The Role of Ultra-widefield Retinal Imaging as a Standard Assessment Tool in the Cataract Practice

US Ophthalmic Review, 2017;10(1):31–4 DOI:


Comprehensive evaluation of retinal health prior to and following cataract surgery is critical to supporting optimal outcomes. In addition to the importance of identifying retinal pathology that may prevent or delay cataract surgery, continuous advances in refractive intraocular lens technology and cataract surgical technique, coupled with increasingly high expectations regarding visual outcomes among younger patients, make the consideration of long-term quality of vision paramount in the cataract assessment. Optos® ultrawidefield retinal imaging supports this clinical objective by providing imaging standardization in a streamlined, patient-friendly exam process, supporting robust documentation that facilitates mapping of disease progression, and offering potential economic advantages in a resourceconstrained environment.
Keywords: Ultra-widefield retinal imaging, UWF, cataract surgery, multifocal IOL, retinal periphery
Disclosure: Kerry K Assil has nothing to disclose in relation to this article. V Nicholas Batra participated in a panel case presentation sponsored by Optos
Acknowledgments: Editorial assistance was provided by BioComm Network, Inc.

Compliance with Ethics: This study a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors.

Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.

Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.
Received: February 06, 2017 Accepted March 22, 2017
Correspondence: Kerry K Assil, 450 N. Roxbury Dr., 3rd Floor, Beverly Hills, CA 90210, US. E:
Support: The publication of this article was supported by Optos. The views and opinions expressed are those of the authors and do not necessarily reflect those of Optos.

Due in part to continuous improvement in the safety, speed, and refractive outcomes of cataract surgery, the number of cataract procedures has increased steadily over the past 30 years, and the percentage of patients undergoing the procedure at a younger age is also increasing. These trends were documented in a frequently cited population-based study of Omsted County, Minnesota, that compared rates of cataract surgery between 2005 and 2011 to those in the prior 25 years. Data on more than 8,000 cataract procedures in the most recent period revealed that the incidence of cataract surgery had increased significantly, the interval between first and second eye surgery narrowed significantly, and 19% of patients elected cataract surgery before age 65.1 This rise in cataract surgery rates will continue to accelerate as the US population ages; the number of Americans over age 65 is expected to nearly double by 2050, to 83.7 million.2

Along with the increasing volume driven by this large demographic wave, there are a number of important implications of the shift to earlier cataract surgery and the increasing use of sophisticated premium intraocular lens (IOL) technologies. Perhaps the most significant of these is that many patients will live for decades after the procedure. These patients have high expectations of their immediate postoperative visual outcomes and also expect to continue to see well as they age. With sustained quality of vision the main therapeutic objective, it has become paramount to perform thorough retinal exams pre-surgically and postoperatively to identify pre-existing retinal disease that might prevent, delay, or alter surgery, to anticipate future retinal problems—particularly to the degree that this prospect may affect lens choice—and to provide an initial, post-cataract baseline for monitoring future pathological changes. In this review, we will describe the integration into our pre- and post-cataract surgery assessments of a specific imaging technology that has shown utility in retinal disease detection and management for both the general ophthalmologist and the retinal specialist. In our experience, ultra-widefield (UWF™) retinal imaging (Optos plc., Dunfermline, Scotland) and the clinical and practical value of the high-resolution, digital optomap® images they produce, have complemented the information available to us from standard approaches, including conventional fundus examination and optical coherence tomography (OCT), thereby improving our ability to rapidly and accurately identify retinal pathology, facilitating consultation with retina colleagues, and resulting in enhanced patient care, increased patient satisfaction, and greater efficiency within our practices. As a result, Optos® UWF retinal imaging has become a routine component of perioperative evaluation in our cataract cases, based on the unique advantages of the technology, and we believe that other cataract practices may benefit from considering this approach.

Relevant capabilities of ultra-widefield retinal imaging for the cataract practice
As occurred with the introduction of OCT, now an essential tool in many cataract practices, UWF retinal imaging is providing new capabilities that are helping to evolve the standard of care. Several platforms for examining the retinal periphery have been developed, including the portable, contact-based RetCam (Natus Medical, Plesanton, California, US) and contact (Staurenghi retinal lens—Ocular Instruments, Washington, US) and non-contact lens additions to the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany), but the Optos systems offer the maximum field of view of any available retinal imaging device.3 Optos UWF devices are also easier to use and capture images more quickly than other platforms. A single, non-contact capture can show 200-degrees or 82% of the retina, often extending beyond the vortex veins and equator. A number of studies have confirmed that Optos UWF imaging helps clinicians identify pathology associated with a wide array of retinal diseases, including non-infectious uveitis and vasculitis, that can be missed with conventional imaging techniques.4–6 A review of data from more than 3 years of research with UWF imaging confirmed that that 66% of clinically relevant retinal pathology is found outside the reach of conventional fundus photography.7

