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Salongcay RP, Jacoba CMP, Salva CMG, Rageh A, Aquino LAC, Saunar AV, Alog GP, Ashraf M, Peto T, Silva PS. One-field, two-field and five-field handheld retinal imaging compared with standard seven-field Early Treatment Diabetic Retinopathy Study photography for diabetic retinopathy screening. Br J Ophthalmol 2024; 108:735-741. [PMID: 37094836 PMCID: PMC11137459 DOI: 10.1136/bjo-2022-321849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/28/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND/AIMS To determine agreement of one-field (1F, macula-centred), two-field (2F, disc-macula) and five-field (5F, macula, disc, superior, inferior and nasal) mydriatic handheld retinal imaging protocols for the assessment of diabetic retinopathy (DR) as compared with standard seven-field Early Treatment Diabetic Retinopathy Study (ETDRS) photography. METHODS Prospective, comparative instrument validation study. Mydriatic retinal images were taken using three handheld retinal cameras: Aurora (AU; 50° field of view (FOV), 5F), Smartscope (SS; 40° FOV, 5F), and RetinaVue (RV; 60° FOV, 2F) followed by ETDRS photography. Images were evaluated at a centralised reading centre using the international DR classification. Each field protocol (1F, 2F and 5F) was graded independently by masked graders. Weighted kappa (Kw) statistics assessed agreement for DR. Sensitivity (SN) and specificity (SP) for referable diabetic retinopathy (refDR; moderate non-proliferative diabetic retinopathy (NPDR) or worse, or ungradable images) were calculated. RESULTS Images from 225 eyes of 116 patients with diabetes were evaluated. Severity by ETDRS photography: no DR, 33.3%; mild NPDR, 20.4%; moderate, 14.2%; severe, 11.6%; proliferative, 20.4%. Ungradable rate for DR: ETDRS, 0%; AU: 1F 2.23%, 2F 1.79%, 5F 0%; SS: 1F 7.6%, 2F 4.0%, 5F 3.6%; RV: 1F 6.7%, 2F 5.8%. Agreement rates of DR grading between handheld retinal imaging and ETDRS photography were (Kw, SN/SP refDR) AU: 1F 0.54, 0.72/0.92; 2F 0.59, 0.74/0.92; 5F 0.75, 0.86/0.97; SS: 1F 0.51, 0.72/0.92; 2F 0.60, 0.75/0.92; 5F 0.73, 0.88/0.92; RV: 1F 0.77, 0.91/0.95; 2F 0.75, 0.87/0.95. CONCLUSION When using handheld devices, the addition of peripheral fields decreased the ungradable rate and increased SN and SP for refDR. These data suggest the benefit of additional peripheral fields in DR screening programmes that use handheld retinal imaging.
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Affiliation(s)
- Recivall P Salongcay
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Cris Martin P Jacoba
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Claude Michael G Salva
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
| | - Abdulrahman Rageh
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
| | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Mohamed Ashraf
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Paolo S Silva
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Joseph S, Selvaraj J, Mani I, Kumaragurupari T, Shang X, Mudgil P, Ravilla T, He M. Diagnostic Accuracy of Artificial Intelligence-Based Automated Diabetic Retinopathy Screening in Real-World Settings: A Systematic Review and Meta-Analysis. Am J Ophthalmol 2024; 263:214-230. [PMID: 38438095 DOI: 10.1016/j.ajo.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 02/03/2024] [Accepted: 02/12/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE To evaluate the diagnostic accuracy of artificial intelligence (AI)-based automated diabetic retinopathy (DR) screening in real-world settings. DESIGN Systematic review and meta-analysis METHODS: We conducted a systematic review of relevant literature from January 2012 to August 2022 using databases including PubMed, Scopus and Web of Science. The quality of studies was evaluated using Quality Assessment for Diagnostic Accuracy Studies 2 (QUADAS-2) checklist. We calculated pooled accuracy, sensitivity, specificity, and diagnostic odds ratio (DOR) as summary measures. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO - CRD42022367034). RESULTS We included 34 studies which utilized AI algorithms for diagnosing DR based on real-world fundus images. Quality assessment of these studies indicated a low risk of bias and low applicability concern. Among gradable images, the overall pooled accuracy, sensitivity, specificity, and DOR were 81%, 94% (95% CI: 92.0-96.0), 89% (95% CI: 85.0-92.0) and 128 (95% CI: 80-204) respectively. Sub-group analysis showed that, when acceptable quality imaging could be obtained, non-mydriatic fundus images had a better DOR of 143 (95% CI: 82-251) and studies using 2 field images had a better DOR of 161 (95% CI 74-347). Our meta-regression analysis revealed a statistically significant association between DOR and variables such as the income status, and the type of fundus camera. CONCLUSION Our findings indicate that AI algorithms have acceptable performance in screening for DR using fundus images compared to human graders. Implementing a fundus camera with AI-based software has the potential to assist ophthalmologists in reducing their workload and improving the accuracy of DR diagnosis.
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Affiliation(s)
- Sanil Joseph
- From the Centre for Eye Research Australia (S.J, X.S, M.H), Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Department of Surgery (Ophthalmology) (S.J, X.S, M.H), The University of Melbourne, Melbourne, Australia; Lions Aravind Institute of Community Ophthalmology (S.J, J.S, T.R), Aravind Eye Care System. Madurai, India.
| | - Jerrome Selvaraj
- Lions Aravind Institute of Community Ophthalmology (S.J, J.S, T.R), Aravind Eye Care System. Madurai, India
| | - Iswarya Mani
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology (I.M, T.K), Madurai, India
| | | | - Xianwen Shang
- From the Centre for Eye Research Australia (S.J, X.S, M.H), Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Department of Surgery (Ophthalmology) (S.J, X.S, M.H), The University of Melbourne, Melbourne, Australia
| | - Poonam Mudgil
- School of Medicine (P.M), Western Sydney University, Campbell town, Australia; School of Rural Medicine (P.M), Charles Sturt University, Orange, NSW, Australia
| | - Thulasiraj Ravilla
- Lions Aravind Institute of Community Ophthalmology (S.J, J.S, T.R), Aravind Eye Care System. Madurai, India
| | - Mingguang He
- From the Centre for Eye Research Australia (S.J, X.S, M.H), Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Department of Surgery (Ophthalmology) (S.J, X.S, M.H), The University of Melbourne, Melbourne, Australia
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Brennan IG, Kelly SR, McBride E, Garrahy D, Acheson R, Harmon J, McMahon S, Keegan DJ, Kavanagh H, O’Toole L. Addressing Technical Failures in a Diabetic Retinopathy Screening Program. Clin Ophthalmol 2024; 18:431-440. [PMID: 38356695 PMCID: PMC10864767 DOI: 10.2147/opth.s442414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/18/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose Diabetic retinopathy (DR) is a preventable cause of blindness detectable through screening using retinal digital photography. The Irish National Diabetic Retina Screening (DRS) programme, Diabetic RetinaScreen, provides free screening services to patients with diabetes from aged 12 years and older. A technical failure (TF) occurs when digital retinal imaging is ungradable, resulting in delays in the diagnosis and treatment of sight-threatening disease. Despite their impact, the causes of TFs, and indeed the utility of interventions to prevent them, have not been extensively examined. Aim Primary analysis aimed to identify factors associated with TF. Secondary analysis examined a subset of cases, assessing patient data from five time points between 2019 and 2021 to identify photographer/patient factors associated with TF. Methods Patient data from the DRS database for one provider were extracted for analysis between 2018 and 2022. Information on patient demographics, screening results, and other factors previously associated with TF were analyzed. Primary analysis involved using mixed-effects logistic regression models with nested patient-eye random effects. Secondary analysis reviewed a subset of cases in detail, checking for causes of TF. Results The primary analysis included a total of 366,528 appointments from 104,407 patients over 5 years. Most patients had Type 2 diabetes (89.2%), and the overall TF rate was 4.9%. Diabetes type and duration, dilate pupil status, and the presence of lens artefacts on the camera were significantly associated with TF. The Secondary analysis identified the primary cause of TF was found to be optically dense cataracts, accounting for over half of the TFs. Conclusion This study provides insight into the causes of TF within the Irish DRS program, highlighting cataracts as the primary contributing factor. The identification of patient-level factors associated with TF facilitates appropriate interventions that can be put in place to improve patient outcomes and minimize delays in treatment and diagnosis.
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Affiliation(s)
- Ian Gerard Brennan
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Stephen R Kelly
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Edel McBride
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Darragh Garrahy
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Robert Acheson
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Joanne Harmon
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - Shane McMahon
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
| | - David J Keegan
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Helen Kavanagh
- Diabetic RetinaScreen, National Screening Service, Health Service Executive, Dublin, Ireland
| | - Louise O’Toole
- Diabetic Retinal Screening Service, NEC Care, Cork City, Co. Cork, Ireland
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Song A, Borkar DS. Advances in Teleophthalmology Screening for Diabetic Retinopathy. Int Ophthalmol Clin 2024; 64:97-113. [PMID: 38146884 DOI: 10.1097/iio.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
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Chen Q, Zhou M, Cao Y, Zheng X, Mao H, Lei C, Lin W, Jiang J, Chen Y, Song D, Xu X, Ye C, Liang Y. Quality assessment of non-mydriatic fundus photographs for glaucoma screening in primary healthcare centres: a real-world study. BMJ Open Ophthalmol 2023; 8:e001493. [PMID: 38092419 PMCID: PMC10729214 DOI: 10.1136/bmjophth-2023-001493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND This study assessed the quality distribution of non-mydriatic fundus photographs (NMFPs) in real-world glaucoma screening and analysed its influencing factors. METHODS This cross-sectional study was conducted in primary healthcare centres in the Yinzhou District, China, from 17 March to 3 December 2021. The quality distribution of bilateral NMFPs was assessed by the Digital Reading Department of the Eye Hospital of Wenzhou Medical University. Generalised estimating equations and logistic regression models identified factors affecting image quality. RESULTS A total of 17 232 photographs of 8616 subjects were assessed. Of these, 11.9% of images were reliable for the right eyes, while only 4.6% were reliable for the left eyes; 93.6% of images were readable in the right eyes, while 90.3% were readable in the left eyes. In adjusted models, older age was associated with decreased odds of image readability (adjusted OR (aOR)=1.07, 95% CI 1.06~1.08, p<0.001). A larger absolute value of spherical equivalent significantly decreased the odds of image readability (all p<0.001). Media opacity and worse visual acuity had a significantly lower likelihood of achieving readable NMFPs (aOR=1.52, 95% CI 1.31~1.75; aOR=1.70, 95% CI 1.42~2.02, respectively, all p<0.001). Astigmatism axes within 31°~60° and 121°~150° had lower odds of image readability (aOR=1.35, 95% CI 1.11~1.63, p<0.01) than astigmatism axes within 180°±30°. CONCLUSIONS The image readability of NMFPs in large-scale glaucoma screening for individuals 50 years and older is comparable with relevant studies, but image reliability is unsatisfactory. Addressing the associated factors may be vital when implementing ophthalmological telemedicine in underserviced areas. TRIAL REGISTRATION NUMBER ChiCTR2200059277.
