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Weng CY, Maguire MG, Flaxel CJ, Jain N, Kim SJ, Patel S, Smith JR, Kim LA, Yeh S. Effectiveness of Conventional Digital Fundus Photography-Based Teleretinal Screening for Diabetic Retinopathy and Diabetic Macular Edema: A Report by the American Academy of Ophthalmology. Ophthalmology 2024; 131:927-942. [PMID: 38613533 DOI: 10.1016/j.ophtha.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 04/15/2024] Open
Abstract
PURPOSE This American Academy of Ophthalmology Ophthalmic Technology Assessment aims to assess the effectiveness of conventional teleretinal screening (TS) in detecting diabetic retinopathy (DR) and diabetic macular edema (DME). METHODS A literature search of the PubMed database was conducted most recently in July 2023 to identify data published between 2006 and 2023 on any of the following elements related to TS effectiveness: (1) the accuracy of TS in detecting DR or DME compared with traditional ophthalmic screening with dilated fundus examination or 7-standard field Early Treatment Diabetic Retinopathy Study photography, (2) the impact of TS on DR screening compliance rates or other patient behaviors, and (3) cost-effectiveness and patient satisfaction of TS compared with traditional DR screening. Identified studies then were rated based on the Oxford Centre for Evidence-Based Medicine grading system. RESULTS Eight level I studies, 14 level II studies, and 2 level III studies were identified in total. Although cross-study comparison is challenging because of differences in reference standards and grading methods, TS demonstrated acceptable sensitivity and good specificity in detecting DR; moderate to good agreement between TS and reference-standard DR grading was observed. Performance of TS was not as robust in detecting DME, although the number of studies evaluating DME specifically was limited. Two level I studies, 5 level II studies, and 1 level III study supported that TS had a positive impact on overall DR screening compliance, even increasing it by more than 2-fold in one study. Studies assessing cost-effectiveness and patient satisfaction were not graded formally, but they generally showed that TS was cost-effective and preferred by patients over traditional surveillance. CONCLUSIONS Conventional TS is an effective approach to DR screening not only for its accuracy in detecting referable-level disease, but also for improving screening compliance in a cost-effective manner that may be preferred by patients. Further research is needed to elucidate the ideal approach of TS that may involve integration of artificial intelligence or other imaging technologies in the future. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Christina Y Weng
- Department of Ophthalmology, Baylor College of Medicine, Cullen Eye Institute, Houston, Texas
| | - Maureen G Maguire
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina J Flaxel
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Nieraj Jain
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen J Kim
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Shriji Patel
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Justine R Smith
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - Leo A Kim
- Department of Ophthalmology, Schepens Eye Research Institute/Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Steven Yeh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia; Department of Ophthalmology, Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, Nebraska
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Nakayama LF, Restrepo D, Matos J, Ribeiro LZ, Malerbi FK, Celi LA, Regatieri CS. BRSET: A Brazilian Multilabel Ophthalmological Dataset of Retina Fundus Photos. PLOS DIGITAL HEALTH 2024; 3:e0000454. [PMID: 38991014 PMCID: PMC11239107 DOI: 10.1371/journal.pdig.0000454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/03/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The Brazilian Multilabel Ophthalmological Dataset (BRSET) addresses the scarcity of publicly available ophthalmological datasets in Latin America. BRSET comprises 16,266 color fundus retinal photos from 8,524 Brazilian patients, aiming to enhance data representativeness, serving as a research and teaching tool. It contains sociodemographic information, enabling investigations into differential model performance across demographic groups. METHODS Data from three São Paulo outpatient centers yielded demographic and medical information from electronic records, including nationality, age, sex, clinical history, insulin use, and duration of diabetes diagnosis. A retinal specialist labeled images for anatomical features (optic disc, blood vessels, macula), quality control (focus, illumination, image field, artifacts), and pathologies (e.g., diabetic retinopathy). Diabetic retinopathy was graded using International Clinic Diabetic Retinopathy and Scottish Diabetic Retinopathy Grading. Validation used a ConvNext model trained during 50 epochs using a weighted cross entropy loss to avoid overfitting, with 70% training (20% validation), and 30% testing subsets. Performance metrics included area under the receiver operating curve (AUC) and Macro F1-score. Saliency maps were calculated for interpretability. RESULTS BRSET comprises 65.1% Canon CR2 and 34.9% Nikon NF5050 images. 61.8% of the patients are female, and the average age is 57.6 (± 18.26) years. Diabetic retinopathy affected 15.8% of patients, across a spectrum of disease severity. Anatomically, 20.2% showed abnormal optic discs, 4.9% abnormal blood vessels, and 28.8% abnormal macula. A ConvNext V2 model was trained and evaluated BRSET in four prediction tasks: "binary diabetic retinopathy diagnosis (Normal vs Diabetic Retinopathy)" (AUC: 97, F1: 89); "3 class diabetic retinopathy diagnosis (Normal, Proliferative, Non-Proliferative)" (AUC: 97, F1: 82); "diabetes diagnosis" (AUC: 91, F1: 83); "sex classification" (AUC: 87, F1: 70). DISCUSSION BRSET is the first multilabel ophthalmological dataset in Brazil and Latin America. It provides an opportunity for investigating model biases by evaluating performance across demographic groups. The model performance of three prediction tasks demonstrates the value of the dataset for external validation and for teaching medical computer vision to learners in Latin America using locally relevant data sources.
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Affiliation(s)
- Luis Filipe Nakayama
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - David Restrepo
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Telematics Department, University of Cauca, Popayán, Cauca, Colombia
| | - João Matos
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Faculty of Engineering of University of Porto, Porto, Portugal
| | - Lucas Zago Ribeiro
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Fernando Korn Malerbi
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Caio Saito Regatieri
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
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Tan TE, Jampol LM, Ferris FL, Tadayoni R, Sadda SR, Chong V, Domalpally A, Blodi BL, Duh EJ, Curcio CA, Antonetti DA, Dutta S, Levine SR, Sun JK, Gardner TW, Wong TY. Imaging Modalities for Assessing the Vascular Component of Diabetic Retinal Disease: Review and Consensus for an Updated Staging System. OPHTHALMOLOGY SCIENCE 2024; 4:100449. [PMID: 38313399 PMCID: PMC10837643 DOI: 10.1016/j.xops.2023.100449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 02/06/2024]
Abstract
Purpose To review the evidence for imaging modalities in assessing the vascular component of diabetic retinal disease (DRD), to inform updates to the DRD staging system. Design Standardized narrative review of the literature by an international expert workgroup, as part of the DRD Staging System Update Effort, a project of the Mary Tyler Moore Vision Initiative. Overall, there were 6 workgroups: Vascular Retina, Neural Retina, Systemic Health, Basic and Cellular Mechanisms, Visual Function, and Quality of Life. Participants The Vascular Retina workgroup, including 16 participants from 4 countries. Methods Literature review was conducted using standardized evidence grids for 5 modalities: standard color fundus photography (CFP), widefield color photography (WFCP), standard fluorescein angiography (FA), widefield FA (WFFA), and OCT angiography (OCTA). Summary levels of evidence were determined on a validated scale from I (highest) to V (lowest). Five virtual workshops were held for discussion and consensus. Main Outcome Measures Level of evidence for each modality. Results Levels of evidence for standard CFP, WFCP, standard FA, WFFA, and OCTA were I, II, I, I, and II respectively. Traditional vascular lesions on standard CFP should continue to be included in an updated staging system, but more studies are required before they can be used in posttreatment eyes. Widefield color photographs can be used for severity grading within the area covered by standard CFPs, although these gradings may not be directly interchangeable with each other. Evaluation of the peripheral retina on WFCP can be considered, but the method of grading needs to be clarified and validated. Standard FA and WFFA provide independent prognostic value, but the need for dye administration should be considered. OCT angiography has significant potential for inclusion in the DRD staging system, but various barriers need to be addressed first. Conclusions This study provides evidence-based recommendations on the utility of various imaging modalities for assessment of the vascular component of DRD, which can inform future updates to the DRD staging system. Although new imaging modalities offer a wealth of information, there are still major gaps and unmet research needs that need to be addressed before this potential can be realized. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Tien-En Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
| | - Lee M. Jampol
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Ramin Tadayoni
- Ophthalmology Department, Lariboisière, AP-HP, Saint Louis and Fondation Adolphe de Rothschild Hospitals, Université Paris Cité, Paris, France
| | - Srinivas R. Sadda
- Doheny Eye Institute, Pasadena, California
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Victor Chong
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Barbara L. Blodi
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elia J. Duh
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine A. Curcio
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - David A. Antonetti
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - S. Robert Levine
- The Mary Tyler Moore & S. Robert Levine, MD Charitable Foundation, Greenwich, Connecticut
| | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Medical School, Boston, Massachusetts
| | - Thomas W. Gardner
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
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Nakayama LF, Restrepo D, Matos J, Ribeiro LZ, Malerbi FK, Celi LA, Regatieri CS. BRSET: A Brazilian Multilabel Ophthalmological Dataset of Retina Fundus Photos. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.23.24301660. [PMID: 38343827 PMCID: PMC10854338 DOI: 10.1101/2024.01.23.24301660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Introduction The Brazilian Multilabel Ophthalmological Dataset (BRSET) addresses the scarcity of publicly available ophthalmological datasets in Latin America. BRSET comprises 16,266 color fundus retinal photos from 8,524 Brazilian patients, aiming to enhance data representativeness, serving as a research and teaching tool. It contains sociodemographic information, enabling investigations into differential model performance across demographic groups. Methods Data from three São Paulo outpatient centers yielded demographic and medical information from electronic records, including nationality, age, sex, clinical history, insulin use, and duration of diabetes diagnosis. A retinal specialist labeled images for anatomical features (optic disc, blood vessels, macula), quality control (focus, illumination, image field, artifacts), and pathologies (e.g., diabetic retinopathy). Diabetic retinopathy was graded using International Clinic Diabetic Retinopathy and Scottish Diabetic Retinopathy Grading. Validation used Dino V2 Base for feature extraction, with 70% training and 30% testing subsets. Support Vector Machines (SVM) and Logistic Regression (LR) were employed with weighted training. Performance metrics included area under the receiver operating curve (AUC) and Macro F1-score. Results BRSET comprises 65.1% Canon CR2 and 34.9% Nikon NF5050 images. 61.8% of the patients are female, and the average age is 57.6 years. Diabetic retinopathy affected 15.8% of patients, across a spectrum of disease severity. Anatomically, 20.2% showed abnormal optic discs, 4.9% abnormal blood vessels, and 28.8% abnormal macula. Models were trained on BRSET in three prediction tasks: "diabetes diagnosis"; "sex classification"; and "diabetic retinopathy diagnosis". Discussion BRSET is the first multilabel ophthalmological dataset in Brazil and Latin America. It provides an opportunity for investigating model biases by evaluating performance across demographic groups. The model performance of three prediction tasks demonstrates the value of the dataset for external validation and for teaching medical computer vision to learners in Latin America using locally relevant data sources.
