In the index, prospective, observational study of patients with non-infectious vasculitis, the first, to our knowledge, to evaluate systematically and prospectively the role of ultra-wide-field imaging in retinal vasculitis, our results suggest that ultra-wide-field imaging may alter management decisions compared to standard-of-care imaging and clinical examination. Such differences are likely due to the ability to image the peripheral retinal and angiographic findings that are not easily visualized or identified without ultra-wide-field imaging. Both the determination of disease ‘activity’ and disease management differed significantly with the use of ultra-wide-field imaging compared with standard imaging. Management decisions were significantly altered, suggesting that qualitative and quantitative differences in the degree of disease activity seen on ultra-wide-field imaging may play an important role.
Our study was designed to investigate the potentials of wide-angle imaging in making management decisions in patients with non-infectious vasculitis, but not to determine the specific changes in patient management. Therefore, we did not obtain data on the management decisions that were made. Future investigations are needed to evaluate the degree of alteration (i.e., changing the dose of prednisone, addition of immunomodulatory therapy) associated with the additional information provided by the wide-angle imaging system and whether such alterations have led to additional benefits to the patients.
There are limitations to our study. The examining clinicians were not masked to 60°, as would have been ideal. Given the demands of clinical care and for practical and ethical reasons, we were unable to perform both the standard FA and the ultra-wide-field FA at the same visit. Thus, to determine disease activity and management based on examination and ‘conventional’ (30° or 60°) FA, investigators were asked to limit their assessment to the central 30° or 60° (based on preference) of the ultra-wide-field images (simulated conventional FA). Simulated peripheral sweeps were permitted if the investigator indicated that based on their clinical examination, peripheral sweeps were needed. The clinicians had to restrict themselves to the central image to evaluate the patient before considering the entire image. We attempted to limit bias by prospectively evaluating the ultra-wide-field imaging and acquiring the activity and management data based on the clinical examination prior to sending the patient for imaging, though the possibility of investigators biasing their responses to the standard FA question cannot be excluded with our study design.
In addition, it is also possible that there is selection bias in this study population towards the investigators selecting patients who may be more likely to have peripheral retinal findings that would change management, and not be representative of all patients with retinal vasculitis. Future studies may choose to enroll all patients with posterior uveitis consecutively to eliminate this potential bias.
In addition, ‘retinal vasculitis’ is a difficult entity to define. The Standardization of Uveitis Nomenclature Working Group
 was unable to agree on a definition of vasculitis. We defined vasculitis as a retinal vascular occlusion, with leakage on fluorescein, overlying vitritis, vascular sheathing, and retinal hemorrhages in the context of ophthalmic inflammation. The definition of retinal vasculitis remains an area of debate, and different clinicians may define vasculitis using different criteria.
The index study was not designed to determine the utility of FA (standard or ultra-wide-field) in patients who do not appear to have active disease, though we did note a number of patients who demonstrated evidence of disease activity on peripheral angiography and who clinically appeared to have quiescent disease. The clinical significance of this ‘additionally noted’ disease activity is unknown since ultra-wide-field imaging modality has not previously been used in clinical practice or clinical trials.