11 January 2021
The development and roll-out of optical coherence tomography (OCT) has been continuing at pace, growing from a technology utilised by a few early adopters to becoming a key part of many practices.
Emily Malbon, head of UK marketing and education at Heidelberg Engineering UK, described the development of OCT technology over the past two to three years as “extremely fast-paced.”
Devices are becoming much faster, with ever-increasing A-scans per second, as well as additional diagnostic functionality, such as OCT angiography imaging, she pointed out.
While roll-out of the technology has been progressing steadily, the company has seen a surge in enquires in recent months from practice owners who are ready to replace their first OCT and are considering the Heidelberg Spectralis.
Topcon has also seen OCT grow to become “firmly a mainstream clinical tool.”
The company suggested there are many reasons for this, including technological developments to optimise ease of use as well as to speed up capture.
In addition, the company has noted that the changing patient demographic, coupled with the practice-building opportunities afforded by shared care, and the increased delegation of eye care from secondary to primary eye care, has fuelled the growth of OCT.
The process for device roll-out has also been optimised over time, with online education available prior to installation, as well as on-the-day training, followed by clinical affairs and e-learning.
Andrew Yorke, managing director for Topcon Great Britain Medical, said: “We have found OCT sales continue to be extremely buoyant,” adding that in the few months following the first lockdown the company had been busy “installing, training and educating our customers in the extensive benefits of their new OCTs.’”
“The current trends remain the same and the outlook for OCT in all market segments in the coming months looks very encouraging,” Mr Yorke added.
The company particularly saw interest grow during COVID-19 for its DRI OCT Triton, due to the device’s ability to image through cataracts and better examine the choroid, a spokesperson told OT.
Peer-to-peer support is a huge part of the integration process as the use of OCT grows
Gareth Steer, vice president of sales for Optos Europe, meanwhile, suggested that the increased need to provide the safest possible environment, while delivering the best standard of eye care, has further increased demand for OCT.
The company’s devices offer a combined use of OCT and optomap retinal imaging, to provide a range of images and clinical information, allowing practitioners to maintain a safe distance.
“Having a combined device also reduces the length of time needed for the complete examination as well as saving precious space within the practice, as it essentially provides two devices in one,” Mr Steer said. “The device design also allows for simple and effective cleaning between appointments.”
Boosting confidence
A key challenge when introducing OCT into practice is to become comfortable with seeing the retina “in a completely new way,” Mr Steer commented.
Optos’ webinars and CET events aim to help customers familiarise themselves with the technology, including reviewing and interpreting pathology, while online forums enable practitioners to discuss images and share knowledge.
“Peer-to-peer support is a huge part of the integration process as the use of OCT grows,” Mr Steer commented, adding that customers regularly use the forums to discuss images and potential issues, share knowledge and “work together to further improve patient care.”
In the six years that Heidelberg Engineering’s Academy has been delivering OCT education, there has been a shift in the confidence of optometrists, Ms Malbon suggested.
“When we began, we found that most optometrists were complete beginners and we focussed on delivering the basics to build their confidence,” she said. “Fast forward to 2020, and now we notice a mix of ability. Many optometrists have been using OCT for five or more years and are very experienced, while others are just beginning their journey.”
Education, typically CET-accredited, now needs to cover both the basics and more advanced interpretation of data. This initial training is key to determining how quickly and successfully the equipment is integrated into practice, Ms Malbon suggested.
While using the devices can be generally “very easy,” and people without a clinical background can be trained to take images competently, Ms Malbon highlighted that, “Evaluating OCT images requires a sound knowledge of the anatomy and physiology of the visual system.”
Key to this, Ms Malbon noted, is the ability to “consistently recognise or monitor abnormalities, establish urgency of referral and provide ophthalmologists with good quality information.”
It is also important to have the buy-in from everybody in the practice, Ms Malbon suggests. “Taking the time to train non-clinical staff so they understand that the practice is serious about eye health and looking for early diagnosis of a wider range of eye conditions will put the practice on the road to success.”
It is still a daunting prospect starting out in OCT interpretation but there is plenty of support and no one is expected to be an expert from day one
Topcon has also seen confidence increasing, helped by more success stories and discussions on the clinical value of OCT, as well as a growing range of educational opportunities.
Dr Catharine Chisholm, global director of education and training for Topcon told OT: “It is still a daunting prospect starting out in OCT interpretation, but there is plenty of support and no one is expected to be an expert from day one.”
Support through training, conferences and online forums help to break down learning barriers. Topcon Healthcare University offers e-learning courses for clinicians along with device operation courses for support staff and plans to introduce courses for front of house staff in presenting the OCT to patients and increasing interest.
Considering some of the challenges in introducing OCT, Topcon noted that some devices can be tricky to use, with a long learning curve associated with aspects such as joystick control and focusing, with image quality critical for analysis.
