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Review Article

Imaging of the peripheral retina

Marcus Kernt, Anselm Kampik
Department of Ophthalmology, Ludwig-Maximilians-University of Munich, Munich, Germany

The technical progress of the recent years has

revolutionized imaging in ophthalmology. Scanning
laser ophthalmoscopy (SLO), digital angiography,
optical coherence tomography (OCT), and detection
of fundus autofluorescence (FAF) have fundamentally
changed our understanding of numerous retinal and
choroidal diseases. Besides the tremendous advances in
macular diagnostics, there is more and more evidence

Retinal vascular diseases such as diabetic retinopathy (DR), retinal

vein occlusion (RVO), and neovascular age-related macular
degeneration (AMD) are in Europe and the US, as well as in the
Middle East main cause of severe vision loss and blindness.[1-3]
Even if central pathologies, such as macular edema are often of
primary importance, there is more and more evidence that these
central changes are often directly linked to the peripheral retina.[4,5]
Considering the pathogenesis of diabetic macular edema (DME)
for example, there are a variety of biochemical changes following
diabetes mellitus leading to vascular endothelial damage and a
consecutive breakdown of the blood retina barrier in both, the
macular region and the peripheral retina. As a final pathway, this
results in both, DR and DME, to an increased secretion of vascular
endothelial growth factor (VEGF). As a consequence, increased
vascular permeability and stimulation of pathological angiogenesis
are not only the main causes of retinal neovascularization, but
also of macular edema.[6,7]
Thanks to new treatment options, such as intravitreal anti-VEGF
therapy, we do have the opportunity to help many of the patients
suffering from macular edema.[8,9] However, with particular
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DOI:
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that central pathologies are often directly linked to

changes in the peripheral retina. This review provides
a brief overview on current posterior segment imaging
techniques with a special focus on the peripheral retina.
Keywords: Angiography, AMD, diabetic retinopathy,
fundus
autofluorescence,
optical
coherence
tomography, RVO, SLO, Wide-field imaging

reference to the excessive secretion of growth factors in patients

with DR, DME, or RVO; we are often only able to treat more or
less in a symptomatic way: Macular edema is located in the center
of the posterior pole, but the ischemic retinal areas providing a
major stimulus for increased VEGF expression are often located
peripherally. In consequence, sole pharmacotherapy will not allow
us to treat causally anyhow. Moreover, recent data clearly indicate
that for long-term stabilization, the quantification of (peripheral)
ischemia is essential, as only this allows us to treat these disease
causally and in a comprehensive way (for example, with an additive
sectorial or pan-retinal laser therapy)[4,10,11] [Figures 1a and b].
To give us a more comprehensive impression of retinal disease,
modern imaging devices are available that are specifically
designed to give us an image of the peripheral retina and therefore
provide additional valuable information for more comprehensive
ophthalmic treatment approaches.
In general, diagnostic fundus imaging has tremendously
evolved over the recent years and thereby significantly gained
importance. Initially consisting mainly from photographic fundus
documentation of central retinal pathologies, supplemented
during the 1970s by analog fluorescein angiography; both
examination techniques were usually based on analogous single
35-50 photographs of the central of the retina, or, when the focus
was set more on peripheral lesions, based on composite images
(e.g., Early Treatment Diabetic Retinopathy Study (ETDRS)
7-field fundus photography), put together out of a series of single
shots being more or less difficult to achieve and also being strongly
operator and patient dependent.

Copyright: 2013 Kernt and Kampik. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Correspondence:
Dr. Marcus Kernt, Department of Ophthalmology, Ludwig-Maximilians-University of Munich, Mathildenstr. 8, 80336 Munich, Germany. E-mail: m.kernt@perfect-vision.de

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Kernt and Kampik: Imaging of the peripheral retina

Figure 1: Optomap ultra-wide-field scanning laser ophthalmoscopy (SLO) color

scan (a) and fluorescein angiography (b) of a patient with proliferative diabetic
retinopathy (PDR). Fluorescein angiography shows extensive ischemic retinal areas in
the periphery

Figure 2: Optomap ultra-wide-field scanning laser ophthalmoscopy (SLO) color

scan (a) and fundus autofluorescence (FAF) (b) of a patient with dry age-related macular
degeneration (AMD). FAF shows both centrally and peripherally significant changes
that are almost invisible on the color image

Fortunately, technology has strongly advanced during the last

decades and especially during the last few years ophthalmic
imaging has made a large step forwards. The technical progress
of the recent years has revolutionized imaging in ophthalmology
and thereby changed our understanding of numerous retinal and
choroidal diseases. In addition, our knowledge about the vitreous
and the vitreoretinal interface has largely expanded and improved.

the surface of the eye and it needs significant experience to handle

the device, impeding the spread of these machines into everyday
diagnostic routine [Figure 3].

