Sensitivity and specificity of high-resolution wide field fundus imaging for detecting neovascular age-related macular degeneration

Comparison of quantitative assessment and efficiency of diabetic retinopathy diagnosis using ETDRS seven-field imaging and two ultra-widefield imaging

PURPOSE

This study compared the efficiency of diabetic retinopathy (DR) diagnosis and differences in the relative visible retinal area among the Early Treatment Diabetic Retinopathy Study (ETDRS) seven-field, ultra-widefield (UWF)-Optos, and UWF-Clarus fundus imaging methods.

METHODS

This was a prospective and clinic-based comparative study. All patients underwent three fundus examinations, and all images were graded using the ETDRS severity scale. We compared and analysed the agreement of DR severity and the relative visible retinal area among the three fundus examination methods, and the number and type of lesions outside the ETDRS seven-field (peripheral lesions) between the two UWF imaging methods.

RESULTS

A total of 202 patients (386 eyes) were included. Weighted kappa for the agreement between ETDRS seven-field and blinded Optos images was 0.485; between ETDRS seven-field and blinded Clarus images, 0.924; and between blinded Optos and Clarus images, 0.461. Blinded Clarus showed excellent performance when a ETDRS scale was used for grading the images. The relative visible retinal area for ETDRS seven-field images was 195 ± 28 disc area (DA); single Optos images, 371 ± 69 DA; single Clarus images, 261 ± 65 DA; two-montage Clarus images, 462 ± 112 DA; and four-montage Clarus images, 598 ± 139 DA. The relative visible retinal area was statistically significant between any two of the imaging systems used. In total, 2015 and 4200 peripheral lesions were detected in single Optos and Clarus images, respectively (P < 0.001). These peripheral lesions on two UWF images suggested a more severe DR level in approximately 10% and 12% of eyes, respectively.

CONCLUSION

UWF-Clarus fundus imaging offers a suitable assessment approach for DR severity; it could improve DR diagnosis and has the potential to replace ETDRS seven-field imaging after additional clinical trials.

Assessment of early diabetic retinopathy severity using ultra-widefield Clarus versus conventional five-field and ultra-widefield Optos fundus imaging

To compare early diabetic retinopathy (DR) severity level and the abilities in detecting early DR lesions among conventional five-field, ultrawide-field (UWF) Optos, and UWF Clarus fundus imaging methods. This was a single-center, prospective, clinic-based, and comparative study. In total, 157 consecutive patients with diabetes mellitus were enrolled in this study. All patients underwent comprehensive ophthalmological examinations. Following mydriasis, each eye was examined with conventional five-field, UWF Optos, and UWF Clarus fundus imaging methods. The initial UWF images were overlaid with a template mask that obscured the retina, which created a five-field view from UWF images (covered UWF images). The covered UWF images were then graded, after which the template mask was removed, and the original UWF images were also evaluated. All images were graded using the International Clinical DR severity scale. DR grades were compared and analyzed by weighted kappa statistics among the three fundus imaging methods. In total, 157 consecutive patients with diabetes (302 eyes) were enrolled in this study. Weighted kappa statistics for agreement were 0.471 (five-field vs. covered Optos), 0.809 (five-field vs. covered Clarus), 0.396 (covered Optos vs. covered Clarus), 0.463 (five-field vs. Optos), 0.521 (five-field vs. Clarus 133°), 0.500 (five-field vs. Clarus 200°), 0.323 (Optos vs. Clarus 133°), and 0.349 (Optos vs. Clarus 200°). The area under curve of covered Clarus images was higher than that of conventional five-field images at three different thresholds. Compared with conventional five-field and Optos fundus imaging methods, Clarus fundus imaging methods exhibited excellent performance in assessing early DR severity. Thus, Clarus fundus imaging methods were superior for early detection of DR.

Prognostic Optical Coherence Tomography Biomarkers in Neovascular Age-Related Macular Degeneration

Optical coherence tomography has revolutionized the diagnosis and management of neovascular age-related macular degeneration. OCT-derived biomarkers have the potential to further guide therapeutic advancements with anti-vascular endothelial growth factor; however, the clinical convergence between these two tools remains suboptimal. Therefore, the aim of this review of literature was to examine the current data on OCT biomarkers and their prognostic value. Thirteen biomarkers were analyzed, and retinal fluid had the strongest-reported impact on clinical outcomes, including visual acuity, clinic visits, and anti-VEGF treatment regimens. In particular, intra-retinal fluid was shown to be associated with poor visual outcomes. Consistencies in the literature with regard to these OCT prognostic biomarkers can lead to patient-specific clinical decision making, such as early-initiated treatment and proactive monitoring. An integrated analysis of all OCT components in combination with new efforts toward automated analysis with artificial intelligence has the potential to further improve the role of OCT in nAMD therapy.

Diagnostic Accuracy of the Amsler Grid Test for Detecting Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-analysis

Importance

Patients with nonneovascular age-related macular degeneration (AMD) are encouraged to use the Amsler grid test for self-assessment to facilitate early diagnosis. The test is widely recommended, suggesting a belief that it signals worsening AMD, warranting its use in home monitoring.