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Affiliation(s)
- Luis Filipe Nakayama
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - David Restrepo
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Telematics Department, University of Cauca, Popayán, Cauca, Colombia
| | - João Matos
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Faculty of Engineering of University of Porto, Porto, Portugal
| | - Lucas Zago Ribeiro
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Fernando Korn Malerbi
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Caio Saito Regatieri
- Department of Ophthalmology, São Paulo Federal University, São Paulo, São Paulo, Brazil
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Wong TY, Tan TE. The Diabetic Retinopathy "Pandemic" and Evolving Global Strategies: The 2023 Friedenwald Lecture. Invest Ophthalmol Vis Sci 2023; 64:47. [PMID: 38153754 PMCID: PMC10756246 DOI: 10.1167/iovs.64.15.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/30/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Tien Yin Wong
- Singapore Eye Research Institute, Singapore, Singapore National Eye Centre, Singapore
- Duke-National University of Singapore, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Tien-En Tan
- Singapore Eye Research Institute, Singapore, Singapore National Eye Centre, Singapore
- Duke-National University of Singapore, Singapore
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Dolar-Szczasny J, Barańska A, Rejdak R. Evaluating the Efficacy of Teleophthalmology in Delivering Ophthalmic Care to Underserved Populations: A Literature Review. J Clin Med 2023; 12:jcm12093161. [PMID: 37176602 PMCID: PMC10179149 DOI: 10.3390/jcm12093161] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Technological advancement has brought commendable changes in medicine, advancing diagnosis, treatment, and interventions. Telemedicine has been adopted by various subspecialties including ophthalmology. Over the years, teleophthalmology has been implemented in various countries, and continuous progress is being made in this area. In underserved populations, due to socioeconomic factors, there is little or no access to healthcare facilities, and people are at higher risk of eye diseases and vision impairment. Transportation is the major hurdle for these people in obtaining access to eye care in the main hospitals. There is a dire need for accessible eye care for such populations, and teleophthalmology is the ray of hope for providing eye care facilities to underserved people. Numerous studies have reported the advantages of teleophthalmology for rural populations such as being cost-effective, timesaving, reliable, efficient, and satisfactory for patients. Although it is being practiced in urban populations, for rural populations, its benefits amplify. However, there are certain obstacles as well, such as the cost of equipment, lack of steady electricity and internet supply in rural areas, and the attitude of people in certain regions toward acceptance of teleophthalmology. In this review, we have discussed in detail eye health in rural populations, teleophthalmology, and its effectiveness in rural populations of different countries.
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Affiliation(s)
- Joanna Dolar-Szczasny
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, 20-079 Lublin, Poland
| | - Agnieszka Barańska
- Department of Medical Informatics and Statistics with E-Learning Laboratory, Medical University of Lublin, 20-090 Lublin, Poland
| | - Robert Rejdak
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, 20-079 Lublin, Poland
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Nakayama LF, Ribeiro LZ, Gonçalves MB, Ferraz DA, Dos Santos HNV, Malerbi FK, Morales PH, Maia M, Regatieri CVS, Mattos RB. Diabetic retinopathy classification for supervised machine learning algorithms. Int J Retina Vitreous 2022; 8:1. [PMID: 34980281 PMCID: PMC8722080 DOI: 10.1186/s40942-021-00352-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Artificial intelligence and automated technology were first reported more than 70 years ago and nowadays provide unprecedented diagnostic accuracy, screening capacity, risk stratification, and workflow optimization. Diabetic retinopathy is an important cause of preventable blindness worldwide, and artificial intelligence technology provides precocious diagnosis, monitoring, and guide treatment. High-quality exams are fundamental in supervised artificial intelligence algorithms, but the lack of ground truth standards in retinal exams datasets is a problem. MAIN BODY In this article, ETDRS, NHS, ICDR, SDGS diabetic retinopathy grading, and manual annotation are described and compared in publicly available datasets. The various DR labeling systems generate a fundamental problem for AI datasets. Possible solutions are standardization of DR classification and direct retinal-finding identifications. CONCLUSION Reliable labeling methods also need to be considered in datasets with more trustworthy labeling.
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Affiliation(s)
- Luis Filipe Nakayama
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil.
| | - Lucas Zago Ribeiro
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Mariana Batista Gonçalves
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil.,Instituto Paulista de Estudos e Pesquisas em Oftalmologia, IPEPO, Vision Institute, São Paulo, SP, Brazil.,NIHR Biomedical Research Centre for Ophthalmology, Moorfield Eye Hospital, NHS Foundation Trust, and UCL Institute of Ophthalmology, London, UK
| | - Daniel A Ferraz
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil.,Instituto Paulista de Estudos e Pesquisas em Oftalmologia, IPEPO, Vision Institute, São Paulo, SP, Brazil.,NIHR Biomedical Research Centre for Ophthalmology, Moorfield Eye Hospital, NHS Foundation Trust, and UCL Institute of Ophthalmology, London, UK
| | - Helen Nazareth Veloso Dos Santos
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Fernando Korn Malerbi
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Paulo Henrique Morales
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil.,Instituto Paulista de Estudos e Pesquisas em Oftalmologia, IPEPO, Vision Institute, São Paulo, SP, Brazil
| | - Mauricio Maia
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Caio Vinicius Saito Regatieri
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Rubens Belfort Mattos
- Physician, Department of Ophthalmology, Universidade Federal de São Paulo - EPM, Botucatu Street, 821, Vila Clementino, São Paulo, SP, 04023-062, Brazil.,Instituto Paulista de Estudos e Pesquisas em Oftalmologia, IPEPO, Vision Institute, São Paulo, SP, Brazil
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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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Bai X, Hua R. Latent Diabetic Macular Edema in Chinese Diabetic Retinopathy Patients. Front Med (Lausanne) 2021; 8:739656. [PMID: 34671623 PMCID: PMC8520952 DOI: 10.3389/fmed.2021.739656] [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: 07/11/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose: To compare the detection rates of optical coherence tomography (OCT) and fluorescein angiography (FA) in a diabetic macular edema (DME) and the severity of diabetic retinopathy in both color fundus images (CFI) and FA, and to investigate the predictive factors in macular leakages in FA. Methods: This was a retrospective study, and a total of 132 eyes of 77 patients with diabetic retinopathy were enrolled. Macular OCT, FA, and CFI were reviewed and measured. Central foveal thickness was also measured. Results: The severity of diabetic retinopathy in FA was significantly higher than that in CFI (p < 0.001). OCT detected 26 eyes with DMEs, which included the following: 13 eyes with cystoid macular edemas; 13 eyes with serous retinal detachments; 11 eyes with diffuse retinal thickening; 4 eyes with vitreomacular interface abnormalities. In contrast, 72 out of 132 eyes (54.5%) showed macular leakages in FA, which was significantly higher than that detected by OCT (p < 0.001). Compared with FA, the sensitivity and the specificity of OCT in detecting DMEs were 30.6 and 93.3%, respectively. However, central foveal thickness was not significantly different between the patients with non-clinically significant macular edema (CSME, 253.1 ± 26.95 μm) and slight CSME (270.9 ± 37.11 μm, p = 0.204). The mean central foveal thickness in diabetic macular edema (FA) eyes was 271.8 ± 66.02 μm, which was significantly higher than that (253. ± 25.21 μm) in non-DME (FA) eyes (p = 0.039). The central foveal thickness in DME (FA) eyes was significantly lower than that in eyes with DME (OCT) (p = 0.014). After adjusting for age and sex, a logistic regression analysis showed that the classification of diabetic retinopathy in FA was positively associated with macular leakage in FA (p < 0.001). Conclusions: The severity of diabetic retinopathy is underestimated in CFI compared with that in FA. FA can detect latent DMEs, which appeared normal on OCT. The central foveal thickness is not a sensitive parameter for detecting latent DMEs.
