UWF-fundus photography and UWF-FA were performed using the Optos California (Optos, Dunfermline, UK). Each image output was automatically corrected for projection errors using the OptosAdvance software (Optos) that uses stereographic projection techniques. The FA images were acquired in the early phase (up to 60 s), recirculation phase (2 to 3 min), and late phase at 5 to 7 min. Two images were selected from the early phase that most clearly presented the margin of nonperfused territories and from the recirculation phase that differentially presented the degree of vascular leakage, respectively. The images were extracted at a resolution of 300×300 dpi.
California
Manufactured by Optos
Sourced in United Kingdom
The Optos California is a compact and versatile ophthalmic imaging device. It captures high-resolution, ultra-widefield retinal images with a single capture. The device utilizes scanning laser ophthalmoscopy technology to produce detailed, panoramic views of the retina.
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21 protocols using california
1
Optos UWF Fundus and Fluorescein Angiography
2
Handheld and Wide-Field Retinal Imaging
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All participants underwent fundus photography using the handheld Aurora (AU, Optomed Ltd) and the Optos California (Optos plc, Dunfermline, Scotland, UK). The Aurora acquired 50° retinal images using a 5-field imaging protocol centered on the disc, macula, superior, inferior, and temporal areas. The sequence of imaging was based on device availability and was usually random. Participants underwent pupil dilation using 1 drop of tropicamide-phenylephrine 0.5% eyedrops.
Retinal imager-graders who underwent training and certification (Gloucestershire Retinal Education Group, Gloucestershire Hospitals NHS Foundation Trust) acquired all handheld retinal images, and UWF photographs were acquired by clinical trials certified ophthalmic photographers.
Before acquiring images for the study, the retinal imager-graders trained with the handheld imaging protocol by taking over 500 images from >50 patients and volunteers. All collected images were anonymized and stored in a secure location.
Retinal imager-graders who underwent training and certification (Gloucestershire Retinal Education Group, Gloucestershire Hospitals NHS Foundation Trust) acquired all handheld retinal images, and UWF photographs were acquired by clinical trials certified ophthalmic photographers.
Before acquiring images for the study, the retinal imager-graders trained with the handheld imaging protocol by taking over 500 images from >50 patients and volunteers. All collected images were anonymized and stored in a secure location.
3
Ophthalmic Imaging Protocol for Comprehensive Eye Examination
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Clinical ophthalmic examination was performed in all patients. Where possible, ophthalmic imaging was performed. Widefield imaging was obtained using either the Optos California (Optos plc, Dunfermline, UK), encompassing up to 200 degrees, or the Retcam fundus imaging system (RetCam, Natus, Pleasanton, CA, USA). Ultra-wide field fundus autofluorescence was obtained with the Optos system. Macular SD-OCT scans were acquired with the Spectralis SD-OCT (Heidelberg Engineering, Heidelberg, Germany) and/or Cirrus 4000 SD-OCT (Carl Zeiss Meditec, Dublin, CA, USA).
4
Grading Ultrawide Field Color Fundus Photos
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UWF-CFP obtained with Optos California (Optos plc, Dunfermline, UK) were graded by two graders independently (SV and RS) according to the International Clinical Diabetic Retinopathy and Diabetic Macular Edema Disease Severity Scales [24] . Before the grading process, the two graders harmonized the gradings, reaching complete agreement. A mask representing the ETDRS seven-field region was overlapped on the UWF-CFP using Optos Advanced option to help identify PPL. PPLs were defined as the presence of more than 50% of lesions outside the 7 standard ETDRS fields (shown in Fig. 1).
5
Quantifying 3D Eye Structures from 2D Images
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There are problems in analyzing the location of the VVA in the Optos California retinal imaging device (Optos PLC, Edinburgh, UK). In this device, the image of the three-dimensional eye is displayed in two-dimensional fundus photographs. Care must then be taken in quantifying the distances, angles, and areas of the structures because they appear to be the shortest distance in the two-dimensional image which is different from that of the actual eye. In addition, the axial length is fixed at 24 mm in measurements made in current available ocular image analyzers, e.g., Optos Advance13 (link). However, different results are obtained by using different axial lengths in spherical bodies of different sizes (Supplementary Table S5 ).
To overcome these problems, we used reverse stereo projection method and axial-length adjustable software in this study. The methods are explained in detail as follows.
To overcome these problems, we used reverse stereo projection method and axial-length adjustable software in this study. The methods are explained in detail as follows.
6
Comprehensive Eye Examination Protocol
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All participants underwent comprehensive ophthalmic examinations including best-corrected visual acuity (BCVA), fundus examination with slit-lamp biomicroscopy, and spectral-domain optical coherence tomography (SD-OCT, Spectralis, Heidelberg Engineering, Heidelberg, Germany). UWF FA (Optos California, Optos, Dunfermline, UK) was performed in patients with DR. Central macular thickness (CMT) was measured by OCT; it was defined as the mean thickness in the central 1000 μm diameter area. The presence of ME was defined as abnormal retinal thickening with increased fluid volume in the macula.
7
Optos California Fundus Imaging
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Fundus images were taken using the Optos California® device (California®, Optos plc, Dunfermland, Scotland, UK) pre- and postoperatively at every follow-up visit. Images were exported in jpeg format and arranged in Adobe InDesign® without further image processing.
8
Ultra-Wide Field Fundus Photography Assessment
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All patients underwent a 200° non-mydriatic UWF-FP with OPTOS California (Optos plc, Dunfermline, UK). This system is a confocal scanning laser ophthalmoscope with 2 light sources (532 nm green laser and a 633 nm red laser) with an ellipsoidal mirror to enable a 200° pseudo-color image of the retina fundus acquired in 0.4 s [8 (link), 9 (link)]. After acquisition, UWF-FP images were analyzed by the OPTOS Advance Review Software (version 4.3.31). Any diabetic lesion was considered, such as microaneurysms, hemorrhages, intraretinal microvascular abnormalities, hard or soft exudates, venous beading, or presence of neovascularization. In case of uncertainty, the graders used the color channel separation feature provided by the review software to correctly identify the presence of retinal lesions.
9
Comprehensive Ophthalmic Examination for RVO
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A comprehensive ophthalmic examination, including best-corrected visual acuity, refractive errors, intraocular pressure, biomicroscopy, and fundoscopy, was conducted in all patients with RVO. Swept-source optical coherence tomography (DRI OCT Triton, Topcon Corporation, Tokyo, Japan), ultra-wide fundus photography, and fluorescein angiography (Optos California; Optos PLC, Dunfermline, United Kingdom) were used to confirm the diagnosis and determine the degree of retinal ischemia and the presence of macular edema. RVO diagnosis was determined by retinal specialists. Patients with other concomitant ocular diseases (diabetic retinopathy, age-related macular degeneration, uveitis, epiretinal membrane, macular hole in either eye), history of ocular trauma or vitreoretinal surgery, low-quality OCT or fundus images, and high refractive errors (spherical equivalent > ± 6) were excluded.
10
Multimodal Retinal Imaging Protocol
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All eyes were imaged using UWF-CFP (Optos California; Optos, PLC, Dunfermline, Scotland; equipped with Optos V2 Vantage review Software) and spectral-domain OCT (Cirrus 5000 SD-OCT; Carl Zeiss Meditec Inc, Dublin, CA). In cases with uncertain NVs, UWF-FA (Optos) was performed. In addition, NPAs were assessed using OCTA (PlexElite, Carl Zeiss Meditec Inc) on a montage of five images of 12 mm ×12 mm (using the photomontage module of the device; theoretical image field of 24 mm × 24 mm).
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