A decade-long telemedicine screening program for diabetic retinopathy in the north-east of Italy

Follow-up in a point-of-care diabetic retinopathy program in Pittsburgh: a non-concurrent retrospective cohort study

BACKGROUND

The Point-of-Care Diabetic Retinopathy Examination Program (POCDREP) was initiated in 2015 at the University of Pittsburgh/UPMC in response to low diabetic retinopathy (DR) examination rates, a condition affecting a quarter of people with diabetes mellitus (PwDM) and leading to blindness. Early detection and treatment are critical with DR prevalence projected to triple by 2050. Approximately, half of PwDM in the U.S. undergo yearly examinations, and there are reported varying follow-up rates with eye care professionals, with limited data on the factors influencing these trends. POCDREP aimed to address screening and follow-up gap, partnering with diverse healthcare entities, including primary care sites, free clinics, and federally qualified health centers.

METHODS

A non-concurrent retrospective cohort study spanning 2015-2018 examined data using electronic health records of patients who underwent retinal imaging. Imaging was performed using 31 cameras across various settings, with results interpreted by ophthalmologists. Follow-up recommendations were made for cases with vision-threatening DR (VTDR), incidental findings, or indeterminate results. Factors influencing follow-up were analyzed, including demographic, clinical, and imaging-related variables. We assessed the findings at follow-up of patients with indeterminate results.

RESULTS

Out of 7,733 examinations (6,242 patients), 32.25% were recommended for follow-up. Among these, 5.57% were classified as having VTDR, 14.34% had other ocular findings such as suspected glaucoma and age-related macular degeneration (AMD), and 12.13% were indeterminate. Of those recommended for follow-up, only 30.87% were assessed by eye care within six months. Older age, marriage, and severe DR were associated with higher odds of following up. Almost two thirds (64.35%) of the patients with indeterminate exams were found with a vision-threatening disease at follow-up.

CONCLUSION

The six-month follow-up rate was found to be suboptimal. Influential factors for follow-up included age, marital status, and the severity of diabetic retinopathy (DR). While the program successfully identified a range of ocular conditions, screening initiatives must extend beyond mere disease detection. Ensuring patient follow-up is crucial to DR preventing programs mission. Recommended strategies to improve follow-up adherence include education, incentives, and personalized interventions. Additional research is necessary to pinpoint modifiable factors that impact adherence and to develop targeted interventions.

A stepwise implementation of the Slovenian National Diabetic Retinopathy Screening Program - evaluation of the first 4.5 years

BACKGROUND

This retrospective cohort study aimed to assess the characteristics of patients enrolled in the national diabetic retinopathy (DR) screening program and evaluate the selected program's quality elements in the first five years after implementation.

METHODS

Patients who underwent DR screening between February 2018 and June 2022 at the University Medical Centre Ljubljana were included. General patient characteristics (age, sex, type and therapy of diabetes mellitus (DM), duration of DM, blood HbA1c levels), best corrected visual acuity, stage of DR, presence of sight-threatening diabetic retinopathy (STDR), and selected quality indicators (quality of photographs, re-screening interval, time to treatment) were recorded and evaluated.

RESULTS

A total of 34 654 screening examinations were performed on 13 513 patients with diabetes. The majority (77.3%) had Type 2 diabetes, with a mean DM duration of 9.74 ± 9.87 years. In 55.9% of patients, DM duration was less than ten years, and the mean HbA1c was 7.33% ± 1.49. DR signs were noted in 29.1% of patients and 0.89% of patients exhibited STDR. After establishing the diagnosis of STDR, treatment was initiated in 3.43 ± 1.98 months.

CONCLUSION

Implementing the DR screening program provides valuable insights into managing diabetic retinopathy nationwide. It allows for the early detection of sight-threatening DR and facilitates timely and effective treatment, which could help prevent severe visual impairment.

Comprehensive insights into a decade-long journey: The evolution, impact, and human factors of an asynchronous telemedicine program for diabetic retinopathy screening in Pennsylvania, United States

Diabetic Retinopathy stands as a leading cause of irreversible blindness, necessitating frequent examinations, especially in the early stages where effective treatments are available. However, current examination rates vary widely, ranging from 25-60%. This study scrutinizes the Point-of-Care Diabetic Retinopathy Examination Program at the University of Pittsburgh/UPMC, delving into its composition, evolution, challenges, solutions, and improvement opportunities. Employing a narrative approach, insights are gathered from key stakeholders, including ophthalmologists and staff from primary care clinics. A quantitative analysis from 2008 to 2020 provides a comprehensive overview of program outcomes, covering 94 primary care offices with 51 retinal cameras. Program components feature automated non-mydriatic 45° retinal cameras, a dedicated coordinator, rigorous training, and standardized workflows. Over this period, the program conducted 21,960 exams in 16,458 unique individuals, revealing a diverse population with an average age of 58.5 and a balanced gender distribution. Average body mass index (33.96±8.02 kg/m2) and hemoglobin A1c (7.58%±1.88%) surpassed normal ranges, indicating prevalent risk factors for diabetes-related complications. Notably, 24.2% of patients underwent more than one exam, emphasizing program engagement. Findings indicated that 86.3% of exams were gradable, with 59.0% within normal limits, 12.1% showing some evidence of diabetic retinopathy, and 6.4% exhibiting vision-threatening diabetic retinopathy. Follow-up appointments with ophthalmologists were recommended in 31.5% of exams due to indeterminate results, positive diabetic retinopathy (≥moderate or macular exudate), or other findings like age-related macular degeneration or suspected glaucoma. The program demonstrated high reproducibility across diverse healthcare settings, featuring a sustainable model with minimal camera downtime, standardized workflows, and financial support from grants, health systems, and clinical revenues. Despite COVID-19 pandemic challenges, this research emphasizes the program's reproducibility, user-friendly evolution, and promising outcomes. Beyond technical contributions, it highlights human factors influencing program success. Future research could explore adherence to follow-up ophthalmological recommendations and its associated factors.