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Affiliation(s)
- Xue Bai
- Department of Ophthalmology, First Hospital of China Medical University, Shenyang, China
| | - Rui Hua
- Department of Ophthalmology, First Hospital of China Medical University, Shenyang, China
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10
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Sharma G, Chauhan A, Tuli R, Raina SK, Sharma RK. Teleophthalmology as a Model for Detecting Ocular Diseases in Tribal Areas of a North West State in India. Indian J Community Med 2021; 46:62-65. [PMID: 34035578 PMCID: PMC8117889 DOI: 10.4103/ijcm.ijcm_199_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 12/07/2020] [Indexed: 11/04/2022] Open
Abstract
Background Lahaul and Spiti district of Himachal Pradesh, a high altitude tribal district, situated at altitudes varying from 10,000 to 15, 000 ft. above mean sea level is cut off from the rest of the country for nearly 6 months due to heavy snowfall in the mountain passes. In the absence of any ophthalmologist and ophthalmic technician, the provision of eye care is virtually absent. The current study (part of a research project funded by the Indian Council of Medical Research) was conducted with the aim to explore teleophthalmology as a model for detecting posterior segment eye diseases in tribal and inaccessible areas. Materials and Methods Fundus images (taken through fundus photography) of 1000 individuals above 5 years of age with no improvement in vision to 6/6 on refraction and individuals with known history of diabetes mellitus, systemic hypertension, or long standing headache with features of raised intracranial tension irrespective of whether their vision improved to 6/6 or not were sent to tertiary care center (base hospital) from regional hospital (field hospital). Transmitted images (through internet after attaching the details and patient particulars on the excel sheet) were analyzed by the ophthalmologists and the final diagnosis along with the line of management if any was transmitted back. Results Eighty-five percent of the images transmitted were of good quality. Retinal, vitreous, optic nerve head, and choroidal diseases could be detected. Conclusions In the present situation, where trained workforce is unavailable in these areas, teleophthamology is an appropriate tool by which a number of eye diseases can be detected at early stages. Most of them can be treated in these early stages by lifestyle modification and medical management.
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Affiliation(s)
- Gaurav Sharma
- Department of Ophthalmology, Dr RP Govt Medical College, Kangra at Tanda, Himachal Pradesh
| | - Anil Chauhan
- Department of Ophthalmology, Dr Radhakrishnan Govt Medical College, Hamirpur, Himachal Pradesh
| | - Rajeev Tuli
- Department of Ophthalmology, Dr RP Govt Medical College, Kangra at Tanda, Himachal Pradesh
| | - Sunil Kumar Raina
- Department of Community Medicine, Dr RP Govt Medical College, Kangra at Tanda, Himachal Pradesh
| | - Rattan Kumar Sharma
- Department of Ophthalmology, Dr RP Govt Medical College, Kangra at Tanda, Himachal Pradesh
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11
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Association between dietary antioxidants and risk for diabetic retinopathy in a Chinese population. Eye (Lond) 2020; 35:1977-1984. [PMID: 33009517 DOI: 10.1038/s41433-020-01208-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) is related to oxidative stress and insufficient intake of dietary antioxidants may be associated with the onset and progression of DR. This study aimed to detect the association between main dietary antioxidants intake and the risk for DR. METHODS This is a cross-sectional study of a Chinese urban population. Four hundred and fifty-five subjects with type 2 diabetes were recruited and divided into diabetic patients without retinopathy (DWR) group and DR group based on their retinal status. CSMO (clinically significant macular oedema) was diagnosed by stereoscopic photography. Demographic and lifestyle characteristics were ascertained by questionnaire. General physical and ophthalmic examinations were completed for all subjects. Dietary antioxidants were assessed by 3-day food records. Subjects who have taken any type of vitamin supplements were excluded from the study. The association of dietary antioxidants with the risk for DR was analysed by logistic regression with adjustment of other factors. The dietary antioxidants levels of the CSMO subjects and non-CSMO subjects were compared using the Wilcoxon rank sum test. RESULTS One hundred and nineteen subjects in DR group and 336 subjects in DWR group participated in the study. Only ten DR subjects had CSMO. The results showed that higher vitamin E (OR (95% CI):0.97 (0.95, 1.00), P = 0.036) and selenium (OR (95% CI):0.98 (0.96, 1.00), P = 0.017) intake appear to be the protective factors of DR. The dietary antioxidants levels of CSMO and non-CSMO subjects had no statistical differences (P > 0.05). CONCLUSIONS Dietary antioxidants intake, particularly vitamin E and selenium, were observed to have protective effects on DR.
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12
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Required Data Elements and Requirements of a Teleoncology System to Provide Treatment Plans for Patients with Breast Cancer. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.100522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Teleoncology refers to the use of telemedicine for remotely providing multiple specialized services in clinical oncology processes, including screening, diagnosis, treatment planning, consultation, supportive care, pathology, surgery, and follow-up services. Objectives: The aim of this study was to identify the required data elements and elicitation of requirements for developing a telemedicine system that aims at providing treatment plans for patients with breast cancer. Methods: In this study, the required data elements for the teleoncology system were identified through both the investigation of clinical guidelines and review of patients’ medical records. Identified data elements were determined by breast cancer specialists through the questionnaire. Besides, an interview method was applied to elicit the requirements of this system. Results: The identified data elements were categorized into 20 groups (e.g., clinical data, breast physical examinations, pathological results, tests, imaging results, etc.). From the 182 data elements included within the questionnaire, 125 were recognized to be necessary (n = 32, 100%). The lowest mean percentage were observed in magnesium blood test (Mg) (n = 21, 65.63%) and protein test (Pr) (n = 21, 65.63%). Other data elements with a minimum mean of 71.87% and a maximum mean of 100% were recognized necessary. In general, 2 major themes, 9 categories, and 45 related sub-categories were extracted from analyzing the findings of the interviews related to the system requirements. Conclusions: The findings of the present study can be used as a basis for developing teleoncology systems that aim at providing treatment plans for patients with breast cancer.
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13
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Nanji K, Kherani IN, Damji KF, Nyenze M, Kiage D, Tennant MT. The Muranga Teleophthalmology Study: A Comparison of Virtual (Teleretina) Assessment with in-person Clinical Examination to Diagnose Diabetic Retinopathy and Age-related Macular Degeneration in Kenya. Middle East Afr J Ophthalmol 2020; 27:91-99. [PMID: 32874041 PMCID: PMC7442076 DOI: 10.4103/meajo.meajo_144_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 04/12/2020] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE: This study compares a web-based teleophthalmology assessment with a clinical slit lamp examination to screen for diabetic retinopathy (DR) and age-related macular degeneration (AMD) among diabetic patients in a rural East African district. METHODS: Six hundred and twelve eyes from 306 diabetic patients underwent both a clinical slit lamp examination and a teleretina (TR) assessment by an experienced ophthalmologist. Both assessments were compared for any DR and AMD using the early treatment diabetic retinopathy study and age-related eye disease study grading scales, respectively. RESULTS: Of the 612 TR assessment photos, 74 (12%) were deemed ungradable due to media opacities, poor patient cooperation, or unsatisfactory photographs. The ability to detect DR and AMD showed a fair agreement (kappa statistic 0.27 and 0.23, respectively) between the TR and clinical slit lamp examination. Relative to a clinical slit lamp evaluation, a positive TR diagnosis carried a 75.0% positive predictive value when diagnosing DR and a 27.3% positive predictive value when diagnosing AMD. A negative TR diagnosis carried a 97.2% negative predictive value for the diagnosis of DR and a 98.1% negative predictive value for the diagnosis of AMD. CONCLUSION: When comparing TR assessments to clinical slit lamp examinations to diagnose DR and AMD, there was a fair agreement. Although further validation is needed, the TR approach provides a promising method to diagnose DR and AMD, two major causes of ocular impairment worldwide.
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Affiliation(s)
- Keean Nanji
- Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Irfan N Kherani
- Department of Ophthalmology, University of Ottawa, Ottawa, Canada
| | - Karim F Damji
- Department of Ophthalmology, University of Alberta, Edmonton, Canada
| | - Muindi Nyenze
- Department of Ophthalmology, University of Nairobi, Nairobi, Canada
| | - Dan Kiage
- Innovation Eye Centre, Chennai, Tamil Nadu, India
| | - Matthew T Tennant
- Department of Ophthalmology, University of Alberta, Edmonton, Canada
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Ullah W, Pathan SK, Panchal A, Anandan S, Saleem K, Sattar Y, Ahmad E, Mukhtar M, Nawaz H. Cost-effectiveness and diagnostic accuracy of telemedicine in macular disease and diabetic retinopathy: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20306. [PMID: 32569163 PMCID: PMC7310976 DOI: 10.1097/md.0000000000020306] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine cost-effectiveness and the diagnostic accuracy of teleophthalmology (TO) in the detection of macular edema (ME) and various grades of diabetic retinopathy (DR). METHODS MEDLINE, EMBASE, and Cochrane databases were searched for TO, ME, and DR on May 25, 2016. The search was updated on April 2, 2019. Pooled sensitivity and specificity for ME and various grades of DR were determined using Meta-Disc software. A systematic review of the articles discussing the cost-effectiveness of TO screening was also performed. RESULTS Thirty-three articles on the diagnostic accuracy and 28 articles on the cost-effectiveness were selected. CONCLUSIONS Telescreening is moderately sensitive but very specific for the diagnosis of diabetic retinopathy. Non-mydriatic Teleretinal screening services are cost-effective, decrease clinics workload, and increase patient compliance if provided free of cost in remote low socioeconomic regions.