Objective

To systematically review studies of the diagnostic test accuracy of the Amsler grid in the diagnosis of neovascular AMD and to perform diagnostic test accuracy meta-analyses.

Data Sources

A systematic literature search was conducted in 12 databases for relevant titles from database inception until May 7, 2022.

Study Selection

Studies included those with groups defined as having (1) neovascular AMD and (2) either healthy eyes or eyes with nonneovascular AMD. The index test was the Amsler grid. The reference standard was ophthalmic examination. After removal of obviously irrelevant reports, 2 authors (J.B. and M.S.) independently screened the remaining references in full text for potential eligibility. Disagreements were resolved by a third author (Y.S.).

Data Extraction and Synthesis

Two authors (J.B. and I.P.) independently extracted all data and evaluated quality and applicability of eligible studies using the Quality Assessment of Diagnostic Accuracy Studies 2. Disagreements were resolved by a third author (Y.S.).

Main Outcomes and Measures

Sensitivity and specificity of the Amsler grid for detecting neovascular AMD with comparators being either healthy control participants or patients with nonneovascular AMD.

Results

Of 523 records screened, 10 studies were included with a total of 1890 eyes (mean participant age ranging from 62 to 83 years). Sensitivity and specificity to diagnose neovascular AMD were 67% (95% CI, 51%-79%) and 99% (95% CI, 85%-100%), respectively, when comparators were healthy control participants and 71% (95% CI, 60%-80%) and 63% (95% CI, 49%-51%), respectively, when control participants were patients with nonneovascular AMD. Overall, potential sources of bias were low across studies.

Conclusions and Relevance

Although the Amsler grid is easy and inexpensive to use for detection of metamorphopsia, its sensitivity may be at levels typically not recommended for monitoring. Coupling this lower sensitivity with only moderate specificity to identify neovascular AMD in a population at risk, these findings suggest that such patients typically should be encouraged to undergo ophthalmic examination regularly, regardless of any results of Amsler grid self-assessment.

Ultra-wide field imaging to assess the optic nerve and retina in Boston type I and II keratoprosthesis patients

Background

The ability to view the posterior segment in keratoprosthesis (Kpro) implanted patients is limited. The purpose of this retrospective, observational study was to investigate the use of ultra-wide field (UWF) scanning laser ophthalmoscopy imaging and its utility for serial evaluation of the retina and optic nerve in patients with either a Boston type I or II Kpro.

Methods

A retrospective chart review was performed for patients with a Boston type I or II Kpro seen at The Ohio State University Wexner Medical Center. Images were graded for quality by two masked observers on a defined four-point scale (“Poor”, “Fair”, “Good”, or “Very good”) and assessed for visible posterior segment anatomy. Interobserver agreement was described using the Kappa statistic coefficient (κ) with 95% confidence intervals.

Results

A total of 19 eyes from 17 patients were included in this study. Eighteen eyes had a type I Kpro, while one eye had a type II Kpro. UWF imaging from 41 patient visits were reviewed by two observers. Interobserver agreement between the two graders was fair for image quality (κ = 0.36), moderate for visibility of the macula with discernible details (κ = 0.59), moderate for visibility of the anterior retina with discernable details (κ = 0.60), and perfect agreement for visibility of the optic nerve with discernible details (κ = 1.0). In 6 eyes, UWF imaging was performed longitudinally (range 3–9 individual visits), allowing for long-term follow-up (range 3–46 months) of posterior segment clinical pathology.

Conclusions

UWF imaging provides adequate and reliable visualization of the posterior segment in Kpro implanted patients. This imaging modality allowed for noninvasive longitudinal monitoring of retinal and optic nerve disease in this selected patient population.

Sensitivity and specificity of pseudocolor ultrawide field imaging in comparison to wide field fundus fluorescein angiography in detecting retinal neovascularization in diabetic retinopathy

OBJECTIVE

To evaluate the diagnostic accuracy of ultrawide pseudocolor retinal photography (pseudocolor UWF) compared to wide field fundus fluorescein angiography (WFFFA) in the detection of retinal neovascularization (NV) and NV of the disc (NVD) in patients with diabetic retinopathy (DR).

DESIGN

Diagnostic accuracy observational study evaluating pseudocolor UWF as the index test. The reference standard was WFFFA.

SETTING

Single retinal centre in India.

PARTICIPANTS

People with severe non-proliferative DR (sNPDR), early proliferative DR (ePDR) or high-risk proliferative DR (HR PDR).

MAIN OUTCOME MEASURES

Sensitivity and specificity of pseudocolor UWF in the detection of NV.

RESULTS

A total of 176 eyes of 94 subjects with sNPDR, ePDR or HR PDR underwent pseudocolor UWF and WFFFA. The sensitivity and specificity of pseudocolor UWF in detecting NVE were 92.5% (95% CI 86.2-96.5) and 81% (95% CI 64.8-92.0), respectively, with moderate interobserver agreement of 0.722 (p value 0.001). The positive predictive value and negative predictive value were 83.0 (71.4-90.5) and 91.5 (84.9-95.3), respectively.

