diagnostics

Article
The Role of Widefield and Ultra Widefield Optical Coherence
Tomography in the Diagnosis and Management of
Vitreoretinal Diseases
Matteo Ripa 1,2,† , Lorenzo Motta 3, *,† , Teresa Florit 4,† , Jean-Yves Sahyoun 5,6 , Veronika Matello 4
and Barbara Parolini 4

1 Ophthalmology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
2 Ophthalmology Unit, Catholic University “Sacro Cuore”, 00168 Rome, Italy
3 Department of Ophthalmology, William Harvey Hospital, East Kent Hospitals University NHS Foundation
Trust, Ashford TN24 0LZ, UK
4 Department of Ophthalmology, Eyecare Clinic, 25124 Brescia, Italy
5 Department of Ophthalmology, Université de Montréal, Montreal, QC H3T 1J4, Canada
6 Department of Ophthalmology, Centre Hospitalier de l’Université de Montréal (CHUM),
Montreal, QC H2X 3E4, Canada
* Correspondence: [email protected]
† These authors contributed equally to this work and should be considered equal first authors.

Abstract: Background: This study reports on the advantages of wide-field (WF)- and ultra-widefield
(UWF)- optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA)
in managing different vitreoretinal diseases in a real-life setting using the new WF—Swept Source
(SS)—OCT Xephilio S1 (Canon, Tokyo, Japan). Methods: We conducted an observational retrospective
case series study involving 1472 eyes that underwent retinal scans with Canon Xephilio® OCT-S1
between 1 March 2021 and 1 December 2021 at Eyecare Clinic (Brescia, Italy). All patients underwent
Citation: Ripa, M.; Motta, L.; Florit,
routine ophthalmologic examinations along with WF and UWF color fundus retinography with
T.; Sahyoun, J.-Y.; Matello, V.;
Parolini, B. The Role of Widefield and
Clarus 500™ (Carl Zeiss Meditec, Inc., Dublin, CA, USA) and Xephilio® OCT-S1. WF SS-OCT, UWF-
Ultra Widefield Optical Coherence OCT, WF-OCTA, and UWF-OCTA were taken by using Xephilio® OCT-S1. Results: We analyzed
Tomography in the Diagnosis and 122 peripheral retinal lesions, 144 retinal detachment, 329 high myopic eyes, 37 pediatric cases,
Management of Vitreoretinal 60 vascular retinopathies, 15 choroidal lesions, and 90 eyes as follow-up post vitreoretinal surgery.
Diseases. Diagnostics 2022, 12, 2247. The OCT-S1 was the only reliable and diagnostic exam for peripheral lesions, pediatric and high
https://doi.org/10.3390/ myopic cases, and significantly influenced the management in 10% of cases and the postoperative
diagnostics12092247 follow-up. Conclusions: WF and UWF OCT and OCTA imaging may help in the management of
Academic Editor: Sang Beom HAN several vitreoretinal diseases, becoming an indispensable tool for the high-quality management
of patients.
Received: 1 September 2022
Accepted: 15 September 2022
Keywords: choroidal lesions; high myopia; peripheral lesions; peripheral retinoschisis; swept-source
Published: 17 September 2022
optical coherence tomography; retinal detachment; ultrawide-field optical coherence tomography;
Publisher’s Note: MDPI stays neutral vitreoretinal diseases; wide-field optical coherence tomography; wide-field optical coherence tomog-
with regard to jurisdictional claims in raphy angiography
published maps and institutional affil-
iations.

1. Introduction
Copyright: © 2022 by the authors.
Optical coherence tomography (OCT) and OCT angiography (OCTA) are widely used
Licensee MDPI, Basel, Switzerland. in evaluating patients with macular and vitreoretinal interface diseases. [1,2].
This article is an open access article Huang et al. published the first retinal OCT images in 1991 [3], and OCT has advanced
distributed under the terms and considerably over the last three decades. Notably, OCT instruments have been widely
conditions of the Creative Commons used in ophthalmology since the commercial introduction of the spectral domain (SD)-OCT
Attribution (CC BY) license (https:// in 2006 due to the SD-OCT’s higher speed and sensitivity over the time-domain (TD)-
creativecommons.org/licenses/by/ OCT. Indeed, its faster image capture and higher definition enabled volumetric imaging
4.0/). with superior image quality [4–6]. Subsequently, the third-generation OCT, swept-source

Diagnostics 2022, 12, 2247. https://doi.org/10.3390/diagnostics12092247 https://www.mdpi.com/journal/diagnostics

Diagnostics 2022, 12, 2247 2 of 17

(SS)-OCT, incorporated many significant technological advancements. SS-OCT enabled

faster scanning speed (100 kHz) and greater tissue penetration, allowing imaging and
quantitative evaluation of the choroid for the first time [4–8], as well as better penetration
through cataracts and other media opacities by combining swept-source technology with
a longer wavelength light source. In addition, SS-OCT enabled vitreous imaging while
maintaining clear visibility of the choroid in the same scan [9–11]. Wide-field (WF) SS-OCT
has recently revolutionized the imaging of vitreoretinal disorders, obtaining images with
enlarged fields-of-view (FOV) of 80◦ compared to the 30◦ of the standard OCT systems.
Furthermore, scans of the peripheral retina are acquired by moving the eye in different
positions, resulting in an ultra-wide FOV.
OCTA is a non-invasive imaging technique based on OCT technology that allows
visualization of the eye’s blood vessels and red blood cell movement detection, thus
demonstrating vascular bed distribution [12]. Despite the advantages, the limited FOV
and eye motion artifacts still represent the main challenge [2]. The recently introduced
WF-OCTA overcomes these limitations by providing an enlarged FOV and thus yielding
peripheral vascularization information [13,14].
The new WF SS-OCT Xephilio S1 (Canon, Tokyo, Japan) with a 1060 nm wavelength
can capture up to 23 × 20 mm WF-OCTA images with a single photograph in a limited
time (100,000 A-scans/second) and leads to an enhanced view from the vitreous to the
sclera offering a better penetration through media opacities, thus yielding outstanding
tomographic images.
Our study aimed to report the advantages of WF- and UWF-OCT and OCTA in
managing different vitreoretinal diseases in a real-life setting using the new WF SS-OCT
Xephilio S1. Therefore, we assessed the “effectiveness” of WF- and UWF-OCT and OCTA
in evaluating vitreoretinal diseases whose diagnosis could not be achieved with any other
clinical or instrumental examination. Furthermore, we evaluated their “effectiveness” in
terms of faster but reliable diagnosis in challenging cases such as pediatric, high myopic,
non-cooperative patients or patients’ eyes that had recently undergone vitreoretinal surgery.