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Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington – Jefferson Health, Abington, PA, USA
| | | | | | | | | | - Yasar Sattar
- Internal Medicine, Icahn School of Medicine Mount Sinai-Elmhurst Hospital, NY, USA
| | - Ejaz Ahmad
- Internal Medicine, Nishtar Hospital Center, Multan
| | | | - Haq Nawaz
- Internal Medicine, Griffin Hospital, CT, USA
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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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Felfeli T, Alon R, Merritt R, Brent MH. Toronto tele-retinal screening program for detection of diabetic retinopathy and macular edema. Can J Ophthalmol 2019; 54:203-211. [DOI: 10.1016/j.jcjo.2018.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 12/31/2022]
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17
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Date RC, Shen KL, Shah BM, Sigalos-Rivera MA, Chu YI, Weng CY. Accuracy of Detection and Grading of Diabetic Retinopathy and Diabetic Macular Edema Using Teleretinal Screening. ACTA ACUST UNITED AC 2019; 3:343-349. [DOI: 10.1016/j.oret.2018.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 01/19/2023]
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18
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Verbraak FD, Abramoff MD, Bausch GCF, Klaver C, Nijpels G, Schlingemann RO, van der Heijden AA. Diagnostic Accuracy of a Device for the Automated Detection of Diabetic Retinopathy in a Primary Care Setting. Diabetes Care 2019; 42:651-656. [PMID: 30765436 DOI: 10.2337/dc18-0148] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 12/30/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy in a real-world primary care setting of a deep learning-enhanced device for automated detection of diabetic retinopathy (DR). RESEARCH DESIGN AND METHODS Retinal images of people with type 2 diabetes visiting a primary care screening program were graded by a hybrid deep learning-enhanced device (IDx-DR-EU-2.1; IDx, Amsterdam, the Netherlands), and its classification of retinopathy (vision-threatening [vt]DR, more than mild [mtm]DR, and mild or more [mom]DR) was compared with a reference standard. This reference standard consisted of grading according to the International Clinical Classification of DR by the Rotterdam Study reading center. We determined the diagnostic accuracy of the hybrid deep learning-enhanced device (IDx-DR-EU-2.1) against the reference standard. RESULTS A total of 1,616 people with type 2 diabetes were imaged. The hybrid deep learning-enhanced device's sensitivity/specificity against the reference standard was, respectively, for vtDR 100% (95% CI 77.1-100)/97.8% (95% CI 96.8-98.5) and for mtmDR 79.4% (95% CI 66.5-87.9)/93.8% (95% CI 92.1-94.9). CONCLUSIONS The hybrid deep learning-enhanced device had high diagnostic accuracy for the detection of both vtDR (although the number of vtDR cases was low) and mtmDR in a primary care setting against an independent reading center. This allows its' safe use in a primary care setting.
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Affiliation(s)
- Frank D Verbraak
- Department of Ophthalmology, VU Medical Center, Amsterdam, the Netherlands
| | - Michael D Abramoff
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospital & Clinics, Iowa City, IA.,VA Medical Center, Iowa City, IA.,IDx, Iowa City, IA
| | | | - Caroline Klaver
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Ophthalmology, Radboud University Medical Center, Rotterdam, the Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Amber A van der Heijden
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
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Abstract
This review describes some of the most recent advances in the development and application of new technologies for detecting and managing glaucoma, including imaging, visual function testing, and tonometry. The widespread availability of mobile technology in the developing world is improving health care delivery, for example, with smartphones and mobile applications that allow patient data to be assessed remotely by health care providers.
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Affiliation(s)
- Ignacio Rodriguez-Una
- Glaucoma Department, Instituto Oftalmologico Fernandez-Vega, University of Oviedo, Oviedo, Spain
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20
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21
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Sharafeldin N, Kawaguchi A, Sundaram A, Campbell S, Rudnisky C, Weis E, Tennant MTS, Damji KF. Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults. Br J Ophthalmol 2018; 102:1485-1491. [PMID: 29680803 DOI: 10.1136/bjophthalmol-2017-311452] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/07/2018] [Accepted: 03/31/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration. METHODS Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease. RESULTS Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings. CONCLUSIONS This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology.
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Affiliation(s)
- Noha Sharafeldin
- School of Public Health, University of Alberta, Edmonton, Canada.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Atsushi Kawaguchi
- School of Public Health, University of Alberta, Edmonton, Canada.,Department of Pediatrics, Pediatric Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Aishwarya Sundaram
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Canada
| | - Sandy Campbell
- JW Scott Library, Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Chris Rudnisky
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Ezekiel Weis
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Matthew T S Tennant
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
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Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017; 10:1909-1918. [PMID: 29259912 PMCID: PMC5733521 DOI: 10.18240/ijo.2017.12.19] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/05/2017] [Indexed: 12/31/2022] Open
Abstract
Telemedicine is an emerging field in recent medical achievements with rapid development. The "smartphone" availability has increased in both developed and developing countries even among people in rural and remotes areas. Tele-based services can be used for screening ophthalmic diseases and also monitoring patients with known diseases. Electronic ophthalmologic records of the patients including captured images by smartphones from anterior and posterior segments of the eye will be evaluated by ophthalmologists, and if patients require further evaluations, they will be referred to experts in the relevant field. Eye diseases such as cataract, glaucoma, age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity are the most common causes of blindness in many countries and beneficial use of teleophthalmology with smartphones will be a good way to achieve the aim of VISION 2020 all over the world. Numerous studies have shown that teleophthalmology is similar to the conventional eye care system in clinical outcomes and even provides more patient satisfaction as it saves time and cost. This review explains how teleophthalmology helps to improve patient outcomes through smartphones.
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Affiliation(s)
- Mehrdad Mohammadpour
- Farabi Eye Hospital, Ophthalmology Department and Eye Research Center, Tehran University of Medical Sciences, Tehran 1336616351, Iran
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran 1968653111, Iran
| | - Zahra Heidari
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran 1968653111, Iran
- Department of Rehabilitation Science, Mazandaran University of Medical Sciences, Sari 4815733971, Iran
| | - Masoud Mirghorbani
- Farabi Eye Hospital, Ophthalmology Department and Eye Research Center, Tehran University of Medical Sciences, Tehran 1336616351, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran 1968653111, Iran
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Hooper P, Boucher MC, Cruess A, Dawson KG, Delpero W, Greve M, Kozousek V, Lam WC, Maberley DAL. Excerpt from the Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy. Can J Ophthalmol 2017; 52 Suppl 1:S45-S74. [PMID: 29074014 DOI: 10.1016/j.jcjo.2017.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Philip Hooper
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)..
| | - Marie Carole Boucher
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Alan Cruess
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Keith G Dawson
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Walter Delpero
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Mark Greve
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Vladimir Kozousek
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - Wai-Ching Lam
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
| | - David A L Maberley
- Philip Hooper, London, ON (Chair) (retina and uveitis); Marie Carole Boucher, Montreal, QC (retina and teleophthalmology); Alan Cruess, Halifax, NS (retina); Keith G. Dawson, Vancouver, BC (endocrinology); Walter Delpero, Ottawa, ON (cataract and strabismus); Mark Greve, Edmonton, AB (retina and teleophthalmology); Vladimir Kozousek, Halifax, NS (medical retina); Wai-Ching Lam, Toronto, ON (retina and research); David A.L. Maberley, Vancouver, BC (retina)
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Xiao D, Vignarajan J, Chen T, Ye T, Xiao B, Congdon N, Kanagasingam Y. Content Design and System Implementation of a Teleophthalmology System for Eye Disease Diagnosis and Treatment and Its Preliminary Practice in Guangdong, China. Telemed J E Health 2017; 23:964-975. [DOI: 10.1089/tmj.2016.0266] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Di Xiao
- The Australian e-Health Research Center, CSIRO, Floreat, Western Australia, Australia
| | - Janardhan Vignarajan
- The Australian e-Health Research Center, CSIRO, Floreat, Western Australia, Australia
| | - Tingting Chen
- Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Tiantian Ye
- Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Baixiang Xiao
- Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Nathan Congdon
- Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yogessan Kanagasingam
- The Australian e-Health Research Center, CSIRO, Floreat, Western Australia, Australia
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Risk factors for progression of diabetic retinopathy in Alberta First Nations communities. Can J Ophthalmol 2017; 52 Suppl 1:S19-S29. [DOI: 10.1016/j.jcjo.2017.09.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/07/2012] [Accepted: 04/08/2012] [Indexed: 01/04/2023]
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Sandhu S, Rudnisky C, Arora S, Kassam F, Douglas G, Edwards MC, Verstraten K, Wong B, Damji KF. Compressed 3D and 2D digital images versus standard 3D slide film for the evaluation of glaucomatous optic nerve features. Br J Ophthalmol 2017; 102:364-368. [PMID: 28835424 DOI: 10.1136/bjophthalmol-2017-310447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/18/2017] [Accepted: 06/19/2017] [Indexed: 11/03/2022]
Abstract
SYNOPSIS Clinicians can feel confident compressed three-dimensional digital (3DD) and two-dimensional digital (2DD) imaging evaluating important features of glaucomatous disc damage is comparable to the previous gold standard of stereoscopic slide film photography, supporting the use of digital imaging for teleglaucoma applications. BACKGROUND/AIMS To compare the sensitivity and specificity of 3DD and 2DD photography with stereo slide film in detecting glaucomatous optic nerve head features. METHODS This prospective, multireader validation study imaged and compressed glaucomatous, suspicious or normal optic nerves using a ratio of 16:1 into 3DD and 2DD (1024×1280 pixels) and compared both to stereo slide film. The primary outcome was vertical cup-to-disc ratio (VCDR) and secondary outcomes, including disc haemorrhage and notching, were also evaluated. Each format was graded randomly by four glaucoma specialists. A protocol was implemented for harmonising data including consensus-based interpretation as needed. RESULTS There were 192 eyes imaged with each format. The mean VCDR for slide, 3DD and 2DD was 0.59±0.20, 0.60±0.18 and 0.62±0.17, respectively. The agreement of VCDR for 3DD versus film was κ=0.781 and for 2DD versus film was κ=0.69. Sensitivity (95.2%), specificity (95.2%) and area under the curve (AUC; 0.953) of 3DD imaging to detect notching were better (p=0.03) than for 2DD (90.5%; 88.6%; AUC=0.895). Similarly, sensitivity (77.8%), specificity (98.9%) and AUC (0.883) of 3DD to detect disc haemorrhage were better (p=0.049) than for 2DD (44.4%; 99.5%; AUC=0.72). There was no difference between 3DD and 2DD imaging in detecting disc tilt (p=0.7), peripapillary atrophy (p=0.16), grey crescent (p=0.1) or pallor (p=0.43), although 3D detected sloping better (p=0.013). CONCLUSIONS Both 3DD and 2DD imaging demonstrates excellent reproducibility in comparison to stereo slide film with experts evaluating VCDR, notching and disc haemorrhage. 3DD in this study was slightly more accurate than 2DD for evaluating disc haemorrhage, notching and sloping.
