When checking someone's dilation, there can be a number of findings in the outer periphery of the eye that have no affect on the person's vision.  That's why dilation or fundus photography like Optos are so important to the ocular examination -- changes in the eye don't necessarily cause changes in vision.  Today we explore a relatively common ocular finding, congenital hypertrophy of the retinal pigment epithelium (or CHRPE for short).

An impressive Optos image of CHRPE just outside of the posterior pole via

CHRPE as viewed by off-axis fundus photography.  This picture was taken by me which explains why it is not that great. All of the white spots are artifact.

Let me tell you just one more thing that I love about being an OD -- optometry is such a small community, your classmates and colleagues are going to be constantly sharing their work (and life) experiences with you!  When you get done seeing your day's patients, you may have 1 or 2 of your friends patients to discuss too via texted images.  As a huge optometry nerd, yes, I enjoy this very much.

Most of you have probably seen the Novant Health commercial promising a doctor's visit via the web from the ease of your desk chair (or lake house deck as the commercial depicts), but have you ever wondered what the real feasibility of telemedicine is?  How likely is it that your medical condition can be accurately treated via a web chat?  How can telemedicine be practically applied?

If a patient's photograph looked like this in their retinal screening, it would prompt a call for a live office visit for the doctor to assess the patient's diabetic retinopathy in person!

The truth is, I do think there is some room for telemedicine in our future, and I am not the only eyecare provider that sees its merits.  Wills Eye Hospital (the optometrist medical bible is named for it, by the way) has a retinal photography telemedicine department, and they aren't the only one.  Similar strategies were being used in the VA Hospital system when I was rotating through several years ago.  What's so great about retinal telemedicine?  Photographs of the retina can be used to track changes for various conditions, like diabetic retinopathy and macular degeneration.  While you can't replace a one on one visit with the doctor altogether, when monitoring a condition for changes, telemedicine can be a great resource.  The patient would be able to come to the clinic with more flexibility since they wouldn't have to be scheduled into the doctor's patient care hours, a technician would be trained to take the photograph, and then the doctor would have a dedicated period of time to review the collected data and images, and then inform patients of their results.  The photography is utilized as screening tool (typically some manner of vision check and compliant questioning would also be recorded by the technician to help detect any other issues). If changes are seen in the photograph (or the patient has specific complaints to be addressed), then a live visit with the doctor would be necessitated.  If the retinal image and vision are stable, the doctor may decide to push back a live follow-up visit.  This method of treatment has proven to be effective in recent studies: at the European Retina Congress, there was a 90% agreement between treatment plans of in-office ophthalmologist visits and telemedicine reviews for a group of patients being followed with macular degeneration.  A photograph can tell the doctor so much about the ocular condition, and a trained doctor can catch the signs of even the smallest of changes.

There is a large gap between photo-monitoring retinal conditions, and ridding the need for any in person office visits with your eye care provider, so I am not purporting that a photograph will replace all patient care.  The retinal evaluation is just one small aspect of the comprehensive ocular exam, and you can't evaluate the entire retina without dilation and a live, in-office view of the retina by the doctor.  But conditions like macular degeneration and diabetic retinopathy do result in the need for more frequent monitoring than just yearly examinations, and telemedicine may help reduce the burden on the healthcare industry by offering patients convenient times without double or even triple-booking doctors.  I don't expect the type of clinical care that the commercials depict where a doctor seems to be on duty full-time with web access is the way of the future--the type of care that can be provided without direct evaluation is very limited.  But the industry around us will continue to change, and telemedicine in eyecare  may become more and more utilized as our population ages and more people are diagnosed with macular degeneration and diabetes.  The health care industy is an exciting landscape, and it is fascinating to see how new technology can entirely change the face of our standard of care!

"There's a freckle in my eye!?"

A small choroidal nevus can be seen inferiorly in this photograph (it looks like a grey-green circle)

That's usually the response to seeing a retinal photograph that contains a freckle or choroidal nevus (as it is formally called).  With today's excellent imaging software, small freckles inside the ocular tissue are easier and easier to detect.  So if you have a nevus, what does this freckle mean to you?

