PACS Brings Retinal Imaging Into the 21st Century

Picture archiving and communications systems have helped streamline and improve patient care.

PACS Brings Retinal Imaging Into the 21st Century

Picture archiving and communications systems have helped streamline and improve patient care.


James Dunlap, an informational systems application support specialist with Retina Consultants in Charlestown, WV, spent eight years capturing retinal images before he began using information technology. He had thought at the time, “Health-care IT is going to explode.”

It was an explosion of which he was glad to be a part. He’d started out his photography career shooting, among other things, sporting events, before moving to retinal work because of its “detail-oriented and scientific nature.” He says, “The images you take matter for health care, instead of merely aesthetics,” he says.

When Retina Consultants, which has six offices, five physicians, and six photographers, moved to OIS (now Merge Healthcare) for image management eight years ago, Mr. Dunlap found that “we were on the bleeding edge.” PACS — for picture archiving and communication system — “is the Cadillac approach to image management; there’s no way we could live without it,” he says.


Comments from retinal physicians about PACS, also known as IMS, or image management system, bear him out.

PACS, which stores, retrieves, manipulates and displays digital diagnostic image capture, gets high marks — rave reviews, really — in such essential areas as speed and accessibility, patient satisfaction, image use at multiple locations, visualization of postoperative changes, tracking of disease progression and treatment response, decision-making, and patient education.

PACS originated in the 1980s. First used in radiology and then in cardiology, ophthalmologists began to utilize PACS during the last decade as a tool to categorize and search a growing number of clinical images from fundus cameras, OCTs, corneal topographers, slit lamps, and other diagnostic devices. PACS has been also especially valuable in the battle against diabetic retinopathy.

These systems have also proved advantageous in treating retinal vascular disease, intraocular tumors, macular holes, epiretinal membranes, vitreomacular traction, and vein occlusion, and as well as in assessing the growth of and assisting in the follow-up of tumors.


In terms of costs — some systems run as high as six figures — retina specialists agree that the investment is well worth the price on two levels. In terms of actual cost savings, leaving 20th century record keeping with paper behind saves large amounts of money (one practice reported its cost cutting on paper and printer ink to run as high as $100,000 annually).

Far more essential, however, is the clear benefit when it comes to patient care, both in terms of actual treatment and in the comfort level of patients who come in with serious or potentially serious conditions. These patients greatly appreciate the nurturing effect of seeing clear images detailing their conditions and hearing from their doctors the details about their treatment, which can be offered with greater clarity thanks to their physicians being freed from paper record keeping.

PACS, says Peter Sonkin, MD, of Tennessee Retina, PC, in Nashville, TN, “has provided the greatest benefit for our patients with diseases such as AMD, diabetic retinopathy, retinal vascular disease, and intraocular tumors, where monitoring and comparison of disease progression or treatment response is critical for decision-making and patient education in the office. It is also helpful for visualization of surgical success for conditions such as macular hole, epiretinal membrane, and vitreomacular traction.

“It allows easy visualization of postoperative changes for both the surgeon and the patients and makes it very simple to show side-by-side images from two time points, even if obtained from different image-capture stations,” he says.


Figure 1. A series of images from fluorescein angiography can be compared side-by-side in a PACS format.



Dr. Sonkin was quickly impressed when his practice implemented the Carl Zeiss Meditec Forum IMS in the main Nashville office and in a single satellite about two years ago. “The limited installation was done to test the functionality of the system, even with only cable modem connectivity speed,” he says. “It worked great. Images obtained at either location (approximately 30 miles apart) were viewable at both offices within 30 to 60 seconds. A single database of all images was created, including OCT, fundus photographs, fluorescein angiography, and ocular ultrasound from instruments made by four different manufacturers.”

Since then, Tennessee Retina has connected its main office and six additional satellite offices, including many different capture units, and has incorporated fiber optics with bandwidth up to 100 mbps.

Dr. Sonkin and others note that the high up-front costs of PACS are mitigated some by the large sums saved by not using paper and ink. “PACS pay for themselves and, in our experience, save money long-term,” says Dr. Sonkin. “Compared to paper charts and printed images, the savings are immediately apparent. In a large practice with eight or more doctors using paper charts and printing images, the cost for paper and printer ink can easily exceed $100,000 in a single year.”


PACS are also said to pay for themselves in ways not measurable on a balance sheet. As Scott Smith, lead photographer for Retina Consultants in West Virginia, notes, the “soft cost” a centralized system saves, as a doctor can “walk into a room and communicate with a patient,” in ways not possible without PACS. “The first thing that hits you is the cost,” Mr. Smith says. His practice paid more than $100,000 for its system. “There is an emotional impact.”

Those who have benefited from PACS in retinal practices, though, don’t let that impact sway them from heartily touting them. Vitreoretinal surgeon Christopher Andreoli, MD, of Atrius Health in the Boston area, says a PACS was “sorely needed” for his practices, which have 20-plus doctors at 15 sites. “It’s a necessity, not a luxury” Dr. Andreoli stresses.

PACS, he says, “saves you in terms of storage” and “eliminates the risk of lost records,” a potential problem when using paper records, especially at multiple sites. Patients “really enjoy the system, as in our setup, we have two monitors in each exam room and we show the patients their images. It’s instructive,” he says.