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Affiliation(s)
- Simrenjeet Sandhu
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Chris Rudnisky
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sourabh Arora
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Faazil Kassam
- Division of Ophthalmology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gordon Douglas
- Division of Ophthalmology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Marianne C Edwards
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Karin Verstraten
- Division of Ophthalmology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Beatrice Wong
- Department of Ophthalmology, Loma Linda University, Loma Linda, California, USA
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alberta, Canada
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Valikodath NG, Leveque TK, Wang SY, Lee PP, Newman-Casey PA, Hansen SO, Woodward MA. Patient Attitudes Toward Telemedicine for Diabetic Retinopathy. Telemed J E Health 2017; 23:205-212. [PMID: 27336678 PMCID: PMC5359684 DOI: 10.1089/tmj.2016.0108] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 05/24/2016] [Accepted: 05/25/2016] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine. MATERIALS AND METHODS Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression. RESULTS Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjusted odds ratio [OR] = 0.08, confidence interval [CI] = 0.02-0.35, p = 0.001) or had a longer duration of diabetes (adjusted OR = 0.93, CI = 0.88-0.99, p = 0.02). Patients had increased odds of willingness if they perceived increased convenience (adjusted OR = 8.10, CI = 1.77-36.97, p = 0.01) or had more systemic comorbidities (adjusted OR = 1.85, CI = 1.10-3.11, p = 0.02). DISCUSSION It is critical to understand the attitudes of people with DM where telemedicine shows promise for disease management and end-organ damage prevention. Patients' attitudes are influenced by their health and perceptions, but not by their demographics. Receptive patients focus on convenience, whereas unreceptive patients strongly value their patient-physician relationships or have long-standing DM. Telemedicine monitoring should be designed for people who are in need and receptive to telemedicine.
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Affiliation(s)
- Nita G. Valikodath
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Thellea K. Leveque
- Department of Ophthalmology, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Sophia Y. Wang
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul P. Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Paula Anne Newman-Casey
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Sean O. Hansen
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Maria A. Woodward
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
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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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Abstract
According to current projections, the number of Americans with diabetes mellitus will increase from 27.8 million in 2007 to 60.7 million in 2030. With the increasing gap between demand for eye care and supply of ophthalmologists and optometrists, and the non-uniform distribution of eye care providers in US counties, barriers to eye examinations will likely increase. Telemedicine assessment of diabetic retinal disease through remote retinal imaging and diagnosis has the potential to meet these growing demands. To establish evidence for a telemedicine program as an effective modality for diabetic retinopathy (DR) assessment, the interpretation of teleretinal images should compare favorably with Early Treatment Diabetic Retinopathy Study film or digital photographs. We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient comfort and satisfaction, and improvement of patient related outcomes.
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Affiliation(s)
- Aditi Gupta
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA
| | - Jerry Cavallerano
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Paolo S Silva
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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Srinivasan S, Shetty S, Natarajan V, Sharma T, Raman R. Development and Validation of a Diabetic Retinopathy Referral Algorithm Based on Single-Field Fundus Photography. PLoS One 2016; 11:e0163108. [PMID: 27661981 PMCID: PMC5035083 DOI: 10.1371/journal.pone.0163108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/03/2016] [Indexed: 11/19/2022] Open
Abstract
Purpose To develop a simplified algorithm to identify and refer diabetic retinopathy (DR) from single-field retinal images specifically for sight-threatening diabetic retinopathy for appropriate care (ii) to determine the agreement and diagnostic accuracy of the algorithm as a pilot study among optometrists versus “gold standard” (retinal specialist grading). Methods The severity of DR was scored based on colour photo using a colour coded algorithm, which included the lesions of DR and number of quadrants involved. A total of 99 participants underwent training followed by evaluation. Data of the 99 participants were analyzed. Fifty posterior pole 45 degree retinal images with all stages of DR were presented. Kappa scores (κ), areas under the receiver operating characteristic curves (AUCs), sensitivity and specificity were determined, with further comparison between working optometrists and optometry students. Results Mean age of the participants was 22 years (range: 19–43 years), 87% being women. Participants correctly identified 91.5% images that required immediate referral (κ) = 0.696), 62.5% of images as requiring review after 6 months (κ = 0.462), and 51.2% of those requiring review after 1 year (κ = 0.532). The sensitivity and specificity of the optometrists were 91% and 78% for immediate referral, 62% and 84% for review after 6 months, and 51% and 95% for review after 1 year, respectively. The AUC was the highest (0.855) for immediate referral, second highest (0.824) for review after 1 year, and 0.727 for review after 6 months criteria. Optometry students performed better than the working optometrists for all grades of referral. Conclusions The diabetic retinopathy algorithm assessed in this work is a simple and a fairly accurate method for appropriate referral based on single-field 45 degree posterior pole retinal images.
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Affiliation(s)
- Sangeetha Srinivasan
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Sharan Shetty
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Viswanathan Natarajan
- Department of Preventive Ophthalmology, Sankara Nethralaya, Chennai-600 006, Tamil Nadu, India
| | - Tarun Sharma
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
- * E-mail:
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Abstract
Teleophthalmology is gaining importance as an effective eye care delivery modality worldwide. In many developing countries, teleophthalmology is being utilized to provide quality eye care to the underserved urban population and the unserved remote rural population. Over the years, technological innovations have led to improvement in evidence and teleophthalmology has evolved from a research tool to a clinical tool. The majority of the current teleophthalmology services concentrate on patient screening and appropriate referral to experts. Specialty care using teleophthalmology services for the pediatric group includes screening as well as providing timely care for retinopathy of prematurity (ROP). Among geriatric eye diseases, specialty teleophthalmology care is focused toward screening and referral for diabetic retinopathy (DR), glaucoma, age-related macular degeneration (ARMD), and other sight-threatening conditions. Comprehensive vision screening and refractive error services are generally covered as part of most of the teleophthalmology methods. Over the past decades, outcome assessment of health care system includes patients' assessments on their health, care, and services they receive. Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care. Teleophthalmology produces the same desired clinical outcome as the traditional system. Remote portals allow specialists to provide care over a larger region, thereby improving health outcomes and increasing accessibility of specialty care to a larger population. A high satisfaction level and acceptance is reported in the majority of the studies because of increased accessibility and reduced traveling cost and time. Considering the improved quality of patient care and patient satisfaction reported for these telemedicine services, this review explores how teleophthalmology helps to improve patient outcomes.
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Tozer K, Woodward MA, Newman-Casey PA. Telemedicine and Diabetic Retinopathy: Review of Published Screening Programs. ACTA ACUST UNITED AC 2015; 2. [PMID: 27430019 DOI: 10.15226/2374-6890/2/4/00131] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diabetic Retinopathy (DR) is a leading cause of blindness worldwide even though successful treatments exist. Improving screening and treatment could avoid many cases of vision loss. However, due to an increasing prevalence of diabetes, traditional in-person screening for DR for every diabetic patient is not feasible. Telemedicine is one viable solution to provide high-quality and efficient screening to large number of diabetic patients. PURPOSE To provide a narrative review of large DR telemedicine screening programs. METHODS Articles were identified through a comprehensive search of the English-language literature published between 2000 and 2014. Telemedicine screening programs were included for review if they had published data on at least 150 patients and had available validation studies supporting their model. Screening programs were then categorized according to their American Telemedicine Association Validation Level. RESULTS Seven programs from the US and abroad were identified and included in the review. Three programs were Category 1 programs (Ophdiat, EyePacs, and Digiscope), two were Category 2 programs (Eye Check, NHS Diabetic Eye Screening Program), and two were Category 3 programs (Joslin Vision Network, Alberta Screening Program). No program was identified that claimed category 4 status. Programs ranged from community or city level programs to large nationwide programs including millions of individuals. The programs demonstrated a high level of clinical accuracy in screening for DR. There was no consensus amongst the programs regarding the need for dilation, need for stereoscopic images, or the level of training for approved image graders. CONCLUSION Telemedicine programs have been clinically validated and successfully implemented across the globe. They can provide a high-level of clinical accuracy for screening for DR while improving patient access in a cost-effective and scalable manner.
