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«Ophthalmic Imaging The IMI National Guidelines have been prepared as baseline guides on specific aspects of medical illustration activity and provide ...»

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IMI National Guidelines

Ophthalmic Imaging

The IMI National Guidelines have been prepared as baseline guides on specific

aspects of medical illustration activity and provide auditable standards for the future.

The Guidelines can be either implemented in full, or may be amended according to

individual requirements.

Copies are available on the IMI website (www.imi.org.uk)

February 2008

1. Iris - Pigment Layer Atrophy 2. Retina - Retinal Infarct

3. Cornea - Epithelial Cyst 4. HRT Optic Nerve Head - Possible Glaucoma

5. FFA - Branch Retinal Artery Occlusion 6. Occulo-Plastic - Anophthalmic Socket

7. OCT - Acquired Pit Optic Nerve (APON) 8. ICG - Subretinal Neovascular Membrane IMI National Guidelines February 2008 Ophthalmic Imaging Introduction These Guidelines provide "Clinical Imaging Standards” and “Recommended Good Practice" for Ophthalmic Imaging. The focus is on a wide spectrum of ophthalmic conditions likely to be encountered by those using the "Guidelines" as a reference for their own practice. It is emphasised that Ophthalmic Imaging is a rapidly changing field and practitioners will need to keep up to date with the changes.

Users of these Guidelines must have a good knowledge of anatomy as related to ophthalmology; the visual appearances of ophthalmic diseases and conditions; be able to recognize structures and pathology within the eye, its layers and supporting structures; the lacrimal apparatus; the orbits; extraocular muscles; eyelids and adnexa. Additionally, users must be able to interpret basic Visual Acuity measurements and relate these to their retinal imaging practice.

It is expected that users will be completely familiar with the operation and functions of the particular ophthalmic equipment used in their practice. For ‘Step by Step’ technical instructions consult the publications listed under Bibliography at the end of the Guidelines and the User Manuals provided by the equipment manufacturers and software suppliers. For newcomers to retinal imaging, or for more experienced personnel wanting to review their techniques and knowledge, references to basic ‘On-Line” tutorial material are given in the Bibliography Standards of Practice It is essential the users of these Guidelines, who carry out fluorescein angiography and indocyanine green angiography, are fully conversant with the contraindications for these procedures; are able to recognise allergic reactions to fluorescein and indocyanine green; and take the appropriate emergency steps according to local procedures. All patient reactions must be reported and documented in accordance with local protocols.

Users who are permitted under local authority to instil medications to achieve mydriasis must be aware of contraindications to the use of certain mydriatics and be able to warn patients, and/or their guardians and caregivers, of the effects and dangers of dilated pupils after imaging procedures. Similarly, users who instil topical anaesthetics in order to carry out gonioscopy or anterior segment photography must also warn patients of the dangers of having an anaesthetised cornea.

Health and Safety considerations must be observed by users in terms of prevention of cross infection, adequacy of the space in which procedures are carried out and the electrical and mechanical safety of the equipment being used. Any Health and Safety issues involving patients or staff must be promptly reported in accordance with local protocols. See references in the Bibliography.

–  –  –

INTRODUCTION

Reproduction Ratios Whilst lens focal lengths have been specified, lenses ±10mm of the stated Focal Lengths would conform provided the appropriate “Reproduction Ratios” and “Lens to Subject Distances” are maintained.

Two Reproduction Ratios with corresponding lens focus settings are given for each Guideline; the first is based on the common CCD imaging format of 23.7mm x

15.6mm (Nikon DX format); the second is the 24mm x 36mm format used for 35mm film. The 24mm x 36mm format is available as a digital format; Canon EOS 5D camera (Canon EOS 23.9mm x 35.8mm); Nikon D3 camera (Nikon FX digital format

23.9mm x 36mm).

Lens settings are based on those marked on the Nikon 60mm and 105mm Micro Nikkor lenses. (Other lenses must be calibrated to meet these standards.) As lenses are not marked for the digital ratios it is common practice to achieve standardisation by using the closest lens focus as marked on the lens barrel. These lens focus settings are included in the Guidelines for each of the two camera formats.

Lenses In general, for the 23.7mm x 15.6mm Digital Imaging Format, the Facial and Orbits views can be readily handled with a 60mm Focal Length Lens. This provides a suitable working distance with adequate space for lighting and eliminates perspective distortion. The Single Eye with Adnexa and Single Eye views require the working distance provided by a 105mm Focal Length lens.