A systematic review of diabetic retinopathy screening intervals

The current evidence on whether annual diabetic retinopathy (DR) screening intervals can be extended was reviewed. A systematic review protocol was followed (PROSPERO ID: CRD42022359590). Original longitudinal articles that specifically assessed DR screening intervals were in English and collected data after 2000 were included. Two reviewers independently conducted the search and reviewed the articles for quality and relevant information. The heterogeneity of the data meant that a meta-analysis was not appropriate. Twelve publications were included. Studies were of good quality and many used data from DR screening programs. Studies fit into three categories; those that assessed specific DR screening intervals, those that determined optimal DR screening intervals and those that developed/assessed DR screening risk equations. For those with type 2 diabetes, extending screening intervals to 3- to 4-yearly in those with no baseline DR appeared safe. DR risk equations considered clinical factors and allocated those at lower risk of DR progression screening intervals of up to five years. Those with baseline DR or type 1 diabetes appeared to have a higher risk of progression to STDR and needed more frequent screening. DR screening intervals can be extended to 3-5 yearly in certain circumstances. These include patients with type 2 diabetes and no current DR, and those who have optimal management of other risk factors such as glucose and blood pressure.

Comparison of 50° handheld fundus camera versus ultra-widefield table-top fundus camera for diabetic retinopathy detection and grading

OBJECTIVES

To compare the performance of a handheld fundus camera with standard 50° visual field to ultra-widefield (UWF) table-top fundus camera in diabetic retinopathy (DR) detection and grading.

METHODS

Patients affected by diabetes mellitus and referred to our diabetic retinopathy clinic were enroled and underwent fundus photography in mydriasis. All photos were taken using the ultra-widefield table-top fundus camera Zeiss Clarus™ 500 (four fields per eye) and the Optomed Aurora® handheld fundus camera (3 fields per eye). The following parameters were analysed: the gradability of the images, the grade of DR, and diabetic maculopathy (DM), the presence of hypertensive retinopathy (HR) and the presence of other ocular diseases.

RESULTS

We enroled 759 eyes of 384 diabetic patients and analysed 5313 fundus photos. The handheld fundus camera obtained a sensitivity of 84.2% and specificity of 95.4% for referable cases. Moreover, it obtained, compared to UWF, an almost perfect agreement with linear weighting for DR, DM and HR (k = 0.877, k = 0.854, and k = 0.961, respectively). The lowest sensitivity was achieved for proliferative DR (58.7% sensitivity, 100% specificity).

CONCLUSIONS

Optomed Aurora® handheld fundus camera imaging showed a strong agreement compared to UWF in grading DR, considering all DR and DM grades, in mydriasis. However, the use of UWF imaging increases the detection of referable eyes.

Automatic Diagnosis of Diabetic Retinopathy Stage Focusing Exclusively on Retinal Hemorrhage

Background and Objectives: The present study evaluated the detection of diabetic retinopathy (DR) using an automated fundus camera focusing exclusively on retinal hemorrhage (RH) using a deep convolutional neural network, which is a machine-learning technology. Materials and Methods: This investigation was conducted via a prospective and observational study. The study included 89 fundus ophthalmoscopy images. Seventy images passed an image quality review and were graded as showing no apparent DR (n = 51), mild nonproliferative DR (NPDR; n = 16), moderate NPDR (n = 1), severe NPDR (n = 1), and proliferative DR (n = 1) by three retinal experts according to the International Clinical Diabetic Retinopathy Severity scale. The RH numbers and areas were automatically detected and the results of two tests—the detection of mild-or-worse NPDR and the detection of moderate-or-worse NPDR—were examined. Results: The detection of mild-or-worse DR showed a sensitivity of 0.812 (95% confidence interval: 0.680–0.945), specificity of 0.888, and area under the curve (AUC) of 0.884, whereas the detection of moderate-or-worse DR showed a sensitivity of 1.0, specificity of 1.0, and AUC of 1.0. Conclusions: Automated diagnosis using artificial intelligence focusing exclusively on RH could be used to diagnose DR requiring ophthalmologist intervention.

Epidemiology of Treated Diabetes Ocular Complications in France 2008-2018-The LANDSCAPE French Nationwide Study

AIM

LANDSCAPE aimed to estimate the annual incidence and prevalence of treated diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) between 2008 and 2018.

METHODS

This French nationwide observational study used data from the French National Health Insurance Databases covering 99% of the French population. Data about healthcare consumption were used to identify adults treated with anti-VEGFs or dexamethasone implants (for DME) and with pan-retinal photocoagulation (for PDR). All French patients newly treated between 2008 and 2018 were included. Incidence and prevalence of treated DME and PDR were estimated for the age-matched general population and the population with diabetes in France. Sociodemographic characteristics and medical history were described in both populations.

RESULTS

We identified 53,584 treated DME patients and 127,273 treated PDR patients between 2008 and 2018, and 11,901 DME and 11,996 PDR new incident patients in 2018. The treated DME incidence in 2018 was 2.5 per 10,000 in the general population and 37.3 per 10,000 in the population with diabetes. Prevalence in 2018 was 9.5 and 143.7 per 10,000 in the respective populations. Treated PDR incidence in 2018 was 2.3 per 10,000 in the general population and 31.2 per 10,000 in the population with diabetes. Prevalence in 2018 was 19.9 and 270.3 per 10,000 in the respective populations. Incidence and prevalence were not age-dependent. Incidence of treated PDR incidence was relatively stable from 2008-2018. Incidence of treated DME incidence rose from 2012-2018, probably due to widening access to newly available treatments, such as anti-VEGFs.

CONCLUSIONS

We provide exhaustive nationwide data on the incidence and prevalence of treated diabetic ocular complications in France over a 10-year period.