When we talk about imaging of the peripheral retina, particular

wide-field scanning laser ophthalmoscopy (SLO), but also digital
wide-field angiography have strongly evolved during recent
years, and still evolving.[12,13] As imaging quality has significantly
improved and handling has become easier, both, wide-field SLO
and angiography have found their way into broader clinical
practice and evidence about the benefits of these imaging
techniques is increasing almost from day to day.[12] But also
wide-field fundus autofluorescence (FAF) is now becoming more
and more clinically available providing completely new insights
into peripheral, retinal pathologies.[14-16]
A good example for new insight provided by wide-field imaging
is given by a recent study that showed clearly that even in the
dry AMD, which was primarily seen as a disease of the macula
region and the posterior pole, typical peripheral retinal changes
commonly occur, allowing the conclusion that AMD must now
be better understood as primarily panretinal disease.[15] As
a consequence, the peripheral retina may provide additional
diagnostic information allowing a better understanding of the
disease [Figures 2a and b].
So, what makes the difference between conventional ophthalmic
imaging and modern wide-field imaging devices? In principle, it
may be even possible to document peripheral retinal changes with
a conventional fundus camera. However, due to the relatively small
image angle (usually between 35 and 55) the implementation
as a documentation tool for peripheral retinal changes into daily
clinical practice is often technically difficult. Especially when
outer peripheral retinal pathologies should be pictured, image
quality is highly dependent on the operators technical skills as
well as the patients collaboration and optical aberrations are often
limiting image quality. In certain cases, for example in premature
infants for monitoring retinopathy of prematurity, contact fundus
cameras, such as the RetCam 120 are a pretty good choice.[17,18]
However, in systems like this the optical head has to be placed on
Oman Journal of Ophthalmology, Vol. 6, No. 3, Supplement 2013

An approach being more suitable for a widespread clinical use

represents noncontact wide-field fundus imaging. There are
several systems on the market right now and some of them are
even non-mydriatic. They are mostly easy to handle, technically
highly developed, and equipped with good image resolution;
allowing to accurately reproducing large areas of the central and
peripheral retina, being essential for a valid DR screening for
example.[3,19,20] In addition, most systems have specific software
solutions that provide additional diagnostic functions, such as
measuring tools or zooming features that allow to enlarge almost
any detail on the fundus in sometimes pretty good image quality.
Wide-field fundus imaging systems like this are either available
as stand-alone devices (such as the Optomap P200Tx system
which includes both a color fundus imaging, but also wide-field
fluorescein angiography (FA) and FAF allowing to map according
to the manufacturer (OPTOS Plc, Dunfermeline, UK) almost 180
of the retina in one scan) or as add-on modules for existing
imaging devices (e.g., spectralis ultra wide-angle angiography
module for Heidelberg Retina Angiograph - 2 (HRA-2),
Heidelberg Engineering, Heidelberg, Germany; allowing
wide-field FA, but also Indocyanine Green Angiography (ICG)
angiography [Figure 4].[12,21] These imaging devices open up a host
of new diagnostic applications and are increasingly integrated into
everyday clinical settings. In (peripheral) retinal vascular disease,
such as DR, and also in patients suffering from uveitis and other
inflammatory diseases of the retina they have gained a particular
area of importance.[3,16,21] Several larger prospective studies for
example found that 200, non-mydriatic, ultra-widefield SLO
imaging by Optomap was as effective as ETDRS 7-field stereo color
photographs for assessing DR and correlates well with clinical
assessment.[3,19] The authors of one of these studies examined 141
consecutive patients with various levels of DR using Optomap
imaging and ETDRS 7-field photography.[3] The level of DR and
the presence of clinically significant macular edema (CSME)
were graded according to ETDRS classification. As a result, the
techniques agreed significantly, with both showing good intergrader
reproducibility and correlation with clinical assessment of DR. Of
note, Optomap imaging had a lower rate of nongradable images
compared with 7-field ETDRS, showing substantial correlation
with clinical assessment for detection of CSME.[3] As conclusion of
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Kernt and Kampik: Imaging of the peripheral retina