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Affiliation(s)
- Qi Chen
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Department of Ophthalmology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Mengtian Zhou
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yang Cao
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xuanli Zheng
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Huiyan Mao
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Changrong Lei
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wanglong Lin
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Junhong Jiang
- Department of Ophthalmology, Shanghai General Hospital, National Clinical Research Center for Eye Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yize Chen
- Department of Ophthalmology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Di Song
- Department of Ophthalmology, The First People's Hospital of Huzhou, The First Affiliated Hospital of Huzhou Teacher College, Huzhou, China
| | - Xiang Xu
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Cong Ye
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yuanbo Liang
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Glaucoma Research Institute, Wenzhou Medical University, Wenzhou, China
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Prayogo ME, Zaharo AF, Damayanti NNR, Widyaputri F, Thobari JA, Susanti VY, Sasongko MB. Accuracy of Low-Cost, Smartphone-Based Retinal Photography for Diabetic Retinopathy Screening: A Systematic Review. Clin Ophthalmol 2023; 17:2459-2470. [PMID: 37614846 PMCID: PMC10443682 DOI: 10.2147/opth.s416422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/21/2023] [Indexed: 08/25/2023] Open
Abstract
Purpose Diabetic retinopathy (DR) is a leading cause of blindness. Early DR screening is essential, but the infrastructure can be less affordable in low resource countries. This study aims to review the accuracy of low-cost smartphone-based fundus cameras for DR screening in adult patients with diabetes. Methods We performed a systematic literature search to find studies that reported the sensitivity and specificity of low-cost smartphone-based devices for fundus photography in adult patients with diabetes. We searched three databases (MEDLINE, Google Scholar, Scopus) and one register (Cochrane CENTRAL). We presented the accuracy values by grouping the diagnosis into three: any DR, referrable DR, and diabetic macular oedema (DMO). Risk of bias and applicability of the studies were assessed using QUADAS-2. Results Five out of 294 retrieved records were included with a total of six smartphone-based devices reviewed. All of the reference diagnostic methods used in the included studies were either indirect ophthalmoscopy or slit-lamp examinations and all smartphone-based devices' imaging protocols used mydriatic drops. The reported sensitivity and specificity for any DR were 52-92.2% and 73.3-99%; for referral DR were 21-91.4% and 64.9-100%; and for DMO were 29.4-81% and 95-100%, respectively. Conclusion Sensitivity available low-cost smartphone-based devices for DR screening were acceptable and their specificity particularly for detecting referrable DR and DMO were considerably good. These findings support their potential utilization for DR screening in a low resources setting.
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Affiliation(s)
- Mohammad Eko Prayogo
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
- Department of Ophthalmology, Universitas Gadjah Mada Academic Hospital, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Alfia Fatma Zaharo
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Novandriati Nur Rizky Damayanti
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Felicia Widyaputri
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Jarir At Thobari
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Clinical Epidemiology and Biostatistics Unit (CE&BU), Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Vina Yanti Susanti
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Muhammad Bayu Sasongko
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada – Sardjito Eye Center, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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Mehra AA, Softing A, Guner MK, Hodge DO, Barkmeier AJ. Diabetic Retinopathy Telemedicine Outcomes With Artificial Intelligence-Based Image Analysis, Reflex Dilation, and Image Overread. Am J Ophthalmol 2022; 244:125-132. [PMID: 35970206 DOI: 10.1016/j.ajo.2022.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE To examine real-world telemedicine outcomes of diabetic retinopathy (DR) screening with artificial intelligence (AI)-based image analysis, reflex dilation, and secondary image overread in a primary care setting. DESIGN Validity and reliability analysis. METHODS Single institution review of 1052 consecutive adult patients who received diabetic retinopathy photoscreening in the primary care setting over an 18-month period. Nonmydriatic fundus photographs were acquired and analyzed by the IDx-DR AI-based system. When nonmydriatic images were ungradable, reflex dilation (1% tropicamide) and mydriatic photography were performed for repeat AI-based analysis. Manual overread was performed on all images. Patient demographics, clinical characteristics, and screening outcomes were recorded. RESULTS A total of 965 of 1052 patients (91.7%) had AI-gradable fundus photographs: 580 had gradable nonmydriatic imaging (55.1%) and 440 of 472 patients with ungradable nonmydriatic photographs had reflex dilation (93.2%). One hundred thirty-eight of 965 patients (14.3%) were AI-graded as "positive" (greater than mild NPDR) and 827 of 965 were "negative" (85.7%), with 100% sensitivity (95% CI 90.8-100%), 89.2% specificity (95% CI 87.0-91.1%), 27.5% positive predictive value (95% CI 24.0-31.4%), and 100% negative predictive value (95% CI 99.6-100%) compared with manual overread assessment of greater than mild NPDR requiring further evaluation with a comprehensive dilated examination. Image gradeability was inversely related to patient age: 93.5% gradable (61.9% nonmydriatic) for patients aged <70 years vs 85.3% (31.0% nonmydriatic) for patients aged 70+ years (P < .001). CONCLUSION Incorporation of AI-based image analysis into real-world primary care diabetic retinopathy screening yielded no false negative results and offered excellent image gradeability within a protocol combining nonmydriatic fundus photography and pharmacologic dilation, as needed. Image gradeability was lower with increasing patient age.
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Affiliation(s)
- Ankur A Mehra
- From Department of Ophthalmology, Mayo Clinic, Rochester, USA (A.A.M, A.S, M.K.G, A.J.B)
| | - Alaina Softing
- From Department of Ophthalmology, Mayo Clinic, Rochester, USA (A.A.M, A.S, M.K.G, A.J.B)
| | | | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, USA (D.O.H)
| | - Andrew J Barkmeier
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, USA (D.O.H).
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Salongcay RP, Aquino LAC, Salva CMG, Saunar AV, Alog GP, Sun JK, Peto T, Silva PS. Comparison of Handheld Retinal Imaging with ETDRS 7-Standard Field Photography for Diabetic Retinopathy and Diabetic Macular Edema. Ophthalmol Retina 2022; 6:548-556. [PMID: 35278726 DOI: 10.1016/j.oret.2022.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To compare nonmydriatic (NM) and mydriatic (MD) handheld retinal imaging with standard ETDRS 7-field color fundus photography (ETDRS photographs) for the assessment of diabetic retinopathy (DR) and diabetic macular edema (DME). DESIGN Prospective, comparative, instrument validation study. SUBJECTS A total of 225 eyes from 116 patients with diabetes mellitus. METHODS Following a standardized protocol, NM and MD images were acquired using handheld retinal cameras (NM images: Aurora, Smartscope, and RetinaVue-700; MD images: Aurora, Smartscope, RetinaVue-700, and iNview) and dilated ETDRS photographs. Grading was performed at a centralized reading center using the International Clinical Classification for DR and DME. Kappa statistics (simple [K], weighted [Kw]) assessed the level of agreement for DR and DME. Sensitivity and specificity were calculated for any DR, referable DR (refDR), and vision-threatening DR (vtDR). MAIN OUTCOME MEASURES Agreement for DR and DME; sensitivity and specificity for any DR, refDR, and vtDR; ungradable rates. RESULTS Severity by ETDRS photographs: no DR, 33.3%; mild nonproliferative DR, 20.4%; moderate DR, 14.2%; severe DR, 11.6%; proliferative DR, 20.4%; no DME, 68.0%; DME, 9.3%; non-center involving clinically significant DME, 4.9%; center-involving clinically significant DME, 12.4%; and ungradable, 5.3%. For NM handheld retinal imaging, Kw was 0.70 to 0.73 for DR and 0.76 to 0.83 for DME. For MD handheld retinal imaging, Kw was 0.68 to 0.75 for DR and 0.77 to 0.91 for DME. Thresholds for sensitivity (0.80) and specificity (0.95) were met by NM images acquired using Smartscope and MD images acquired using Aurora and RetinaVue-700 cameras for any DR and by MD images acquired using Aurora and RetinaVue-700 cameras for refDR. Thresholds for sensitivity and specificity were met by MD images acquired using Aurora and RetinaVue-700 for DME. Nonmydriatic and MD ungradable rates for DR were 15.1% to 38.3% and 0% to 33.8%, respectively. CONCLUSIONS Following standardized protocols, NM and MD handheld retinal imaging devices have substantial agreement levels for DR and DME. With mydriasis, not all handheld retinal imaging devices meet standards for sensitivity and specificity in identifying any DR and refDR. None of the handheld devices met the established 95% specificity for vtDR, suggesting that lower referral thresholds should be used if handheld devices must be utilized. When using handheld devices, the ungradable rate is significantly reduced with mydriasis and DME sensitivity thresholds are only achieved following dilation.
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Affiliation(s)
- Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Paolo S Silva
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines; Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
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Yeh TC, Lo KJ, Hwang DK, Lin TC, Chou YB. Evaluation of a remote telemedicine platform using a novel handheld fundus camera: Physician and patient perceptions from real-world experience. J Chin Med Assoc 2022; 85:793-798. [PMID: 35648158 DOI: 10.1097/jcma.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although teleophthalmology has gained traction in recent years, it is at the center of the coronavirus disease pandemic. However, most hospitals are not ready owing to a severe lack of real-world experience. Furthermore, a limited number of studies have evaluated telemedicine applications on remote islands. This study aimed to evaluate real-world clinical and referral accuracy, image quality, physician-perceived diagnostic certainty, and patient satisfaction with telemedicine eye screening using a novel handheld fundus camera in a rural and medically underserved population. METHODS This prospective study included 176 eyes from a remote island. All participants underwent a comprehensive ophthalmic examination. Nonmydriatic retinal images obtained using a handheld fundus camera were reviewed by two retinal specialists to determine image quality, diagnosis, and need for referrals. The agreement of diagnosis between image-based assessments was compared with that of binocular indirect ophthalmoscopic assessments. RESULTS Image quality of fundus photographs was considered acceptable or ideal in 97.7% and 95.5% of eyes assessed by two reviewers, respectively. There was considerable agreement in diagnosis between the indirect ophthalmoscopic assessment and image-based assessment by two reviewers (Cohen's kappa = 0.80 and 0.78, respectively). Likewise, substantial agreement was achieved in the referrals. The sensitivity for referable retinopathy from the two reviewers was 78% (95% confidence interval [CI], 57%-91%) and 78% (95% CI, 57%-91%), whereas specificity was 99% (95% CI, 95%-99%] and 98% (95% CI, 93%-99%), respectively. For physicians' perceived certainty of diagnosis, 93.8% and 90.3% were considered either certain or reliable. Overall, 97.4% of participants were satisfied with their experiences and greatly valued the telemedicine services. CONCLUSION Novel fundus camera-based telemedicine screening demonstrated high accuracy in detecting clinically significant retinopathy in real-world settings. It achieved high patient satisfaction and physician-perceived certainty in diagnosis with reliable image quality, which may be scaled internationally to overcome geographical barriers under the global pandemic.
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Affiliation(s)
- Tsai-Chu Yeh
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Kang-Jung Lo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - De-Kuang Hwang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tai-Chi Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Bai Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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10
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Lal A, Dave N, Kazi S, Mitchell P, Thiagalingam A. Comparison of experiences and preferences following non-invasive cardiovascular risk procedures: a cross-sectional survey in participants with and without diabetes mellitus. J Diabetes Metab Disord 2022; 21:463-474. [PMID: 35673505 PMCID: PMC9167168 DOI: 10.1007/s40200-022-00996-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
Aims Endothelial dysfunction is an early risk marker of cardiovascular disease in diabetes mellitus. Timely screening is important in reducing cardiovascular disease-associated morbidity and mortality. This cross-sectional study investigates the acceptability and preferability of non-invasive cardiovascular risk procedures (EndoPAT2000 system and the ECG-gated fundoscope) in participants with diabetes mellitus compared to controls. Methods A self-administered Likert scale-based questionnaire was completed by 106 controls and 117 participants with diabetes mellitus, identified through stratified random sampling, upon conclusion of an Australian Heart Eye sub-study conducted at Westmead Hospital, NSW, Australia from 2012 to 2014. Pearson’s χ2 test, independent-samples t-test and regression analysis were performed. Results Study participants who responded to the questionnaire had no preference for procedures (controls: 2.4 ± 1.1 vs diabetes mellitus: 2.5 ± 0.9, p = 0.38) but had an overall more negative experience with most aspects of the ECG-gated fundoscope than the EndoPAT2000 system. Of those with diabetes mellitus, participants who provided poorer self-rated health expressed discomfort with the mydriatic drops (ß 0.27, 95%CI 0.001 - 0.54, p = 0.049) and the fundoscope’s green light filter (ß 0.27, 95%CI 0.07 - 0.47, p = 0.009), as well as maintaining still (ß 0.40, 95%CI 0.08 - 0.72, p = 0.02) and not blinking (ß 0.38, 95%CI 0.07 - 0.70, p = 0.02) during photo acquisition. These participants were also less willing to repeat the ECG-gated fundoscope procedure (ß 0.29, 95%CI 0.07 - 0.52, p = 0.01). Conclusions Participants with diabetes mellitus, especially with poorer self-rated health, had a more negative experience with the ECG-gated fundoscope than the EndoPAT2000 system. Difficulties experienced under examination by the ECG-gated fundoscope appear related to the procedural design, which requires amendments improving patient comfort and compliance.