2. Materials and Methods

2.1. Patients
In this observational retrospective case-series study, we collected data from 1472
eyes that underwent retinal scans (WF-OCT, UWF-OCT, WF-OCTA, and UWF-OCTA)
with Canon Xephilio ® OCT-S1 and with Clarus 500™, (Carl Zeiss Meditec, Inc., Dublin,
CA, USA) between 1 March 2021 and 1 December 2021 at Eyecare Clinic (Brescia, Italy).
Data from patients who underwent retinal scans were retrieved and collected. This study
followed the tenets of the Declaration of Helsinki for research involving human subjects.
Informed consent was obtained from all subjects to use the data for the study. All images
of patients with vitreous abnormalities (floaters, opacities, and cellularity), peripheral
retinal lesions, retinal detachment, and choroidal and optic nerve lesions were included.
In addition, images of challenging cases (miosis, severe media opacity, pediatric cases,
postoperative follow-up) were also grounds for inclusion. However, poor OCT or OCTA
images due to severe media opacity or unstable fixation were excluded.

2.2. Examinations and Image Acquisition Protocol

All patients underwent routine ophthalmologic examinations, including the measure-
ment of corrected distance visual acuity (CDVA) in the logarithm of the minimum angle of
resolution (logMAR), the measurement of intraocular pressure (IOP) with a non-contact
tonometer, a slit lamp bio-microscopy, and a dilated fundus evaluation using 90 diopters
(D) lens. Afterwards, a single trained technician took all retinal images comprised of color
fundus retinography, standard macular OCT, and widefield OCT.
WF and UWF color fundus retinography were obtained with Clarus 500™, (Carl
Zeiss Meditec, Inc., Dublin, CA, USA). The Clarus 500™ fundus image was acquired by
a Confocal Scanning Laser Ophthalmoscope (cSLO) with partial confocal optics. Using
Diagnostics 2022, 12, 2247 3 of 17

an internal fixation light, a single image and two fundus images were recorded from two
different horizontal visual angles. These two images were automatically merged to create a
montage image with a wide field of view.
The Xephilio® OCT-S1 (Scanning Laser Ophthalmoscope, SLO: 855 nm) was obtained
for each patient using the three-dimensional (3D) macula scan with a maximum scan width
of 10 mm. The confocal image was obtained alongside each OCT examination. Based on
OCT scanning, the projection image was obtained from collecting all the A-scans and the
reflectivity of the various layers. Specifically, the WF SS-OCT, UWF-OCT, WF-OCTA, and
UWF-OCTA were taken using Xephilio® OCT-S1. In more depth, all patients were imaged
using single-capture twelve 10 mm cross-sectional radial scan patterns at 15◦ intervals.
The scanned line length was 10 mm in the horizontal and vertical directions, and the scan
depth was 2.0 mm. Cross-sectional scans and long radial scans centered on the fovea were
obtained. The map scans were performed with 256 single horizontal scans in the region of
interest. In addition, the WF-OCTA images were obtained by scanning areas of different
sizes that ranged from small areas (3 × 3 mm, 10◦ ) to super large areas (23 × 20 mm,
80◦ ). A UWF-OCTA was obtained by collecting different images and creating a mosaic
of 31 × 27 mm (110◦ ). All images were extracted as JPG files and converted to tiff format.
Afterwards, two independent investigators (B.P and L.M) collected and analyzed all images.
Both the investigators were blinded to the retinal findings of the patients.

2.3. Image Grading

Two OCT specialists (B.P. and L.M.) blinded to the subject’s retinal findings examined
all images according to a pre-specified protocol. If consensus could not be reached, a third
specialist (M.R.) was consulted for the final decision. The protocol evaluated either the
presence or the absence of five parameters: motion (image interruptions), decentration
(center of scan not aligned with the center of the macula), defocus (reduced retinal reflec-
tivity due to poor autofocus), masking (light blockage due to anterior or posterior ocular
abnormalities such as vitreous opacities and pigment clumps, which do not permit the
beam to reach deeper layers), and segmentation errors (unclear boundary of the different
layers of the retina). Images with at least one artifact were discarded.
Finally, the images were classified according to the main diagnosis. However, some
eyes were affected by multiple conditions; therefore, the number of diagnoses exceeded the
number of eyes.

2.4. Statistical Analysis

The interobserver agreement was calculated using a kappa (κ) statistic [9]. The κ
statistics were calculated and assessed as following: <0.20, poor; 0.21–0.40, fair; 0.41–0.60,
moderate; 0.61–0.80, substantial; and 0.81–1.00, almost perfect agreement.

3. Results
3.1. Demographics
Demographics and categories are listed in Tables 1 and 2. The mean examination times
per different types of scans in cooperative patients are reported in Table 3. All patients
underwent WF and UWF color fundus retinography, standard macular OCT, and WF-OCT.
The UWF-OCT, WF-OCTA, and UWF-OCTA were performed in 21%, 40%, and 3% of the
eyes, respectively. The interobserver agreement between the two examiners was not inferior
to 0.93 for each comparison.
Diagnostics 2022, 12, 2247 4 of 17

Table 1. Patients’ demographics.

Features Number (%)

Sex: 768
Male 358 (46.61%)
Female 410 (53.39%)
Age (years); (mean-range) 59.6 (5–94)
Eye involved 1472
Right 735 (49.93%)
Left 737 (50.07%)

Table 2. Diagnosis features.

Diagnosis Number, N = 1472 Eyes

High myopia 329
Myopic Tractional Maculopathy (MTM) 91
Macular buckle 37
Retinal detachment 144
Follow up 108
Primary detachment 36
Peripheral lesions 122
Retinal tears 12
Peripheral retinoschisis 63
Other peripheral lesions 47
Vascular retinal diseases 60
BRVO/CRVO 26
CRAO 2
Diabetic retinopathy 32
Pediatric cases 37
Normal 16
Best dystrophy 4
RRD associated with Peter’s anomaly 2
FEVR 2
ROP 2
Diffuse choroidal hemangioma in Sturge Weber syndrome 2
Combined hamartoma of the retina and RPE 2
Incontinentia pigmenti 2
Morning glory syndrome 1
Traumatic FTMH with VH and traumatic retinopathy 1
Traumatic retinal detachment 1
Retinal detachment associated with Marfan syndrome 1
Optic disc pit maculopathy 1
Choroidal lesions 16
Choroidal granuloma 1
Choroidal melanoma 4
Choroidal nevus 4
Circumscribed choroidal hemangioma 3
Diffuse choroidal hemangioma 2
Combined hamartoma of the retina and RPE 2
Diagnostics 2022, 12, 2247 5 of 17

Table 2. Cont.

