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Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth COPE 38496-PD Michael Chaglasian, OD Boomers and Disease Detection with OCT Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth KOA 2014 Disclosure: Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth Michael Chaglasian, OD, FAAO COPE # 38496-PD This course material and information was developed independently of any assistance. I do have the following financial arrangements to disclose: Michael Chaglasian, OD, FAAO Alcon– Honorarium/Advisory Board Allergan - Honorarium/Advisory Board Carl Zeiss Meditec - Honorarium/Advisory Board Illinois Eye Institute Illinois College of Optometry [email protected] Objectives: 1. Understand the increasing prevalence of ophthalmic disease in the typical optometric practice. 2. Identify what the risk factors and clinical indicators are in patient examinations that suggest the need for OCT imaging. 3. Learn how to read and review OCT images of patients with diabetes, glaucoma, AMD. 4. Understand how latest generation spectral domain OCT instruments have improved their ability to detect and monitor disease. The “Problem” is an Opportunity America's 78 million baby boomers are turning 65 at a rate of one every 10 seconds (3 million to 4 million per year). Michael Chaglasian, O.D. What is a “Boomer” A baby boomer is a person who was born during the demographic postWorld War II baby boom, between the years 1946 and 1964, according to the U.S. Census Bureau. Healthcare has become a big issue for baby boomers. Over 60% of adults ages 50 to 64 who are working (or have a working spouse) have been diagnosed with at least one chronic health condition, such as arthritis, cancer, diabetes, heart disease, high cholesterol, or high blood pressure, according to a report from The Commonwealth Fund. 1 Boomers and Disease Detection with OCT KOA 2014 Possible Indications for Performing OCT Where does optometry and OCT technology fit? Requirements of OCT Technology Validation / Accuracy / Improved Outcomes Peer reviewed articles in the literature Not sales/marketing hype Cost Effectiveness Can be challenging. Survey your patients for three months Consider “added value” to your practice Ease of Use / Ease of Interpretation Elevated IOP > 21mm Hg C/D >.5 or Asymm. > 0.2 Poor visual field test-takers Narrow anterior chamber angles High myopia Personal or family history of - diabetes - glaucoma - hypertension - field defects Suspicious Optic Nerves - Marcus Gunn pupil - Acquired color defect - poor confrontation fields - Disc pallor Unexplained decreased vision Drusen / AMD Numerous maculopathies and retinopathies And Many Others OCT out performs Photography Conclusions: For detection of a variety of retinal irregularities evaluated in the current study, volume OCT scanning was more sensitive than non-mydriatic retinal photography in our asymptomatic individuals. OCT detected clinically relevant disease features, such as subretinal fluid, that were missed by FP, and had a lower ungradable image rate. It is likely that OCT will be added to photography screening in the near future for chorioretinal disease. The Retinal Disease Screening Study: Prospective Comparison of Nonmydriatic Fundus Photography and Optical Coherence Tomography for Detection of Retinal Irregularities IOVS February 2013 54:1460-1468;published ahead of print January 15, 2013. Michael Chaglasian, O.D. 2 Boomers and Disease Detection with OCT Growth of OCT (2009) KOA 2014 OCT Coding / Billing 2013 92132 Used for cornea and narrow angle diagnoses Some carriers/insurances are not covering 92133 Used for ALL Glaucoma and optic neuropathy diagnoses 92134 Used for ALL (approved) Retinal diagnoses Mutually exclusive and cannot be billed on the same day as 92133. Can be billed with 92132. None can billed on same day as fundus photos, 92250 OCT Coding / Billing 2013 Must be based upon “Medical Necessity” and entering CC / reason for visit Reason for diagnostic test? Directly stated or easily implied Will it effect diagnosis or treatment? Always requires an “Order” and an Interpretation and Report John Rumpakis, OD, MBA 2013 Avg. Reimbursement: $45-48 Each of these new codes is considered unilateral or bilateral Frequency varies with diagnosis