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Affiliation(s)
- Anchal Lal
- Department of Cardiology, Room 2082, Level 2, Clinical Sciences Corridor, Westmead Hospital, Cnr Darcy and Hawkesbury Roads, Westmead, Sydney, NSW 2145 Australia
- Sydney Medical School (Westmead Clinical School), The University of Sydney, Sydney, NSW 2145 Australia
- Centre for Vision Research, Westmead Institute for Medical Research, Sydney, NSW Australia 2145
| | - Neha Dave
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW 2308 Australia
| | - Samia Kazi
- Department of Cardiology, Room 2082, Level 2, Clinical Sciences Corridor, Westmead Hospital, Cnr Darcy and Hawkesbury Roads, Westmead, Sydney, NSW 2145 Australia
- Sydney Medical School (Westmead Clinical School), The University of Sydney, Sydney, NSW 2145 Australia
| | - Paul Mitchell
- Sydney Medical School (Westmead Clinical School), The University of Sydney, Sydney, NSW 2145 Australia
- Centre for Vision Research, Westmead Institute for Medical Research, Sydney, NSW Australia 2145
| | - Aravinda Thiagalingam
- Department of Cardiology, Room 2082, Level 2, Clinical Sciences Corridor, Westmead Hospital, Cnr Darcy and Hawkesbury Roads, Westmead, Sydney, NSW 2145 Australia
- Sydney Medical School (Westmead Clinical School), The University of Sydney, Sydney, NSW 2145 Australia
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11
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Vinayaki VD, Kalaiselvi R. Multithreshold Image Segmentation Technique Using Remora Optimization Algorithm for Diabetic Retinopathy Detection from Fundus Images. Neural Process Lett 2022; 54:2363-2384. [PMID: 35095328 PMCID: PMC8784591 DOI: 10.1007/s11063-021-10734-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 12/21/2022]
Abstract
One of the most common complications of diabetes mellitus is diabetic retinopathy (DR), which produces lesions on the retina. A novel framework for DR detection and classification was proposed in this study. The proposed work includes four stages: pre-processing, segmentation, feature extraction, and classification. Initially, the image pre-processing is performed and after that, the Multi threshold-based Remora Optimization (MTRO) algorithm performs the vessel segmentation. The feature extraction and classification process are done by using a Region-based Convolution Neural Network (R-CNN) with Wild Geese Algorithm (WGA). Finally, the proposed R-CNN with WGA effectively classifies the different stages of DR including Non-DR, Proliferative DR, Severe, Moderate DR, Mild DR. The experimental images were collected from the DRIVE database, and the proposed framework exhibited superior DR detection performance. Compared to other existing methods like fully convolutional deep neural network (FCDNN), genetic-search feature selection (GSFS), Convolutional Neural Networks (CNN), and deep learning (DL) techniques, the proposed R-CNN with WGA provided 95.42% accuracy, 93.10% specificity, 93.20% sensitivity, and 98.28% F-score results.
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12
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Attiku Y, He Y, Nittala MG, Sadda SR. Current status and future possibilities of retinal imaging in diabetic retinopathy care applicable to low- and medium-income countries. Indian J Ophthalmol 2021; 69:2968-2976. [PMID: 34708731 PMCID: PMC8725126 DOI: 10.4103/ijo.ijo_1212_21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Diabetic retinopathy (DR) is a leading cause of blindness among adults and the numbers are projected to rise. There have been dramatic advances in the field of retinal imaging since the first fundus image was captured by Jackman and Webster in 1886. The currently available imaging modalities in the management of DR include fundus photography, fluorescein angiography, autofluorescence imaging, optical coherence tomography, optical coherence tomography angiography, and near-infrared reflectance imaging. These images are obtained using traditional fundus cameras, widefield fundus cameras, handheld fundus cameras, or smartphone-based fundus cameras. Fluorescence lifetime ophthalmoscopy, adaptive optics, multispectral and hyperspectral imaging, and multicolor imaging are the evolving technologies which are being researched for their potential applications in DR. Telemedicine has gained popularity in recent years as remote screening of DR has been made possible. Retinal imaging technologies integrated with artificial intelligence/deep-learning algorithms will likely be the way forward in the screening and grading of DR. We provide an overview of the current and upcoming imaging modalities which are relevant to the management of DR.
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Affiliation(s)
- Yamini Attiku
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California
| | - Ye He
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, California; Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | | | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute; Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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13
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Ramasamy K, Mishra C, Kannan NB, Namperumalsamy P, Sen S. Telemedicine in diabetic retinopathy screening in India. Indian J Ophthalmol 2021; 69:2977-2986. [PMID: 34708732 PMCID: PMC8725153 DOI: 10.4103/ijo.ijo_1442_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
With ever-growing prevalence of diabetes mellitus and its most common microvascular complication diabetic retinopathy (DR) in Indian population, screening for DR early for prevention of development of vision-threatening stages of the disease is becoming increasingly important. Most of the programs in India for DR screening are opportunistic and a universal screening program does not exist. Globally, telemedicine programs have demonstrated accuracy in classification of DR into referable disease, as well as into stages, with accuracies reaching that of human graders, in a cost-effective manner and with sufficient patient satisfaction. In this major review, we have summarized the global experience of telemedicine in DR screening and the way ahead toward planning a national integrated DR screening program based on telemedicine.
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Affiliation(s)
- Kim Ramasamy
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Chitaranjan Mishra
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Naresh B Kannan
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - P Namperumalsamy
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Sagnik Sen
- Department of Retina and Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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14
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Kanclerz P, Tuuminen R, Khoramnia R. Imaging Modalities Employed in Diabetic Retinopathy Screening: A Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11101802. [PMID: 34679501 PMCID: PMC8535170 DOI: 10.3390/diagnostics11101802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Urbanization has caused dramatic changes in lifestyle, and these rapid transitions have led to an increased risk of noncommunicable diseases, such as type 2 diabetes. In terms of cost-effectiveness, screening for diabetic retinopathy is a critical aspect in diabetes management. The aim of this study was to review the imaging modalities employed for retinal examination in diabetic retinopathy screening. METHODS The PubMed and Web of Science databases were the main sources used to investigate the medical literature. An extensive search was performed to identify relevant articles concerning "imaging", "diabetic retinopathy" and "screening" up to 1 June 2021. Imaging techniques were divided into the following: (i) mydriatic fundus photography, (ii) non-mydriatic fundus photography, (iii) smartphone-based imaging, and (iv) ultrawide-field imaging. A meta-analysis was performed to analyze the performance and technical failure rate of each method. RESULTS The technical failure rates for mydriatic and non-mydriatic digital fundus photography, smartphone-based and ultrawide-field imaging were 3.4% (95% CI: 2.3-4.6%), 12.1% (95% CI: 5.4-18.7%), 5.3% (95% CI: 1.5-9.0%) and 2.2% (95% CI: 0.3-4.0%), respectively. The rate was significantly different between all analyzed techniques (p < 0.001), and the overall failure rate was 6.6% (4.9-8.3%; I2 = 97.2%). The publication bias factor for smartphone-based imaging was significantly higher than for mydriatic digital fundus photography and non-mydriatic digital fundus photography (b = -8.61, b = -2.59 and b = -7.03, respectively; p < 0.001). Ultrawide-field imaging studies were excluded from the final sensitivity/specificity analysis, as the total number of patients included was too small. CONCLUSIONS Regardless of the type of the device used, retinal photographs should be taken on eyes with dilated pupils, unless contraindicated, as this setting decreases the rate of ungradable images. Smartphone-based and ultrawide-field imaging may become potential alternative methods for optimized DR screening; however, there is not yet enough evidence for these techniques to displace mydriatic fundus photography.
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Affiliation(s)
- Piotr Kanclerz
- Hygeia Clinic, 80-286 Gdańsk, Poland
- Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland;
- Correspondence: ; Tel./Fax: +48-58-776-4046
| | - Raimo Tuuminen
- Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland;
- Eye Centre, Kymenlaakso Central Hospital, 48100 Kotka, Finland
| | - Ramin Khoramnia
- The David J. Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, University of Heidelberg, 69120 Heidelberg, Germany;
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15
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Boucher MC, Qian J, Brent MH, Wong DT, Sheidow T, Duval R, Kherani A, Dookeran R, Maberley D, Samad A, Chaudhary V. Evidence-based Canadian guidelines for tele-retina screening for diabetic retinopathy: recommendations from the Canadian Retina Research Network (CR2N) Tele-Retina Steering Committee. Can J Ophthalmol 2021; 55:14-24. [PMID: 32089161 DOI: 10.1016/j.jcjo.2020.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this report is to develop a consensus for Canadian national guidelines specific to a tele-medicine approach to screening for diabetic retinopathy (DR) using evidence-based and clinical data. METHODS Canadian Tele-Screening Grading Scales for DR and diabetic macular edema (DME) were created primarily based on severity grading scales outlined by the International Clinical Diabetic Retinopathy Disease Severity Scale (ICDR) and the Scottish DR Grading Scheme 2007. Other grading scales used in international screening programs and the clinical expertise of the Canadian Retina Research Network members and retina specialists nationwide were also used in the creation of the guidelines. RESULTS National Tele-Screening Guidelines for DR and DME with and without optical coherence tomography (OCT) images are proposed. These outline a diagnosis and management algorithm for patients presenting with different stages of DR and/or DME. General guidelines detailing the requirements for imaged retina fields, image quality, quality control, and follow-up care and the role of visual acuity, pupil dilation, OCT, ultra-wide-field imaging, and artificial intelligence are discussed. CONCLUSIONS Tele-retina screening can help to address the need for timely and effective screening for DR, whose prevalence continues to rise. A standardized and evidence-based national approach to DR tele-screening has been proposed, based on DR/DME grading using two 45° image fields or a single widefield or ultra-wide-field image, preferable use of OCT imaging, and a focus on local quality control measures.
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Affiliation(s)
- M C Boucher
- Centre universitaire d'ophtalmologie (CUO)-Hôpital Maisonneuve-Rosemont, Département d'ophtalmologie, Université de Montréal, Montréal, Qué
| | - J Qian
- Hamilton Regional Eye Institute, St. Joseph's Healthcare Hamilton, Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ont.; Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont
| | - M H Brent
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont.; Department of Ophthalmology, University Health Network-Donald K. Johnson Eye Institute, Toronto Western Hospital, Toronto, Ont
| | - D T Wong
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ont.; Department of Ophthalmology, Unity Health Toronto-St. Michael's Hospital, Toronto, Ont
| | - T Sheidow
- Department of Ophthalmology, Ivey Eye Institute-St. Joseph's Hospital, London, Ont
| | - R Duval
- Centre universitaire d'ophtalmologie (CUO)-Hôpital Maisonneuve-Rosemont, Département d'ophtalmologie, Université de Montréal, Montréal, Qué
| | - A Kherani
- Southern Alberta Eye Center, Calgary Retina Consultants, Calgary, Alta
| | - R Dookeran
- Misericordia Health Centre, University of Manitoba, Winnipeg, Man
| | - D Maberley
- Department of Ophthalmology & Visual Sciences, Eye Care Centre-Vancouver General Hospital, Vancouver, B.C
| | - A Samad
- Department of Ophthalmology & Visual Sciences, Dalhousie University, Halifax, N.S
| | - V Chaudhary
- Hamilton Regional Eye Institute, St. Joseph's Healthcare Hamilton, Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ont..
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Review of retinal cameras for global coverage of diabetic retinopathy screening. Eye (Lond) 2020; 35:162-172. [PMID: 33168977 DOI: 10.1038/s41433-020-01262-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022] Open
Abstract
The global burden of diabetes has resulted in an increase in the prevalence of diabetic retinopathy (DR), a microvascular complication of diabetes. Lifelong repetitive screening for DR is essential for early detection and timely management to prevent visual impairment due to the silent sight-threatening disorder. Colour fundus photography (CFP) is helpful for documentation of the retinopathy as well as for counselling the patient. CFP has established roles in DR screening, detection, progression and monitoring of treatment response. DR screening programmes use validated mydriatic or non-mydriatic fundus cameras for retinal imaging and trained image graders identify referable DR. Smartphone-based fundus cameras and handheld fundus cameras that are cost-effective, portable and easy to handle in remote places are gaining popularity in recent years. The images captured with these low-cost devices can be immediately sent to trained ophthalmologists for grading of DR. Recent increase in numbers of telemedicine programmes based on imaging with digital fundus cameras and remote interpretation has facilitated larger population coverage of DR screening and timely referral of those with sight-threatening DR to ophthalmologists. Good-quality retinal imaging and accurate diagnosis are essential to reduce inappropriate referrals. Advances in digital imaging such as ultra-wide field imaging and multi-modal imaging have opened new avenues for assessing DR. Fundus cameras with integrated artificial intelligence (AI)-based automated algorithms can also provide instant DR diagnosis and reduce the burden of healthcare systems. We review the different types of fundus cameras currently used in DR screening and management around the world.