Diagnosis Number, N = 1472 Eyes

Vitreomacular Traction (VMT) syndrome 10
Optic nerve pathologies 8
Optic nerve coloboma 1
Optic nerve drusen 4
Optic disc pit 3
Uveitis 5
Toxoplasma retinitis 3
Behçet disease 2
Abbreviations: Myopic Tractional Maculopathy: MTM; Branch Retinal Vein Occlusion: BRVO; Central Retinal
Vein Occlusion: CRVO; Central Retinal Artery Occlusion: CRAO; Rhegmatogenous Retinal Detachment: RRD;
Familial Exudative Vitreoretinopathy: FEVR; Retinopathy of Prematurity: ROP; Retinal Pigment Epithelium: RPE;
Full Thickness Macular Hole: FTMH; Vitreous Hemorrhage: VH; Vitreomacular Traction: VMT; Number: n.

Table 3. Time of wide-field imaging acquisition in cooperative patients and those with good
visual acuity.

Modality of Scan Time of Acquisition (Seconds)

Radial 23 mm 7s
Radial HD 23 mm 14 s
3 D Cube 23 mm 14 s
Choroid 14 s
OCTA 23 × 20 mm 30 s
NDB:
Macular 3D 3s
Glaucoma 3D 2s
Disc 3D 3s
Abbreviations: High definition: HD, Optical coherence tomography angiography: OCTA, Normative database:
NDB, Millimeters: mm, Seconds: s, Three-dimensional: 3D.

3.2. Vitreous Pathologies

3.2.1. Floaters and Posterior Vitreous Detachment (PVD)
Floaters were detected as hyper-reflective images with non-homogenous patterns on
OCT and dark shadows on the WF-SLO image. Only 131 of 644 eyes with floaters reported
symptoms. WF-OCT detected a complete PVD in 571 (39%), partial PVD (detached from
macula or papilla) in 69 (5%), and no PVD in 560 eyes (38%). The vitreous cavity appeared
homogeneous and optically empty in 272 (18%) vitrectomized eyes.
WF-retinography could neither detect floaters nor PVD. Standard macular OCT al-
lowed suspecting a complete PVD in 200 eyes (14%) to diagnose a partial PVD (detached
from macula or papilla) in 50 (3%) and suspected no PVD in 230 eyes (16%). The vitreous
cavity appeared homogeneous and optically empty in 272 (16%) vitrectomized eyes.

3.2.2. Anomalous PVD

OCT-S1 detected the location and extension of vitreoretinal anomalous adhesions and
tractions (Figure 1).

3.2.3. Vitreous Opacities and Cellularity

Eleven eyes with various densities of vitreous hemorrhage (VH) underwent WF-
OCT scans.
Retinography, standard macular OCT, and slit lamp biomicroscopy could not thor-
oughly examine the fundus. Blood’s cellularity was perceived as a collection of numerous
aggregate dots (Figure 1). The vitreous cellularity in five uveitic eyes was remarkably simi-
Diagnostics 2022, 12, 2247 6 of 17

lar to that originating from blood. Furthermore, the cellularity could be neither detected
with retinography nor standard macular OCT.
Six eyes were diagnosed with asteroid hyalosis (AH). WF-OCT detected these anoma-
lies in the vitreous as multiple hyperreflective dots with posterior shadowing (Figure 1C).
AH’s cellularity size was larger than that related to inflammation and hemorrhage.
No significant differences were found on OCT between inflammatory vitreous cellu-
Diagnostics 2022, 12, x FOR PEER REVIEW 6 of 19
larity and VH (Figure 1). Indeed, both inflammatory and hemorrhage cells appeared as
small and aggregated dots.

Figure 1.1.WF
Figure WFSS-OCT
SS-OCT shows
shows vitreous
vitreous cellularity
cellularity (arrowheads)
(arrowheads) in toxoplasma
in toxoplasma retinitisretinitis
(A) and(A) and
bilateral
bilateral macular and optic nerve edema secondary to Behçet disease (B). Asteroid hyalosis induces
macular and optic nerve edema secondary to Behçet disease (B). Asteroid hyalosis induces bigger and
bigger and hyper-reflective vitreous opacities (C). Vitreomacular Traction with subfoveal outer
hyper-reflective
lamellar macular vitreous
hole andopacities (C). Vitreomacular
initial foveal Traction is
schisis. The vitreous with subfoveal
attached outer
to the lamellar
central foveamacular
and at
hole and initial
the equator (D).foveal schisis. The vitreous is attached to the central fovea and at the equator (D).
3.3. Peripheral Retinal Lesions and Retinal Detachment
3.2.3. Vitreous Opacities and Cellularity
3.3.1. Peripheral Lesions
Eleven eyes with various densities of vitreous hemorrhage (VH) underwent WF-OCT
UWF-OCT was acquired in 311 eyes (21%). In this subgroup, 39% had peripheral
scans.
lesions, and 31% were not detectable with slit lamp biomicroscopy, WF retinography, and
Retinography, standard macular OCT, and slit lamp biomicroscopy could not
standard macular OCT.
thoroughly examine the fundus. Blood’s cellularity was perceived as a collection of
numerous
3.3.2. aggregate
Retinal dots. (Figure 1). The vitreous cellularity in five uveitic eyes was
Detachment
remarkably similar to that originating from blood. Furthermore, the cellularity could be
WF and UWF-OCT revealed the location and extent of the retinal detachment (RD),
neither detected with retinography nor standard macular OCT.
the retinal tears location, and preretinal membranes in all eyes with RD.
Six eyes were diagnosed with asteroid hyalosis (AH). WF-OCT detected these
WF-retinography could also demonstrate the presence of RD in all 36 primary and
anomalies in the vitreous as multiple hyperreflective dots with posterior shadowing
108 recurrent RD. WF retinography and standard OCT did not always detect the tears and
(Figure 1C). AH’s cellularity size was larger than that related to inflammation and
peripheral lesions (Figure 2).
hemorrhage.
No significant differences were found on OCT between inflammatory vitreous
cellularity and VH (Figure 1). Indeed, both inflammatory and hemorrhage cells appeared
as small and aggregated dots.

3.3. Peripheral Retinal Lesions and Retinal Detachment

3.3.1. Peripheral Lesions
UWF-OCT was acquired in 311 eyes (21%). In this subgroup, 39% had peripheral
lesions, and 31% were not detectable with slit lamp biomicroscopy, WF retinography, and
standard macular OCT.
Diagnostics 2022, 12, x FOR PEER REVIEW 7 of 19

WF-retinography could also demonstrate the presence of RD in all 36 primary and

Diagnostics 2022, 12, 2247 7 of 17
108 recurrent RD. WF retinography and standard OCT did not always detect the tears and
peripheral lesions. (Figure 2)