For staff, the benefit is straightforward: It involves in some cases “fewer clicks than we used with paper,” Dr. Andreoli notes. Paper records, meanwhile, can also fade or become blurry, he adds.


Another clear plus with PACS, Dr. Sonkin notes, is improved flow for staff and patients alike. “Image management systems inherent to EHR are limited in their ability to manipulate images and utilize the review software that is very important for calculations and time comparison, particularly with high-definition OCTs,” he says.

The Zeiss Forum system allows his practice to utilize Cirrus OCT review capabilities and manipulate the fundus photographs and angiograms sufficiently. “This, combined with the single-image database created with Forum, creates improved workflow for our staff and improved patient flow, resulting in overall improved office efficiency and productivity,” Dr. Sonkin says. “A patient can be scanned on any of our many OCT units with no regard to which machine was used in the past. The new images are immediately ‘merged’ with all older images, regardless of the capture station or even the office location.”

For doctors and patients alike, Dr. Sonkin sees other benefits. “PACS allows for greater image security, easier backup, easier storage, easier access for the doctor and patient, and easier sharing with referral sources,” he says. “It can also allow for easier telemedicine and disease screening. PACS improves quality of care, efficiency in clinic, staff workflow, patient flow, and patient education. It eliminates image transfer issues between locations.”

Pravin Dugel, MD, managing partner for Retinal Consultants of Arizona, in Phoenix, says that his 24-office practice adopted PACS (along with EHR) about 10 years ago, when systems were first being developed for eye care.


Figure 2. iPad and tablet functions make PACS solutions easy to mobilize and access in the clinic.


In those days, Dr. Dugel says, “The learning curve was very steep, and it wasn’t as user-friendly as it is now. The learning curve isn’t as steep now.” Now, most of Retinal Consultants of Arizona’s offices have PACS.


Dr. Dugel is among the chorus of physicians unmoved by the price of PACS, in ways tangible and otherwise. Besides saving on the cost of printing and paper, he says, what PACS does for the quality of patient care makes it truly worthwhile.

PACS, he adds, has helped him and his colleagues share vital information about unusual cases, as physicians with various levels of expertise can share images. The use of EMR in general, and PACS in particular, has allowed for more “eye-to-eye” conversations and the functionality to pull up and share centralized images.

Improved patient care, Dr. Dugel stresses, is “more important than things that are tangible.” Thanks to these technologies, he says, a doctor has greater ease when it comes to providing his or her “undivided attention.”

“No matter how busy I am,” he says, “I look the patient in the eye and ask if there are any questions.” Many of those questions, for his practice, center on the treatment of diabetic retinopathy, because his area has a large diabetic population.

PACS, then, helps refine treatment plans because it can track changes in retinal disease. “We don’t want [patients] coming in and saying, ‘I lost my vision three days ago,’ ” Dr. Dugel says. PACS is also essential, he adds, for evaluating vascular leakage before vision loss.


A user-friendly system has a “clear advantage,” Dr. Dugel says, especially when managing wet AMD, diabetic retinopathy, and RVO. PACS is also vital for managing tumors. Although Dr. Dugel does not treat tumors, he does note that PACS is helpful in follow-up and in assessing growth.

Looking to the future, Dr. Dugel sees PACS hopefully playing a role in the treatment of dry AMD. “That,” he says, “could be the next imaging breakthrough.”

Dr. Sonkin expects PACS to continue to evolve and incorporate a number of sought-after changes. “The greatest challenge is creating streamlined communication between multiple image modalities and instrument manufacturers, DICOM connectivity, and network, and IT challenges,” Dr. Sonkin says. “It also requires strong support from the PACS vendor and good IT support. The future challenge is to improve universal image review software functionality for all manufacturers within the PACS.

“PACS are most valuable for larger practices with multiple locations, multiple doctors, and multiple image capture machines with various modalities,” Dr. Sonkin adds. “Having a single database creates a virtual ‘single office’ for the images, with all the inherent benefits of all images being viewable from anywhere at any time.”


Keys to success with PACS, Dr. Sonkin adds, are “a really strong IT systems and you need good support,” regardless of the manufacturer.

Add to that list an Internet connection capable of trafficking that data. “Image management systems usually create more bandwidth demand than EHR and practice management software, so it is critical to assess bandwidth and connectivity needs, as well as hardware requirements, on the front end,” Dr. Sonkin says. “We implemented both at the same time.”

Paul Sternberg, Jr., MD, is a retina specialist at the Vanderbilt Eye Institute in Nashville, which moved to PACS for its 30-clinician practice, with 140,000 outpatients a year, in 2008.

PACS, Dr. Sternberg says, is a “big win for patients,” especially for those with ocular tumors, because an easy-to-retrieve image library is important when it comes to showing if a tumor’s size has been reduced and if leakage has decreased.

He adds, PACS is also helpful when it comes to injections and the treatment of macular degeneration. PACS “allows easy access for our physicians in the examining room” and makes “decision-making about surgery simpler,” he says. “It is a necessary tool for our practice. You can’t run a large practice without a PACS system. It is hard-wired into our practice. There is no option.”

Mr. Dunlap in West Virginia echoes that assessment. “You are able to illustrate to a patient and visually document something that is hard to describe in a matter of seconds,” Mr. Dunlap says. “It is a lightning rod for a physician.

“For both diagnosis and procedures,” he concludes, “it is irreplaceable.” RP