Clinical and Molecular Characteristics of Diabetic Retinopathy and Its Severity Complications among Diabetic Patients: A Multicenter Cross-Sectional Study

Background: Diabetic retinopathy (DR) is a complication associated with uncontrolled DM. It is a leading preventable cause of visual impairment in the world and a cause of blindness in those under 75 years old in developing countries. We aimed to explore the prevalence and associated risk factors of DR among diabetic patients in the West Bank. Materials and Methods:A quantitative multicenter cross-sectional study was conducted in all West Bank cities. Nearly, 385 patients underwent a comprehensive eye examination in addition to blood and urine tests. A previously validated questionnaire for ocular examination classification was used together with a socio-demographic and past medical history information sheet. Results: The prevalence of all DR in the West Bank was 41.8%. The prevalence of non-proliferative diabetic retinopathy (NPDR) was 50.3% (38.5% for mild NPDR, 10.6% for moderate NPDR and 1.2% for severe NPDR). The prevalence of proliferative diabetic retinopathy (PDR) was 9.9% and 39.7% for diabetic macular edema (DME) (17.4% for mild, 15.5% for moderate and 6.8% for severe DME). The prevalence of vision-threatening PDR and DME was 49.7% for both. In a univariate analysis, DR was significantly associated with body mass index; BMI (p = 0.035), DM duration (p = 0.002), Low-density lipoprotein (LDL) (p = 0.034), glutamic-oxaloacetic transaminase (GOT) level (p = 0.016) andblood urea (BU) (p = 0.044). A multivariate analysis showed a strong significant association between DR andpatients who had DM for 10-19years (adjusted odds ratio; AOR (95%CI); 1.843 (1.05–3.22)), abnormal levels of LDL (AOR (95%CI); 0.50 (0.30–0.83)), abnormal levels of GOT (AOR (95%CI); 0.49 (0.27–0.89)), and overweight (AOR (95%CI); 0.39 (0.19–0.80)). Conclusions: We found that the prevalence of DR in Palestine was higher than the global prevalence. Referral coordination between ophthalmologists and internal physicians is necessary to better follow up with DR patients. An interventional educational program by clinicians and public health professionals is recommended.

Handheld Fundus Camera for Diabetic Retinopathy Screening: A Comparison Study with Table-Top Fundus Camera in Real-Life Setting

The aim of the study was to validate the performance of the Optomed Aurora^® handheld fundus camera in diabetic retinopathy (DR) screening. Patients who were affected by diabetes mellitus and referred to the local DR screening service underwent fundus photography using a standard table-top fundus camera and the Optomed Aurora^® handheld fundus camera. All photos were taken by a single, previously unexperienced operator. Among 423 enrolled eyes, we found a prevalence of 3.55% and 3.31% referable cases with the Aurora^® and with the standard table-top fundus camera, respectively. The Aurora^® obtained a sensitivity of 96.9% and a specificity of 94.8% in recognizing the presence of any degree of DR, a sensitivity of 100% and a specificity of 99.8% for any degree of diabetic maculopathy (DM) and a sensitivity of 100% and specificity of 99.8% for referable cases. The overall concordance coefficient k (95% CI) was 0.889 (0.828–0.949) and 0.831 (0.658–1.004) with linear weighting for DR and DM, respectively. The presence of hypertensive retinopathy (HR) was recognized by the Aurora^® with a sensitivity and specificity of 100%. The Optomed Aurora^® handheld fundus camera proved to be effective in recognizing referable cases in a real-life DR screening setting. It showed comparable results to a standard table-top fundus camera in DR, DM and HR detection and grading. The Aurora^® can be integrated into telemedicine solutions and artificial intelligence services which, in addition to its portability and ease of use, make it particularly suitable for DR screening.

Prevalence and incidence of diabetic retinopathy (DR) in the UK population of Gloucestershire

Purpose

To estimate prevalence and incidence of diabetic retinopathy (DR) in a UK region by severity between 2012 and 2016 and risk factors for progression to proliferative DR (PDR).

Methods

Electronic medical records from people with diabetes (PWD) ≥18 years seen at the Gloucestershire Diabetic Eye Screening Programme (GDESP) and the hospital eye clinic were analysed (HEC). Prevalence and incidence of DR per 100 PWD (%) by calendar year, grade and diabetes type were estimated using log‐linear regression. Progression to PDR and associated risk factors were estimated using parametric survival analyses.

Results

Across the study period, 35 873 PWD had at least one DR assessment. They were aged 66 (56–75) years (median (interquartile range)), 57% male, 5 (1–10) years since diabetes diagnosis, 93% Type 2 diabetes. Prevalence of DR decreased from 38.9% (95% CI: 38.1%, 39.8%) in 2012 to 36.6% (95% CI: 35.9%, 37.3%) in 2016 (p < 0.001). Incidence of any DR decreased from 10.9% (95% CI: 10.4%, 11.5%) in 2013 to 8.5% (95% CI: 8.1%, 9.0%) in 2016 (p < 0.001). Prevalence of PDR decreased from 3.5% (95% CI: 3.3%, 3.8%) in 2012 to 3.1% (95% CI 2.9%, 3.3%) in 2016 (p = 0.008). Incidence of PDR did not change over time. HbA_1c and bilateral moderate–severe NPDR were statistically significant risk factors associated with progression to PDR.

Conclusions

Incidence and prevalence of DR decreased between 2012 and 2016 in this well‐characterized population of the UK.

MiR-181 enhances proliferative and migratory potentials of retinal endothelial cells in diabetic retinopathy by targeting KLF6

PURPOSE

We aimed to uncover the role of microRNA-181 (miR-181) in the disease onset of diabetic retinopathy (DR) and its underlying mechanism.

METHODS

MiR-181 levels in plasma and aqueous humor samples of non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR) and healthy subjects were analyzed by microarray and quantitative real-time polymerase chain reaction (qRT-PCR). Proliferative and migrative capacities of human retinal endothelial cells (hRECs) regulated by miR-181 were assessed. The binding between miR-181 and kruppel-like factor 6 (KLF6) was verified by dual-luciferase reporter assay.

RESULTS

MiR-181 was upregulated in plasma and aqueous humor samples of NPDR and PDR patients. Overexpression of miR-181 stimulated hRECs to proliferate and migrate. KLF6 was the downstream gene binding miR-181, which was involved in the regulation of hRECs by miR-181.

CONCLUSIONS

MiR-181 is upregulated in plasma and aqueous humor of DR patients. It enhances proliferative and migratory potentials of retinal endothelial cells by targeting KLF6.

