Limitations of the Panoramic 200 Optomap

I would like to respond to Dr. Brian Chou's correspondence in the October issue of Optometry and Vision Science. 1 First, I would like to thank Dr. Chou for his feedback and the opportunity for this discussion. It is forums such as this that allow us to enhance the quality of our profession. The article states that he missed four peripheral lesions with the Panoramic 200 (Optomap retinal exam). Although small in number, he feels that the user of the instrument is in “undue professional liability.” In my experience, I have seen well over 5000 images taken with the Panoramic 200. I have used the instrument for 18 months in my private practice setting. In Dr. Chou's 4-month study period, he only reported the lesions that were missed and not the peripheral lesions found. Therefore, the question is how many peripheral lesions were found. It is as important to report on the number and kind of peripheral lesions found, as well as those missed. I have almost completed my study (800 of 1000 patients) comparing it with a dilated binocular indirect ophthalmoscopy (BIO) examination, and the number of lesions missed is very small compared to the number found. There have been over 1.26 million patients imaged in the world with the Panoramic 200, and thousands of lesions have been found that were both significant and insignificant in nature. What we all have to acknowledge is that we can and have missed peripheral lesions with a BIO. We must understand that we are as liable for the BIO examination as we are with other methods, such as the Panoramic 200. The courts are not going to forgive us for missing something with the BIO or other techniques. Image documented fundoscopy often proves that there was no significant lesion (retinal detachment, tumor, etc.) at the time of the examination. Furthermore, for those practitioners that do not dilate, dilate little, or have difficulty with fundoscopy, this documentation generally greatly reduces the potential for liability. With the lids and lashes out of the way, the Panoramic 200 can acquire a 200 degree view of the fundus, which is well past the equator in the primary gaze position. Dr. Chou asserts that the Panoramic 200 does not produce a view from ora to ora, but neither does a BIO in most cases, unless one performs scleral depression. Most clinicians do not perform depression very often (unless they are a retinologist). If the author wanted the Panoramic 200 to be essentially equivalent to a dilated BIO examination, then he would have had to use the same methods with the instrument as he does with a BIO. This sounds simplistic, but how do you use a BIO? You have the patient move their eyes in different fields of gaze. This usually requires raising the upper lids (as you do with one of your fingers during the BIO examination), especially in down gaze. Now that I have been perfecting the steering the eye technique with the Panoramic 200, I usually find all peripheral lesions seen with the BIO or that are previously known in the eye. If Dr. Chou had performed the steering technique, he may have seen just about all of the scleral buckle he presented and, additionally, this may have helped him find the four lesions in question. Please note, on the image of a scleral buckle in Figure 1, about 90% of it is seen. Optos does not state nor has ever stated that the instrument negates dilation. Dilation when using the Panoramic 200 is at the clinical discretion of the doctor. Dilation may be required when lesions in question are found on the image or in patients with appropriate symptoms (e.g., flashes and floaters) or have risk factors present. Relevant risk factors include: high myopia, history of vitreoretinal disease, history of retinal detachment or breaks in the fellow eye, family history of retinal detachment, occupation prior to intraocular surgery, history of ocular trauma, and other significant risk factors that may be present. The article comments on sensitivity and specificity in the University of Pittsburgh Department of Ophthalmology study. 2 It is important to understand that this study was designed to see how well the instrument detected diabetic fundus changes. While most diabetic changes are usually found in the posterior pole, I have seen many cases of retinopathy with the Optomap located in the periphery only. Often they were the first sign of the disease in the person's eyes. The sensitivity and specificity was based on the discovery of diabetic fundus changes and did not reflect the ability to detect other lesions. There is cur-rently a multicenter study being performed in three schools or colleges of optometry that will address the sensitivity and speci- ficity of the Panoramic 200 in an academic environment. Lastly, I have had many doctors who are using the instrument communicate their successes to me. They have told me that they are much better clinicians now and are doing better fundoscopy. Comments have included “I could barely see the retinal break” or “I missed a peripheral break with the BIO that was found with the Panoramic 200.” With new technologies such as the Optos Panoramic 200, we can continue to strive to improve the quality of eye care. William L. Jones