Figure 2.
Figure 2. Color
Color fundus
fundus retinography
retinography(A) (A)and
andscanner
scannerlaser
laserophthalmoscopy
ophthalmoscopy (SLO)
(SLO) image
image(B,C) of of
(B,C) a
peripheral temporal retinal detachment that could only be diagnosed on the wide-field optical
a peripheral temporal retinal detachment that could only be diagnosed on the wide-field optical
coherence tomography (WF-OCT) (D arrow). Peripheral retinoschisis is visualized in the color
coherence tomography (WF-OCT) (D) (arrow). Peripheral retinoschisis is visualized in the color
fundus retinography (E) and SLO image (F). The two different areas seen in the SLO image (F)
fundus
allowedretinography (E) and SLO
us to differentiate theimage (F). The two
retinoschisis areadifferent
(arrow)areas
fromseen
thein the SLOdetachment
retinal image (F) allowed
area
us to differentiate the retinoschisis area (arrow) from the retinal detachment
(arrowhead). With the WF-OCT (G), an outer retinal break and a contiguous area of retinal area (arrowhead). With
the WF-OCT (arrowhead)
detachment (G), an outercanretinal breakThis
be seen. and limited
a contiguous
retinalarea of retinalwas
detachment detachment (arrowhead)
missed with can
the fundus
retinography.
be Color fundus
seen. This limited retinography
retinal detachment was (H)missed
SLO image
with the(I)fundus
and WF-OCT (J) of Color
retinography. a peripheral
fundus
retinoschisis (H)
retinography withSLO
vitreous
imagetractions and internal
(I) and WF-OCT (J) of retinal breakretinoschisis
a peripheral (arrowhead)withthatvitreous
could be better
tractions
visualized with WF-OCT.
and internal retinal break (arrowhead) that could be better visualized with WF-OCT.

3.4.
3.4. High Myopia
Only
Only WF-OCT
WF-OCTcould coulddetect the posterior
detect staphyloma’s
the posterior presence,
staphyloma’s depth, and
presence, perimeter.
depth, and
Specifically, the projection
perimeter. Specifically, theimage could image
projection better see
couldthebetter
edge of
seethe
thestaphyloma
edge of theasstaphyloma
a dark ring.
Whenring.
as a dark compared with WF-retinography, the edge of the staphyloma was easily visual-
ized with the projectionwith
When compared image as a dark ring (Figure
WF-retinography, 3). of the staphyloma was easily
the edge
visualized with the projection image as a dark ring (Figurein3).
Myopic Traction Maculopathy (MTM) was diagnosed 28% of high myopic eyes, and
the stage was identified in all MTM cases, according
Myopic Traction Maculopathy (MTM) was diagnosed in 28% to the MTM Staging System
of high myopic[15].eyes,
Due
to
andthethe
height
stageofwas
theidentified
detachment andMTM
in all the depth
cases,of the staphyloma,
according to the MTMstandard field
Staging OCT could
System [15].
not
Duedepict
to the30% of the
height cases
of the of MTM, particularly
detachment and the depth in of
stages 3 and 4 withstandard
the staphyloma, foveal and macular
field OCT
detachment.
could not depict At the
30%same
of thetime,
casesthe
of WF-OCT could completely
MTM, particularly in stages illustrate them.
3 and 4 with Neither
foveal and
WF-retinography nor slit lamp biomicroscopy could detect the MTM’s
macular detachment. At the same time, the WF-OCT could completely illustrate them. presence and stage.
Neither WF-retinography nor slit lamp biomicroscopy could detect the MTM’s presence
3.5. Choroidal Lesions
and stage.
WF-OCT diagnosed the choroidal lesions providing information on their size, shape,
distance from the optic nerve and macula, and impact on the choriocapillaris and choroid.
Indeed, it revealed no vascularity in benign nevi and tubercular granuloma but dense
vascularity in melanoma and choroidal hemangioma. The SLO image appeared dark in
melanoma and grey in hemangioma and benign nevi. Furthermore, the granulomas’ SLO
Diagnostics 2022, 12, 2247 8 of 17

Diagnostics 2022, 12, x FOR PEER REVIEW 8 of 19

image was lighter than the surrounding tissue in benign nevi and comparable to the shade
of the surrounding tissue in granulomas (Figure 4).

Figure 3. Wide-Field (WF) color fundus retinography of pathologic myopia and posterior
Figure 3. Wide-Field (WF) color fundus retinography of pathologic myopia and posterior staphy-
staphyloma (A). The wide-field optical coherence tomography (WF-OCT) image (B) shows the
loma (A). The wide-field optical coherence tomography (WF-OCT) image (B) shows the posterior
posterior staphyloma and the choroidal thinning in these eyes. Myopic Traction Maculopathy
staphyloma
(MTM) stageand the choroidal
3b was thinning
diagnosed. The OCT in (C)
these eyes. Myopic
projection imageTraction Maculopathy
shows the (MTM)
staphyloma’s stage
perimeter.
3b
Thewas diagnosed.
patient The OCT
underwent (C) projection
a macular image
buckle that showsthe
resolved the retinal
staphyloma’s perimeter.
detachment Themacular
and the patient
underwent
schisis (D). a macular buckle that resolved the retinal detachment and the macular schisis (D).

WF-retinography
3.5. Choroidal Lesions diagnosed the choroidal lesions providing additional information on
size, shape, distance from optic nerve and macula, color, and the presence of concomitant
WF-OCT diagnosed the choroidal lesions providing information on their size, shape,
findings such as drusen of pigment alterations.
distance from the optic nerve and macula, and impact on the choriocapillaris and choroid.
Indeed,
3.6. OpticitNerve
revealed no vascularity in benign nevi and tubercular granuloma but dense
Lesions
vascularity in melanoma and choroidal hemangioma. The SLO image appeared dark in
Optic nerve drusen (OND) were detected with WF OCT as low-reflective multiple
melanoma and grey in hemangioma and benign nevi. Furthermore, the granulomas’ SLO
ovoid lesions with hyperreflective borders in the optic nerve head (Figure 5). Despite being
image was lighter than the surrounding tissue in benign nevi and comparable to the shade
also seen with color retinography and with standard OCT, only WF OCT could show the
of the surrounding tissue in granulomas (Figure 4).
depth of the lesions into the optic nerve.
WF-retinography diagnosed the choroidal lesions providing additional information
The WF OCT showed the optic pit as a tubular excavation into the optic nerve, visual-
on size, shape, distance from optic nerve and macula, color, and the presence of
izing the secondary retinal detachment in a single scan and the vitreous strands connected
concomitant findings such as drusen of pigment alterations.
to the optic disc pit.
Although only WF OCT could show the depth of the lesions into the optic nerve,
optic pit and coloboma could also be detected with color retinography and standard OCT.
Specifically, retinal tissue herniated into the colobomatous area was visualized in optic
nerve coloboma cases (Figure 5).
Diagnostics 2022,12,
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x FOR PEER REVIEW 99ofof19
17