Obtain List of covered ICD-9 codes (Medicare LCD) Optimize Revenue •The OCT model can help you improve your billing and coding •Help you build glaucoma and retina patients “Here’s the bottom line: •According to Dr. John Rumpakis, a new glaucoma patient can require procedures valued up to $985 the first year.1 FIRST YEAR GLAUCOMA PATIENT REVENUE Your patients’ medical insurance is not the same thing as your malpractice insurance.” VISIT # TOTAL FEES PER VISIT RUNNING TOTAL FIRST $164 $164 SECOND $288 $452 THIRD $224 $676 FOURTH $ 55 $731 FIFTH $144 $875 SIXTH $ 55 $930 SEVENTH $ 55 $985 http://www.revoptom.com/content/d/coding___and___practice_management/c/36039/ 1Rumpakis, Michael Chaglasian, O.D. “Putting an Economic Spin on Glaucoma”, Optometric Management, Marc 3 Boomers and Disease Detection with OCT ADDITIONAL INCOME DUE TO IMPROVED CASE DETECTION KOA 2014 It’s definitely not getting easier. One ROI Example: OCT only 13.5 per month or 3.4 week for breakeven Procedures for each Glaucoma suspect and diagnosed, 2nd and 3rd visits2 92014 Ophthalmological services, comprehensive medical examination 92250 Fundus Photography 92020 Gonioscopy 92083 Threshold Visual Fields 76514 Corneal Pachymetry 92012 Ophthalmological services, intermediate 92132 Dqiagnostic Anterior Digital Imaging, - Spectralis 92133 Diagnostic Posterior ONH Digital Imaging, -Spectralis $ 113 $ 47 $ 26 $ 52 $ 12 $ 77 $ 38 $ 42 Income generated by two follow-up visits of each glaucoma suspect $ 407 2. Rumpakis, Putting an Economic Spin on Glaucoma, Optometric Management March 2004, pp 53-54. http://www.revoptom.com/content/c/22520/ There is no guarantee that your Medicare carrier will pay for these procedures when performed on the same day. Please contact your local Medicare carrier to determine appropriate billing guidelines. “3 Reasons your Optometry Practice is decreasing in value” Chad Fleming, OD, FAAO 1.Technology 2.New Patient Ratios - Boomers!! 3.Resistance to the Medical Model CASE EXAMPLES http://www.optometryceo.com/2013/01/23/3-reasons-your-optometry-practice-is-decreasing-in-value/ Spectral Domain Comparison Spectral Domain OCT Time Domain OCT Stratus SPECTRALIS Typical SD OCT SD OCT w/tracking & Noise Reduction Michael Chaglasian, O.D. 4 Boomers and Disease Detection with OCT Spectral Domain: Many Options KOA 2014 Spectral Domain: Many Options Optical Coherence Tomography RS-3000 Advance NOT FDA Approved for US Sales Still Valuable: But Perhaps Limited Future (I am unaware of any timelines) SD-OCT - Heidelberg Engineering SD-OCT Spectralis 40,000 scans per sec. Stratus GDx SPECTRALIS® Eye Tracking Reference scan Cross section scan EYE TRACKING Eye Movement The reference image tracks eye movement, and the cross section is moved to match Michael Chaglasian, O.D. 5 Boomers and Disease Detection with OCT Eye-Tracker Controls Scan Location in Real Time KOA 2014 Cirrus™ HD-OCT Eye tracker recognizes eye movement and repositions scan pattern Data acquired during eye movement is discarded Stored data is free of motion artifacts Optovue: RTVue Cirrus™ HD-OCT X 6.5 Optovue Family Optovue: iCam and Normative DB 35 Michael Chaglasian, O.D. 6 Boomers and Disease Detection with OCT OCT Gives You a Powerful New Perspective on These Most Common Ophthalmic Diseases Pre & Post- Cataract Complications 2 million patients diagnosed annually AMD 6 million patients diagnosed annually DME 5 million patients diagnosed annually GLAUCOMA 3 million patients diagnosed annually KOA 2014 What are practitioners' most common misunderstandings of imaging technology? “The thought that these devices can diagnose glaucoma in the absence of corroborating clinical evidence is, in my opinion, the most common (and potentially dangerous) misunderstanding. The limited normative databases against which scans are compared can never cover the remarkably varied appearance and structure of the optic nerve we encounter in normal individuals.” James Brandt, MD Red Disease! Red Disease CASE AK 54 year old woman Recently moved from Poland VA = 20/40 and 20/50 -14D myope Current Medications Dorzolamide TID Timolol BID Complaints of topical SE’s with drops Michael Chaglasian, O.D. 7 Boomers and Disease Detection with OCT KOA 2014 CASE AK Glaucoma Madness • Plethora of information • Nothing