'Old Is Gold': How Traditional Indian Dietary Practices Can Support Pediatric Diabetes Management

Nutrition is crucial for maintaining normal growth, development, and glycemic control in young people with diabetes (PwD). Undue restrictions cause nutrient deficiencies as well as poor adherence to meal plans. Widespread availability of low-cost, ultra-processed, and hyperpalatable food is further damaging. Most families struggle to find ways to provide nutritious, yet attractive, food with a low glycemic index (GI). India is one of the oldest continuous civilizations with a rich and diverse cultural and culinary heritage. Traditional dietary practices, including the centuries-old 'Thali' (meaning plate) concept, emphasize combinations (grains, lentils, vegetables, dairy, spices, prebiotics and probiotics, and fats) of local, seasonal, and predominantly plant-based ingredients. These practices ensure that all of the necessary food groups are provided and fit well with current evidence-based recommendations, including the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2018 Guidelines. Techniques for the preparation, cooking, and preservation of food further impact the GI and nutrient availability. These practices benefit nutrient density, diet diversity, and palatability and thus improve adherence to meal plans and glycemic control. This narrative review describes the ancient wisdom, food composition, and culinary practices from across India which are still valuable today. These may be of benefit worldwide to improve glycemic control as well as quality of life, especially in PwD.

Prevalence and associated factors of diabetic retinopathy among type 2 diabetes mellitus patients in Brunei Darussalam - A cross-sectional study

Purpose

To determine the prevalence of diabetic retinopathy (DR) and the factors associated with retinopathy among type 2 diabetes mellitus (DM) patients in Brunei Darussalam.

Methods

Cross-sectional study of all type 2 DM patients who attended diabetic eye screening over a 3-month period at one of four government hospitals. We assessed association between DR with the following variables: age, sex, glycated hemoglobin (HbA1c), duration of DM, hypertension, hyperlipidemia, and microalbuminuria.

Results

There were 341 patients (female, 58.9%; mean age, 55.3 ± 11.9 years) with a mean duration of DM of 9.4 ± 7.4 years and mean serum HbA1c of 8.4% ± 1.9%. The overall prevalence of any DR was 22.6% (95% confidence interval, 18.8–27.1) with prevalence rates of 4.1% (95% confidence interval, 2.1–6.4) for proliferative DR and 9.7% (95% confidence interval, 6.8–13.2) for vision-threatening DR. Multivariate analysis showed that DR was significantly associated with certain age groups (reduced in older age groups), longer duration of DM (11 years or more), poor control (HbA1c >9.0%) and presence of any microalbuminuria.

Conclusions

DR affects one in five patients with DM in Brunei Darussalam, comparable to rates reported for other Asian populations. It is especially worrying that one in ten patients with DM had vision-threatening DR. DR was significantly associated with longer duration of DM, poor control and presence of microalbuminuria but reduced in older age groups. It is important to advocate good control right from the time of diagnosis of DM and institute timely and effective management of retinopathy. DR was significantly associated with longer duration of DM, poor control of diabetes, and presence of microalbuminuria but reduced in older age groups.

Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic

The current COVID-19 pandemic has boosted a sudden demand for telemedicine due to quarantine and travel restrictions. The exponential increase in the use of telemedicine is expected to affect ophthalmology drastically. The aim of this review is to discuss the utility, effectiveness and challenges of teleophthalmological new tools for eyecare delivery as well as its implementation and possible facilitation with artificial intelligence. We used the terms: “teleophthalmology,” “telemedicine and COVID-19,” “retinal diseases and telemedicine,” “virtual ophthalmology,” “cost effectiveness of teleophthalmology,” “pediatric teleophthalmology,” “Artificial intelligence and ophthalmology,” “Glaucoma and teleophthalmology” and “teleophthalmology limitations” in the database of PubMed and selected the articles being published in the course of 2015-2020. After the initial search, 321 articles returned as relevant. A meticulous screening followed and eventually 103 published manuscripts were included and used as our references. Emerging in the market, teleophthalmology is showing great potential for the future of ophthalmological care, benefiting both patients and ophthalmologists in times of pandemics. The spectrum of eye diseases that could benefit from teleophthalmology is wide, including mostly retinal diseases such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration but also glaucoma and anterior segment conditions. Simultaneously, artificial intelligence provides ways of implementing teleophthalmology easier and with better outcomes, contributing as significant changing factors for ophthalmology practice after the COVID-19 pandemic.

The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy

In the presence of the ever-increasing incidence of diabetes mellitus (DM), the prevalence of diabetic eye disease (DED) is also growing. Despite many improvements in diabetic care, DM remains a leading cause of visual impairment in working-age patients. So far, prevention has been the best way to protect vision. The sooner we diagnose DED, the more effective the treatment is. Thus, diabetic retinopathy (DR) screening, especially with imaging techniques, is a method of choice for vision protection. To alleviate the burden of diabetic patients who need ophthalmic care, telemedicine and in-home testing are used, supported by artificial intelligence (AI) algorithms. This is why we decided to evaluate current image teleophthalmology methods used for DR screening. We searched the PubMed platform for papers published over the last 5 years (2015–2020) using the following key words: telemedicine in diabetic retinopathy screening, diabetic retinopathy screening, automated diabetic retinopathy screening, artificial intelligence in diabetic retinopathy screening, smartphone diabetic retinopathy testing. We have included 118 original articles meeting the above criteria, discussing imaging diabetic retinopathy screening methods. We have found that fundus cameras, stable or mobile, are most commonly used for retinal photography, with portable fundus cameras also relatively common. Other possibilities involve the use of ultra-wide-field (UWF) imaging and even optical coherence tomography (OCT) devices for DR screening. Also, the role of smartphones is increasingly recognized in the field. Retinal fundus images are assessed by humans instantly or remotely, while AI algorithms seem to be useful tools facilitating retinal image assessment. The common use of smartphones and availability of relatively cheap, easy-to-use adapters for retinal photographs augmented by AI algorithms make it possible for eye fundus photographs to be taken by non-specialists and in non-medical setting. This opens the way for in-home testing conducted on a much larger scale in the future. In conclusion, based on current DR screening techniques, we can suggest that the future practice of eye care specialists will be widely supported by AI algorithms, and this way will be more effective.