1. Gollogly HE, Hodge DO, St Sauver JL, Erie JC, Increasing incidence of cataract surgery: population-based study, J Cataract Refract Surg, 2013;39:1383–9.
2. Ortman JM, Velkoff VA, Hogan H, An aging nation: the older population in the United States. Current population reports, May 2014, U.S. Census Bureau.
3. Witmer MT, Parlitsis G, Patel S, et al., Comparison of ultra-widefield fluorescein angiography with the Heidelberg Spectralis® noncontact ultra-widefield module versus the Optos® Optomap®, Clin Ophthalmol, 2013;7:389–94.
4. Leder HA, Campbell JP, Sepah YJ, et al., Ultra-wide-field retinal imaging in the management of non-infectious retinal vasculitis, J Ophth Inflamm Infect, 2013;3:30.
5. Nicholson BP, Nigam D, Miller D, et al., Comparison of wide-field fluorescein angiography and nine-field montage angiography in uveitis, Am J Ophthalmol, 2014;157:673–7.
6. Hong BK, Khanamiri HN, Rao NA, Role of ultra-widefield fluorescein angiography in the management of uveitis, Can J Ophthalmol, 2013;48:489–93.
7. Optos. Data on file.
8. Kernt M, Hadi I, Pinter F, et al., Assessment of diabetic retinopathy using nonmydriatic ultra-widefield scanning laser ophthalmoscopy (optomap) compared with ETDRS 7-field stereo photography, Diabetes Care, 2012;35:2459–63.
9. Silva PS, Cavallerano JD, Sun JK, et al., Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy, Am J Ophthalmol, 2012;154:549–59.
10. Liegl R, Liegl K, Ceklic L, et al., Nonmydriatic ultra-wide-field scanning laser ophthalmoscopy (optomap) versus two-field fundus photography in diabetic retinopathy, Ophthalmologica, 2014;231:31–6.
11. Wessel MM, Aaker GD, Parlitsis G, et al., Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy,Retina, 2012;32:785–91.
12. Tsui I, Franco-Cardenas V, Hubschman J, et al., Ultra wide field fluorescein angiography can detect macular pathology in central retinal vein occlusion, Ophthalmic Surg Lasers Imaging, 2012;43:257–62.
13. Singer M, Tan CS, Bell D, et al., Area of peripheral retinal nonperfusion and treatment response in branch and central retinal vein occlusion, Retina, 2014;34:1736–42.
14. Forooghian F, Agron E, Clemons TE, et al., Visual acuity outcomes after cataract surgery in patients with age-related macular degeneration: age-related eye disease study report no. 27, Ophthalmology, 2009;116:2093–100.
15. Chew EY, Benson WE, Remaley NA, et al., Results after lens extraction in patients with diabetic retinopathy: early treatment diabetic retinopathy study report number 25, Arch Ophthalmol, 1999;117:1600–6.
16. Hong T, Mitchell P, de Loryn T, et al., Development and progression of diabetic retinopathy 12 months after phacoemulsification cataract surgery, Ophthalmology, 2009;116:1510–14.
17. Klein BEK, Howard KP, Lee KE, et al., The relationship of cataract and cataract extraction to age-related macular degeneration: the Beaver Dam eye study, Ophthalmology, 2012;119:1628–33.
18. Cugati S, Mitchell P, Rochtchina E, et al., Cataract surgery and the 10-year incidence of age-related maculopathy: the Blue Mountains eye study, Ophthalmology, 2006;113:2020–25.
19. Henderson BA, Kim JY, Ament CS, et al., Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment, J Cataract Refract Surg, 2007;33:1550–58.
20. Braga-Mele R, Chang D, Dewey S, et al., Multifocal intraocular lenses: Relative indications and contraindications for implantation, J Cataract Refract Surg, 2014;40:313–22.
21. De Vries NE, Nuijts RMMA, Multifocal intraocular lenses in cataract surgery: literature review of benefits and sides effects, J Cataract Refract Surg, 2013;39:268–78.
22. Faberowski N, Quiroz-Mercado H, Gonzalez C, et al., Retina evaluation with non mydriatic ultra wide field color imaging after cataract surgeries in asymptomatic patients, Invest Ophthalmol Vis Sci, 2013;54:2997.
23. Peng J, Zhang Q, Jin H-Y, et al., Ultra-wide field imaging system and traditional retinal examinations for screening fundus changes after cataract surgery, Int J Ophthalmol, 2016;9:1299–303.
Keywords: Ultra-widefield retinal imaging, UWF, cataract surgery, multifocal IOL, retinal periphery