Definitive in Early Stages • • • • • • • • Nothing Stable ONH –IOP-C/D Ratio Pachymetry Gonio – family history Ethnicity –Stereo Photos Pallor – Rim Area Asymmetry-Blood Flow Visual Fields FRUSTRATION Increasing Prevalence of Glaucoma IOVS, Special Issue 2012, Vol. 53, No. 5 Michael Chaglasian, O.D. Increasing Prevalence: African American IOVS, Special Issue 2012, Vol. 53, No. 5 8 Boomers and Disease Detection with OCT Increasing Prevalence: Hispanic KOA 2014 Glaucoma At Risk Review African-Americans Glaucoma is the leading cause of blindness among African-Americans. It is six to eight times more common in African-Americans than in Caucasians. People Over 60 Glaucoma is much more common among older people. You are six times more likely to get glaucoma if you are over 60 years old. Family Members with Glaucoma Family history increases risk of glaucoma four to nine times. Hispanics in Older Age Groups IOVS, Special Issue 2012, Vol. 53, No. 5 Glaucoma At Risk Review Asians People of Asian descent appear are at higher risk for angle-closure glaucoma. Steroid Users OCT for Glaucoma 40% increase in the incidence of ocular hypertension and open-angle glaucoma in adults who require approximately 14 to 35 puffs of steroid inhaler to control asthma. Other Risk Factors Other possible risk factors include: high myopia (nearsightedness), diabetes, Hypertension, Central corneal thickness less than .5 mm 65 yo with Hx of OHTN x 3 yrs Michael Chaglasian, O.D. RNFL Optic Nerve Head Ganglion Cell Thickness 38 yo GAT= 22 OD 25 OS 9 Boomers and Disease Detection with OCT Cirrus RNFL KOA 2014 Optic Nerve Analysis Optic Nerve Cross Sections Visual Fields Michael Chaglasian, O.D. Combined Report 10 Boomers and Disease Detection with OCT The Ganglion Cell Complex (GCC) KOA 2014 RTVue: RNFL and GCC Inner retinal layers provide complete Ganglion cell assessment: • Nerve fiber layer (g‐cell axons) • Ganglion cell layer (g-cell body) • Inner plexiform layer (g-cell dendrites) Images courtesy of Dr. Ou Tan, USC NEW for Glaucoma: Ganglion Cell Analysis Anatomy: Ganglion Cell Layer and IPL Measures thickness for the sum of the ganglion cell layer and inner plexiform layer (GCL + IPL layers) using data from the Macular 200 x 200 or 512 x 128 cube scan patterns. Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012 Cirrus: Ganglion Cell Analysis Glaucoma Suspect Initial 3 years later The analysis contains: Data for both eyes (OU) Thickness Map – shows thickness measurements of the GCL + IPL in the 6mm by 6mm cube and contains an elliptical annulus centered about the fovea. Deviation Maps – shows a comparison of GCL + IPL thickness to normative data. Thickness table – shows average and minimum thickness within the elliptical annulus. Michael Chaglasian, O.D. 11 Boomers and Disease Detection with OCT RTVue and Cirrus OCT KOA 2014 Topography of Retinal Ganglion Cells • Large variation in total ocular axonal count (0.5 to 1.2 mil) amongst normals and thus large variation in normative databases. • However, the variation in ganglion cell numbers in the central macula is small. Curcio CA, Allen KA.. J Comp Neurol 1990;300(1):5-25 Posterior Pole Asymmetry Analysis Glaucoma Case Study 1: Asymmetry of Ganglion Cell Analysis • A new SPECTRALIS software feature to help assess RNFL and GCL loss by mapping retinal thickness across the posterior pole • Potential to detect earlier RNFL loss compared to RNFL thickness circle scans, fundus photos or visual fields Glaucoma Case Study 1: IOP 28 OD, Early VF Defect, Inferior RNFL defect Michael Chaglasian, O.D. Posterior Pole Case Study 2 12 Boomers and Disease Detection with OCT New Reports – RNFL & Post. Pole Posterior Pole Assessment RNFL & P. Pole Asymmetry KOA 2014 Progression Analysis: Absolutely Essential Progression Analysis: Absolutely Essential Detecting Structural Progression of Glaucoma A Key Component of Glaucoma Management GPA Analysis Cirrus HD-OCT GPA Analysis Guided Progression Analysis Image Progression Map SS = 10 Baseline Registration SS = 10 Baseline Baseline Registration SS = 8 Registration SS = 9 TSNIT Progression Graph 250 RNFLT (microns) Cirrus HD-OCT 200 150 100 50 Two baseline exams are required 0 0 50 100 150 TSNIT 200 250 TSNIT values from each exam are shown Significant difference is colorized yellow or red Yellow denotes change from both baseline exams Red denotes change from 3 of 4 comparisons Third exam is compared to the two baseline exams Sub pixel map demonstrates change from baseline Yellow pixels denote change from both baseline exams Trend Analysis: Summary Parameter Third and fourth exams are compared to both baselines. Change identified in three of the four comparisons is indicated by red pixels; yellow pixels denote change from both baselines A Regression Line is drawn to determine rate of change for all the data that has been collected over time. Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies Michael Chaglasian, O.D. Less variability with Structural/OCT testing as compared to Functional/ Visual Field testing. 13 Boomers and Disease Detection with OCT New Updates on Cirrus HD-OCT (Zeiss): Ganglion Cell Analysis KOA 2014 Updated Guided Progression Analysis (GPA™) Optic Nerve Head information now included • Average Cup-to-Disc Ratio plotted on graph with rate of change information. • RNFL/ONH Summary includes item “Average Cup-toDisc Progression”. • Printout includes an optional second page with table of values, including Rim Area, Disc Area, Average & Vertical Cup-to-Disc Ratio and Cup Volume. Each cell of the table can be color coded if change is detected. Ver 6.0 Ver 6.0 Updated Guided Progression Analysis (GPA™) Provide the best possible glaucoma care to your patients Page 1 Page 2 •Find more glaucoma suspects •Diagnose glaucoma earlier Glaucoma is a leading cause of blindness in the US Over a million people in this country have glaucoma but don’t know it.1 Failure to diagnose open-angle glaucoma is a leading cause of liability claims involving eye care practitioners.2 Ver 6.0 Retina 81 1The Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477485. JG. Glaucoma--a clinicolegal review. J Am Optom Assoc. 1997; 68:389-394. 2Classe Retina AMD 1.47% >40 age have Macular Degeneration Over 7 Million at risk for AMD Drusen >125um 1.75 million individuals in US w/significant AMD 15% of the white women older than 80 years AMD will increase by 50% to 2.95 million in 2020 Source National Eye Institute Citations and Abstracts from April 2004 Archives of Ophthalmology Prevalence of Age-Related Macular Degeneration in the United States The Eye Diseases Prevalence Research Group Michael Chaglasian, O.D. 14 Boomers and Disease Detection with OCT KOA 2014 AMD Risk Factors Many faces of AMD Smoking Smoking may increase the risk of AMD. Obesity Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD. Race Whites are much more likely to lose vision from AMD than African Americans. Family History Those with immediate family members who have AMD are at a higher risk of developing the disease. Gender Women appear to be at greater risk than men. Dry AMD HD Raster with Enhanced Depth Imaging (Cirrus) HD 5 Line Raster Michael Chaglasian, O.D. Dry AMD Classic CNVM 20/40 CF@ 5 ft 15 Boomers and Disease Detection with OCT KOA 2014 Advanced RPE Analysis Gain new insights on your AMD patients • RPE Elevations. If the RPE is raised above a baseline plane, a new proprietary algorithm for Cirrus maps and measures the area and volume of the elevations. RPE Elevations Sub-RPE Illumination • Sub-RPE Illumination. If the RPE is absent or has lost integrity, the OCT beam penetrates into the choroid. A new proprietary algorithm for Cirrus can determine when this occurs and then map and measure the affected area. 92 Missed PED PED Idiopathic CNV Retina-Diabetes 1 in 17 Americans or 16 Million with Diabetes 10.2 million US adults 40 years and older known to have Diabetes Mellitus (Proliferative/Non or DME) 4.1 million US adults 40 years and older have diabetic retinopathy 3.4% or 4.1MM of Population w/vision threatening retinopathy Retina Michael Chaglasian, O.D. Source National Eye Institute Citations and Abstracts from April 2004 Archives of Ophthalmology The Prevalence of Diabetic Retinopathy Among Adults in the United States 16 Boomers and Disease Detection with OCT KOA 2014 CSME DME Full Thickness Macular Hole Macular Hole Vitreo Macular Traction: OCT Anterior Segment Imaging Anterior Segment Module provides a close up view of chamber angles Michael Chaglasian, O.D. 17 Boomers and Disease Detection with OCT Lasik