Normal, benign choroidal nevi occur in as much as 7.9% of the population (though with new technology we may find this incidence is a little higher since it is easier than ever to spot faint, small nevi).  Melanoma inside the eye, conversely, are exceedingly rare, with only 6 in 1 million incidence rate. In neither a melanoma or a normal nevus will there be any visual effect (unless the melanoma is significantly advanced), so your doctor will only detect these lesions through dilation or retinal photography.  Just like any freckle, the most important thing you can do is protect it from UV exposure.   A normal freckle can turn into a malignant melanoma under certain conditions, and this malignant change has an incidence rate of 1 in over 8,000 freckles.  While exceedingly rare based on these numbers, it is best to protect yourself.  I always recommend sunglasses with 100% UV protection, but it is an absolute must for my patients with ocular nevi!

Can you find all the nevi in this person's retinal photo?  Hint (there are a total of 3).

What do I look for in detecting suspicious freckles?  Growth from year to year is a big risk factor, so I use retinal photographs to find any small changes in size or shape from year to year.  A freckle that is 3 x larger than the optic nerve is highly suspicious.  I also look for changes in thickness (if the blood vessels run over top of the freckle without changing their path, the freckle is flat!), coloration, and position inside the eye.  Freckles that are closer to the optic nerve are in a higher suspicion category.  Your nerve is the eye's highway to the brain, so we don't want any malignant changes occurring so close to this pathway.

Always remember, most of the internal ocular findings that your doctor evaluates at your annual eye examination have no real consequence to vision, so you wouldn't know anything was changing inside your eye just by judging vision alone.  Always best to get your eye evaluated regularly even if you don't need glasses or contact lenses!

I was reviewing retinal photography with a patient today, and everything looked healthy.

A retinal hemorrhage tells us that blood flow has been compromised, a huge red flag for blood pressure issues!

Today's technology driven world is an incredible place.  Not too many years ago, your doctor dilated your eyes to look inside to check for bleeding, holes, tears, and growths.  He or she may have been able to describe to you what they were seeing, but you were left to using your imagination for the most part, even with the use of the best diagrams and artistic renditions.  With retinal photography available at most eyecare providers now, the world inside the eye is a place both your doctor and you as the patient are able to explore.

Here's another healthy dosage of retinal photos from my days at work.  Again, the white reflections are really just unfortunate camera artifacts.

Wouldn't it be incredible if you could see your own blood vessels inside your body?  What if you could see your own brain tissue?

Wait.  You can with retinal photography.  Every day I take photos of the back (and front) of my patient's eyes and it is amazing how much information can be gleaned.  Your eye doctor can detect high blood pressure, high cholesterol, and diabetes just from looking for changes in your eyes.  Sometimes detecting these changes can save a person's vision from permanent damage; sometimes they can even save them from the repercussions of serious systemic diseases.

I can't recommend having a comprehensive eye examination more, even if you have no vision issues.  We all should want to see the inner workings of our bodies, and the eye is the perfect window inside!

Here are some of the photographs I have taken of common ocular conditions and diseases just this year.  I apologize about the persistent artifacts from my camera -- they look like 2 white circular glare areas in every photo.

MYELINATED NERVE FIBER LAYER (looks bad, but this is actually a harmless finding ) Myelination typically only exists behind the eye, but sometimes passes into the eye without harming vision

SCATTERED DRUSEN Enlarge this photo and you will see tiny yellow areas that are known as drusen near the dark central vision spot (the macula) Drusen are harmless by themselves, but can put you at a heightened risk for Macular Degeneration

CENTRAL RETINAL VEIN OCCLUSION This prompts an immediate referral and investigation for systemic health issues

CENTRAL SEROUS RETINOPATHY The area of edema is visible as subtle color changes around the macula This condition causes central vision changes, and is often due to stress Usually no treatment is necessary, just time for the swelling to resolve

ADULT VITELLIFORM DYSTROPHY See the yellow area at the macula?  It shouldn't be there.  This condition can cause central vision disruption, and no real treatment exists

Back in July, I wrote about the potential use of retinal photography in the early detection of Alzheimer's Disease in this post.  At that time, research had just been published showing a correlation between narrowed arteriole lumens (which can only be seen by a doctor during a retinal exam without cutting into the body!) and individuals with Alzheimer's.  Utilizing retinal photography in this way is still in its infancy, but new studies are emerging all the time supporting comprehensive eye exams as a potential source of early detection.