Figure 4. Images from left to right: color fundus retinography, green-autofluorescence, scanner laser
Figure 4. Images from left to right: color fundus retinography, green-autofluorescence, scanner laser
ophthalmoscopy (SLO) image, wide-field optical coherence tomography (WF-OCT), and wide-field
ophthalmoscopy (SLO) image, wide-field optical coherence tomography (WF-OCT), and wide-field
optical coherence tomography angiography (WF-OCTA). Choroidal hemangioma adjacent to the
optical coherence
optic nerve is showntomography
at the topangiography (WF-OCTA).
(1A–1E), choroidal Choroidal
granuloma hemangioma
secondary adjacentintothe
to tuberculosis the
optic nerve is shown at the top (1A–1E), choroidal granuloma secondary to tuberculosis
middle (2A–2E), and choroidal melanoma at the bottom (3A–3E). A dark image on the SLO is in the middle
(2A–2E),
observed and choroidal melanoma
in hemangioma at the bottom
(1C) and melanoma (3C). (3A–3E).
WF-OCTA darkintraretinal
shows image on the andSLO is observed
subretinal fluid
the hemangioma
in hemangioma (1C) (1D), intraretinal(3C).
and melanoma fluid in the granuloma
WF-OCT (2D) and
shows intraretinal andsubretinal
subretinalfluid
fluidininthe
the
melanoma (3D).
hemangioma (1D),Vascularization
intraretinal fluidcan begranuloma
in the seen on the WF-OCTA
(2D) in the
and subretinal hemangioma
fluid (1E) (3D).
in the melanoma and
melanoma (3E) can
Vascularization but not in the
be seen ongranuloma
the WF-OCTA (2E).in the hemangioma (1E) and melanoma (3E) but not in
the granuloma (2E).
3.6. Optic Nerve Lesions
3.7. Difficult Situations
Optic nerve drusen (OND) were detected with WF OCT as low-reflective multiple
3.7.1. Miosis
ovoid lesions with hyperreflective borders in the optic nerve head (Figure 5). Despite
beingEyes
alsowhose fundus
seen with could
color not be inspected
retinography withstandard
and with slit lampOCT,
biomicroscopy
only WF OCTor standard
could
OCT
showdue to the narrowed
the depth angle
of the lesions into configuration, allergy to mydriatics, posterior synechiae,
the optic nerve.
or dilation
The WF refusal
OCTwere analyzed
showed with pit
the optic WF-OCT and WFexcavation
as a tubular retinography.
into the optic nerve,
visualizing the secondary retinal detachment in a single scan and the vitreous strands
3.7.2. Media
connected toOpacities
the optic disc pit.
WF-OCT
Although images
only WF were
OCTobtained in 10the
could show eyes withofcorneal
depth opacity
the lesions intoand
the 20 eyes
optic with
nerve,
lens
opticcloudiness (cataract,
pit and coloboma intraocular
could lens opacification,
also be detected or posteriorand
with color retinography capsule opacifica-
standard OCT.
tion). WF-retinography
Specifically, could
retinal tissue partially
herniated intoinspect the fundus ofarea
the colobomatous those eyes
was but not slit
visualized lamp
in optic
biomicroscopy
nerve colobomaorcases standard OCT.
(Figure 5).

3.7.3. Pediatric Cases

Thirty-seven eyes of patients of pediatric age (≤18 years) were analyzed. The mean
age was 11.4 (range 5–17). The fundus could be inspected with WF-retinography. However,
the slit lamp biomicroscopy and standard OCT could partially examine the same findings.
Figures 6 and 7 report two challenging pediatric cases of an 11-year-old boy who showed
vitreous and preretinal hemorrhage (VH) and traumatic macular hole three days after
contusive trauma with a tennis ball and a case of familial exudative vitreoretinopathy
(FEVR) in a 4-year-old boy.
Diagnostics 2022, 12, 2247 10 of 17
Diagnostics 2022, 12, x FOR PEER REVIEW 10 of 19

Figure 5. Optic nerve color photo (A,D) and autofluorescence (B,E) of a patient with bilateral optic
Figure 5. Optic nerve color photo (A,D) and autofluorescence (B,E) of a patient with bilateral optic
nerve drusen (OND). Notice the hyper-autofluorescence in both optic nerves. Wide-field (WF) and
nerve
deepdrusen (OND).
field (DF) Notice
optical the hyper-autofluorescence
coherence tomography (OCT) radialin both
scan optic nerves.
centered Wide-field
on the optic (WF) and
nerve (C,F)
deepof field (DF)and
the right optical coherence
left eye. tomography
OCT shows the OND (OCT)
as ovalradial scan centered
hyporeflective lesionson thehyperreflective
with optic nerve (C,F) of
the borders.
right andOptic nerve
left eye. OCT retinography
shows the OND(G) and autofluorescence
as oval hyporeflective(H) of a with
lesions temporal optic nerve
hyperreflective borders.
coloboma. WF-OCT image (I) shows the herniation of the retina into the colobomatous area. This
Optic nerve retinography (G) and autofluorescence (H) of a temporal optic nerve coloboma. WF-OCT
patient underwent a vitrectomy and internal limiting membrane (ILM) flap to treat the retinal
image (I) shows
detachment. the herniation
Notice the ILM flapof(arrow)
the retina
and into the colobomatous
the absence area. This
of retinal detachment fivepatient underwent
years after the a
Diagnostics 2022, 12, x FOR PEERvitrectomy
REVIEW
surgery. and internal limiting membrane (ILM) flap to treat the retinal detachment. Notice 11 of 19
the ILM
flap (arrow) and the absence of retinal detachment five years after the surgery.
3.7. Difficult Situations
3.7.1. Miosis
Eyes whose fundus could not be inspected with slit lamp biomicroscopy or standard
OCT due to the narrowed angle configuration, allergy to mydriatics, posterior synechiae,
or dilation refusal were analyzed with WF-OCT and WF retinography.

3.7.2. Media Opacities

WF-OCT images were obtained in 10 eyes with corneal opacity and 20 eyes with lens
cloudiness (cataract, intraocular lens opacification, or posterior capsule opacification).
WF-retinography could partially inspect the fundus of those eyes but not slit lamp
biomicroscopy or standard OCT.

3.7.3. Pediatric Cases

Thirty-seven eyes of patients of pediatric age (≤18 years) were analyzed. The mean
age was 11.4 (range 5–17). The fundus could be inspected with WF-retinography.
However, the slit lamp biomicroscopy and standard OCT could partially examine the
same findings. Figures 6 and 7 report two challenging pediatric cases of an 11-year-old
boy who showed vitreous and preretinal hemorrhage (VH) and traumatic macular hole
three days after contusive trauma with a tennis ball and a case of familial exudative
vitreoretinopathy (FEVR) in a 4-year-old boy.