For 24mm x 36mm imaging format a 105mm Focal Length lens is used for all views and should adhere to the established “Westminster” Reproduction Ratios.

Variable focal length (Zoom) lenses should be avoided unless “Reproduction Ratios” and “Lens focus settings” are comparable to the parameters in these Guidelines.





Reference - Maintaining standard scales of reproduction in patient photography using digital cameras – Stephen Young.J Audiov Media Med 2001; 24: 162 – 165.

(The standards introduced by this paper have been adopted for other IMI Published Guidelines and form the basis for these Oculo-Plastic Guidelines).

IMI National Guidelines February 2008 Ophthalmic Imaging Lighting Lighting must be simple and reproducible; large, multiple conflicting reflections and shadows must be avoided. Some degree of 'modelling' must be used. The aim is to produce a single, small corneal or conjunctival reflex with minimal reflections from the Cornea, Conjunctiva and Lid margins. However, reflections must not be totally eliminated.

Coaxial illumination is rarely indicated.

When lighting the Single Eye with Adnexa and the Single Eye views the light reflection is positioned to fall on an unimportant area of the conjunctiva or cornea.

The standardised lighting parameters should be applied equally in the Studio; Clinic Examination room; Ward or Procedure Room.

IMI National Guidelines February 2008 Ophthalmic Imaging Positioning the Patient The Anatomical Planes and Lines of the Head as related to Ophthalmology must be used to define patient position and its relationship to the camera's optical axis using surface anatomical landmarks.

Figure 1 Showing the Sagittal or Median Plane; Coronal Plane; Interpupillary Line; Frankfurt Line or Reid's Base Line; the Orbito-Helix Line; Corneal Parasagittal Planes (The two planes running parallel to the Sagittal Plane through the centre of each Cornea when the patients fixes in the Primary position of Gaze). The Interpupillary Line and the Orbito-Helix Line together form a Transverse plane which is especially useful to the Ophthalmic or Clinical Photographer in positioning the patient's head relative to the camera optical axis.

Lateral and Oblique positions must be achieved by moving the seated patient rather than using axial rotation of the patient's head. The Oblique angle can be standardised by adjusting the camera axis so that the tip of the patient’s nose aligns with the profile of the distal cheek. Due to patient variation of the cheek soft tissue profile and nasal architecture this can only be standardised for a particular individual patient.

Positions of Gaze (refer to SECTION F. NEURO-OPHTHALMOLOGY)

–  –  –

Ideally the head should be restrained to prevent compensatory head movement with the Secondary and Tertiary positions.

Primary Position

• The direction of gaze is straight ahead into the camera lens.

Secondary Positions The patient is directed to look: Straight Up as far as possible

• Straight Down as far as possible

• Straight over to the Right as far as possible, and

• Straight over to the Left as far as possible.

Tertiary Positions The patient is directed to look: Up and to the Right as far as possible

• Up and to the Left as far as possible

• Down and to the Right as far as possible

• Down to the Left as far as possible.

Upper Eyelids must be retracted for the Secondary and Tertiary Inferior Positions.

Special Note: Conditions such as eyelid lesions may require the higher magnification and controlled illumination provided by an ophthalmic photo-slitlamp in addition to the views described in this section.

–  –  –

EXOPHTHALMOS; THYROID EYE DISEASE; PROPTOSIS; PTOSIS;

ORBITAL TUMOURS; ORBITAL FRACTURES;

MARCUS GUNN SYNDROME; TRAUMA; COSMETIC PROCEDURES

FACIAL VIEWS

• Anterior Full Face

• Right Lateral Face

• Left Lateral Face

• Right and/or Left Oblique Face may be indicated

• Camera Axis is directed to the point where the Median Plane meets the Interpupillary Line at the level of the Orbito-Helix Line.

–  –  –

Image Orientation - Vertical Plane of Focus - Anterior view - the Corneal Reflex.

Lateral and Oblique views the Focus is on the Corneal profile closest to the camera, i.e. Corneal para -sagittal plane.