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Kalogeropoulos D, Kalogeropoulos C, Stefaniotou M, Neofytou M. The role of tele-ophthalmology in diabetic retinopathy screening. JOURNAL OF OPTOMETRY 2020; 13:262-268. [PMID: 31948924 PMCID: PMC7520530 DOI: 10.1016/j.optom.2019.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/10/2019] [Accepted: 12/03/2019] [Indexed: 06/01/2023]
Abstract
Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States. Considering the increasing incidence of DR, it is extremely important to detect the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system. Despite the advances in retinal imaging, analysis techniques are still superseded by expert ophthalmologist interpretation. Teleophthalmology presents an immense opportunity, with high rates of sensitivity and specificity, to manage the steadily increasing demand for eye care of patients with diabetes, but challenges remain in the delivery of practical, viable, and clinically proven solutions.
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Affiliation(s)
- Dimitrios Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
| | - Chris Kalogeropoulos
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Maria Stefaniotou
- Department of Ophthalmology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
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18
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Comparison of automated and expert human grading of diabetic retinopathy using smartphone-based retinal photography. Eye (Lond) 2020; 35:334-342. [PMID: 32341536 DOI: 10.1038/s41433-020-0849-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/08/2019] [Accepted: 03/15/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The aim of this study is to investigate the efficacy of a mobile platform that combines smartphone-based retinal imaging with automated grading for determining the presence of referral-warranted diabetic retinopathy (RWDR). METHODS A smartphone-based camera (RetinaScope) was used by non-ophthalmic personnel to image the retina of patients with diabetes. Images were analyzed with the Eyenuk EyeArt® system, which generated referral recommendations based on presence of diabetic retinopathy (DR) and/or markers for clinically significant macular oedema. Images were independently evaluated by two masked readers and categorized as refer/no refer. The accuracies of the graders and automated interpretation were determined by comparing results to gold standard clinical diagnoses. RESULTS A total of 119 eyes from 69 patients were included. RWDR was present in 88 eyes (73.9%) and in 54 patients (78.3%). At the patient-level, automated interpretation had a sensitivity of 87.0% and specificity of 78.6%; grader 1 had a sensitivity of 96.3% and specificity of 42.9%; grader 2 had a sensitivity of 92.5% and specificity of 50.0%. At the eye-level, automated interpretation had a sensitivity of 77.8% and specificity of 71.5%; grader 1 had a sensitivity of 94.0% and specificity of 52.2%; grader 2 had a sensitivity of 89.5% and specificity of 66.9%. DISCUSSION Retinal photography with RetinaScope combined with automated interpretation by EyeArt achieved a lower sensitivity but higher specificity than trained expert graders. Feasibility testing was performed using non-ophthalmic personnel in a retina clinic with high disease burden. Additional studies are needed to assess efficacy of screening diabetic patients from general population.
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Al-Fawaz K, Al Rubaie K, Zia Y, Khandekar R. Comparison of Digital Retinal Images and Information Tele-Transferred Through the Hala System to Manual Image Transfer of Diabetic Patients from Primary Health Care Centers in Riyadh. Telemed J E Health 2020; 26:1400-1405. [PMID: 32298600 DOI: 10.1089/tmj.2019.0245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Diabetes is a significant problem in Saudi Arabia, and telemedicine in the form of tele-screening for diabetic retinopathy (DR) is recommended. Introduction: A comparison of the quality of images and information transferred through the Hala system of the Ministry of Health, Saudi Arabia, with images transferred in a survey at Primary Healthcare Centers in Riyadh, Saudi Arabia, was conducted. Methods: A review of health records was undertaken in 2017-2018. Digital retinal images of diabetics were tele-transferred from a diabetes center to the King Khaled Eye Specialist Hospital (KKESH) for review by medical retina specialists (Group I). Similarly, images of diabetic patients that were transferred from seven primary health clinics to KKESH during a survey were used as images for research (Group II). Additional information reviewed for completeness included patient demographics, risk factors of DR, and previous eye surgery. Results: There were 40 images of 40 patients transferred through the Hala system. There were 120 randomly selected images from survey files. There were significantly more poor images from the Hala system (12.5%) than the research survey system (2.4%). There was no significant difference in the severity of DR between groups. The median Rasch score for the images was -0.58 (interquartile range [IQR] -5.6, 2.6) in Group I and 19.7 (IQR 18.3, 19.7) in Group II. The image reader perceived that the quality of digital retinal images was significantly better in images transferred from the research survey compared with those transferred through the Hala DR tele-transfer system. (Mann-Whitney p < 0.001). Conclusions: Digital image capture and supplementary risk factor information require improvement to enhance DR screening using the Hala system.
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Affiliation(s)
- Khalid Al-Fawaz
- Department of Administration, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Khalid Al Rubaie
- Department of Retina, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Yasir Zia
- Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Rajiv Khandekar
- Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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Lim G, Bellemo V, Xie Y, Lee XQ, Yip MYT, Ting DSW. Different fundus imaging modalities and technical factors in AI screening for diabetic retinopathy: a review. EYE AND VISION (LONDON, ENGLAND) 2020; 7:21. [PMID: 32313813 PMCID: PMC7155252 DOI: 10.1186/s40662-020-00182-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Effective screening is a desirable method for the early detection and successful treatment for diabetic retinopathy, and fundus photography is currently the dominant medium for retinal imaging due to its convenience and accessibility. Manual screening using fundus photographs has however involved considerable costs for patients, clinicians and national health systems, which has limited its application particularly in less-developed countries. The advent of artificial intelligence, and in particular deep learning techniques, has however raised the possibility of widespread automated screening. MAIN TEXT In this review, we first briefly survey major published advances in retinal analysis using artificial intelligence. We take care to separately describe standard multiple-field fundus photography, and the newer modalities of ultra-wide field photography and smartphone-based photography. Finally, we consider several machine learning concepts that have been particularly relevant to the domain and illustrate their usage with extant works. CONCLUSIONS In the ophthalmology field, it was demonstrated that deep learning tools for diabetic retinopathy show clinically acceptable diagnostic performance when using colour retinal fundus images. Artificial intelligence models are among the most promising solutions to tackle the burden of diabetic retinopathy management in a comprehensive manner. However, future research is crucial to assess the potential clinical deployment, evaluate the cost-effectiveness of different DL systems in clinical practice and improve clinical acceptance.
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Affiliation(s)
- Gilbert Lim
- School of Computing, National University of Singapore, Singapore, Singapore
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Valentina Bellemo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, 11 Third Hospital Road Avenue, Singapore, 168751 Singapore
| | - Yuchen Xie
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Xin Q. Lee
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Michelle Y. T. Yip
- Duke-NUS Medical School, National University of Singapore, 11 Third Hospital Road Avenue, Singapore, 168751 Singapore
| | - Daniel S. W. Ting
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, 11 Third Hospital Road Avenue, Singapore, 168751 Singapore
- Vitreo-Retinal Service, Singapore National Eye Center, 11 Third Hospital Road Avenue, Singapore, 168751 Singapore
- Artificial Intelligence in Ophthalmology, Singapore Eye Research Institute, 11 Third Hospital Road Avenue, Singapore, 168751 Singapore
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21
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Horton MB, Brady CJ, Cavallerano J, Abramoff M, Barker G, Chiang MF, Crockett CH, Garg S, Karth P, Liu Y, Newman CD, Rathi S, Sheth V, Silva P, Stebbins K, Zimmer-Galler I. Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition. Telemed J E Health 2020; 26:495-543. [PMID: 32209018 PMCID: PMC7187969 DOI: 10.1089/tmj.2020.0006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/11/2020] [Accepted: 01/11/2020] [Indexed: 12/24/2022] Open
Abstract
Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.
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Affiliation(s)
- Mark B. Horton
- Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program, Phoenix Indian Medical Center, Phoenix, Arizona
| | - Christopher J. Brady
- Division of Ophthalmology, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Michael Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa
- Department of Biomedical Engineering, and The University of Iowa, Iowa City, Iowa
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, Iowa
- Department of Ophthalmology, Stephen A. Wynn Institute for Vision Research, The University of Iowa, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- IDx, Coralville, Iowa
| | - Gail Barker
- Arizona Telemedicine Program, The University of Arizona, Phoenix, Arizona
| | - Michael F. Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | | | - Seema Garg
- Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Siddarth Rathi
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Veeral Sheth
- University Retina and Macula Associates, University of Illinois at Chicago, Chicago, Illinois
| | - Paolo Silva
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Kristen Stebbins
- Vision Care Department, Hillrom, Skaneateles Falls, New York, New York
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22
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Keshvardoost S, Bahaadinibeigy K, Shadman H, Tafreshi AG, Baneshi MR. Design, Development, and Evaluation of a Teleophthalmology System Using a Low-Cost Fundus Camera. Acta Inform Med 2020; 28:12-17. [PMID: 32210509 PMCID: PMC7085307 DOI: 10.5455/aim.2019.28.12-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The increasing prevalence of diabetic retinopathy in developing countries has become a worldwide concern. This problem is preventable by timely diagnosis and treatment; however, in the majority of cases, patients attend the eye clinics very late because of a lack of specialists and travel difficulties. Running a teleophthalmology system would significantly help to manage this disease. Aim: This study seeks to assess the accuracy of the teleophthalmology system and its effect on reducing unnecessary referrals in Iran. Methods: This study was conducted on 125 diabetic patients. First, the patients were examined by a retina specialist using a slit lamp and, then, single-field digital photos were captured by a portable, low-cost fundus camera. The images were uploaded onto a website and, after two months, were assessed by two retina specialists and two general practitioners (GPs). Finally, the diagnoses based on the digital photos were contrasted with the diagnoses established through face-to-face visits as a gold standard. Results: Out of 125 diabetic patients, eight (6.4%) were removed because of low-quality images and a total of 117 were evaluated. The sensitivity and specificity of each retina specialist presented with the photographs produced success rates of 90% and 97% respectively when judged against the gold standard of face-to-face visits. The rates of sensitivity for retinopathy referrals from the retina specialists were 92% and 85%. The sensitivity and specificity of their diagnoses of clinically significant macular edema (CSME) were calculated at 93% and 100%. The rates of sensitivity for each GP were 95% and 93% and the level of specificity was estimated to be approximately 98% for both GPs. The diagnosis rate for GPs when viewing the photographs as opposed to hosting face-to-face visits was more than 90%. Generally, with the implementation of this system, between 40% and 55% of referrals were calculated to have been avoidable. Conclusion: Our results from the first-ever research conducted on this topic in Iran showed that the teleophthalmology system is extremely accurate, that it can prevent unnecessary referrals and that it is useful for locating treatable patients. The results of this study could be of assistance in the running and expansion of such systems throughout Iran and Kerman Province to reduce eye damage arising from diabetes, decrease avoidable referrals to clinics, increase the availability of specialist visits for people in remote and rural areas and optimize the use of clinical infrastructures for patients in emergencies.
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Affiliation(s)
- Sareh Keshvardoost
- Medical Informatics Research Center, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Kambiz Bahaadinibeigy
- Modeling in Health Research Center, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | | | | | - Mohammad Reza Baneshi
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Li P, Paulus YM, Davila JR, Gosbee J, Margolis T, Fletcher DA, Kim TN. Usability testing of a smartphone-based retinal camera among first-time users in the primary care setting. ACTA ACUST UNITED AC 2019; 5:120-126. [PMID: 32864157 DOI: 10.1136/bmjinnov-2018-000321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Smartphone-based retinal photography is a promising method for increasing accessibility of retinal screening in the primary care and community settings. Recent work has focused on validating its use in detection of diabetic retinopathy. However, retinal imaging can be technically challenging and additional work is needed to improve ease of retinal imaging in the primary care setting. We therefore performed usability testing of a smartphone-based retinal camera, RetinaScope, among medical assistants in primary care who had never performed retinal imaging. A total of 24 medical assistants performed first-time imaging in a total of five rounds of testing, and iterative improvements to the device were made between test rounds based on the results. The time to acquire a single ~50 degree image of the posterior pole of a model eye decreased from 283 ± 60 seconds to 34 ± 17 seconds (p < 0.01) for first-time users. The time to acquire 5 overlapping images of the retina decreased from 325 ± 60 seconds to 118 ± 26 seconds (p = 0.02) for first-time users. Testing in the human eye demonstrated that a single wide-view retinal image could be captured in 65 ± 7 seconds and 5 overlapping images in 229 ± 114 seconds. Users reported high Systems Usability Scores of 86 ± 13 throughout the rounds, reflecting a high level of comfort in first-time operation of the device. Our study demonstrates that smartphone-based retinal photography has the potential to be quickly adopted among medical assistants in the primary care setting.