Figure 6. WF color fundus retinography (A) of an 11-year-old boy showed vitreous and preretinal
Figure 6. WF color fundus retinography (A) of an 11-year-old boy showed vitreous and preretinal
hemorrhage (VH) and traumatic macular hole three days after contusive trauma with a tennis ball.
Despite the VH, high-quality wide-field (WF) optical coherence tomography (OCT) images could
be obtained (B,C). The VH was observed as mild, diffuse white dots in the vitreous chamber
(arrowheads), and the formation of a macular hole can be observed. Only the external retinal layer
is still continuous (C). The WF-OCT shows an area of peripheral retinal thinning (arrow) and
confirmed neither detachment nor other retinal breaks, even in the most peripheral area. WF color
fundus retinography of a vitreous hemorrhage in a case of proliferative diabetic retinopathy (D).
Diagnostics 2022, 12, 2247 11 of 17

hemorrhage (VH) and traumatic macular hole three days after contusive trauma with a tennis
ball. Despite the VH, high-quality wide-field (WF) optical coherence tomography (OCT) images
could be obtained (B,C). The VH was observed as mild, diffuse white dots in the vitreous chamber
(arrowheads), and the formation of a macular hole can be observed. Only the external retinal layer is
still continuous (C). The WF-OCT shows an area of peripheral retinal thinning (arrow) and confirmed
neither detachment nor other retinal breaks, even in the most peripheral area. WF color fundus
retinography of a vitreous hemorrhage in a case of proliferative diabetic retinopathy (D). WF-OCT
shows VH, although some posterior shadows onto the retina can be noticed. The vitreous cortex
appears partially detached, taut, and thickened (arrowheads) (E,F). Color fundus retinography (G) of
an 8-year-old boy with Peter’s anomaly, who underwent a second perforating keratoplasty and
vitreous surgery for retinal detachment relapsed with proliferative vitreoretinopathy (PVR) in his
left eye. The child presented corneal opacity, and despite the partial and challenging visualization of
Diagnostics 2022, 12, x FOR PEER REVIEW
the fundus on the retinography, WF-OCT could be obtained to confirm that the retina12was of 19
wholly
attached (H,I).

Figure 7. A case of familial exudative vitreoretinopathy (FEVR) in a 4-year-old boy is shown in the
Figure 7. A case of familial exudative vitreoretinopathy (FEVR) in a 4-year-old boy is shown in
wide-field (WF) fundus color image (1A), showing temporal vessels rectification, macula and
the papilla
wide-field (WF) fundus
displacement, and acolor image
macular fold.(1A), showing
Wide-field temporal
optical coherencevessels rectification,
tomography macula and
(OCT) shows
papilla displacement,
the retinal tractions and andfolds
a macular
(1B,1C).fold. Wide-field
WF fundus optical(2A),
color image coherence
scanner tomography (OCT) shows
laser ophthalmoscopy
the (SLO)
retinalimage
tractions(2B),and
andfolds
WF-OCT (2C)WF
(1B,1C). of fundus
a 10-year-old girl with
color image a large
(2A), macular
scanner laser detachment
ophthalmoscopy
secondary to an optic pit. The perimeter of the retinal detachment is delimitated on the SLO image
(SLO) image (2B), and WF-OCT (2C) of a 10-year-old girl with a large macular detachment secondary
(2B). In one scan, we can appreciate the entire macular detachment, the depth of the pit, and the
to an optic strand
vitreous pit. The in perimeter of the
the pit (2C)—a retinal detachment
9-year-old girl affected byis tuberous
delimitated on the
sclerosis SLO image
presented with a(2B). In
onechoroidal
scan, welesion.
can appreciate
The WF colorthefundus
entireimage
macular
(3A)detachment,
shows irregular theelevations
depth ofatthe thepit, and the
posterior vitreous
pole.
The in
strand WF-OCT
the pit(3B,3C)
(2C)—a showed a minimal
9-year-old extrafoveal
girl affected byserous detachment
tuberous sclerosis of presented
the superiorwithmacula, a
a choroidal
thickened choroid (white line), and new lesions with irregular shape under the choroid (white
lesion. The WF color fundus image (3A) shows irregular elevations at the posterior pole. The WF-
dotted line). A diagnosis of subchoroidal granuloma compatible with neurofibromatosis was made.
OCT A (3B,3C)
4-year-oldshowed
boy wasa minimal
diagnosedextrafoveal serous detachment
with retinopathy of prematurity of the superior
(ROP), macula,
showing a thickened
a bilateral
choroid
macular(white line), an
irregular, and new lesions
atrophic with
area with irregular
multiple shape under
pigmented dots inthe
thechoroid (white
fundus color dotted
image (4A,line). A
right and
diagnosis ofleft eye). The WF-OCT
subchoroidal of thecompatible
granuloma right (4B) and the left
with eye (4C) confirmed
neurofibromatosis themade.
was atrophyAof all
4-year-old
boythewasmacular layerswith
diagnosed withretinopathy
the normal choroid.
of prematurity (ROP), showing a bilateral macular irregular, an
atrophic area with multiple pigmented dots in the fundus color image (4A, right and left eye). The
3.7.4. Postoperative Follow-Up
WF-OCT of the right (4B) and the left eye (4C) confirmed the atrophy of all the macular layers with
During the first week after vitreoretinal surgery, ninety eyes were examined as part
the normal choroid.
of a follow-up examination. A tamponade (air, gas, or silicone oil) was used to replace the
removed vitreous. The OCT-S1 image was obtained, allowing the assessment of the
fundus that had not been covered by air/gas.
Residual subretinal fluid and the location of small breaks could be detected in cases
of persistent or recurrent detachment. WF-retinography could inspect the fundus of the
same eyes, but slit lamp biomicroscopy and standard OCT could only inspect it partially.
Diagnostics 2022, 12, 2247 12 of 17

3.7.4. Postoperative Follow-Up

During the first week after vitreoretinal surgery, ninety eyes were examined as part of
a follow-up examination. A tamponade (air, gas, or silicone oil) was used to replace the
removed vitreous. The OCT-S1 image was obtained, allowing the assessment of the fundus
that had not been covered by air/gas.
Residual subretinal fluid and the location of small breaks could be detected in cases of
persistent or recurrent detachment. WF-retinography could inspect the fundus of the same
eyes, but slit lamp biomicroscopy and standard OCT could only inspect it partially.

3.8. Role of WF and UWF OCTA

WF-OCTA was performed in 595 eyes (40%), and UWF-OCTA was deployed to analyze
a subgroup of only 41 eyes (3%) (Figure 8).
WF-OCTA could detect ischemic areas and new vessels in eyes with vein or artery
Diagnostics 2022, 12, x FOR PEER REVIEW 13 of 19
occlusions. When the B-scan was combined with WF-OCTA, neovascularization (NV) as
preretinal vessels and intraretinal shunts as intraretinal vessels were easily distinguished.