Flap Cirrus HD-OCT Anterior Segment Imaging Images courtesy of Martha Leen, M.D. & Paul Kremer M.D. Achieve Eye and Laser Specialists, Silverdale, WA Cirrus Anterior Segment Imaging Cirrus HD-OCT image with a visible angle recess (blue arrow). Schlemm’s canal is very well clearly seen (red arrow). Michael Chaglasian, O.D. KOA 2014 Cornea, Angle & Sclera Mode Cirrus Anterior Segment Imaging Cirrus HD-OCT scan of normal cornea. Layers identified with colored arrows as follows: tear film (blue), epithelium (white), Bowman’s layer (red), Descemet’s/endothelium (green). RTVue Clinical Applications Retina Glaucoma Anterior Chamber 18 Boomers and Disease Detection with OCT MultiColor Technology MultiColor image composed of three selective colour laser images Infrared, green and blue reflectance MultiColor Automatic color balance to match fundus appearance on photographs Limitations: KOA 2014 The Versatility of MultiColor Imaging View images of individual laser colors to gain better understanding of anatomic and pathologic detail at different depths within the retina ERM, RNFL, macular pigment blood vessels, blood, excudates drusen, RPE, choroid Optic disc colour does not match natural appearance Uveal pigment appears pale blue reflectance green reflectance infrared reflectance Image courtesy of S. Wolf, MD, PhD, Bern, Switzerland Online Education Widely Available How do you view all of this data and image imformation? Image Management System. Designed for EyeCare http://www.elearning.zeiss.com/ Michael Chaglasian, O.D. 19 Boomers and Disease Detection with OCT KOA 2014 “Why would I need more than an Electronic Health Record (EHR) system for my ophthalmic practice? A Few Definitions Acronym Term DICOM Digital Imaging and Communications in Medicine EHR Electronic Health Record EMR Electronic Medical Record IMS Image Management System PACS IMS The IT Landscape in an Ophthalmic Practice IT integration is key Picture Archiving and Communication System HIS Health Information System PMS Practice Management System What does an EHR alone offer? Clinical Management PMS or HIS Manages the practice business (administration, scheduling, accounting, billing) EHR / EMR Medical charts. Documentation of clinical decisions, treatments and prescriptions Medical data standard protocols IMS Manages and archives diagnostic reports and images. Viewing, comparing and reviewing ophthalmic data What can EHR + an IMS offer? EMR/EH R Medical charting √ Treatment Plan √ Ophthalmology exam templates √ e -prescribing √ Report storage √ √ Treatment Plan √ Ophthalmology exam templates √ e -prescribing √ Report storage √ √ Central scheduling of patient tests √ Side-by-side report viewing √ Customizable viewer for images and reports √ Combined reports from instruments √ Full resolution images (Fundus Images) √ Billing √ CCHT Certification √ AARA Certification √ What clinical needs can an IMS uniquely address? IMS (PACS) Clinical Need IMS Feature An Image Management System helps: √ Store all test data & reports on a Broad device connectivity via DICOM & file server imports •Reduce errors Perform change analysis (GPA) Centralized, raw data storage √ Central scheduling of patient tests* √ •Save time See your HFA data in your EHR Side-by-side report viewing √ Customizable viewer for images & reports √ Combined reports from instruments √ Full resolution images (Fundus Images) •Better appreciate patient’s diagnostic data √ Billing Michael Chaglasian, O.D. √ √ Raw data storage from instruments Raw data storage Practice Management IMS (PACS) Practice Management 117 Clinical Management EHR/EMR Medical charting A single FORUM - EHR interface with many EHRs supported Review reports in context Display VF, OCT, fundus photos, structurefunction GPA side by side Clean up legacy records Merge tool to find & merge multiple patient records using a variety of match criteria. Innovative analyses Combined Visual Field - OCT Reports * A feature that helps reduce errors in formatting patient records Patient education Customizable viewer for images and reports 20 Boomers and Disease Detection with OCT An IMS can integrate patient data in unique ways KOA 2014 Zeiss Forum Viewer Software Example: VF-OCT combined report Zeiss Forum Viewer Software Zeiss Forum Viewer Software Zeiss Forum