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Affiliation(s)
- Patrick Li
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Yannis M Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jose R Davila
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John Gosbee
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Todd Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Daniel A Fletcher
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Tyson N Kim
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
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Al Thani A, Fthenou E, Paparrodopoulos S, Al Marri A, Shi Z, Qafoud F, Afifi N. Qatar Biobank Cohort Study: Study Design and First Results. Am J Epidemiol 2019; 188:1420-1433. [PMID: 30927351 DOI: 10.1093/aje/kwz084] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/21/2022] Open
Abstract
We describe the design, implementation, and results of the Qatar Biobank (QBB) cohort study for the first 10,000 participants. QBB is a prospective, population-based cohort study in Qatar, established in 2012. QBB's primary goal was to establish a cohort accessible to the local and international scientific community, providing adequate health data and biological samples to enable evidence-based research. The study design is based on an agnostic hypothesis, collecting data using questionnaires, biological samples, imaging data, and -omics. QBB aims to recruit 60,000 participants, men and women, adult (aged ≥18 years) Qataris or long-term residents (≥15 years living in Qatar) and follow up with them every 5 years. Currently, QBB has reached 28% (n = 17,065) of the targeted enrollee population and more than 2 million biological samples. QBB is a multinational cohort including 33 different nationalities, with a relatively young population (mean age, 40.5 years) of persons who are highly educated (50% university-educated) and have high monthly incomes. The 4 main noncommunicable diseases found among the QBB population are dyslipidemia, diabetes, hypertension, and asthma with prevalences of 30.1%, 17.4%, 16.8%, and 9.1%, respectively. The QBB repository can provide data and biological samples sufficient to demonstrate valid associations between genetic and/or environmental exposure and disease development to scientists worldwide.
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Affiliation(s)
- Asma Al Thani
- Qatar Biobank for Medical Research, Qatar Foundation for Education, Science, and Community, Doha, Qatar
- College of Health Sciences, Qatar University, Doha, Qatar
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Eleni Fthenou
- Qatar Biobank for Medical Research, Qatar Foundation for Education, Science, and Community, Doha, Qatar
| | - Spyridon Paparrodopoulos
- Qatar Biobank for Medical Research, Qatar Foundation for Education, Science, and Community, Doha, Qatar
| | | | - Zumin Shi
- College of Health Sciences, Qatar University, Doha, Qatar
| | - Fatima Qafoud
- Qatar Biobank for Medical Research, Qatar Foundation for Education, Science, and Community, Doha, Qatar
| | - Nahla Afifi
- Qatar Biobank for Medical Research, Qatar Foundation for Education, Science, and Community, Doha, Qatar
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Scanlon PH. Update on Screening for Sight-Threatening Diabetic Retinopathy. Ophthalmic Res 2019; 62:218-224. [PMID: 31132764 DOI: 10.1159/000499539] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE The aim of this article was to describe recent advances in the use of new technology in diabetic retinopathy screening by looking at studies that assessed the effectiveness and cost-effectiveness of these technologies. METHODS The author conducts an ongoing search for articles relating to screening or management of diabetic retinopathy utilising Zetoc with keywords and contents page lists from relevant journals. RESULTS The areas discussed in this article are reference standards, alternatives to digital photography, area of retina covered by the screening method, size of the device and hand-held cameras, mydriasis versus non-mydriasis or a combination, measurement of distance visual acuity, grading of images, use of automated grading analysis and cost-effectiveness of the new technologies. CONCLUSIONS There have been many recent advances in technology that may be adopted in the future by screening programmes for sight-threatening diabetic retinopathy but each device will need to demonstrate effectiveness and cost-effectiveness before more widespread adoption.
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Affiliation(s)
- Peter H Scanlon
- Clinical Director English NHS Diabetic Eye Screening Programme, Cheltenham, United Kingdom, .,Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom, .,Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom, .,University of Gloucestershire, Cheltenham, United Kingdom,
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26
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Mathis T, Lereuil T, Bruneteau L, Apoustoulo C, Vartin C, Chambard C, Denis P, Kodjikian L. [Performance of ultra-wide field retinophotography for screening of diabetic retinopathy]. J Fr Ophtalmol 2019; 42:572-578. [PMID: 31104875 DOI: 10.1016/j.jfo.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Early diagnosis of diabetic retinopathy is a public health issue. Fundus retinophotography (FRP) is widely used for the detection of the disease. Recently, ultra-wide field retinophotography (WFRP) device allows imaging of approximately 80% of the retinal surface in a single image. The goal of the present study was to evaluate the efficacy of WFRP in the diagnosis and gradation of diabetic retinopathy compared to the gold standard of FRP. METHODS The non-mydriatic Optos P200Tx was used for WFRP imaging. FRP in the 9 positions of gaze was then acquired with the Topcon TRC-NW6S after pupillary dilation. The processing time for each imaging modality was recorded. RESULTS One hundred and sixteen eyes of 58 patients were included in this study. Fourteen eyes were excluded from the analysis due to insufficient imaging quality. WFRP sensitivity was 96% and specificity was 92%. Only 6 eyes received a higher severity grade of diabetic retinopathy by WFRP compared to FRP. In these cases, when the WFRP was analyzed in the same field as the FRP, the severity grade was similar for 5 of the 6 eyes. The mean time of acquisition was significantly lower for WFRP compared to FRP. CONCLUSION WFRP is fast and effective in screening for diabetic retinopathy. The severity grade of the disease was similar to the gold standard of FRP in most cases. WFRP could thus be used in mass screening for diabetic retinopathy.
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Affiliation(s)
- T Mathis
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; UMR-CNRS 5510 Matéis, 345, avenue Gaston-Berger, 69100 Villeurbanne, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France.
| | - T Lereuil
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - L Bruneteau
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France
| | - C Apoustoulo
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France
| | - C Vartin
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - C Chambard
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France
| | - P Denis
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France
| | - L Kodjikian
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, université Lyon 1, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France; UMR-CNRS 5510 Matéis, 345, avenue Gaston-Berger, 69100 Villeurbanne, France; Institut des sciences et techniques de réadaptation, université Lyon 1, 8, avenue Rockfeller, 69373 Lyon cedex 08, France
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Piyasena MMPN, Yip JLY, MacLeod D, Kim M, Gudlavalleti VSM. Diagnostic test accuracy of diabetic retinopathy screening by physician graders using a hand-held non-mydriatic retinal camera at a tertiary level medical clinic. BMC Ophthalmol 2019; 19:89. [PMID: 30961576 PMCID: PMC6454614 DOI: 10.1186/s12886-019-1092-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background The evidence on diagnostic test accuracy (DTA) of diabetic retinopathy (DR) screening utilising photographic studies by non-ophthalmologist personnel in low and middle-income country (LMIC) settings is scarce. We aimed to assess DTA of DR screening using a nonmydriatic hand-held digital camera by trained general physicians in a non-ophthalmic setting. Methods This study is a validation of a screening intervention. We selected 700 people with diabetes (PwDM) > 18 years of age, not previously screened or treated for DR, presenting at a tertiary medical clinic in Sri Lanka. Two-field retinal imaging was used to capture fundus images before and after pupil dilatation, using a hand-held non-mydriatic (Visuscout 100®-Germany) digital retinal camera. The images were captured and graded by two trained, masked independent physician graders. The DTA of different levels of DR was assessed comparing physician’s grading with a retinologist’s clinical examination by mydriatic bio-microscopy, according to a locally adopted guideline. Results Seven hundred eligible PwDM were screened by physician graders. The mean age of participants was 60.8 years (SD ±10.08) and mean duration of DM was 9.9 years (SD ±8.09). Ungradable image proportion in non-mydriatic imaging was 43.4% (either eye-31.3%, both eyes 12.1%). This decreased to 12.8% (either eye-11.6%, both eyes-1.2%) following pupil dilatation. In comparison to detection of any level of DR, a referable level DR (moderate non-proliferative DR and levels above) showed a higher level of DTA. The sensitivity of the defined referable DR was 88.7% (95% CI 81.7–93.8%) for grader 1 (positive predictive value [PPV] 59.1%) and 92.5% (95% CI 86.4–96.5%) for grader 2 (PPV 68%), using mydriatic imaging, after including ungradable images as screen positives. The specificity was 94.9% (95% CI 93.6–96.0%) for grader 1 (negative predictive value [NPV] 99%) and 96.4% (95% CI 95.3–97.3%) for grader 2 (NPV 99.4%). Conclusions The Physicians grading of images from a digital hand-held non-mydriatic camera at a medical clinic, with dilatation of pupil of those who have ungradable images, provides a valid modality to identify referable level of DR. This could be a feasible alternative modality to the existing opportunistic screening to improve the access and coverage. Trial registration Current Controlled Trials ISRCTN47559703. Date of Registration 18th March 2019, Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12886-019-1092-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Jennifer L Y Yip
- Public Health Ophthalmology, International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - David MacLeod
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Min Kim
- Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Venkata S Murthy Gudlavalleti
- Public Health for Eye Care and Disability, International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Piyasena MMPN, Gudlavalleti VSM, Gilbert C, Yip JL, Peto T, MacLeod D, Fonseka C, Kulatunga A, Bandutilake B, Dhanapala M, Pathirana L, Dissanayake H. Development and Validation of a Diabetic Retinopathy Screening Modality Using a Hand-Held Nonmydriatic Digital Retinal Camera by Physician Graders at a Tertiary-Level Medical Clinic: Protocol for a Validation Study. JMIR Res Protoc 2018; 7:e10900. [PMID: 30530458 PMCID: PMC6305894 DOI: 10.2196/10900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/05/2018] [Accepted: 09/13/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Visual impairment and blindness from diabetic retinopathy (DR), which can be reduced by early screening and treatment, is an emerging public health concern in low-income and middle-income countries (LMICs) owing to the increasing prevalence of diabetes mellitus (DM). However, no systematic screening exists in most LMIC settings. The Western province of Sri Lanka has the highest prevalence of DM (18.6%) in the country. A situational analysis identified a marked gap in DR screening (DRS) and treatment services uptake in this region; only opportunistic screening is practiced currently. OBJECTIVE The aim of this protocol is to describe the methods of development and validation of a DRS intervention using a hand-held nonmydriatic digital camera by physician graders in a non-ophthalmological setting at a tertiary-level medical clinic to propose a valid and feasible modality to improve uptake. METHODS DRS modality was developed after assessing barriers and identifying the most appropriate personnel, methods, and location for screening services, following formative research work. The validation will be conducted in a public sector tertiary care center in the Western province of Sri Lanka. The selected physicians will be trained on capturing and grading images according to a valid locally adopted protocol. Two physicians rated high on training will screen a sample of 506 people with DM at a medical clinic. They will use nonmydriatic and mydriatic 2-field imaging strategy. The validity of the proposed screening procedure will be assessed and compared with the mydriatic indirect biomicroscopic examination by a senior retinologist. RESULTS The validity of screening by physician graders will be analyzed and the sensitivity, specificity, and predictive values (with 95% CIs) calculated by the dilation status and for each grader. The diagnostic accuracy at each level of severity of DR will be assessed to define the most appropriate referable criteria. Data is currently being collected. CONCLUSIONS The outcome of this study will be useful for the detection of a defined level of DR at non-ophthalmological setting to filter the people with DM before referral to an eye clinic. This will be helpful to improve the uptake and identify risk groups in advance to prevent sight-threatening DR. Furthermore, evidence from this study will be useful for the implementation of a DRS program in this region and in similar communities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/10900.