the study the author stated that the results clearly demonstrate that
Optomap imaging provides at least similar results for assessment
of DR levels and presence of CSME compared with ETDRS 7-field
stereo color photographs. They added that Optomap examination
does not require much photographer experience and has a fast
learning curve; it also can be performed easily by trained medical
personnel. Therefore, Optomap provides promising properties
for peripheral screening programs and telemedicine in diabetes
patients.[3,19]
The key technology of the past decade in ophthalmology is surely
optical coherence tomography (OCT). Since its introduction in
1991, OCT has revolutionized diagnostics in ophthalmology
and has become an indispensable tool in both, retina and
glaucoma practice. It provides noninvasive high-resolution
in vivo imaging of retinal, choroidal, and optic nerve head
structures.[8,22-24] Therefore, OCT is becoming more and more
relevant for ophthalmic diagnostics and has increasing impact
on therapy. Beside substantial improvements in resolution
the increase of scanning speed has led to a wide application in
ophthalmology. Furthermore, the evolution of software solutions
for image analysis has contributed significantly to make OCT
technology an indispensable standard in macular diagnostics.
But we still have a different situation in the assessment of
peripheral retinal changes. So far, OCT was not really applicable
to detect or monitor peripheral retinal pathologies, since there
were no OCT systems that owned a sufficiently high scanning
speed allowing to asses wide-angle OCT scans and thereby
enabling a valid OCT imaging of the peripheral retina. An
important step towards this direction has recently been done by
a cooperation project of the Institute for Biomolecular Optics of
the Ludwig-Maximilians-University (LMU) in Munich and the
Department of Ophthalmology at LMU. The development of a
novel laser source allowed the development of an ultra-high-speed
swept source Fourier domain mode locking (FDML) OCT that
was built to improve existing technology.[25,26] FDML technology
allows ultra-fast, dense isotropic OCT sampling running at
1.68 MHz axial line rate and also enables reconstruction of
en-face fundus images out of complete 3D datasets. Thus,
using high-resolution OCT technology, wide-field OCT scans
can be produced which make it possible to examine peripheral
retinal changes in detail [Figures 5a and b]. The availability of
this technology, but also by means of commercially available
wide-field OCT systems, such as the recently introduced DRI
Topcon OCT-1, the assessment of both, central and the peripheral
retina with OCT comes closer to every day clinical practice.
In summary, besides all the progresses in macular diagnostics
and treatment, the technological advances of the last years have
brought the peripheral retina once again back in the focus and
a more comprehensive look at the ocular fundus steps into
everyday clinical practice. Even if not all interrelations between
the central and the peripheral retina are completely understood,
new imaging technologies allow now to display both, the macular
and peripheral retina, and thereby providing new insights that

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Figure 3: Right eye fundus of a premature infant with retinal hemorrhages, taken with
the RetCam 120 (image courtesy of Prof. Ehrt, LMU Munich)

Figure 4: Spectralis Ultra wide-field fluorescein (a) and indocyanine (b) angiography
of a patient with choroidal hemangioma. Both retina and choroid show significant
abnormalities (courtesy of Prof. Staurenghi, Milan)

b
Figure 5: Ultra-high-speed Swept Source Fourier domain mode locking (FDML)
optical coherence tomography (OCT): En face imaging of a left eye with proliferative
diabetic retinopathy (PDR) and status post panretinal and macular laser treatment (a),
and a left eye of a patient with central serous retinopathy (unprocessed data, without
image averaging) (b). Due to the large angle covered, FDML OCT technology allows to
image both, optic nerve and macular on one scan

have the potential to further improve our understanding of retinal

disease.

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Kernt and Kampik: Imaging of the peripheral retina

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Cite this article as: Kernt M, Kampik A. Imaging of the peripheral retina.
Oman J Ophthalmol 2013;6:S32-5.
Source of Support: Nil, Conflict of Interest: None declared.

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