveled some different views. It seems tht the issue of screening ptients hs potentil legl nd ethicl rmifictions for doctors nd ptients. Some points the doctors rised were; (1) The question of screening ptients for other conditions without their explicit consent, (2) If screening revels findings, it cn led to unnecessry nxiety for the ptient, (3) The cost of screening dds up, for exmple, the time tken for extr imging dded up for n entire yer my result in sustntil costs for wges for the time spent doing them. The cost of printing the extr scns my lso e sustntil. These costs my outweigh the enefits of the findings nd e etter spent elsewhere. There re guidelines for screening which doctors follow. The World Helth Orgnistion Principles of Screening were pulished in 1968 5 ut re still pplicle tody. These include; () eing specific out wht disese is eing screened for, () the condition eing n importnt helth prolem, nd (c) hving n greed policy on who to tret. Performing OCT screening scns on every ptient referred for OCT meets none of these criteri. OCT Scn Protocol Aside from screening scns, the discussion with doctors reveled tht more scnning ws eing crried out thn ws required. For exmple, the doctors sid for some unilterl conditions they did not even require oth eyes to e scnned. The photogrpher relised the need to develop protocol for OCT scnning in her clinic, nd with tht in mind surveyed the ten or so doctors in regrd to their OCT Scns Initil visit = cue + line oth eyes Follow-up visits = cue + line Eye of Interest + cue other Cue + VERTICAL line on Eye of Interest Initil visit = cue on Eye of Interest Follow up = By request Cue oth eyes (No Dietic Retinopthy = No OCT) Initil visit = cue on Eye of Interest Follow up = By request Initil visit = cue oth eyes + line on Eye of Interest Follow up = cue + line on Eye of Interest By request Initil visit = cue + line oth eyes Follow up = y request Initil visit = cue on oth eyes Follow up = cue on Eye of Interest Disc + cue oth eyes Disc oth eyes Cue oth eyes Tle 1: Protocol for OCT scnning developed t Flinders Eye Clinic using Zeiss Cirrus HD-OCT device.
68 The Journl of Ophthlmic Photogrphy Volume 35, Numer 2 Fll 2013 scn requirements for the most common conditions referred for OCT. The survey results were then collted nd presented to clinicl meeting of these doctors, in order for them to come to consensus out which scns should e crried out, nd n OCT protocol (Tle 1) ws formulted. The doption of the protocol resulted in (1) less scns eing performed, (2) corresponding reduction of printing costs, nd (3) fster ptient throughput. Reporting Incidentl Findings With ny incidentl finding, the photogrpher hs choice of severl wys to ring it to the doctor s ttention. At the time, it is simple to mke nottion in the ptient csenotes efore sending the ptient ck out to the clinic to see their doctor. It is lso simple to pproch the doctor t this time to verlly communicte finding nd to enquire out its relevnce. If the finding comes to light fter completion of ptient s imging visit, then n emil or phone cll to the doctor re other options. If the photogrpher suspects n incidentl finding my e importnt, in the interest of ptient sfety it is prudent to spek to the doctor directly s soon s possile. Since the role of the photogrpher does not include mking dignosis, it is helpful to use pproprite terminology to descrie n incidentl finding in the csenotes, for exmple, the word normlity in preference to pthology. Also, it is not in the ptient s interest for the photogrpher to flg ny incidentl findings directly with the ptient s this could result in unnecessry nxiety for them. This photogrpher hs developed good rpport with the doctors she works with, hving worked with some of them for mny yers. Even so, one doctor suggested tht reporting incidentl findings might e seen s telling the doctor how to do their jo. A fellow photogrpher lso suggested photogrphers might e wry of pointing out incidentl findings to the doctors they work with, s this might not e cceptle to the doctors. Doctors re prt of multidisciplinry tem working in the eye clinic for the est interests of their eye ptients. Reserch in hospitls shows tht good communiction nd good temwork leds to the est outcomes for ptients. Experienced photogrphers hve well developed oservtion skills, nd occsionlly their extr set of eyes nd ers cn e useful to doctors since, like their collegues, they im to do the est for their eye ptients. So wht is ctully est for ptient outcomes is for the ophthlmic photogrpher to consider it their duty to report incidentl findings to doctors. TemSTEPPS It is worth noting the Helth Deprtment of South Austrli hs recognised tht n open, supportive environment where stff from ny discipline cn confidently rise concerns or sk questions without fer of criticism results in the est clinicl cre for ptients. TemSTEPPS (Tem Strtegies nd Tools to Enhnce Performnce nd Ptient Sfety) is temwork progrm from the US which ws piloted in 2008 6 nd lter implemented throughout South Austrlin hospitls. The pilot progrm showed TemSTEPPS led to improved qulity of tem work, communiction (involving flttening of hierrchies) nd clinicl cre. Conclusion This series of cse reports shows tht smll proportion of incidentl findings cn e significnt for the ptient nd consequently it is importnt they re rought to the ttention of the treting doctor. If ptient hs not hd thorough eye exmintion the photogrpher is more likely to encounter incidentl findings. Experienced photogrphers my recognise rre eye conditions nd unusul findings which my e overlooked y less experienced collegues. OCT cn esily detect incidentl findings, ut inititing screening scns my led to potentil unexpected prolems, unless the doctor hs greed. We recommend doctors e surveyed in regrd to their OCT requirements, in order to formulte n greed OCT protocol. Reporting incidentl findings contriutes to good temwork nd communiction, nd to ptients receiving the optiml cre. Bsed on oservtions mde in these eleven cse studies we recommend tht ophthlmic photogrphers report incidentl findings to the treting doctor. Acknowledgments The uthors wish to thnk Stewrt Lke FRANZCO; Nildri Sh FRANZCO; Celi Chen FRANZCO; Richrd Mills FRANZCO; Joel Johnston RBI; Christopher Sprod AAIMBI; Greg Hoffmeyer BFA, CPT. 1. Segens Medicl Dictionry References 2. Ahmed R, Khetpl V, Merin LM et l. Cse series: retrospective review of incidentl retinl emoli found on dietic retinopthy screening: is there enefit to referrl for work-up nd possile mngement?. Clinicl Dietes 2008; 26:179-182. 3. Bruno A, Jones WL, Austin JK et l. Vsculr outcome in men with symptomtic retinl cholesterol emoli. A cohort study. Ann Intern Med 1995;122: 249-53. 4. OPTIMAL Discussion forum, Tuesdy Jn 12, 2010 5. Wilson JMG, Jungner G. Principles nd prctice of screening for disese. WHO Chronicle Genev, 1968 22(11):473. Pulic Helth Ppers, #34. 6. Sted. K, Pirone. C, Adms. R, Phillips. P, Kumr. S, & Schultz. T. TemSTEPPS - pulic report on pilot study. Adelide: Deprtment of Helth, South Austrli. 2008