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Peripheral lesions identified on ultra-widefield imaging


200-degree optomap image showing diabetic retinopathy with ETDRS 7 standard fields comparison field of view


Paolo S Silva MD, Jerry D Cavallerano OD PhD, Nour Maya N Haddad MD, Hanna Kwak BS, Kelli H Dyer DO, Ahmed F Omar MD, Hasanain Shikari MD, Lloyd M Aiello MD, Jennifer K Sun MD MPH, Lloyd Paul Aiello MD PhD

Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA


According to Diabetes Australia, there are approximately 1.7 million Australians who have diabetes and this number is rising year on year, becoming the epidemic of the 21st century and a major challenge that Australia’s health system needs to address.

Diabetes is the fastest growing chronic condition in Australia and is increasing at a quicker rate than other chronic diseases such as heart disease and cancer.1

The results of several clinical studies comparing optomap ultra-widefield images have indicated that there is substantial agreement with Early Treatment Diabetic Retinopathy Study (ETDRS) 7-standard (ETDRS) film photographs and dilated fundus examination in determining diabetic retinopathy severity.2,3 The results of the study published in Ophthalmolog 4 identified that 40 per cent of diabetic lesions were located outside of the area captured by ETDRS and that in 10 per cent of patients these lesions suggested a more severe grade of retinopathy. In addition, the presence of predominantly peripheral lesions was associated with the progression of diabetic retinopathy over four years, independent of baseline severity and A1C.4

Researchers found that eyes with predominantly peripheral lesions had a 4.7-fold increased risk of progression to proliferative diabetic retinopathy (PDR) and a 3.2-fold risk of two-step progression in diabetic retinopathy. Authors also suggest that: ‘Given that evaluation of these peripheral lesions may substantially alter risks of DR progression and onset of PDR, revision of the current ETDRS standard grading system may become necessary.’ Further studies have confirmed that peripheral lesions are also associated with large areas of nonperfusion.5

The patented ultra-widefield scanning laser technology from Optos provides a 200-degree image, which can be captured in less than half a second through an undilated pupil. Two laser wavelengths are used, providing separate views of the retinal pigment epithelium and the choroid. Each image documents 82 per cent of the retina in high resolution, which facilitates the detection, diagnosis and management of ocular pathology and systemic disease. 

Due to the ease of use, dual channel view and wide-field area captured, several large telemedicine programs have implemented optomap as a part of their retinal screening programs. These programs have reported up to an 81 per cent reduction in ungradeables, increased the detection of diabetic retinopathy two-fold and reduced image evaluation time by 28 per cent.6,7

It has been hypothesised that some diseases may first present in the periphery and this study emphasises the importance of properly examining and documenting the peripheral retina for diabetic retinopathy. There are larger ongoing longitudinal studies that seek to confirm these results and determine a grading system based on the retinal periphery.

The content of this article was presented in part at the Association for Research in Vision and Ophthalmology Annual Meeting, May 2014, Orlando, Florida.

Published in: Ophthalmology 2015. DOI:


1. 2015 Diabetes Australia, The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia.

2. Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35mm photography and retinal specialist examination for evaluation of diabetic retinopathy. Am J Ophthalmol 2012.

3. Peripheral lesions identified by mydriatic ultrawide field imaging: distribution and potential impact on diabetic retinopathy severity. Ophthalmology 2013.

4. Silva PS, Cavallerano JD, Haddad NM et al. Peripheral lesions identified on ultrawide field imaging predict increased risk of diabetic retinopathy progression over 4 years. Ophthalmology 2015; 122: 5:949-956.

5. Diabetic retinopathy severity and peripheral lesions are associated with nonperfusion on ultrawide field angiography. Ophthalmology 2015.

6. Identification of diabetic retinopathy and ungradable image rate with ultrawide field imaging in a national teleophthalmology program. Ophthalmology 2016.

7. Potential efficiency benefits of nonmydriatic ultrawide field retinal imaging in an ocular telehealth diabetic retinopathy program. Diabetes Care 2014.

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