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Affiliation(s)
- Kevin Tozer
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
| | - Maria A Woodward
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
| | - Paula A Newman-Casey
- Department of Ophthalmology & Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, USA
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Kim J, Driver DD. Teleophthalmology for first nations clients at risk of diabetic retinopathy: a mixed methods evaluation. JMIR Med Inform 2015; 3:e10. [PMID: 25705814 PMCID: PMC4376131 DOI: 10.2196/medinform.3872] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/12/2014] [Accepted: 01/14/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Access to health services is a particular challenge for First Nations (aboriginal Canadians) communities living in remote or underserviced areas. Teleophthalmology can provide them with the same level of retinal screening services provided to those in urban centers. This screening can lead to the identification of high-risk individuals who can then be monitored and receive treatment related to their diabetes or other health issues. OBJECTIVE The intent was to develop, implement, and evaluate a service delivery model for teleophthalmology screening and follow-up for at-risk and diabetic First Nations clients on Vancouver Island, British Columbia, Canada. METHODS A highly consultative, culturally appropriate, and collaborative approach was used to develop and deploy a teleophthalmology service delivery model to First Nations communities. This project was evaluated with regard to utilization and operational costs. Also, clinicians and team members involved in the teleophthalmology project provided assessments of the teleopthalmology quality, productivity, and access. Health providers in First Nations communities provided their perceptions of areas of improvement for the remote retinal screening services, areas where expansion of services could be offered, and opportunities to increase client education and health promotion. RESULTS All 51 First Nations communities on Vancouver Island expressed interest in receiving teleopthalmology services. During the 1-year project, teleopthalmology clinics were held in 43 of 51 communities on Vancouver Island. During these clinics, 524 clients were screened and 140 of those clients were referred to a general ophthalmologist, family doctor, retinal specialist, optometrist, or other provider. Ratings of teleopthalmology system quality, information quality, service quality, and system usage were positive. Satisfaction with the teleopthalmology project was high among clinicians involved with the project. Satisfaction was also high among health providers in First Nations communities, with clinic scheduling identified as a potential area of improvement moving forward. The average cost savings per client, taking project costs into consideration, was calculated to be CAN $28.16, which was largely due to the elimination of client travel costs. CONCLUSIONS Teleophthalmology was a welcome addition to health services by the First Nations communities on Vancouver Island, as evidenced by the 100% rate of interest from those communities. There was no evidence of dissatisfaction by clinicians involved in the teleopthalmology project or by First Nations community health providers. The now-operational teleopthalmology program is a testament to the early success of the project.
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Affiliation(s)
- Julie Kim
- University of Victoria, Victoria, BC, Canada.
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Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol 2015; 99:823-31. [PMID: 25563767 PMCID: PMC4453504 DOI: 10.1136/bjophthalmol-2014-305631] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 12/10/2014] [Indexed: 11/25/2022]
Abstract
Objective To determine the diagnostic accuracy of telemedicine in various clinical levels of diabetic retinopathy (DR) and diabetic macular oedema (DME). Methods PubMed, EMBASE and Cochrane databases were searched for telemedicine and DR. The methodological quality of included studies was evaluated using the Quality Assessment for Diagnostic Accuracy Studies (QUADAS-2). Measures of sensitivity, specificity and other variables were pooled using a random effects model. Summary receiver operating characteristic curves were used to estimate overall test performance. Meta-regression and subgroup analyses were used to identify sources of heterogeneity. Publication bias was evaluated using Stata V.12.0. Results Twenty articles involving 1960 participants were included. Pooled sensitivity of telemedicine exceeded 80% in detecting the absence of DR, low- or high-risk proliferative diabetic retinopathy (PDR), it exceeded 70% in detecting mild or moderate non-proliferative diabetic retinopathy (NPDR), DME and clinically significant macular oedema (CSME) and was 53% (95% CI 45% to 62%) in detecting severe NPDR. Pooled specificity of telemedicine exceeded 90%, except in the detection of mild NPDR which reached 89% (95% CI 88% to 91%). Diagnostic accuracy was higher with digital images obtained through mydriasis than through non-mydriasis, and was highest when a wide angle (100–200°) was used compared with a narrower angle (45–60°, 30° or 35°) in detecting the absence of DR and the presence of mild NPDR. No potential publication bias was detected. Conclusions The diagnostic accuracy of telemedicine using digital imaging in DR is overall high. It can be used widely for DR screening. Telemedicine based on the digital imaging technique that combines mydriasis with a wide angle field (100–200°) is the best choice in detecting the absence of DR and the presence of mild NPDR.
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Affiliation(s)
- Lili Shi
- Department of Medical informatics, Nantong University, Nantong, China Nantong University Library, Nantong, China
| | - Huiqun Wu
- Department of Medical informatics, Nantong University, Nantong, China
| | - Jiancheng Dong
- Department of Medical informatics, Nantong University, Nantong, China
| | - Kui Jiang
- Department of Medical informatics, Nantong University, Nantong, China
| | - Xiting Lu
- Department of Ophthalmology, Suzhou Municipal Hospital, Suzhou, China
| | - Jian Shi
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, China
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Influence of image compression on the interpretation of spectral-domain optical coherence tomography in exudative age-related macular degeneration. Eye (Lond) 2014; 28:825-31. [PMID: 24788012 DOI: 10.1038/eye.2014.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/17/2014] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To evaluate the effect of image compression of spectral-domain optical coherence tomography (OCT) images in the examination of eyes with exudative age-related macular degeneration (AMD). METHODS Thirty eyes from 30 patients who were diagnosed with exudative AMD were included in this retrospective observational case series. The horizontal OCT scans centered at the center of the fovea were conducted using spectral-domain OCT. The images were exported to Tag Image File Format (TIFF) and 100, 75, 50, 25 and 10% quality of Joint Photographic Experts Group (JPEG) format. OCT images were taken before and after intravitreal ranibizumab injections, and after relapse. The prevalence of subretinal and intraretinal fluids was determined. Differences in choroidal thickness between the TIFF and JPEG images were compared with the intra-observer variability. RESULTS The prevalence of subretinal and intraretinal fluids was comparable regardless of the degree of compression. However, the chorio-scleral interface was not clearly identified in many images with a high degree of compression. In images with 25 and 10% quality of JPEG, the difference in choroidal thickness between the TIFF images and the respective JPEG images was significantly greater than the intra-observer variability of the TIFF images (P=0.029 and P=0.024, respectively). CONCLUSIONS In OCT images of eyes with AMD, 50% of the quality of the JPEG format would be an optimal degree of compression for efficient data storage and transfer without sacrificing image quality.
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Arora S, Rudnisky CJ, Damji KF. Improved Access and Cycle Time with an “In-House” Patient-Centered Teleglaucoma Program Versus Traditional In-Person Assessment. Telemed J E Health 2014; 20:439-45. [DOI: 10.1089/tmj.2013.0241] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sourabh Arora
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
| | - Chris J. Rudnisky
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
| | - Karim F. Damji
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
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Verma S, Arora S, Kassam F, Edwards MC, Damji KF. Northern Alberta remote teleglaucoma program: clinical outcomes and patient disposition. Can J Ophthalmol 2014; 49:135-40. [DOI: 10.1016/j.jcjo.2013.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/07/2013] [Accepted: 11/07/2013] [Indexed: 10/25/2022]
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Standards and Guidelines in Telemedicine and Telehealth. Healthcare (Basel) 2014; 2:74-93. [PMID: 27429261 PMCID: PMC4934495 DOI: 10.3390/healthcare2010074] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/14/2014] [Accepted: 02/07/2014] [Indexed: 02/08/2023] Open
Abstract
The development of guidelines and standards for telemedicine is an important and valuable process to help insure effective and safe delivery of quality healthcare. Some organizations, such as the American Telemedicine Association (ATA), have made the development of standards and guidelines a priority. The practice guidelines developed so far have been well received by the telemedicine community and are being adopted in numerous practices, as well as being used in research to support the practice and growth of telemedicine. Studies that utilize published guidelines not only help bring them into greater public awareness, but they also provide evidence needed to validate existing guidelines and guide the revision of future versions. Telemedicine will continue to grow and be adopted by more healthcare practitioners and patients in a wide variety of forms not just in the traditional clinical environments, and practice guidelines will be a key factor in fostering this growth. Creation of guidelines is important to payers and regulators as well as increasingly they are adopting and integrating them into regulations and policies. This paper will review some of the recent ATA efforts in developing telemedicine practice guidelines, review the role of research in guidelines development, review data regarding their use, and discuss some of areas where guidelines are still needed.