Epidemiology of moderately severe and severe non-proliferative diabetic retinopathy in South West England

Aims

To estimate the incidence of early treatment diabetic retinopathy study (ETDRS) level 47 and 53 and progression to treatment with panretinal photocoagulation (PRP) for proliferative DR (PDR).

Methods

Log-linear regression was used to estimate the incidence of level 47–53 or worse for 33,009 people with diabetes (PWD) in Gloucestershire during 2013–2016 by calendar year and diabetes type, based on the first recording. Progression was analysed in Gloucestershire and Bristol with a parametric survival analysis examining the association of baseline and time-varying demographic and clinical factors on time to PRP after the first recording of level 47–53.

Results

Incidence decreased from 0.57 (95% confidence intervals (CI) 0.48–0.67) per 100 PWD in 2013 to 0.35 (95% CI 0.29–0.43) in 2016 (p < 0.001). For progression, 338 eligible PWD from Gloucestershire and 418 from Bristol were followed for a median of 1.4 years; 78 and 83% had Type 2 diabetes and a median (interquartile range) of 15 (10–22) and 17 (11–25) years duration of diagnosed diabetes respectively. Three years from the incident ETDRS 47–53, 18.9% and 17.2% had received PRP respectively. For Gloucestershire, severe IRMA and updated mean HbA_1c were associated with an increase in the risk of initiating PRP (hazard ratio 3.14 (95% CI: 1.60–6.15) and 1.21 (95% CI: 1.06–1.38 per 10 mmol/mol) respectively).

Conclusion

This study provides additional understanding of this population and shows that a high proportion of patients with ETDRS levels 47–53 need to be monitored as they are at high risk of progressing to PDR.

A 15 month experience with a primary care-based telemedicine screening program for diabetic retinopathy

Background

Using telemedicine for diabetic retinal screening is becoming popular especially amongst at-risk urban communities with poor access to care. The goal of the diabetic telemedicine project at Temple University Hospital is to improve cost-effective access to appropriate retinal care to those in need of close monitoring and/or treatment.

Methods

This will be a retrospective review of 15 months of data from March 2016 to May 2017. We will investigate how many patients were screened, how interpretable the photographs were, how often the photographs generated a diagnosis of diabetic retinopathy (DR) based on the screening photo, and how many patients followed-up for an exam in the office, if indicated.

Results

Six-hundred eighty-nine (689) digital retinal screening exams on 1377 eyes of diabetic patients were conducted in Temple’s primary care clinic. The majority of the photographs were read to have no retinopathy (755, 54.8%). Among all of the screening exams, 357 (51.8%) triggered a request for a referral to ophthalmology. Four-hundred forty-nine (449, 32.6%) of the photos were felt to be uninterpretable by the clinician. Referrals were meant to be requested for DR found in one or both eyes, inability to assess presence of retinopathy in one or both eyes, or for suspicion of a different ophthalmic diagnosis. Sixty-seven patients (9.7%) were suspected to have another ophthalmic condition based on other findings in the retinal photographs. Among the 34 patients that were successfully completed a referral visit to Temple ophthalmology, there was good concordance between the level of DR detected by their screening fundus photographs and visit diagnosis.

Conclusions

Although a little more than half of the patients did not have diabetic eye disease, about half needed a referral to ophthalmology. However, only 9.5% of the referral-warranted exams actually received an eye exam. Mere identification of referral-warranted diabetic retinopathy and other ophthalmic conditions is not enough. A successful telemedicine screening program must close the communication gap between screening and diagnosis by reviewer to provide timely follow-up by eye care specialists.

Longitudinal Screening for Diabetic Retinopathy in a Nationwide Screening Program: Comparing Deep Learning and Human Graders

OBJECTIVE

To evaluate diabetic retinopathy (DR) screening via deep learning (DL) and trained human graders (HG) in a longitudinal cohort, as case spectrum shifts based on treatment referral and new-onset DR.

METHODS

We randomly selected patients with diabetes screened twice, two years apart within a nationwide screening program. The reference standard was established via adjudication by retina specialists. Each patient's color fundus photographs were graded, and a patient was considered as having sight-threatening DR (STDR) if the worse eye had severe nonproliferative DR, proliferative DR, or diabetic macular edema. We compared DR screening via two modalities: DL and HG. For each modality, we simulated treatment referral by excluding patients with detected STDR from the second screening using that modality.

RESULTS

There were 5,738 patients (12.3% STDR) in the first screening. DL and HG captured different numbers of STDR cases, and after simulated referral and excluding ungradable cases, 4,148 and 4,263 patients remained in the second screening, respectively. The STDR prevalence at the second screening was 5.1% and 6.8% for DL- and HG-based screening, respectively. Along with the prevalence decrease, the sensitivity for both modalities decreased from the first to the second screening (DL: from 95% to 90%, p = 0.008; HG: from 74% to 57%, p < 0.001). At both the first and second screenings, the rate of false negatives for the DL was a fifth that of HG (0.5-0.6% vs. 2.9-3.2%).

CONCLUSION

On 2-year longitudinal follow-up of a DR screening cohort, STDR prevalence decreased for both DL- and HG-based screening. Follow-up screenings in longitudinal DR screening can be more difficult and induce lower sensitivity for both DL and HG, though the false negative rate was substantially lower for DL. Our data may be useful for health-economics analyses of longitudinal screening settings.

A personalised screening strategy for diabetic retinopathy: a cost-effectiveness perspective

AIMS/HYPOTHESIS

In this study we examined the cost-effectiveness of three different screening strategies for diabetic retinopathy: using a personalised adaptive model, annual screening (fixed intervals), and the current Dutch guideline (stratified based on previous retinopathy grade).

METHODS

For each individual, optimal diabetic retinopathy screening intervals were determined, using a validated risk prediction model. Observational data (1998-2017) from the Hoorn Diabetes Care System cohort of people with type 2 diabetes were used (n = 5514). The missing values of retinopathy grades were imputed using two scenarios of slow and fast sight-threatening retinopathy (STR) progression. By comparing the model-based screening intervals to observed time to develop STR, the number of delayed STR diagnoses was determined. Costs were calculated using the healthcare perspective and the societal perspective. Finally, outcomes and costs were compared for the different screening strategies.