Figure 8.8. Ultra-wide-field

Figure Ultra-wide-field (UWF)
(UWF) color
color fundus
fundus retinography
retinography(A,C,E),
(A,C,E),wide-field
wide-fieldoptical
opticalcoherence
coherence
tomography angiography (WF-OCTA) (B,F), and UWF-OCTA created with the mosaic software (D).
tomography angiography (WF-OCTA) (B,F), and UWF-OCTA created with the mosaic software (D).
(A,C) show two cases of central retinal vein occlusion (CRVO). The WF-OCTA images (B,D)
(A,C) show
revealed two casesretinal
peripheral of central retinalwith
ischemia veinaocclusion (CRVO). The WF-OCTA
nasal neovascularization images
bud in (B) (B,D) revealed
(arrowheads) and
peripheral
without neovascularization in (D). (E) shows an eye with diabetic retinopathywithout
retinal ischemia with a nasal neovascularization bud in (B) (arrowheads) and neo-
and the
vascularization
corresponding inWF-OCTA
(D). (E) shows
(F) an eye with diabetic
manifested retinopathy
mild peripheral and the corresponding
ischemia WF-OCTA
and neovascularization
elsewhere
(F) manifested(NVE) (arrowheads).
mild peripheral ischemia and neovascularization elsewhere (NVE) (arrowheads).

4.
4. Discussion
Discussion
In
In this
this study,
study, wewe report
report the
the advantages
advantages ofof WF-
WF- and
and UWF-OCT
UWF-OCTand andWF-
WF-and
andUWF
UWF
OCTA
OCTAin in managing
managing different
different vitreoretinal diseases using
vitreoretinal diseases usingthe
thenew
newWFWFSS-OCT
SS-OCTXephilio
XephilioS1S1
as
aswell
wellas as
the the
“effectiveness” of WF-
“effectiveness” of and
WF-UWF-OCT and OCTA
and UWF-OCT in diagnosing
and vitreoretinal
OCTA in diagnosing
diseases whose
vitreoretinal diagnosis
diseases whose could not be could
diagnosis achieved
not with any other
be achieved clinical
with or instrumental
any other clinical or
examination
instrumental examination in a real-life setting. The results were analyzedofper
in a real-life setting. The results were analyzed per type lesions
type and
of
conditions encountered.
lesions and conditions encountered.

4.1. Vitreous Pathologies

Despite being easily detected with slit lamp biomicroscopy, vitreous floaters
evaluation through color retinography is still challenging.
In our study, the combination of color SLO, WF, and deep field (DF) OCT proved to
Diagnostics 2022, 12, 2247 13 of 17

4.1. Vitreous Pathologies

Despite being easily detected with slit lamp biomicroscopy, vitreous floaters evaluation
through color retinography is still challenging.
In our study, the combination of color SLO, WF, and deep field (DF) OCT proved to be
a useful diagnostic tool for vitreous floaters, as reported by previous studies [16,17].
Indeed, floaters were clearly detected as hyper-reflective spots with non-homogenous
patterns on OCT and dark shadows on the WF-SLO image, regardless of the symptoms.
WF-OCT detected the physiologic PVD and its features, such as the detachment extension
and the location of residual vitreoretinal adhesions. Despite being easily diagnosed with
ocular ultrasounds (US), the WF-OCT may quickly help detect the PVD in less time than the
US. In addition, the ocular US requires more cooperative patients and skilled technicians
as it may be challenging to differentiate a retinal from a vitreous detachment, depending
on the angle of visualization [18]. However, further comparative studies are required.
Notably, PVD was present in only 66% of patients with symptomatic floaters. Therefore,
PVD diagnosis can be routinely overrated with standard fundus examination.
WF-OCT detected several vitreous opacities. Despite fairly different OCT patterns
(AH cellularity was bigger than inflammatory and red blood cells), no definitive diagnosis
could have been provided to differentiate the findings across the images. Indeed, the
vitreous opacities appeared as hyperreflective aggregated dots in all images. Therefore, the
fundus examination or retinography is still necessary to distinguish the nature of cellularity.

4.2. Peripheral Retinal Lesions and Retinal Detachment

Only a subgroup of 311 eyes was analyzed with UWF-OCT due to patients’ cooperation
and the length of the examination. Indeed, while a central radial 23 mm takes less than 10 s,
a UWF-OCT with a complete raster scan of 8 peripheral areas takes 10 min. In this subgroup,
the occurrence of significant peripheral lesions not visible with slit lamp biomicroscopy
(with and without contact lenses) nor with WF or UWF retinography was detected in
39% of eyes. Indeed, in a case series of 125 eyes, Sodhi et al. found that eighty-six out
of 125 eyes (69%) had peripheral retinal lesions. Therefore, the UWF-OCT can provide
further information on the area that cannot be visualized by standard OCT devices with a
50-degree field of view, thus providing a holistic clinical picture, which can potentially aid
in understanding the various retinal pathologies [19].
Furthermore, one case of shallow retinal detachment was detected. Regarding the
rhegmatogenous retinal detachment, WF and UWF-OCT showed the detachment’s location
and extension, the retinal breaks’ location, and the presence of preretinal membranes. In
addition, peripheral retinal imaging helped in discriminating limited areas of retinoschisis
in a high number of eyes, in the differential diagnosis between retinal detachment and
retinoschisis, and further assessing the location of inner or outer breaks in the retinoschisis.
All features observed are consistent with previous reports, including relative thinning of all
nuclear layers and the attenuation of choroidal vessels [14].

4.3. High Myopia

Although high-resolution three-dimensional magnetic resonance imaging (3D-MRI)
could be an excellent research tool for deepening our understanding of myopia, it is not prac-
tical for routine clinical care due to its high cost and limited availability. The recently intro-
duced WF and UW technology greatly visualize high myopic eyes (axial length ≥ 26.5 mm),
whose irregular eyewall and staphyloma profile are often difficult to visualize in one exam
alone. Indeed, the new OCT device allowed the 3D-maps reconstruction of posterior
staphylomas by using multiple scan lines. A recent study by Shinohara et al. involving
100 highly myopic eyes with a mean axial length of 30.2 ± 2.1 mm showed that the UWF
SS-OCT provided results according to those found with 3D MRI in detecting posterior
staphylomas. In addition, they detected a spatial relation between myopic retinoschisis
and staphylomas [14,20].
Diagnostics 2022, 12, 2247 14 of 17

According to the previous reports, the wide-field technology helps provide peripheral
retinal lesions details even in “only-macular” diseases such as MTM, thus aiding a holistic
picture of the myopic eye. However, despite the great results, further studies are required
to deeply analyze the role of peripheral retinal visualization in managing MTM [21].

4.4. Choroidal Lesions

The DF images offered an excellent visualization of the choroid. WF-OCT allowed
assessment of the size, shape, and extension of choroidal lesions and macula and the
intraretinal or subretinal fluid effect on choroid and choriocapillaris [13].
In our study, the WF-OCTA showed the presence or absence of tumor vasculariza-
tion, although we could not find specific patterns of vascularization nor differentiate one
choroidal lesion from others.
Although the US and clinical ophthalmoscopy still represents the gold standard in
detecting ocular tumors [22], wide-field OCTA is increasingly playing an important role in
visualizing choroidal vasculature, especially in situations in which serial imaging could
be beneficial in follow-up and management of the disease. Moreover, offering WF color
fundus retinography, WF autofluorescence in one consultation alone, WF-OCT, and OCTA
may represent an adjunctive tool in ocular tumor management [23].