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Affiliation(s)
| | - Venkata S Murthy Gudlavalleti
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Gilbert
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer Ly Yip
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tunde Peto
- School of Medicine, Dentistry and Bio-medical Science, Queen's University, Belfast, Ireland
| | - David MacLeod
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charith Fonseka
- Vitreo-retina Unit, National Eye Hospital, Colombo, Sri Lanka
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Fenner BJ, Wong RLM, Lam WC, Tan GSW, Cheung GCM. Advances in Retinal Imaging and Applications in Diabetic Retinopathy Screening: A Review. Ophthalmol Ther 2018; 7:333-346. [PMID: 30415454 PMCID: PMC6258577 DOI: 10.1007/s40123-018-0153-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 12/23/2022] Open
Abstract
Rising prevalence of diabetes worldwide has necessitated the implementation of population-based diabetic retinopathy (DR) screening programs that can perform retinal imaging and interpretation for extremely large patient cohorts in a rapid and sensitive manner while minimizing inappropriate referrals to retina specialists. While most current screening programs employ mydriatic or nonmydriatic color fundus photography and trained image graders to identify referable DR, new imaging modalities offer significant improvements in diagnostic accuracy, throughput, and affordability. Smartphone-based fundus photography, macular optical coherence tomography, ultrawide-field imaging, and artificial intelligence-based image reading address limitations of current approaches and will likely become necessary as DR becomes more prevalent. Here we review current trends in imaging for DR screening and emerging technologies that show potential for improving upon current screening approaches.
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Affiliation(s)
- Beau J Fenner
- Residency Program, Singapore National Eye Centre, Singapore, Singapore
| | - Raymond L M Wong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai-Ching Lam
- Department of Ophthalmology, The University of Hong Kong, Shatin, Hong Kong
| | - Gavin S W Tan
- Surgical Retina Department, Singapore National Eye Centre, Singapore, Singapore
- Ophthlamology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
- Retina Research Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Gemmy C M Cheung
- Ophthlamology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore.
- Retina Research Group, Singapore Eye Research Institute, Singapore, Singapore.
- Medical Retina Department, Singapore National Eye Centre, Singapore, Singapore.
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Piyasena MMPN, Murthy GVS, Yip JLY, Gilbert C, Peto T, Gordon I, Hewage S, Kamalakannan S. Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging. Syst Rev 2018; 7:182. [PMID: 30404665 PMCID: PMC6222985 DOI: 10.1186/s13643-018-0846-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 10/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visual impairment from diabetic retinopathy (DR) is an increasing global public health concern, which is preventable with screening and early treatment. Digital retinal imaging has become a preferred choice as it enables higher coverage of screening. The aim of this review is to evaluate how different characteristics of the DR screening (DRS) test impact on diagnostic test accuracy (DTA) and its relevance to a low-income setting. METHODS We conducted a systematic literature search to identify clinic-based studies on DRS using digital retinal imaging of people with DM (PwDM). Summary estimates of different sub-groups were calculated using DTA values weighted according to the sample size. The DTA of each screening method was derived after exclusion of ungradable images and considering the eye as the unit of analysis. The meta-analysis included studies which measured DTA of detecting any level of DR. We also examined the effect on detection from using different combinations of retinal fields, pupil status, index test graders and setting. RESULTS Six thousand six hundred forty-six titles and abstracts were retrieved, and data were extracted from 122 potentially eligible full reports. Twenty-six studies were included in the review, and 21 studies, mostly from high-income settings (18/21, 85.7%), were included in the meta-analysis. The highest sensitivity was observed in the mydriatic greater than two field strategy (92%, 95% CI 90-94%). The highest specificity was observed in greater than two field methods (94%, 95% CI 93-96%) where mydriasis did not affect specificity. Overall, there was no difference in sensitivity between non-mydriatic and mydriatic methods (86%, 95% CI 85-87) after exclusion of ungradable images. The highest DTA (sensitivity 90%, 95% CI 88-91%; specificity 95%, 95% CI 94-96%) was observed when screening was delivered at secondary/tertiary level clinics. CONCLUSIONS Non-mydriatic two-field strategy could be a more pragmatic approach in starting DRS programmes for facility-based PwDM in low-income settings, with dilatation of the pupils of those who have ungradable images. There was insufficient evidence in primary studies to draw firm conclusions on how graders' background influences DTA. Conducting more context-specific DRS validation studies in low-income and non-ophthalmic settings can be recommended.
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Affiliation(s)
| | - Gudlavalleti Venkata S. Murthy
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Jennifer L. Y. Yip
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Clare Gilbert
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Tunde Peto
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, 97, Lisburn Road, Belfast, BT9 7BL Northern Ireland
| | - Iris Gordon
- Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Suwin Hewage
- Retina Research Unit, National Eye Hospital, Deans Road, Colombo, 01000 Sri Lanka
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Kim TN, Myers F, Reber C, Loury PJ, Loumou P, Webster D, Echanique C, Li P, Davila JR, Maamari RN, Switz NA, Keenan J, Woodward MA, Paulus YM, Margolis T, Fletcher DA. A Smartphone-Based Tool for Rapid, Portable, and Automated Wide-Field Retinal Imaging. Transl Vis Sci Technol 2018; 7:21. [PMID: 30280006 PMCID: PMC6166894 DOI: 10.1167/tvst.7.5.21] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/05/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose High-quality, wide-field retinal imaging is a valuable method for screening preventable, vision-threatening diseases of the retina. Smartphone-based retinal cameras hold promise for increasing access to retinal imaging, but variable image quality and restricted field of view can limit their utility. We developed and clinically tested a smartphone-based system that addresses these challenges with automation-assisted imaging. Methods The system was designed to improve smartphone retinal imaging by combining automated fixation guidance, photomontage, and multicolored illumination with optimized optics, user-tested ergonomics, and touch-screen interface. System performance was evaluated from images of ophthalmic patients taken by nonophthalmic personnel. Two masked ophthalmologists evaluated images for abnormalities and disease severity. Results The system automatically generated 100° retinal photomontages from five overlapping images in under 1 minute at full resolution (52.3 pixels per retinal degree) fully on-phone, revealing numerous retinal abnormalities. Feasibility of the system for diabetic retinopathy (DR) screening using the retinal photomontages was performed in 71 diabetics by masked graders. DR grade matched perfectly with dilated clinical examination in 55.1% of eyes and within 1 severity level for 85.2% of eyes. For referral-warranted DR, average sensitivity was 93.3% and specificity 56.8%. Conclusions Automation-assisted imaging produced high-quality, wide-field retinal images that demonstrate the potential of smartphone-based retinal cameras to be used for retinal disease screening. Translational Relevance Enhancement of smartphone-based retinal imaging through automation and software intelligence holds great promise for increasing the accessibility of retinal screening.
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Affiliation(s)
- Tyson N Kim
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA.,Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Frank Myers
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Clay Reber
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - P J Loury
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Panagiota Loumou
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Doug Webster
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Chris Echanique
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA
| | - Patrick Li
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jose R Davila
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Robi N Maamari
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA.,Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neil A Switz
- Department of Physics and Astronomy, San José State University, San Jose, CA, USA
| | - Jeremy Keenan
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Maria A Woodward
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Yannis M Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Todd Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Daniel A Fletcher
- Department of Bioengineering and Biophysics Program, University of California, Berkeley, Berkeley, CA, USA.,Chan-Zuckerberg Biohub, San Francisco, CA, USA
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Salongcay RP, Silva PS. The Role of Teleophthalmology in the Management of Diabetic Retinopathy. Asia Pac J Ophthalmol (Phila) 2018; 7:17-21. [PMID: 29376232 DOI: 10.22608/apo.2017479] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The emergence of diabetes as a global epidemic is accompanied by the rise in diabetes‑related retinal complications. Diabetic retinopathy, if left undetected and untreated, can lead to severe visual impairment and affect an individual's productivity and quality of life. Globally, diabetic retinopathy remains one of the leading causes of visual loss in the working‑age population. Teleophthalmology for diabetic retinopathy is an innovative means of retinal evaluation that allows identification of eyes at risk for visual loss, thereby preserving vision and decreasing the overall burden to the health care system. Numerous studies worldwide have found teleophthalmology to be a reliable and cost‑efficient alternative to traditional clinical examinations. It has reduced barriers to access to specialized eye care in both rural and urban communities. In teleophthalmology applications for diabetic retinopathy, it is critical that standardized protocols in image acquisition and evaluation are used to ensure low image ungradable rates and maintain the quality of images taken. Innovative imaging technology such as ultrawide field imaging has the potential to provide significant benefit with integration into teleophthalmology programs. Teleophthalmology programs for diabetic retinopathy rely on a comprehensive and multidisciplinary approach with partnerships across specialties and health care professionals to attain wider acceptability and allow evidence‑based eye care to reach a much broader population.
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Affiliation(s)
| | - Paolo S Silva
- Department of Ophthalmology, The Medical City, Pasig City, Philippines
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
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Bursztyn L, Woodward MA, Cornblath WT, Grabe HM, Trobe JD, Niziol L, De Lott LB. Accuracy and Reliability of a Handheld, Nonmydriatic Fundus Camera for the Remote Detection of Optic Disc Edema. Telemed J E Health 2017; 24:344-350. [PMID: 29027884 DOI: 10.1089/tmj.2017.0120] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optic disc edema can be an important indicator of serious neurological disease, but is poorly detected using the direct ophthalmoscope. Portable fundus photography may overcome this difficulty. INTRODUCTION The purpose of this study was to determine the sensitivity and specificity of a handheld, nonmydriatic fundus camera for the detection of optic disc edema. MATERIALS AND METHODS Retrospective review of nonmydriatic optic disc photographs taken with a portable fundus camera (Pictor Plus; Volk Optical, Mentor, OH) from the University of Michigan Neuro-Ophthalmology Clinics. We included 103 consecutive eyes with optic disc edema and 103 consecutive eyes without optic disc edema of 109 patients. Four masked neuro-ophthalmologists graded a single photograph of each optic disc presented in randomized order and documented the presence of optic disc edema. Sensitivity and specificity of graders' photographic interpretation was compared with clinical examinations. Reliability of assessments within and between graders was determined using kappa statistics. RESULTS The sensitivity and specificity for detection of optic disc edema were 71.8-92.2% and 81.6-95.2%, respectively. Photos were found to be ungradable in 0-8.3% of cases. The intergrader reliabilities ranged from 0.60 [95% confidence interval (CI): 0.52-0.67] to 0.72 (95% CI: 0.66-0.77). Intragrader reliability ranged from 0.76 (95% CI: 0.63-0.92) to 0.82 (95% CI: 0.69-0.95). DISCUSSION Photographs taken with portable, nonmydriatic technology met threshold sensitivity and specificity for remote screening for optic disc edema when performed by most, but not all graders. Reliability between graders was moderate-strong and strong within individual providers. CONCLUSIONS Portable photography holds promise for use in remote screening of optic disc edema.