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Kiage D, Kherani IN, Gichuhi S, Damji KF, Nyenze M. The Muranga Teleophthalmology Study: Comparison of Virtual (Teleglaucoma) with in-Person Clinical Assessment to Diagnose Glaucoma. Middle East Afr J Ophthalmol 2014; 20:150-7. [PMID: 23741134 PMCID: PMC3669492 DOI: 10.4103/0974-9233.110604] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE While the effectiveness of teleophthalmology is generally accepted, its ability to diagnose glaucomatous eye disease remains relatively unknown. This study aimed to compare a web-based teleophthalmology assessment with clinical slit lamp examination to screen for glaucoma among diabetics in a rural African district. MATERIALS AND METHODS Three hundred and nine diabetic patients underwent both the clinical slit lamp examination by a comprehensive ophthalmologist and teleglaucoma (TG) assessment by a glaucoma subspecialist. Both assessments were compared for any focal glaucoma damage; for TG, the quality of photographs was assessed, and vertical cup-to-disk ratio (VCDR) was calculated in a semi-automated manner. In patients with VCDR > 0.7, the diagnostic precision of the Frequency Doubling Technology (FDT) C-20 screening program was assessed. RESULTS Of 309 TG assessment photos, 74 (24%) were deemed unreadable due to media opacities, patient cooperation, and unsatisfactory photographic technique. While the identification of individual optic nerve factors showed either fair or moderate agreement, the ability to diagnose glaucoma based on the overall assessment showed moderate agreement (Kappa [κ] statistic 0.55% and 95% confidence interval [CI]: 0.48-0.62). The use of FDT to detect glaucoma in the presence of disc damage (VCDR > 0.7) showed substantial agreement (κ statistic of 0.84 and 95% CI 0.79-0.90). A positive TG diagnosis of glaucoma carried a 77.5% positive predictive value, and a negative TG diagnosis carried an 82.2% negative predicative value relative to the clinical slit lamp examination. CONCLUSION There was moderate agreement between the ability to diagnose glaucoma using TG relative to clinical slit lamp examination. Poor quality photographs can severely limit the ability of TG assessment to diagnose optic nerve damage and glaucoma. Although further work and validation is needed, the TG approach provides a novel, and promising method to diagnose glaucoma, a major cause of ocular morbidity throughout the world.
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Affiliation(s)
- Dan Kiage
- Department of Ophthalmology, Aga Khan University Nairobi, Kenya
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Kurji K, Kiage D, Rudnisky CJ, Damji KF. Improving diabetic retinopathy screening in Africa: patient satisfaction with teleophthalmology versus ophthalmologist-based screening. Middle East Afr J Ophthalmol 2014; 20:56-60. [PMID: 23580853 PMCID: PMC3617530 DOI: 10.4103/0974-9233.106388] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose: To assess patient preference for diabetic retinopathy (DR) screening with teleophthalmology or face-to-face ophthalmologist evaluation in Nairobi, Kenya. Materials and Methods: Fifty seven diabetic patients from a one-stop multidisciplinary diabetic clinic (consisting of a diabetologist, nurse educator, foot specialist, nutritionist, ophthalmologist, and neurologist) in Nairobi, Kenya were included if they had undergone both a teleophthalmology (stereoscopic digital retinal photographs graded by an ophthalmologist remotely) and a traditional clinical screening exam (face to face examination). A structured questionnaire with a 5-point Likert scale was developed in both English and Swahili. The questionnaire was administered over the telephone. Ten questions were used to compare patient experience and preferences between teleophthalmology and a traditional clinical examination for DR. A mean score >3.25 on the Likert scale was considered favourable. Results: Successfully telephone contact was possible for 26 (58% male, 42% females) of the 57 patients. The mean ages of the male and female patients were 52.4 and 46.5 years respectively. Patients were satisfied with their teleophthalmology examination (mean 4.15 ± 0.97). Patients preferred the teleophthalmology option for future screenings (mean 3.42 ± 1.52). This preference was driven primarily by convenience, reduced examination time, and being able to visualize their own retina. Conclusion: In this study, diabetic patients preferred a teleophthalmology based screening over a traditional ophthalmologist-based screening. The use of teleophthalmology in Africa warrants further study and has the potential to become the screening model of choice. Cost effectiveness in comparison to an ophthalmologist-based screening also requires evaluation.
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Affiliation(s)
- Khaliq Kurji
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Vaziri K, Moshfeghi DM, Moshfeghi AA. Feasibility of telemedicine in detecting diabetic retinopathy and age-related macular degeneration. Semin Ophthalmol 2013; 30:81-95. [PMID: 24171781 DOI: 10.3109/08820538.2013.825727] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Age-related macular degeneration and diabetic retinopathy are important causes of visual impairment and blindness in the world. Because of recent advances and newly available treatment modalities along with the devastating consequences associated with late stages of these diseases, much attention has been paid to the importance of early detection and improving patient access to specialist care. Telemedicine or, more specifically, digital retinal imaging utilizing telemedical technology has been proposed as an important alternative screening and management strategy to help meet this demand. In this paper, we perform a literature review and analysis that evaluates the validity and feasibility of telemedicine in detecting diabetic retinopathy and age-related macular degeneration. Understanding both the progress and barriers to progress that have been demonstrated in these two areas is important for future telemedicine research projects and innovations in telemedicine technology.
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Affiliation(s)
- Kamyar Vaziri
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Palm Beach Gardens , Florida , USA and
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Kassam F, Yogesan K, Sogbesan E, Pasquale LR, Damji KF. Teleglaucoma: improving access and efficiency for glaucoma care. Middle East Afr J Ophthalmol 2013; 20:142-9. [PMID: 23741133 PMCID: PMC3669491 DOI: 10.4103/0974-9233.110619] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Teleglaucoma is the application of telemedicine for glaucoma. We review and present the current literature on teleglaucoma; present our experience with teleglaucoma programs in Alberta, Canada and Western Australia; and discuss the challenges and opportunities in this emerging field. Teleglaucoma is a novel area that was first explored a little over a decade ago and early studies highlighted the technical challenges of delivering glaucoma care remotely. Advanced technologies have since emerged that show great promise in providing access to underserviced populations. Additionally, these technologies can improve the efficiency of healthcare systems burdened with an increasing number of patients with glaucoma, and a limited supply of ophthalmologists. Additional benefits of teleglaucoma systems include e-learning and e-research. Further work is needed to fully validate and study the cost and comparative effectiveness of this approach relative to traditional models of healthcare.
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Affiliation(s)
- Faazil Kassam
- Division of Ophthalmology, University of Calgary, Calgary, Alberta, Canada
| | - Kanagasingam Yogesan
- Australian E-Health Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Enitan Sogbesan
- Division of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
| | - Louis R. Pasquale
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Karim F. Damji
- Department of Ophthalmology, University of Alberta, Canada
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Kassam F, Amin S, Sogbesan E, Damji KF. The use of teleglaucoma at the University of Alberta. J Telemed Telecare 2012; 18:367-73. [DOI: 10.1258/jtt.2012.120313] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the teleglaucoma service at the University of Alberta is to improve access for people in northern Alberta who have early-stage glaucoma or who are at risk for glaucoma. Two types of teleglaucoma service are offered: remote and in-house. A standardized approach is used to capture patient information (structured histories, examinations and fundus photographs) which is then sent to a tertiary care centre for grading and recommendations. Only one grader reads and makes management recommendations for each case. Reports are sent electronically. A total of 195 cases have been graded through the remote service since 2008. A total of 62 cases have been graded through the in-house service since 2011. The average reporting time for consultations in the in-house service was 7 days, and it was also 7 days for the remote service. We believe that the use of teleglaucoma can improve the way that patients are diagnosed and managed, both in industrialized and developing countries. Teleglaucoma is currently being used as a screening tool at the Aga Khan University Hospital in Nairobi with mobile units equipped with a fundus camera and a visual field machine.
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Affiliation(s)
- Faazil Kassam
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
| | - Samreen Amin
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
| | - Enitan Sogbesan
- Division of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
| | - Karim F Damji
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada
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Silva PS, Cavallerano JD, Sun JK, Noble J, Aiello LM, Aiello LP. Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy. Am J Ophthalmol 2012; 154:549-559.e2. [PMID: 22626617 DOI: 10.1016/j.ajo.2012.03.019] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/03/2012] [Accepted: 03/06/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare nonmydriatic stereoscopic Optomap ultrawide field images with dilated stereoscopic Early Treatment Diabetic Retinopathy Study 7-standard field 35-mm color 30-degree fundus photographs (ETDRS photography) and clinical examination for determining diabetic retinopathy (DR) and diabetic macular edema (DME) severity. DESIGN Single-site, prospective, comparative, instrument validation study. METHODS One hundred three diabetic patients (206 eyes) representing the full spectrum of DR severity underwent nonmydriatic ultrawide field 100-degree and 200-degree imaging, dilated ETDRS photography, and dilated fundus examination by a retina specialist. Two independent readers graded images to determine DR and DME severity. A third masked retina specialist adjudicated discrepancies. RESULTS Based on ETDRS photography (n = 200), the results were as follows: no DR (n = 25 eyes [12.5%]), mild nonproliferative DR (NPDR; 47 [23.5%]), moderate NPDR (61 [30.5%]), severe NPDR (11 [5.5%]), very severe NPDR (3 [1.5%]), and proliferative DR (52 [2.5%]). One (0.5%) eye was ungradable and 6 eyes did not complete ETDRS photography. No DME was found in 114 eyes (57.0%), DME was found in 28 eyes (14.0%), and clinically significant DME was found in 47 eyes (23.5%), and 11 (5.5%) eyes were ungradable. Exact DR severity agreement between ultrawide field 100-degree imaging and ETDRS photography occurred in 84%, with agreement within 1 level in 91% (K(W) = 0.85; K = 0.79). Nonmydriatic ultrawide field images exactly matched clinical examination results for DR in 70% and were within 1 level in 93% (K(W) = 0.71; K = 0.61). Nonmydriatic ultrawide field imaging acquisition time was less than half that of dilated ETDRS photography (P < .0001). CONCLUSIONS Nonmydriatic ultrawide field images compare favorably with dilated ETDRS photography and dilated fundus examination in determining DR and DME severity; however, they are acquired more rapidly. If confirmed in broader diabetic populations, nonmydriatic ultrawide field imaging may prove to be beneficial in DR evaluation in research and clinical settings.