Viewer Software Zeiss Forum Viewer Michael Chaglasian, O.D. 21 Boomers and Disease Detection with OCT Zeiss Forum: Combined Report KOA 2014 Forum Glaucoma Workplace FORUM 3.2 Forum Glaucoma Workplace What‘s new ? Clinical Displays – Auto-selection rules Clinical Displays – Auto-selection rules Cataract Glaucoma (OCT-VF-FI) 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: Overview report from CZM Atlas B. Middle panel: Macular Thickness Analysis Report from CZM Cirrus or Stratus C. Right panel: IOLMaster report 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection: IOLMaster report with laterality ‘Both‘ is selected in both cases (R/L) 131 Michael Chaglasian, O.D. A. Left panel: ONH and RNFL Analysis report or RNFL Thickness Analysis report from CZM Cirrus B. Middle panel: SFA report from Humphrey Field Analyzer C. Right panel: COLOR Fundus Image 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection: ONH / RNFL report with laterality ‘Both‘ is selected in both cases (R/L) 132 22 Boomers and Disease Detection with OCT KOA 2014 Clinical Displays – Auto-selection rules Clinical Displays – Auto-selection rules Glaucoma OU (OCT-VF-FI) Glaucoma Progression (FI) 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically 1. Display is set to 2 x 2 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: COLOR Fundus Image of the right eye B. Middle panel: HFA Visual Field and Cirrus ONH (/RNFL) Combined Report C. Right panel: COLOR Fundus Image of the left eye 3. The most recent visit date will be selected. All documents must be from the same date A. B. C. D. Top left panel: Top right panel: Bottom left panel: Bottom right panel: COLOR Fundus Image COLOR Fundus Image COLOR Fundus Image COLOR Fundus Image from the patient’s latest ( / current) visit from the patient’s 2nd latest ( / last) visit from the patient’s 2nd earliest visit from the patient’s earliest ( = first) visit 3. Laterality (R/L) according to the user selection 133 134 Clinical Displays – Auto-selection rules Clinical Displays – Auto-selection rules Glaucoma Progression (OCT-VF) Retina Overview 1. Display is set to 4 x 1 (fixed arrangement) 2. The following documents are selected automatically 1. Display is set to 3 x 2 (fixed arrangement) 2. The following documents are selected automatically A. B. C. D. Left panel: 2nd panel from left: 3rd panel from left: Right panel: GPA Optic Disc Cube report CZM Cirrus – Right eye GPA report from Humphrey Field Analyzer – Right eye GPA Optic Disc Cube report CZM Cirrus – Left eye GPA report from Humphrey Field Analyzer – Left eye 3. The most recent GPA reports will be selected. A. Top left panel: COLOR Fundus Image B. Top middle panel: RED FREE / GREEN Image C. Top right panel and bottom panels (left to right): 4 phases of a FA or ICG series: i. Early phase (earliest image within 0 s and 25 s), ii. Earliest image within 25 s and 1 min, iii. Earliest image within 1 min and 2 min, iv. First image after 2 min 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection 135 Clinical Displays – Auto-selection rules 136 Image Management Systems AMD Progression (OCT) 1. Display is set to 4 x 1 (fixed arrangement) 2. The following documents are selected automatically A. B. C. D. Left panel: 2nd panel from left: 3rd panel from left: Right panel: Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s earliest (= first) visit Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s 2nd earliest visit Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s 2nd latest ( / last) visit Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s latest ( / current) visit 3. Laterality (R/L) according to the user selection Topcon Synergy OIS Symphony Web Canon Retinal Imaging Control Software Kowa DigiVersal EHR Systems Generally don’t offer as much functionality All should be “DICOM” compliant 137 Michael Chaglasian, O.D. 23 Boomers and Disease Detection with OCT Retain the glaucoma/retina patients that you identify KOA 2014 OCT in Optometric Practice: Increase patient retention rates by: • Diagnosing patients early • Educating them on glaucoma and retina pathology • Managing them with state-of-the art technology YOU WILL MAXIMIZE YOUR RETURN ON INVESTMENT WHLE PROVIDING BETTER PATIENT CARE [email protected] Michael Chaglasian, O.D. 24