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Affiliation(s)
- Lulu Bursztyn
- 1 Department of Ophthalmology, Western University , London, Ontario, Canada
| | - Maria A Woodward
- 2 Department of Ophthalmology & Visual Sciences, University of Michigan , Ann Arbor, Michigan
| | - Wayne T Cornblath
- 2 Department of Ophthalmology & Visual Sciences, University of Michigan , Ann Arbor, Michigan
| | - Hilary M Grabe
- 3 Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern , Bern, Switzerland
| | - Jonathan D Trobe
- 2 Department of Ophthalmology & Visual Sciences, University of Michigan , Ann Arbor, Michigan
| | - Leslie Niziol
- 2 Department of Ophthalmology & Visual Sciences, University of Michigan , Ann Arbor, Michigan
| | - Lindsey B De Lott
- 2 Department of Ophthalmology & Visual Sciences, University of Michigan , Ann Arbor, Michigan
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Foreman J, Keel S, van Wijngaarden P, Taylor HR, Dirani M. Recruitment and Testing Protocol in the National Eye Health Survey: A Population-Based Eye Study in Australia. Ophthalmic Epidemiol 2017; 24:353-363. [DOI: 10.1080/09286586.2017.1296166] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Joshua Foreman
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Ophthalmology, University of Melbourne, Department of Surgery, Melbourne, Australia
| | - Stuart Keel
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Ophthalmology, University of Melbourne, Department of Surgery, Melbourne, Australia
| | - Peter van Wijngaarden
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Ophthalmology, University of Melbourne, Department of Surgery, Melbourne, Australia
| | - Hugh R. Taylor
- Indigenous Eye Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Mohamed Dirani
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Ophthalmology, University of Melbourne, Department of Surgery, Melbourne, Australia
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Scanlon PH, Stratton IM, Bachmann MO, Jones C, Leese GP. Risk of diabetic retinopathy at first screen in children at 12 and 13 years of age. Diabet Med 2016; 33:1655-1658. [PMID: 27646856 PMCID: PMC5434868 DOI: 10.1111/dme.13263] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2016] [Indexed: 11/28/2022]
Abstract
AIMS To investigate the relationships between age at diagnosis of diabetes, age at diabetic eye screening and severity of diabetic retinopathy at first and subsequent screenings in children aged 12 or 13 years. METHODS Data were extracted from four English screening programmes and from the Scottish, Welsh and Northern Irish programmes on all children with diabetes invited for their first and subsequent screening episodes from the age of 12 years. Retinopathy levels at first and subsequent screens, time from diagnosis of diabetes to first screening and age at diagnosis in years were calculated. RESULTS Data were available for 2125 children with diabetes screened for the first time at age 12 or 13 years. In those diagnosed with diabetes at 2 years of age or less, the proportion with retinopathy in one or both eyes was 20% and 11%, respectively, decreasing to 8% and 2% in those diagnosed between 2 and 12 years (P < 0.0001). Only three children (aged 8, 10 and 11 years at diagnosis of diabetes) had images graded with referable retinopathy and, of these, two had non-referable diabetic retinopathy at all subsequent screenings. Of 1703 children with subsequent images, 25 were graded with referable diabetic retinopathy over a mean follow-up of 3.1 years, an incidence rate of 4.7 (95% confidence interval, 3.1-7.0) per 1000 per year. CONCLUSIONS In this large cohort of children, the low prevalence and incidence rates of referable diabetic retinopathy suggest that screening earlier than age 12 is not necessary.
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Affiliation(s)
| | - I. M. Stratton
- University of Warwick Clinical Sciences Research InstituteGloucestershire Retinal Research GroupGloucesterUK
| | | | - C. Jones
- Norfolk and Norwich University HospitalNorwichUK
| | - G. P. Leese
- Ninewells Hospital and Medical SchoolDundeeUK
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DeBuc DC. The Role of Retinal Imaging and Portable Screening Devices in Tele-ophthalmology Applications for Diabetic Retinopathy Management. Curr Diab Rep 2016; 16:132. [PMID: 27841014 DOI: 10.1007/s11892-016-0827-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In the years since its introduction, retinal imaging has transformed our capability to visualize the posterior pole of the eye. Increasing practical advances in mobile technology, regular monitoring, and population screening for diabetic retinopathy management offer the opportunity for further development of cost-effective applications through remote assessment of the diabetic eye using portable retinal cameras, smart-phone-based devices and telemedicine networks. Numerous retinal imaging methods and mobile technologies in tele-ophthalmology applications have been reported for diabetic retinopathy screening and management. They provide several advantages of automation, sensitivity, specificity, portability, and miniaturization for the development of point-of-care diagnostics for eye complications in diabetes. The aim of this paper is to review the role of retinal imaging and mobile technologies in tele-ophthalmology applications for diabetic retinopathy screening and management. At large, although improvements in current technology and telemedicine services are still needed, telemedicine has demonstrated to be a worthy tool to support health caregivers in the effective management and prevention of diabetes and its complications.
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Affiliation(s)
- Delia Cabrera DeBuc
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136, USA.
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Abstract
Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care, but there are no universal standards regarding camera choice or protocol for ocular telemedicine. We review the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but further development of telemedicine specific technology and standardization of operations are needed to better realize its potential.
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Affiliation(s)
- Mark B Horton
- Joslin Vision Network - Indian Health Service Teleophthalmology Program, Phoenix, AZ, USA.
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Gupta V, Bansal R, Gupta A, Bhansali A. Sensitivity and specificity of nonmydriatic digital imaging in screening diabetic retinopathy in Indian eyes. Indian J Ophthalmol 2016; 62:851-6. [PMID: 25230960 PMCID: PMC4185162 DOI: 10.4103/0301-4738.141039] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Nonmydriatic digital imaging (NMDI) is ideal for screening diabetic retinopathy (DR), but its use in Indian eyes has not been evaluated. Aim: The aim was to evaluate the sensitivity and specificity of NMDI as a screening tool in detecting DR in Indian eyes. Design: A prospective, nonrandomized, noncomparative, noninterventional study. Materials and Methods: A total of 500 diabetic patients visiting the endocrinology clinic (September 2008-June 2010) underwent NMDI (Zeiss Procam), followed by routine dilated fundus photography (FP; Zeiss Visupac 450+) of 345° retinal fields (1) optic disc and macula, (2) superotemporal, and (3) nasal to optic disc. Two-masked retina specialists graded the images for quality and severity of DR, and compared between NMDI and dilated FP. Statistical Analysis: SPSS Windows 17 for version. Results: Mean age was 52.97 ± 13.46 years (306 males: 194 females). The rate of ungradable images was 30.6% and 31% by the two observers. By observer 1, the sensitivity and specificity of detecting any DR was 58.8% and 69.1%, respectively, (κ = 0.608) and sight-threatening DR (STDR) was 63.1% and 68.9%, respectively, (κ = 0.641). By observer 2, the sensitivity and specificity was 57.3% and 68.3%, respectively, for any DR (κ = 0.593) and 62.8% and 68.3%, respectively, for STDR (κ = 0.637). The level of agreement between two observers was high (κ = 0.96). Conclusion: A high rate of poor quality photographs and low sensitivity limited the use of NMDI as a perfect screening system, particularly in dark iris population with diabetes as seen in Indian eyes.
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Affiliation(s)
- Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Pareja-Ríos A, Bonaque-González S, Serrano-García M, Cabrera-López F, Abreu-Reyes P, Marrero-Saavedra MD. Tele-ophthalmology for diabetic retinopathy screening: 8 years of experience. ACTA ACUST UNITED AC 2016; 92:63-70. [PMID: 27756515 DOI: 10.1016/j.oftal.2016.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the results of a diabetic retinopathy screening program implemented in a primary care area. METHODS A retrospective study was conducted using data automatically collected since the program began on 1 January 2007 until 31 December 2015. RESULTS The number of screened diabetic patients has progressively increased, from 7,173 patients in 2007 to 42,339 diabetic patients in 2015. Furthermore, the ability of family doctors to correctly interpret retinographies has improved, with the proportion of retinal images classified as normal having increased from 55% in 2007 to 68% at the end of the study period. The proportion of non-evaluable retinographies decreased to 7% in 2015, having peaked at 15% during the program. This was partly due to a change in the screening program policy that allowed the use of tropicamide. The number of severe cases detected has declined, from 14% with severe non-proliferative and proliferativediabetic retinopathy in the initial phase of the program to 3% in 2015. CONCLUSIONS Diabetic eye disease screening by tele-ophthalmology has shown to be a valuable method in a growing population of diabetics. It leads to a regular medical examination of patients, helps ease the workload of specialised care services and favours the early detection of treatable cases. However, the results of implementing a program of this type are not immediate, achieving only modest results in the early years of the project that have improved over subsequent years.
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Affiliation(s)
- A Pareja-Ríos
- Hospital Universitario de Canarias, La Laguna, Tenerife, España
| | - S Bonaque-González
- Departamento de Física, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, España; Grupo de Ciencias de la Visión, Universidad de Murcia., Murcia, España
| | - M Serrano-García
- Hospital Universitario de Canarias, La Laguna, Tenerife, España.
| | - F Cabrera-López
- Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - P Abreu-Reyes
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - M D Marrero-Saavedra
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
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Toy BC, Aguinaldo T, Eliason J, Egbert J. Non-Mydriatic Fundus Camera Screening for Referral-Warranted Diabetic Retinopathy in a Northern California Safety-Net Setting. Ophthalmic Surg Lasers Imaging Retina 2016; 47:636-42. [DOI: 10.3928/23258160-20160707-05] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 05/06/2016] [Indexed: 11/20/2022]
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Angle closure glaucoma in the Northern Ireland Diabetic Retinopathy Screening Programme. Eye (Lond) 2016; 30:1091-3. [PMID: 27229706 DOI: 10.1038/eye.2016.98] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 04/19/2016] [Indexed: 11/09/2022] Open
Abstract
PurposeTo ascertain the risk of angle closure glaucoma associated with mydriasis in the Northern Ireland Diabetic Retinopathy Screening Programme.MethodsA retrospective case note review was carried out, cross referencing hospital records with those of the screening programme, to identify episodes of angle closure glaucoma, which occurred within 14 days of a retinopathy screening episode involving pharmacological mydriasis.ResultsThree cases of angle closure following mydriasis for screening were identified. The incidence of angle closure within the screening programme was calculated to be 1 in 31 755 patients dilated or 0.75 patients per year.ConclusionAngle closure is a rare complication of mydriasis used in photographic screening for diabetic retinopathy. We advocate the provision of clear instructions to patients in screening programmes on when and how to access emergency ophthalmic care following dilation to prevent loss of vision in this rare event.
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Knyazer B, Schachter O, Plakht Y, Serlin Y, Smolar J, Belfair N, Lifshitz T, Levy J. Epiretinal membrane in diabetes mellitus patients screened by nonmydriatic fundus camera. Can J Ophthalmol 2016; 51:41-6. [DOI: 10.1016/j.jcjo.2015.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 08/23/2015] [Accepted: 09/23/2015] [Indexed: 12/20/2022]
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Goh JKH, Cheung CY, Sim SS, Tan PC, Tan GSW, Wong TY. Retinal Imaging Techniques for Diabetic Retinopathy Screening. J Diabetes Sci Technol 2016; 10:282-94. [PMID: 26830491 PMCID: PMC4773981 DOI: 10.1177/1932296816629491] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Due to the increasing prevalence of diabetes mellitus, demand for diabetic retinopathy (DR) screening platforms is steeply increasing. Early detection and treatment of DR are key public health interventions that can greatly reduce the likelihood of vision loss. Current DR screening programs typically employ retinal fundus photography, which relies on skilled readers for manual DR assessment. However, this is labor-intensive and suffers from inconsistency across sites. Hence, there has been a recent proliferation of automated retinal image analysis software that may potentially alleviate this burden cost-effectively. Furthermore, current screening programs based on 2-dimensional fundus photography do not effectively screen for diabetic macular edema (DME). Optical coherence tomography is becoming increasingly recognized as the reference standard for DME assessment and can potentially provide a cost-effective solution for improving DME detection in large-scale DR screening programs. Current screening techniques are also unable to image the peripheral retina and require pharmacological pupil dilation; ultra-widefield imaging and confocal scanning laser ophthalmoscopy, which address these drawbacks, possess great potential. In this review, we summarize the current DR screening methods using various retinal imaging techniques, and also outline future possibilities. Advances in retinal imaging techniques can potentially transform the management of patients with diabetes, providing savings in health care costs and resources.
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Affiliation(s)
- James Kang Hao Goh
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore Duke-NUS Graduate Medical School, Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong
| | | | - Pok Chien Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Gavin Siew Wei Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore Duke-NUS Graduate Medical School, Singapore Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
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Wu D, Xuan Y, Ruan Y, Feng X, Zhu Y, Jia C, Liu J, Li H, Li L, Dong X. Prevalence of macro- and microvascular complications in patients with type 2 diabetes and kidney disease with or without albuminuria in a single Chinese Diabetes Centre. Diab Vasc Dis Res 2016; 13:21-30. [PMID: 26499917 DOI: 10.1177/1479164115610247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate the relationship between diabetic retinopathy, neuropathy and low ankle-brachial index in mild-to-moderate chronic kidney disease of type 2 diabetic patients. METHODS We enrolled 875 type 2 diabetic patients who were divided into two phenotypes (with or without albuminuria) and stratified into three groups (stage 1 with estimated glomerular filtration rate ⩾ 90 mL/min/1.73 m(2), stage 2 with estimated glomerular filtration rate of 60-89, stage 3 with estimated glomerular filtration rate of 30-59). The prevalence of diabetic retinopathy, neuropathy and low ankle-brachial index was compared and the risk factors of renal impairment were determined. RESULTS Among chronic kidney disease stages, the prevalence of diabetic retinopathy increased from 42.5%, 56.6% to 66.7% in albuminuric subjects and from 29.4%, 33.0% to 50.0% with no significant trend in normoalbuminuric subjects (p = 0.005, 0.007 and 0.399 compared with albuminuric subjects in each stage). There was a significantly increased prevalence of low ankle-brachial index (17.5%, 22.6% and 44.4%) in normoalbuminuric subjects but no significant trend in albuminuric subjects. Diabetic retinopathy (odds ratio = 2.474, 95% confidence interval = 1.009-6.068) was an independent risk factor of declining kidney function in albuminuric patients. CONCLUSION The prevalence of diabetic retinopathy was graded according to the estimated glomerular filtration rate declining in albuminuric patients while the prevalence of low ankle-brachial index was gradually increased in normoalbuminuric patients, indicating the diverse underlying mechanisms of mild to moderate chronic kidney disease between these two phenotypes.