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Hooper P, Boucher MC, Cruess A, Dawson KG, Delpero W, Greve M, Kozousek V, Lam WC, Maberley DAL. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy. Can J Ophthalmol 2012; 47:S1-30, S31-54. [PMID: 22632804 DOI: 10.1016/j.jcjo.2011.12.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Risk factors for progression of diabetic retinopathy in Alberta First Nations communities. CANADIAN JOURNAL OF OPHTHALMOLOGY 2012; 47:365-75. [PMID: 22883847 DOI: 10.1016/j.jcjo.2012.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/07/2012] [Accepted: 04/08/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The Screening for Limb, I-Eye, Cardiovascular, and Kidney Complications (SLICK) Program was implemented in 1999 to improve diabetic care for Alberta First Nations individuals living on reserve. The purpose of this review is to determine the rate and predictors of progression of diabetic retinopathy (DR) over a 10-year period. DESIGN Cohort study. PARTICIPANTS Nine hundred and eighty First Nations patients with diabetes that underwent at least 2 teleophthalmology examinations during the study period. METHODS Patients underwent serial laboratory testing, and stereoscopic, mydriatic, retinal photography. Modified Early Treatment Diabetic Retinopathy Study grading of retinal images was performed via teleophthalmology. Progression was defined as an increase of 2 or more steps on the Diabetes Control and Complications Trial classification. RESULTS At baseline, most patients had no diabetic retinopathy (n = 777, 79.3%) whereas 203 people (20.7%) had either nonproliferative DR (n = 179, 18.3%) or proliferative DR (n = 24, 2.5%). Two-step progression occurred in 163 patients (16.6%), with only a minority of these individuals progressing to proliferative DR (n = 23). The median time to progression was 7.6 years. Multivariate Cox regression demonstrated that elevated hemoglobin A1C (hazard ratio [HR] = 1.42; p < 0.0001) and systolic blood pressure (HR = 1.24 per 10 mm Hg; p = 0.009) were independent predictors of progression of DR. CONCLUSIONS This population-based study has shown that the rate and predictors of progression of DR among First Nations individuals parallels non-First Nations populations, with HbA1C and systolic blood pressure being the strongest predictors. These findings suggest that targeted, individualized care to reduce blood pressure and control blood sugars could reduce progression of diabetic retinopathy, and possibly blindness in First Nations individuals living on reserve.
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Maker MP, Noble J, Silva PS, Cavallerano JD, Murtha TJ, Sun JK, Aiello LM, Bursell SE, Aiello LP. Automated Retinal Imaging System (ARIS) compared with ETDRS protocol color stereoscopic retinal photography to assess level of diabetic retinopathy. Diabetes Technol Ther 2012; 14:515-22. [PMID: 22385213 DOI: 10.1089/dia.2011.0270] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Early Treatment Diabetic Retinopathy Study (ETDRS) seven-standard-field color stereoscopic retinal photography (ETDRS photos) has been a gold standard for determining diabetic retinopathy (DR) severity. The Automated Retinal Imaging System (ARIS™, model 110, Visual Pathways, Inc., Prescott, AZ) acquires seven-sequential color stereoscopic digital images (ARIS images) by a semiautomated technician-run process generally corresponding to ETDRS photos. We assessed the correlation between a single semiautomated ARIS imaging session without any re-imaging and ETDRS photos performed by a certified photographer for the determination of DR severity. METHODS Two independent masked readers graded mydriatic ARIS images and ETDRS photos. A third masked retinal specialist adjudicated discrepancies. Correlation between the two modalities was compared using weighted-κ statistics. RESULTS We evaluated 211 eyes of 106 patients with varying levels of DR. Partially ungradable images were present in 3.4% of ETDRS photos versus 31.8% of ARIS images. Exact agreement and agreement within one level between ETDRS photos and ARIS images using only completely gradable image sets occurred in 69% (κ=0.81) and 90% of cases, respectively. Exact agreement for clinically significant macular edema was 92.1% (κ=0.59). There was 100% agreement for eyes with high-risk proliferative DR. Within one level of DR severity, 100% agreement occurred for the following: questionable nonproliferative DR (NPDR), moderate NPDR, and severe NPDR. CONCLUSIONS Results suggest that semiautomated ARIS images compare favorably with ETDRS photos when full image sets can be obtained; however, partially ungradable image sets occurred almost 10 times more frequently with ARIS images than with ETDRS photos. In the two-thirds of cases where ARIS images can be utilized, ARIS can obtain retinal images comparable to ETDRS photos while requiring less highly trained personnel than generally needed for standard ETDRS photos.
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Affiliation(s)
- Manvi P Maker
- Beetham Eye Institute, Joslin Diabetes Center, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 02215, USA
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Hooper P, Boucher MC, Cruess A, Dawson KG, Delpero W, Greve M, Kozousek V, Lam WC, Maberley DA, Maberley DAL. Canadian Ophthalmological Society Evidence-Based Clinical Practice Guidelines for the Management of Diabetic Retinopathy – Executive Summary. Can J Ophthalmol 2012; 47:91-6. [DOI: 10.1016/j.jcjo.2012.01.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gangaputra S, Pak JW, Peng Q, Hubbard LD, Thayer D, Krason Z, Joyce J, Danis RP. Transition from film to digital fundus photography in the Longitudinal Studies of the Ocular Complications of AIDS. Retina 2012; 32:600-5. [PMID: 21857393 PMCID: PMC4164651 DOI: 10.1097/iae.0b013e318221592f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the transition to digital imaging and assess any impact on ocular disease classification. METHODS Film and digital images, acquired by certified photographers, were evaluated independently according to standard procedures for the following: image quality, presence of cytomegalovirus retinitis lesions, and their extent and proximity from disk and macula. Intergrader agreement within the digital medium was also assessed. RESULTS Among the 15 eyes with cytomegalovirus retinitis, the mean difference between film and digital images for linear distance of lesion edge to disk was 0.02 disk diameters, for distance to center of macula was -0.04 disk diameters, and area covered by cytomegalovirus retinitis was 0.95 disk area. There was no statistically significant difference in distance and area measurements between media. Intergrader agreement in measurements of digital images was excellent for distance and area estimated. CONCLUSION Our results suggest that digital grading of cytomegalovirus retinitis in Longitudinal Studies of the Ocular Complications of AIDS is comparable with that from film regarding disease classification, measurements, and reproducibility. These findings provide support for continuity of grading data, despite the necessary transition in imaging media.
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Affiliation(s)
- Sapna Gangaputra
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Jeong Won Pak
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Qian Peng
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Larry D. Hubbard
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Dennis Thayer
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Zbigniew Krason
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
| | - Jeff Joyce
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
| | - Ronald P. Danis
- Fundus Photograph Reading Center, Department of Ophthalmology, University of Wisconsin- Madison
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Ausayakhun S, Skalet AH, Jirawison C, Ausayakhun S, Keenan JD, Khouri C, Nguyen K, Kalyani PS, Heiden D, Holland GN, Margolis TP. Accuracy and reliability of telemedicine for diagnosis of cytomegalovirus retinitis. Am J Ophthalmol 2011; 152:1053-1058.e1. [PMID: 21861977 DOI: 10.1016/j.ajo.2011.05.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 05/23/2011] [Accepted: 05/24/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the feasibility of remote diagnostic screening for cytomegalovirus (CMV) retinitis among HIV patients in northern Thailand. DESIGN Prospective, observational cross-sectional study. METHODS One hundred eighty-two eyes from 94 consecutive patients with HIV seen in 2008 and 2009 at a tertiary university-based medical center were photographed using a digital retinal camera. Individual and composite images were uploaded to a secure web site. Three expert graders accessed the electronic images and graded each image for signs of CMV retinitis. Results of remote expert grading were compared with on-site patient examination by local expert ophthalmologists. RESULTS On-site ophthalmologists diagnosed CMV retinitis in 89 (48.9%) of 182 eyes. Trained ophthalmic photographers obtained digital retinal images for all 182 eyes. As compared with the on-site examinations, the sensitivity for detecting CMV retinitis by remote readers using composite retinal images ranged from 89% to 91%. The specificity for detecting CMV retinitis by remote readers ranged from 85% to 88%. Intrarater reliability was high, with each grader achieving a κ value of 0.93. Interrater reliability among the 3 graders also was high, with a κ value of 0.86. CONCLUSIONS Remote diagnostic screening for CMV retinitis among HIV-positive patients may prove to be a valuable tool in countries where the burden of HIV exceeds the capacity of the local eye care providers to screen for ocular opportunistic infections.
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