IMI National Guidelines February 2008 Ophthalmic Imaging

EXOPHTHALMOS; THYROID EYE DISEASE; PROPTOSIS; PTOSIS;

ORBITAL TUMOURS; ORBITAL FRACTURES; BLEPHAROSIS;

ECTROPION; TRAUMA; ENTROPION; TRICHIASIS;

KERATOCONUS; COSMETIC PROCEDURES; LAGOPHTHALMOS;

NINE POSITIONS OF GAZE

ORBITS - ORBITAL (also referred to as "Both Eyes")

• Anterior

• Right Lateral

• Left Lateral

• Right and Left Oblique

• Superior ("Birds Eye View"); or Inferior ("Worms Eye View") may be indicated For example, the Superior ("Birds Eye View") is useful to record degree of Proptosis and Keratoconus (Munson’s Sign)

• Camera Axis is directed to the point where the Median Plane meets the Interpupillary Line at the level of the Orbito-Helix Line.

Unless otherwise indicated the eyes are in the Primary Position of Gaze. The eyelids would be in a normal "resting" open position.

In cases of exophthalmos or proptosis where the lids do not close to cover the cornea, lagophthalmos, an additional view with the eyes closed is required.

–  –  –

Image Orientation - Horizontal Plane of Focus - Anterior view - the Corneal Reflex.

Lateral and Oblique views the Focus is on the corneal profile closest to the camera, i.e. the corneal para -sagittal plane.

–  –  –

SINGLE EYE WITH ADNEXA

• Anterior

• Right Lateral

• Left Lateral

• Additionally Oblique, Superior (“Birds Eye View”) or Inferior (“Worms Eye View”) may also be indicated

• Camera Axis is directed to the point where the Corneal Para-sagittal line meets the Interpupillary Line at the level of the Orbito-Helix Line.

The eyes are normally in the Primary Position of Gaze. The direction of gaze is used to bring an off-centred lesion to the centre of the field of view. This should conform to one of the nine defined positions of gaze. An off-centre lesion should additionally be routinely imaged anteriorly in the Primary Position. Upper and Lower Eye Lids must be retracted where indicated and the Upper lid must be everted for lesions on the conjunctival tarsus.

–  –  –

Image Orientation - Horizontal Plane of Focus - The specific area of interest, i.e., periorbital; lids; internal (medial) or external (lateral) canthus; lacrimal punctum, & etc.

• This is a complimentary view to the SINGLE EYE VIEW and the ORBITAL VIEW.

IMI National Guidelines February 2008 Ophthalmic Imaging

TRAUMA TO THE GLOBE; CONJUNCTIVITIS; SCLERITIS;

PIGMENTED LESIONS OF SCLERA AND CONJUNCTIVA;

CORNEAL LESIONS; PTERYGIA; TRACOMA; TRICHIASIS;

ENTROPION; ECTROPION; PERIORBITAL LESIONS AND LIDS;

KERATOCONUS

SINGLE EYE

• Anterior

• Lateral

• Medial

• Oblique

• Superior (“Birds Eye View”) Ectropion; or Inferior (“Worms Eye View”) Entropion views may also be indicated

• The Superior ("Birds Eye View") is also indicated to record Proptosis and Keratoconus (Munson’s Sign)

• Keratoconus will also require Slit-Lamp images of the corneal thickness.

Refer to SECTION B. ANTERIOR SEGMENT SECTION.

• Camera Axis is directed to the point where the Corneal Para-sagittal line meets the Interpupillary Line at the level of the Orbito-Helix Line.

The eye is normally in the Primary Position of Gaze. The direction of gaze is used to bring an off-centred lesion, i.e. a pterygium, to the centre of the field of view. This should conform to one of the nine defined positions of gaze. An off-centre lesion should additionally be routinely imaged anteriorly in the Primary Position. Upper and Lower Eye Lids must be retracted where indicated and the Upper lid must be everted for lesions on the conjunctival tarsus.

Reproduction Ratio 1:1.6 - 0.37metre (105mm focal length lens) 16mm x 24mm 1:1 - 0.31metre (105mm focal length lens) 24mm x 36mm Image Orientation - Horizontal Plane of Focus - The specific area of pathology or injury, i.e. Periorbital; Lids;

Conjunctiva; Sclera; Cornea; Limbus (Corneo-Scleral Junction).

• This may be used as a supplementary view to the SINGLE EYE WITH ADNEXA if indicated and as an adjunct to Ophthalmic Photo-Slitlamp Microscope images.

–  –  –

INTRODUCTION



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