Brain tissue imaging depicting anomalous amyloid proteins

In a study by Susan Stark at the University of Washington, 125 individuals of "normal cognition" with an average age of 75 were asked to record the number of falls they suffered over a period of 6 months.  Brain scans were performed on all study participants looking for amyloid beta plaques (a calling card of Alzheimer's brain damage), and it was found that the risk of falling was 3 times greater for every unit of amyloid plaques found!  What does this have to do with eye exams? While we aren't the only doctors that treat people after a fall, we do see patients on a regular basis with injuries around their eyes from falls.  Additionally, patients discuss with their eye doctors at their annual exams if they are having dizziness or falling because they often attribute this imbalance to a problem with their glasses.  People suffering or complaining of frequent falls traditionally are referred to their primary care doctor to be screened for blood pressure issues, but these new study results support screening for signs of dementia as well!

As I mentioned earlier in this post, one of the most important aspects of your eye exam is screening the health of the retina.  It is so important because it is the only place we can look at blood vessels and nervous tissue without invasive procedures!  Ongoing research by Dr. Lee Goldstein at Boston University and the company Neuroptix is trying to utilize our easy access to the eye by developing a laser scanner to detect amyloid proteins in the eyes.  According to Dr. Goldstein, the presence of amyloid proteins (which form the brain plaques) can be measured in the lens of the eye (the structure where cataracts form, which is also entirely comprised of proteins).

Retinal Photography gives a high-definition view of the optic nerve (center) as well as the retinal arterioles and venules which aids in detection of hypertension, diabetes, and potentially even Alzheimer's!

Early detection of amyloid plaques and misfolded tau proteins has captured the medical community, and new research is being published almost daily.  Most recently, we are learning that these anomalous tau proteins are found even in young people that are suffering traumatic brain injuries, such as football players.  Most recently investigators found the proteins in the brain of an 18 year old football athlete who had suffered multiple concussions.

Anomalous proteins in the brain of an 18 year old football player; image courtesy link above

We are only beginning to understand this disease, and there is a lot of research yet to come before detection of Alzheimer's in its earliest stages is possible.  What we do know is that routine health care, including eye exams, is our best option for catching health issues in their earliest stages.  So even if you don't need glasses, remember it is really worth your time to have a comprehensive examination!

At this year's Alzheimer's Association International Conference, researchers reported that a dilated fundus examination can aid in the detection of Alzheimer's.  The study found a high correlation between patients diagnosed with Alzheimer's or "pre-Alzheimer's" and changes in the blood vessels when viewed with retinal photography or via live fundus examination.  Thinning of retinal vessels (arterioles and venules) was noted, as well as a narrowed arteriole lumen.  Vessel changes were shown to correlate with PET scan findings of amyloid plaques (a typical brain scan finding associated with Alzheimer's).  Retinal findings will precede the onset of Alzheimer's dementia, and scientists are purporting that changes may be evident as early as 20 years earlier than the onset of symptoms.  

A normal retinal fundus photograph, depicting optic nerve (white circular area), retinal vessels, and macula (dark central area)

This is not the first time that researchers have reported the link between eye exams and earlier detection of Alzheimer's disease.  Previous studies (linked article from 2002) have shown an association between visual field defects and neuro-degenerative damage of Alzheimer's disease.

Sample Visual Field test, depicting right eye field loss

MRI depicting degenerative changes of Alzheimer's disease courtesy BBC News

Take away point: A complete eye exam with retinal photography and dilation can help detect a number of systemic conditions and is highly recommended!  Hypertension, diabetes, and numerous other diseases can be monitored and detected via retinal exams. Even if your vision is great and you have noticed no changes, a yearly eye exam can be an important part of monitoring your overall health.