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Affiliation(s)
- Dingting Wu
- Department of Nutrition Division, Zhejiang University Affiliated Fourth Hospital, School of Medicine, Yiwu, P.R. China
| | - Yanyan Xuan
- Medical Clinic of Ningbo First Hospital, Ningbo, P.R. China
| | - Yu Ruan
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
| | - Xiaocheng Feng
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
| | - Yinchao Zhu
- Institute of Non-Communicable Disease Control and Prevention, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, P.R. China
| | - Chengfang Jia
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
| | - Jun Liu
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
| | - Hong Li
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
| | - Lianxi Li
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Xuehong Dong
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, P.R. China
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Pasquel FJ, Hendrick AM, Ryan M, Cason E, Ali MK, Narayan KMV. Cost-effectiveness of Different Diabetic Retinopathy Screening Modalities. J Diabetes Sci Technol 2015; 10:301-7. [PMID: 26719134 PMCID: PMC4773976 DOI: 10.1177/1932296815624109] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Current screening strategies aimed at detection of diabetic retinopathy (DR) historically have poor compliance, but advancements in technology can enable improved access to care. Nearly 80% of all persons with diabetes live in low- and middle-income countries (LMICs), highlighting the importance of a cost effective screening program. Establishing mechanisms to reach populations with geographic and financial barriers to access is essential to prevent visual disability. Teleretinal programs leverage technology to improve access and reduce cost. The quality of currently employed screening modalities depends on many variables including the instrument used, use of pupillary mydriasis, number of photographic fields, and the qualifications of the photographer and image interpreter. Recent telemedicine and newer technological approaches have been introduced, but data for these technologies is yet limited. We present results of a systematic review of studies evaluating cost-effectiveness of DR screening, and discuss potential relevance for LMICs.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew M Hendrick
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Ryan
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Emily Cason
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - K M Venkat Narayan
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Malerbi FK, Morales PH, Farah ME, Drummond KRG, Mattos TCL, Pinheiro AA, Mallmann F, Perez RV, Leal FSL, Gomes MB, Dib SA. Comparison between binocular indirect ophthalmoscopy and digital retinography for diabetic retinopathy screening: the multicenter Brazilian Type 1 Diabetes Study. Diabetol Metab Syndr 2015; 7:116. [PMID: 26697120 PMCID: PMC4687381 DOI: 10.1186/s13098-015-0110-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/01/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Diabetic retinopathy is the main cause of preventable blindness in the economically active population in western countries. Diabetic retinopathy screening is effective in preventing blindness and can be performed through various diagnostic methods. Our objective is to compare binocular indirect ophthalmoscopy (BIO) to telemedicine protocols of digital retinography for diabetic retinopathy screening in a large and heterogenous type 1 diabetes population in a developing country. METHODS Data from 1266 Type 1 Diabetes Mellitus patients from a Brazilian multicenter study were analyzed. Patients underwent BIO and digital retinography, non-mydriatic and mydriatic. Images were sent to a reading center in a telemedicine protocol. Agreement between the different methods was calculated with kappa statistic for diabetic retinopathy and maculopathy classification. Clinical outcome was either observation or referral to specialist. RESULTS Agreement between BIO and mydriatic retinography was substantial (kappa 0.67-0.74) for diabetic retinopathy observation vs referral classification. Agreement was fair to moderate (kappa 0.24-0.45) between retinography and BIO for maculopathy. Poor mydriasis was the main obstacle to image reading and classification, especially on the non-mydriatic strategy, occurring in 11.9 % of right eyes and 16.9 % of left eyes. CONCLUSION Mydriatic retinography showed a substantial agreement to BIO for diabetic retinopathy observation vs referral classification. A significant amount of information was lost on the non-mydriatic technique because of poor mydriasis. We recommend a telemedicine-based diabetic retinopathy screening strategy with digital mydriatic retinography, preferably with 2 fields, and advise against non-mydriatic retinography in developing countries.
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Affiliation(s)
- Fernando Korn Malerbi
- />Departments of Endocrinology and Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Michel Eid Farah
- />Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | - Felipe Mallmann
- />Department of Ophthalmology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Marília Brito Gomes
- />Department of Endocrinology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sergio Atala Dib
- />Department of Endocrinology, Federal University of São Paulo, São Paulo, Brazil
| | - On behalf of The Brazilian Type 1 Diabetes Study Group
- />Departments of Endocrinology and Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
- />Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
- />Department of Ophthalmology, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
- />Department of Ophthalmology, Centro de Endocrinologia e Diabetes do Estado da Bahia, Salvador, Brazil
- />Department of Ophthalmology, Hospital Regional de Taguatinga, Brasília, Brazil
- />Department of Ophthalmology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- />Department of Endocrinology, University of São Paulo, São Paulo, Brazil
- />Department of Ophthalmology, University of Campinas, Campinas, Brazil
- />Department of Endocrinology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
- />Department of Endocrinology, Federal University of São Paulo, São Paulo, Brazil
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Al Kuwari H, Al Thani A, Al Marri A, Al Kaabi A, Abderrahim H, Afifi N, Qafoud F, Chan Q, Tzoulaki I, Downey P, Ward H, Murphy N, Riboli E, Elliott P. The Qatar Biobank: background and methods. BMC Public Health 2015; 15:1208. [PMID: 26635005 PMCID: PMC4669623 DOI: 10.1186/s12889-015-2522-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/18/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Qatar Biobank aims to collect extensive lifestyle, clinical, and biological information from up to 60,000 men and women Qatari nationals and long-term residents (individuals living in the country for ≥15 years) aged ≥18 years (approximately one-fifth of all Qatari citizens), to follow up these same individuals over the long term to record any subsequent disease, and hence to study the causes and progression of disease, and disease burden, in the Qatari population. METHODS Between the 11(th)-December-2012 and 20(th)-February-2014, 1209 participants were recruited into the pilot study of the Qatar Biobank. At recruitment, extensive phenotype information was collected from each participant, including information/measurements of socio-demographic factors, prevalent health conditions, diet, lifestyle, anthropometry, body composition, bone health, cognitive function, grip strength, retinal imaging, total body dual energy X-ray absorptiometry, and measurements of cardiovascular and respiratory function. Blood, urine, and saliva were collected and stored for future research use. A panel of 66 clinical biomarkers was routinely measured on fresh blood samples in all participants. Rates of recruitment are to be progressively increased in the coming period and the recruitment base widened to achieve a cohort of consented individuals broadly representative of the eligible Qatari population. In addition, it is planned to add additional measures in sub-samples of the cohort, including Magnetic Resonance Imaging (MRI) of the brain, heart and abdomen. RESULTS The mean time for collection of the extensive phenotypic information and biological samples from each participant at the baseline recruitment visit was 179 min. The 1209 pilot study participants (506 men and 703 women) were aged between 28-80 years (median 39 years); 899 (74.4%) were Qatari nationals and 310 (25.6%) were long-term residents. Approximately two-thirds of pilot participants were educated to graduate level or above. CONCLUSIONS The pilot has proven that recruitment of volunteers into the Qatar Biobank project with intensive baseline measurements of behavioural, physical, and clinical characteristics is well accepted and logistically feasible. Qatar Biobank will provide a powerful resource to investigate the major determinants of ill-health and well-being in Qatar, providing valuable insights into the current and future public health burden that faces the country.
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Affiliation(s)
| | - Asma Al Thani
- Department of Health Sciences, College of Arts and Sciences, Qatar University, P O Box 348, Doha, Qatar.
| | | | | | - Hadi Abderrahim
- Qatar Biobank, Qatar Foundation for Education, Science, and Community, P O Box 5825, Doha, Qatar.
| | - Nahla Afifi
- Qatar Biobank, Qatar Foundation for Education, Science, and Community, P O Box 5825, Doha, Qatar.
| | - Fatima Qafoud
- Qatar Biobank, Qatar Foundation for Education, Science, and Community, P O Box 5825, Doha, Qatar.
| | - Queenie Chan
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Ioanna Tzoulaki
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Paul Downey
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Heather Ward
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Neil Murphy
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Elio Riboli
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
| | - Paul Elliott
- School of Public Health, Imperial College London, St Mary's campus, Norfolk Place, London, UK.
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Rajalakshmi R, Arulmalar S, Usha M, Prathiba V, Kareemuddin KS, Anjana RM, Mohan V. Validation of Smartphone Based Retinal Photography for Diabetic Retinopathy Screening. PLoS One 2015; 10:e0138285. [PMID: 26401839 PMCID: PMC4581835 DOI: 10.1371/journal.pone.0138285] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/29/2015] [Indexed: 12/18/2022] Open
Abstract
Aim To evaluate the sensitivity and specificity of “fundus on phone’ (FOP) camera, a smartphone based retinal imaging system, as a screening tool for diabetic retinopathy (DR) detection and DR severity in comparison with 7-standard field digital retinal photography. Design Single-site, prospective, comparative, instrument validation study. Methods 301 patients (602 eyes) with type 2 diabetes underwent standard seven-field digital fundus photography with both Carl Zeiss fundus camera and indigenous FOP at a tertiary care diabetes centre in South India. Grading of DR was performed by two independent retina specialists using modified Early Treatment of Diabetic Retinopathy Study grading system. Sight threatening DR (STDR) was defined by the presence of proliferative DR(PDR) or diabetic macular edema. The sensitivity, specificity and image quality were assessed. Results The mean age of the participants was 53.5 ±9.6 years and mean duration of diabetes 12.5±7.3 years. The Zeiss camera showed that 43.9% had non-proliferative DR(NPDR) and 15.3% had PDR while the FOP camera showed that 40.2% had NPDR and 15.3% had PDR. The sensitivity and specificity for detecting any DR by FOP was 92.7% (95%CI 87.8–96.1) and 98.4% (95%CI 94.3–99.8) respectively and the kappa (ĸ) agreement was 0.90 (95%CI-0.85–0.95 p<0.001) while for STDR, the sensitivity was 87.9% (95%CI 83.2–92.9), specificity 94.9% (95%CI 89.7–98.2) and ĸ agreement was 0.80 (95%CI 0.71–0.89 p<0.001), compared to conventional photography. Conclusion Retinal photography using FOP camera is effective for screening and diagnosis of DR and STDR with high sensitivity and specificity and has substantial agreement with conventional retinal photography.
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Affiliation(s)
- Ramachandran Rajalakshmi
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Subramanian Arulmalar
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Manoharan Usha
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Vijayaraghavan Prathiba
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Khaji Syed Kareemuddin
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Ranjit Mohan Anjana
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation & Dr.Mohan’s Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention and Control, IDF Centre of Education, Gopalapuram, Chennai, India
- * E-mail:
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Das T, Raman R, Ramasamy K, Rani PK. Telemedicine in diabetic retinopathy: current status and future directions. Middle East Afr J Ophthalmol 2015; 22:174-8. [PMID: 25949074 PMCID: PMC4411613 DOI: 10.4103/0974-9233.154391] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Telemedicine is exchange of medical data by electronic telecommunications technology that allows a patient's medical problems evaluated and monitored by a remotely located physician. Over the years, telemedicine and telescreening have become important components in health care, in both disease detection and treatment. Highly visual and image intensive ophthalmology is uniquely suited for telemedicine. Because of rising disease burden coupled with high opportunity cost in detection, diabetic retinopathy is an ideal ophthalmic disease for telescreening and decision-making. It fits to Wilson and Jungner's all 10 criteria of screening for chronic diseases and the American Telehealth Association's 4 screening categories.
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Affiliation(s)
| | - Rajiv Raman
- Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Kim Ramasamy
- Aravind Eye Care System, Madurai, Tamil Nadu, India
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