RESULTS

For the fast STR progression scenario, personalised screening resulted in 11.6% more delayed STR diagnoses and €11.4 less costs per patient compared to annual screening from a healthcare perspective. The personalised screening model performed better in terms of timely diagnosis of STR (8.8% less delayed STR diagnosis) but it was slightly more expensive (€1.8 per patient from a healthcare perspective) than the Dutch guideline strategy.

CONCLUSIONS/INTERPRETATION

The personalised diabetic retinopathy screening model is more cost-effective than the Dutch guideline screening strategy. Although the personalised screening strategy was less effective, in terms of timely diagnosis of STR patients, than annual screening, the number of delayed STR diagnoses is low and the cost saving is considerable. With around one million people with type 2 diabetes in the Netherlands, implementing this personalised model could save €11.4 million per year compared with annual screening, at the cost of 658 delayed STR diagnoses with a maximum delayed time to diagnosis of 48 months.

Andalusian program for early detection of diabetic retinopathy: implementation and 15-year follow-up of a population-based screening program in Andalusia, Southern Spain

INTRODUCTION

Diabetic retinopathy (DR) is a preventable cause of vision loss and blindness worldwide. We aim at analyzing the impact of a population-based screening program of DR using retinal photography with remote reading in terms of population coverage, diagnosis of asymptomatic DR and impact on visual disability, in the region of Andalusia, Spain, in the period 2005-2019.

RESEARCH DESIGN AND METHODS

Descriptive study. Sociodemographic and clinical features included in the Andalusian program for early detection of diabetic retinopathy (APDR) were analyzed. Population coverage, annual incidence of DR, and DR severity gradation were analyzed. Estimated data on prevalence and incidence of legal blindness due to DR were included.

RESULTS

407 762 patients with at least one successful DR examination during the study period were included. Most of the performed retinographies (784 584, 84.3%) were 'non-pathological.' Asymptomatic DR was detected in 52 748 (5.9%) retinographies, most of them (94.2%) being classified as 'mild to moderate non-proliferative DR.' DR was detected in 44 815 patients, while sight-threatening DR (STDR) in 6256 patients; cumulative incidence of DR was 11.0% and STDR was 1.5%, as DR and STDR was detected in 44 815 and 6256 patients, respectively. Annual incidence risk per patient recruitment year progressively decreased from 22.0% by January 2005 to 3.2% by June 2019.

CONCLUSIONS

Implementation of a long-term population-based screening program for early detection of DR is technically feasible and clinically viable. Thus, after 15 years of existence, the program has enabled the screening of the vast majority of the target population allowing the optimization of healthcare resources and the identification of asymptomatic DR.

The case for open science: rare diseases

The premise of Open Science is that research and medical management will progress faster if data and knowledge are openly shared. The value of Open Science is nowhere more important and appreciated than in the rare disease (RD) community. Research into RDs has been limited by insufficient patient data and resources, a paucity of trained disease experts, and lack of therapeutics, leading to long delays in diagnosis and treatment. These issues can be ameliorated by following the principles and practices of sharing that are intrinsic to Open Science. Here, we describe how the RD community has adopted the core pillars of Open Science, adding new initiatives to promote care and research for RD patients and, ultimately, for all of medicine. We also present recommendations that can advance Open Science more globally.

Application of non-mydriatic fundus examination and artificial intelligence to promote the screening of diabetic retinopathy in the endocrine clinic: an observational study of T2DM patients in Tianjin, China

Background

We aimed to determine the role of non-mydriatic fundus examination and artificial intelligence (AI) in screening diabetic retinopathy (DR) in patients with diabetes in the Metabolic Disease Management Center (MMC) in Tianjin, China.

Methods

Adult patients with type 2 diabetes mellitus who were first treated by MMC in Tianjin First Central Hospital and Tianjin 4th Center Hospital were divided into two groups according to the time that MMC was equipped with the non-mydriatic ophthalmoscope and AI system and could complete fundus examination independently (the former was the control group, the latter was the observation group). The observation indices were as follows: the incidence of DR, the fundus screening rate of the two groups, and fundus screening of diabetic patients with different course of disease.

Results

A total of 5039 patients were enrolled in this study. The incidence rate of DR was 18.6%, 29.8%, and 49.6% in patients with diabetes duration of ⩽1 year, 1-5 years, and >5 years, respectively. The screening rate of fundus in the observation group was significantly higher compared with the control group (81.3% versus 28.4%, χ ² = 1430.918, p < 0.001). The DR screening rate of the observation group was also significantly higher compared with the control group in patients with diabetes duration of ⩽1 year (77.3% versus 20.6%; χ ² = 797.534, p < 0.001), 1-5 years (82.5% versus 31.0%; χ ² = 197.124, p < 0.001) and ⩾5 years (86.9% versus 37.1%; χ² = 475.609, p < 0.001).

Conclusions

In the case of limited medical resources, MMC can carry out one-stop examination, treatment, and management of DR through non-mydratic fundus examination and AI assistance, thus incorporating the DR screening process into the endocrine clinic, so as to facilitate early diagnosis.

Screening for diabetic retinopathy: new perspectives and challenges

Although the prevalence of all stages of diabetic retinopathy has been declining since 1980 in populations with improved diabetes control, the crude prevalence of visual impairment and blindness caused by diabetic retinopathy worldwide increased between 1990 and 2015, largely because of the increasing prevalence of type 2 diabetes, particularly in low-income and middle-income countries. Screening for diabetic retinopathy is essential to detect referable cases that need timely full ophthalmic examination and treatment to avoid permanent visual loss. In the past few years, personalised screening intervals that take into account several risk factors have been proposed, with good cost-effectiveness ratios. However, resources for nationwide screening programmes are scarce in many countries. New technologies, such as scanning confocal ophthalmology with ultrawide field imaging and handheld mobile devices, teleophthalmology for remote grading, and artificial intelligence for automated detection and classification of diabetic retinopathy, are changing screening strategies and improving cost-effectiveness. Additionally, emerging evidence suggests that retinal imaging could be useful for identifying individuals at risk of cardiovascular disease or cognitive impairment, which could expand the role of diabetic retinopathy screening beyond the prevention of sight-threatening disease.