4.5. Optic Nerve Lesions

Alongside macular structure, the DF images of the optic nerve allowed us to visualize
optic nerve anomalies and secondary retinal detachments. The role of WF and UWF
imaging in managing optic nerve lesions is controversial. Despite the SS-OCT providing
plenty of information, wide-field retinal imaging could help detect retinal nerve fiber layer
(RNFL) changes in patients with glaucoma. Indeed, Lee et al. first evaluated the diagnostic
ability of wide-field NRFL maps with SS-OCT to detect preperimetric and early perimetric
glaucoma. In their study involving one hundred eighty-four eyes, the wide-field RNFL
thickness map showed a high sensitivity in preperimetric glaucoma and early-perimetric
diagnosis [24]. Nonetheless, further studies are required to investigate the role of WF and
WF-OCT in optic nerve diseases.

4.6. Difficult Situations

The imaging acquisition of pediatric, high myopic, non-cooperative patients or pa-
tients’ eyes who recently underwent vitreoretinal surgery is often challenging. Indeed, the
long acquisition time and the pupillary dynamic status may prevent a reliable diagnosis.
The new WF- and UWF technology, whose scan time is less than a minute and requires a
minimum of 2.5 mm pupil size, may overcome these limitations.
In our case series, the WF and UWF had a significant role in pediatric cases. To be
specific, this technology played a crucial role in an 11-year-old boy case with a 3-day
history of contusive trauma, which had caused vitreous and preretinal hemorrhage and an
atraumatic macular hole. Despite the VH preventing a reliable ophthalmoscopy diagnosis,
the high-quality WF-OCT images clearly showed a macular hole alongside the VH.
Furthermore, the WF- and UWF technology helped assess an 8-year-old boy with
Peter’s anomaly who had previously undergone perforating keratoplasty and vitreous
surgery for retinal detachment. Despite the severe corneal opacity, the WF-OCT could be
obtained, confirming that the retina was completely attached.
According to Kothari et al., widespread WF- and UWF- technology may be crucial,
especially in pediatric diseases that cause irreversible blindness, such as retinopathy of
prematurity and Coat’s disease. Indeed, it overcomes several limitations of other imaging
methods, such as sedation and intravenous dye injection [25]. Moreover, as previously
demonstrated by Athikarisamy et al., performing quality wide-field imaging may also help
in an off-site telehealth diagnosis of all patients with referral-warranting pediatric retinal
diseases [26].
Diagnostics 2022, 12, 2247 15 of 17

Moreover, due to a faster scan and great depth of focus, the WF and UWF technology
may allow the detection of retinal images in eyes with nystagmus or in patients with
intellectual disabilities.
Regarding the early postoperative follow-up, ninety eyes were analyzed during the
first week after vitreoretinal surgery. Due to the considerable depth of focus, the UWF
system allowed the peripheral retina, intraocular gas bubble, and posterior pole to be
simultaneously in focus in gas-filled eyes, allowing us to inspect the fundus not covered by
air/gas and assess the residual subretinal fluid and the location of small breaks in recurrent
retinal detachments [26].

4.7. WF and UWF OCTA

Despite acquiring less than 40 patients, WF and UWF OCTA helped provide informa-
tion regarding the peripheral vascular pattern in specific diseases.
As previously described for choroidal lesions, this technology may implement the
standard clinical practice for widespread diseases such as diabetic retinopathy and vein
occlusions [27,28]. Hirano et al. found a higher sensitivity and specificity than fluorescein
angiography (FA) in detecting non-perfusion area (NPA) and neovascularization (NV) [27].
Accordingly, by combining the B-scan with the WF-OCTA in our series, we detected NPA
and distinguished the NV from intraretinal shunts.
Furthermore, a significant correlation between FA and WF-OCTA was found by
Shiraki in analyzing the branch retinal vein occlusions’ NPA. Indeed, the images showed a
significant association with vascular length by using a separate regression analysis of the
areas of retinal nonperfusion in FA and the total FA. In addition, the WF-OCTA may help
detect NV that could not be clinically evaluated, as previously demonstrated by Huemer
et al., that reported an additional 31% detection of NV [29].

5. Conclusions
In summary, the information acquired with WF, UWF OCT, and OCTA helped manage
298 eyes (20%), representing the only technology that allowed a reliable examination of
challenging cases such as miosis, severe media opacity, pediatric patients, and postoper-
ative follow-up. In our case series, the WF and DP images helped assess several lesions
that could not be investigated by enrolling in any different technology, further proving
underrated features of the retina and choroid. Moreover, without involving long lasting
and painful image acquisition protocols, this imaging technology enables faster manage-
ment and increases patient compliance, providing reliable diagnoses that do not require
further investigations.
Despite the advantages, several limitations have been found across the analysis. First,
the processing time for acquiring and analyzing raster scans is still longer. Second, the
mean acquisition time for cooperative patients with good visual function can be lengthened
depending on the visual disturbances and the fixation capacity, which allowed us to
perform UWF-OCT and OCTA in a selected number of patients. Third, the motion artifacts,
more common at the periphery of the retina and in non-compliant patients, can lead to
misalignment and undocumented areas in the B-scans, 3D reconstructions, and OCTA
mosaics. Fourth, due to a high time in acquisition and mosaic creation in OCTA, we advise
performing this exam only in eyes with vascular diseases. Fourth, the OCTA imaging
detection could be problematic in high myopic eyes because of an unreliable segmentation.
Fifth, the costs and the limited availability of the WF and UWF technologies restrict their
use in clinical practice. Sixth, while all patients underwent widefield OCT, much smaller
percentages underwent imaging with the other techniques. Finally, we did not compare our
findings with those obtained with other retinal imaging modalities such as the Optos UWF
apparatus (Optos Daytona, Optos PLC, Dunfermline, UK). Despite these limitations, WF
and UWF OCT and OCTA imaging helped manage a significant number of cases, becoming
an indispensable tool for the high-quality management of patients.
Diagnostics 2022, 12, 2247 16 of 17

Author Contributions: Conceptualization, B.P. and T.F.; methodology, T.F.; software, T.F. and M.R.;
validation, B.P., L.M. and M.R.; formal analysis, M.R.; investigation, T.F.; resources, T.F., V.M., L.M.,
B.P. and J.-Y.S.; data curation, V.M.; writing—original draft preparation, T.F. and M.R.; writing—
review and editing, M.R. and B.P.; visualization, M.R.; supervision, B.P.; project administration, B.P.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Conflicts of Interest: The authors declare no conflict of interest.

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