The Maestro2 was designed to overcome these issues, the company has suggested, as a plug-and-play device that would allow anyone to capture a quality image, with the optional OCT angiography also fully automated. Taking away the variability introduced by the operator is valuable in terms of time and clinical decision making, Topcon said. What does require time, a spokesperson shared, is becoming confident in interpretation to be able to make full use of the OCT output both in terms of quantitative and qualitative data, but pointed to available e-learning courses and webinars as easing this process.
The impact of COVID-19
In a webinar held to explore the challenges practices have faced in returning to business after lockdown, Optos found 74% of optometrists surveyed reported finding it challenging to implement new practice protocols and communicate those changes to patients. However, practitioners reported that technologies had helped to ease the process.
The company has seen interest in its OCT and optomap technologies accelerate as a result of the pandemic.
“We know that some patients and practitioners were understandably somewhat nervous about starting eye examinations again, following the easing of lockdown restrictions,” Mr Steer said, but noted that the OCT and optomap technologies had helped provide the confidence “that this can be done safely and effectively.”
Taking the time to train non-clinical staff so they understand that the practice is serious about eye health and looking for early diagnosis of a wider range of eye conditions will put the practice on the road to success
Topcon, too, has seen demand for OCTs impacted by COVID-19 with devices offering easy-clean benefits and helping to reduce the infection risk associated with traditional posterior segment imaging, the company suggested. A new remote tablet control for the Maestro2 and other automated Topcon devices has also supported practices.
Demand has extended beyond OCT scanning, as the company has seen requests for guidance on using the peripheral photograph and mosaic function. To further increase patient confidence, a Maestro-specific breath shield is also under development.
As for many, the pandemic necessitated a pivot to providing support and training virtually, but the company noted that through the new approach, the clinical affairs team are able to meet customer needs in shorter periods of time.
Considering the impact COVID-19 has had on the development and roll-out of OCT, Emily Malbon shared that she expects to see a small delay in development of the technology.
“Cancellation of ophthalmic exhibitions globally in 2020 has meant manufacturers have nowhere to launch or show a new product or technology,” she suggested. “I also think that during the height of lockdown, between March and June, OCT roll-out was delayed for obvious reasons.”
“Once we were out of the full lockdown situation, we noticed that roll-out is perhaps even being accelerated by those wishing to utilise the government bounce-back loan to invest in a new OCT,” Ms Malbon noted.
Practices reflect on introducing OCT
Here for the future
Martin Memory, director and optometrist, Memory Opticians, a Hakim Group practice
“The challenging thing about OCT is that it allows us to see the kind of structures of the eye, in the sort of detail, that we had only ever seen in textbooks. It was challenging and exciting at the same time.
“Post-lockdown, I think it has come into its own, and I would have struggled personally with not having an OCT in practice. We’ve not really been able to use direct ophthalmoscopy because we would have to get too close to clients.
There is an element of being apprehensive about new technology, but the more familiar you are with it, the more you use it, the more intuitive it becomes, and the better you interpret what you are doing
“Now, everybody, whether seven or 97 years-old, will be put onto an OCT machine. We might not perform the full gamut, but we will certainly look at the macular, optic nerve and do an OCT scan.
“There is an element of being apprehensive about new technology, but the more familiar you are with it, the more you use it, the more intuitive it becomes, and the better you interpret what you are doing. It is here to stay and is something for the future.”
An enhanced service
Ian Jarvis, principal optometrist of independent practice, Jarvis Optometrist
“The challenging thing about OCT is that it is a completely different way of looking at people’s retinas. It was a bit of a voyage of discovery early on, but there is a lot more support now.
“In Scotland, during the spring lockdown we were all shut, except for practices like ourselves who were emergency eyecare treatment centres. Having an OCT helps in clinical decision making and reduced patient contact time, which was something we were nervous about at the start of lockdown.
“From a business point of view, there is still a view that OCT is a business expense. We see it as an income generator. How we have funded this, is that we offer it to everyone – that way we can charge a relatively low fee and widen access.
“Having said that, you really have to work on educating your patients. They have to know you are not selling them something, you are providing an enhanced service because you believe that is a good thing to do. Then, because you are doing something that they perceive to be an enhanced service, that raises the profile of the practice.”
Boosting confidence
Hayler Wainer, of Hawkes & Wainer, London
“It is one of the best clinical decisions I have made in the last 10 years. I feel that the practice is operating at a much higher level. Up until now, we only had a fundus camera. Now when I look at a macula, I want to see the scans as that is the only way I feel I know what is really going on. It has given me the confidence to put up the cost of our examinations and I have not had one patient refuse to have the scans as the benefits are so easy to explain.”
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