IDF Diabetes Atlas: A review of studies utilising retinal photography on the global prevalence of diabetes related retinopathy between 2015 and 2018

AIMS

The purpose of this study is to assess the prevalence of diabetic retinopathy (DR) world-wide from articles published since 2015 where the assessment of the presence and severity of DR was based on retinal images.

METHODS

A total of 4 databases were searched for the MESH terms diabetic retinopathy and prevalence. Of 112 publications 32 studies were included and individual data pooled for analysis. The presence of any DR or diabetic macular edema (DME) was recorded and severity as mild, moderate or severe non-proliferative DR (NPDR), proliferative DR (PDR) and DME and/or clinically significant macular edema (CSME). The level of severity of DR reported refer to persons with diabetes and not individual eyes.

RESULTS

The global prevalence of DR and DME, for the period 2015 to 2019 were 27.0% for any DR comprising of 25.2%, NPDR, 1.4% PDR and 4.6% DME. The lowest prevalence was in Europe at 20.6% and South East Asia at 12.5% and highest in Africa at 33.8%, Middle East and North Africa 33.8%, and the Western Pacific region at 36.2%.

CONCLUSIONS

This study illustrated difficulties in deriving a meaningful global prevalence rate for DR and DME due to the lack of uniformity in defining the study populations, methodological differences, retinal image capture and grading criteria. Therefore, international consensus is required using a minimal data set for future studies.

Non-mydriatic fundus camera screening with diagnosis by telemedicine for diabetic retinopathy patients with type 1 and type 2 diabetes: a hospital-based cross-sectional study

BACKGROUND

Diabetic retinopathy (DR) is considered the fifth leading cause of visual impairment worldwide and is associated with a huge social and economic burden.

OBJECTIVE

Describe the practicality of non-mydriatic funduscopic screening photography for the detection of DR among patients with type 1 and type 2 diabetes.

DESIGN

Cross-sectional hospital-based study.

SETTING

Diabetes center, Riyadh.

PATIENTS AND METHODS

Between July and December 2017, patients with diabetes and aged ≥18 years were selected by systematic random sampling from the University Diabetes Center. Fundoscopic eye examination was performed using the TRC-NW8 non-mydriatic camera, which performs ocular coherence tomography (OCT) to detect macular edema. Using telemedicine, pictures were graded by a retinal-specialized ophthalmologist using the international clinical DR disease severity scale. Patients were classified according to the type and severity of DR.

MAIN OUTCOME MEASURES

Detection and classification of DR.

SAMPLE SIZE

978 Saudi patients with diabetes.

RESULTS

Of 426 (43.5%) patients with DR, 370 had nonproliferative DR and 55 had proliferative DR. Nineteen (1.9%) had macular edema. The most important risk factors for DR were longer diabetes duration and poor glycemic control. Both older age and insulin use contributed to the higher prevalence of DR and macular edema. DR was more common among type 1 patients at 55.4% compared with 49% among type 2 patients. In addition, more females had macular edema (57.1% versus 42.9% among males). Nine patients with macular edema (47.3%) had hypertension while 154 of 426 patients with DR (36.2%) had hypertension.

CONCLUSION

Non-mydriatic funduscopic screening photography was practical and useful for the detection of DR in patients with type 1 and type 2 diabetes.

LIMITATIONS

Conducted in a single center.

CONFLICT OF INTEREST

None.

Diabetic retinopathy and age-related macular degeneration: a survey of pharmacoutilization and cost in Calabria, Italy

The aged population is constantly growing, thus fostering an increase in age-dependent diseases. Among these, diabetic retinopathy (DR) along with age-related macular degeneration entails progressive vision loss. Since such conditions are associated with the proliferation of novel vessels, their pharmacotherapeutic management consists of the intravitreal injection of anti-vascular endothelial growth factor drugs, able to hinder the driving of vascular proliferation prompted by vascular endothelial growth factor. The humanized anti-vascular endothelial growth factor monoclonal antibody ranibizumab provided evidence for efficacy in several trials, hence earning approval by the US Food and Drug Administration for therapeutic use in all the stages of DR. Due to the lack of epidemiologic and pharmacoeconomic evaluation in the local Calabria Region context, the present retrospective observational study focused on prevalence of DR and age-related macular degeneration, treatment and cost of therapy with ranibizumab in 870 patients arriving to clinical observation at the "Mater Domini" University Hospital in Calabria, Italy from January 2014 to June 2017. Data were extracted from the database of ophthalmology ward and subjected to statistical analysis. The results suggest that the most frequent retinal diseases are age-related macular degeneration and DR and that the use of ranibizumab has been decreasing over the 4-year study period together with the associated cost per patient which was similar for both disorders. Therefore, appropriateness of treatment with drugs other than ranibizumab needs to be assessed in this setting and deep monitoring of pharmacologic treatment for retinal diseases is necessary to prevent or delay visual acuity decrease and complete vision loss. Study procedures were performed in accordance with the "Mater Domini" University Hospital ethical standards of the responsible committee on human experimentation.

Mobile Screening Units for the Early Detection of Breast Cancer and Cardiovascular Disease: A Pilot Telemedicine Study in Southern Italy