CONCLUSION

Compared to WFFFA as the gold standard, pseudocolor UWF has high sensitivity and specificity in detection of NV in all retinal quadrants and NVD. Therefore, pseudocolor UWF may be used as a non-invasive tool for screening and managing DR.

Diagnostic accuracy of teleretinal screening for detection of diabetic retinopathy and age-related macular degeneration: a systematic review and meta-analysis

Objective

To evaluate the diagnostic accuracy of teleretinal screening compared with face-to-face examination for detection of diabetic retinopathy (DR) and age-related macular degeneration (AMD).

Methods and analysis

This study adhered to the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). A comprehensive search of OVID MEDLINE, EMBASE and Cochrane CENTRAL was performed from January 2010 to July 2021. QUADAS-2 tool was used to assess methodological quality and applicability of the studies. A bivariate random effects model was used to perform the meta-analysis. Referrable DR was defined as any disease severity equal to or worse than moderate non-proliferative DR or diabetic macular oedema (DMO).

Results

28 articles were included. Teleretinal screening achieved a sensitivity of 0.91 (95% CI: 0.82 to 0.96) and specificity of 0.88 (0.74 to 0.95) for any DR (13 studies, n=7207, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) low). Accuracy for referrable DR (10 studies, n=6373, GRADE moderate) was lower with a sensitivity of 0.88 (0.81 to 0.93) and specificity of 0.86 (0.79 to 0.90). After exclusion of ungradable images, the specificity for referrable DR increased to 0.95 (0.90 to 0.98), while the sensitivity remained nearly unchanged at 0.85 (0.76 to 0.91). Teleretinal screening achieved a sensitivity of 0.71 (0.49 to 0.86) and specificity of 0.88 (0.85 to 0.90) for detection of AMD (three studies, n=697, GRADE low).

Conclusion

Teleretinal screening is highly accurate for detecting any DR and DR warranting referral. Data for AMD screening is promising but warrants further investigation.

PROSPERO registration number

CRD42020191994.

Comparison of Two Ultra-Widefield Cameras With High Image Resolution and Wider View for Identifying Diabetic Retinopathy Lesions

Purpose

To compare the effectiveness of the Optos P200dTx and Zeiss Clarus 500 fundus cameras in detecting diabetic retinopathy (DR) lesions.

Methods

A cross-sectional study was conducted among 243 patients with clinically diagnosed diabetes mellitus who were referred for an eye examination from two tertiary eye care centers in Chennai, India. Patients underwent DR screening based on mydriatic fundal images acquired by both fundal cameras. Fundal images from the two separate devices for each eye were compared based on accurately identified pathological retinal lesions with respect to type and location.

Results

When studying lesions of the central retina, they were better identified by the Zeiss Clarus compared with the Optos P200dTx, with six out of eight being statistically significant (P < 0.05). However, lesions of the mid-peripheral retina and peripheral retina were better identified by the Optos P200dTx than the Zeiss Clarus, with three out of eight lesions and five out of eight lesions being statistically significant (P < 0.05), respectively. Based on the color and size of lesions, the Optos P200dTx had a higher chance (59.6%) of missing white lesions than did the Zeiss Clarus (17%) (P < 0.0001). Consequently, small- and medium-sized lesions were missed more by the Optos P200dTx (30.72% and 32.63%, respectively) than the Zeiss Clarus (22.3% and 19.30%, respectively).

Conclusions

The capability of detecting or missing a particular DR lesion among diabetics differed between the two cameras based on effective field of view, resolution, and the retinal zone being imaged.

Translational Relevance

The choice of which ultra-widefield camera to be used for screening DR can be based on the greater prevalence of central versus peripheral retinal lesions noted in the patient population seen in a clinical practice.

Association Between Retinal Artery Angle and Visual Function in Eyes With Idiopathic Epiretinal Membrane

Purpose

This study investigated the relationship between retinal artery angle and visual function in eyes with idiopathic epiretinal membrane (ERM).

Methods

Ultra-wide field fundus imaging was conducted to analyze ERM and normal contralateral eyes. In addition to the logMAR visual acuity (VA) measurement, the average of the vertical and horizontal metamorphopsia scores (Mave) was measured using m-Charts for each eye. We calculated the retinal artery angle (Yugami correlated angle [YCA]) in all the examined eyes using ImageJ software. The YCAs were then compared between the ERM and normal contralateral eyes. Additionally, the relationship between YCA and visual function was investigated in the ERM eyes.

Results

Data from 40 patients with ERM were analyzed. The mean age of the participants was 67.1 ± 8.1 years. The YCA was significantly smaller in the ERM eyes, compared with the contralateral eyes (P < 0.001, respectively; Wilcoxon signed rank test). Among age, axial length, YCAs, central retinal thickness (CRT), and central choroidal thickness (CCT), the optimal model for logMAR VA included age, YCA, and CRT. On the other hand, the optimal model for Mave included YCA and CCT.

Conclusions

The retinal artery angle may be useful for predicting visual function in eyes with ERM.

Translational Relevance

Our established quantitative measurements in fundus photography have potential clinical use in predicting visual function in ERM.