Introduction: Telemedicine is the use of Information and Communication Technologies (ICT) to improve patient outcomes by increasing access to care, medical information and services. The aim of this pilot study was to evaluate and support the implementation of screening and early detection programs in the prevention of breast cancer and cardiovascular diseases with the establishment of a remote diagnosis through the use of ICT in mobile units. Materials and Methods: A total of 430 individuals were recruited in an area of Southern Italy. Particularly, 321 women were recruited to undergo breast cancer screening in accordance with Italian guidelines. Likewise, cardiovascular screening interested 109 subjects. A self-contained mobile unit with connectivity was provided to offer breast and cardiovascular screenings. To maximize the benefit, we have evaluated the return of investment. Results: The telemedicine screening program allowed the detection of early pathologies. In breast cancer screening, 40.8% of cases were negative to lesions, 34.9% were positive to benign lesions, and 3.1% presented suspicious malignant lesions; these lesions were further checked by histological analyses, which showed a positive response in 70% of cases. The cardiovascular screening concerned 109 participants based on age and other risk factors. We observed a significant difference among risk factors in patients with cardiac disease (p < 0.001); particularly, hypertension was significantly the most present risk factor (51.4%, p < 0.05), followed by smoking (28.4%, p < 0.05). A cardiovascular pathology was detected in 40.4% of enrolled subjects. A 3.3:1 return on investment was calculated. Conclusion: Our findings demonstrate that telemedicine may represent a promising approach to deliver several health services, such as screening programs, with users who cannot utilize services in their locations. The use of telemedicine on diagnostic campers greatly reduces the costs of screening for breast cancer and major cardiovascular diseases within the Southern Italian Health Service. We believe that public investment can have a further significant return on investment by implementing the principles of precision medicine.

Pathological changes in the cellular structures of retina and choroidea in the early stages of alloxan-induced diabetes

AIM

To investigate the temporal sequence of pathological changes in the cellular structures of retina and choroidea in the early stages of diabetes in laboratory animals.

METHODS

Experimental type 1 diabetes was modeled by three intraperitoneal injections of an alloxan solution into 30 male nonlinear rats at 16 wk of age. The 30^th and 60^th days from the final alloxan injection were chosen as the endpoints. Light and electron microscopy and morphometric and immunohistochemical studies were performed on histological slices of eyeballs from experimental animals.

RESULTS

Diabetic disturbances progressed to 60 d of the experiment. Thus, in the retina, a partial destruction of photoreceptors accompanied by interstitial edema was observed. The morphometric analysis revealed a reduction in the thickness of the retina. A reduction in the number of blood vessels of the choroid with disturbances of the endothelial cells and the vascular walls and a persistent reduction in the number of melanocytes were observed. The number of proliferating Ki-67 positive cells decreased, and the number of macrophages increased with diabetes development.

CONCLUSION

The starting point in the development of destructive changes involves early reduction in the number of melanocytes of the choroidea and alterations in the retinal pigment epithelium.

Identification of factors to increase efficacy of telemedicine screening for diabetic retinopathy in endocrinology practices using the Intelligent Retinal Imaging System (IRIS) platform

AIMS

Diabetic retinopathy (DR) and diabetic macular edema (DME) can be evaluated using telemedicine systems, such as the Intelligent Retinal Imaging Systems (IRIS), in patients with Diabetes Mellitus (DM). In an endocrinology-based population utilizing IRIS we determine prevalence rates of DR and DME, and identify associated epidemiologic correlations.

METHODS

This is a multicenter, retrospective chart review using screening data from IRIS. Centers for Disease Control and Prevention (CDC) data on epidemiologic variables (by county) namely, prevalence of DM, incidence of DM, obesity, and time of physical inactivity, were compared against prevalence rates of DR found at screening.

RESULTS

A total of 10,223 eyes of 5,242 patients with DM were imaged. DR and DME were noted in 1781 (33.98%) and 226 imaging studies (4.31%) respectively. The coefficient of determination was greatest for incidence of DM (R² = 0.92), followed by DM prevalence (R² = 0.79), obesity, (R² = 0.67), and physical inactivity (R² = 0.34). The presence of DR during screening varied significantly by county (p < 0.001).

CONCLUSIONS

Screening in counties with a higher incidence of DM led to a higher prevalence of identified DR at time of screening. The current work suggests that telemedicine screening in areas known to have a higher incidence of DM may be worthwhile.

A systematic review of teleophthalmological studies in Europe

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

Non-Mydriatic Fundus Retinography in Screening for Diabetic Retinopathy: Agreement Between Family Physicians, General Ophthalmologists, and a Retinal Specialist

PURPOSE

To determine the level of agreement between trained family physicians (FPs), general ophthalmologists (GOs), and a retinal specialist (RS) in the assessment of non-mydriatic fundus retinography in screening for diabetic retinopathy (DR) in the primary health-care setting.

METHODS

200 Diabetic patients were submitted to two-field non-mydriatic digital fundus camera. The images were examined by four trained FPs, two GOs, and one RS with regard to the diagnosis and severity of DR and the diagnosis of macular edema. The RS served as gold standard. Reliability and accuracy were determined with the kappa test and diagnostic measures.

RESULTS

A total of 397 eyes of 200 patients were included. The mean age was 55.1 (±11.7) years, and 182 (91%) had type 2 diabetes. The mean levels of serum glucose and glycosylated hemoglobin A1c were 195.6 (±87.3) mg/dL and 8.9% (±2.1), respectively. DR was diagnosed in 166 eyes by the RS and in 114 and 182 eyes by GO₁ and GO₂, respectively. For severity, DR was graded as proliferative in 8 eyes by the RS vs. 15 and 9 eyes by GO₁ and GO₂, respectively. The agreement between the RS and the GOs was substantial for both DR diagnosis (GO₁k = 0.65; GO₂k = 0.74) and severity (GO₁k = 0.60; GO₂k = 0.71), and fair or moderate for macular edema (GO₁k = 0.27; GO₂k = 0.43). FP₁, FP₂, FP₃, and FP₄ diagnosed DR in 108, 119, 163, and 117 eyes, respectively. The agreement between the RS and the FPs with regard to DR diagnosis was substantial (FP₂k = 0.69; FP₃k = 0.73; FP₄k = 0.71) or moderate (FP₁k = 0.56). As for DR severity, the agreement between the FPs and the RS was substantial (FP₂k = 0.66; FP₃k = 069; FP₄k = 0.64) or moderate (FP₁k = 0.51). Agreement between the FPs and the RS with regard to macular edema was fair (FP₁k = 0.33; FP₂k = 0.39; FP₃k = 0.37) or moderate (FP₄k = 0.51).

CONCLUSION

Non-mydriatic fundus retinography was shown to be useful in DR screening in the primary health-care setting. FPs made assessments with good levels of agreement with an RS. Non-mydriatic fundus retinography associated with appropriate general physicians training is essential for the DR screening.