Telemedicine in diabetic retinopathy screening

Telemedicine in diabetic retinopathy screening in India

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.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis

Background: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED.Methods: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.).Results: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI.Conclusions: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Role of Oral Antioxidant Supplementation in the Current Management of Diabetic Retinopathy

Oxidative stress has been postulated as an underlying pathophysiologic mechanism of diabetic retinopathy (DR), the main cause of avoidable blindness in working-aged people. This review addressed the current daily clinical practice of DR and the role of antioxidants in this practice. A systematic review of the studies on antioxidant supplementation in DR patients was presented. Fifteen studies accomplished the inclusion criteria. The analysis of these studies concluded that antioxidant supplementation has a IIB level of recommendation in adult Type 1 and Type 2 diabetes mellitus subjects without retinopathy or mild-to-moderate nonproliferative DR without diabetic macular oedema as a complementary therapy together with standard medical care.

Nonmydriatic Photographic Screening for Diabetic Retinopathy in Pregnant Patients with Pre-Existing Diabetes in a Safety Net Population: 1 Year Results from the Diabetic Retinopathy in Pregnant Patients Study

Background: Pregnant patients with pre-existing diabetes mellitus (DM) are at increased risk for development or progression of existing diabetic retinopathy (DR). A quality improvement project was initiated to improve DR screening during pregnancy at a safety net hospital. This article highlights the utility and generalizability of our telemedicine-based screening model. Materials and Methods: In April 2018, we implemented a photographic retinal screening system in the Maternal Fetal Medicine (MFM) clinic at Santa Clara Valley Medical Center in San Jose, CA. The system is intended to screen all pregnant patients with pre-existing diabetes (type 1 and 2). Retinal images are automatically uploaded to a secure server and interpreted by a retina specialist (C.K.P.). Results: A total of 71 pregnant patients with pre-existing DM were seen in the MFM clinic during the study period. Sixty-six of 71 patients (93.0%) were screened compared with 69.1% in the year prior. Of the 64 patients screened with readable images 11 (17.2%) had DR, whereas 53 did not. Forty-nine of the 64 (74.2%) patients screened underwent screening using the new nonmydriatic system in the MFM clinic. Only 7 out of 47 (14.9%) patients with readable images in the MFM clinic required referral to the ophthalmology clinic. Conclusion: Our model for DR screening in pregnant patients in safety net hospitals is effective in improving screening rates and expediting evaluation and treatment for those in need. This system can prevent irreversible vision loss in pregnant patients and provides an effective framework for ophthalmic care in a safety net hospital system.

Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: The University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits

The coronavirus disease 2019 pandemic has led to widespread change as public health strategies for containment have emphasized social distancing and remaining at home. These policies have led to downscaled clinic volumes, cancellation of elective procedures, enhanced personal protective strategies in the clinic, and adoption of telemedicine encounters. We describe the evidence-based practical approach taken in our ophthalmology department to continue delivering eye care during the pandemic by rescheduling visits, enhancing clinic safety, and adopting virtual video encounters.

Factors associated with retinal screening among patients with diabetes in Taiwan

PURPOSE

The purpose of this study is to explore the factors associated with having a diabetic retinopathy exam (DRE) during the past 2 years among patients with diabetes.

METHODS

Patients visiting the eye clinic at Shin-Kong Memorial Hospital in Taipei were enrolled in this study from January to June 2009. A total of 313 patients participated in this study. Excluding patients with missing responses for more than three questions (38) yielded a final sample of 275 participants. Chi-square and Mann-Whitney U-tests were used for bivariate analysis. Multivariable logistic regression examined factors associated with having a DRE controlling for demographic and health factors.

RESULTS

Although 83% of participants said that their physician suggested DRE, only 60% were screened during the past 2 years. In response to the question about why patients did not seek a DRE exam, 43.2% reported that they did not know having this exam was necessary. In adjusted results, receiving information about the relationship between diabetes and retinopathy from medical staff and believing that diabetes could damage the vision were associated with having a DRE in the past 2 years (both P < 0.05).

CONCLUSIONS

Although most patients indicated that their physician suggested the need for eye care, a substantial percentage of patients with diabetes were not aware of the need for a regular DRE. Information about the relationship between diabetes and retinopathy and concerns about damage to vision were associated with greater likelihood of seeking a DRE. These factors should be considered to promote DR screening.

Advances in Retinal Imaging and Applications in Diabetic Retinopathy Screening: A Review

Rising prevalence of diabetes worldwide has necessitated the implementation of population-based diabetic retinopathy (DR) screening programs that can perform retinal imaging and interpretation for extremely large patient cohorts in a rapid and sensitive manner while minimizing inappropriate referrals to retina specialists. While most current screening programs employ mydriatic or nonmydriatic color fundus photography and trained image graders to identify referable DR, new imaging modalities offer significant improvements in diagnostic accuracy, throughput, and affordability. Smartphone-based fundus photography, macular optical coherence tomography, ultrawide-field imaging, and artificial intelligence-based image reading address limitations of current approaches and will likely become necessary as DR becomes more prevalent. Here we review current trends in imaging for DR screening and emerging technologies that show potential for improving upon current screening approaches.

Operational Components of Telemedicine Programs for Diabetic Retinopathy

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 and improve outcomes, but incomplete implementation of published standards creates a risk to program utility and sustainability. In a prior article, we reviewed 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. This article reviews the literature regarding the impact of automated image grading, cost effectiveness, program standards, and quality assurance (QA) on telemedicine assessment of diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but greater attention to development and implementation of standards is needed to better realize its potential.

Clinical Components of Telemedicine Programs for Diabetic Retinopathy

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.

Diabetic retinopathy screening with pharmacy-based teleophthalmology in a semiurban setting: a cost-effectiveness analysis

BACKGROUND

Diabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario.

METHODS

A decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results).

RESULTS

The cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers.

INTERPRETATION

The study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.

Telemedicine in diabetic retinopathy: Access to rural India

Diabetic retinopathy (DR) is a growing concern in India. The first step in management of DR is timely screening. With 10% prevalence in rural India, 11 million people are likely to have DR by the year 2030. With limited resources and skilled manpower, it will not be possible to have routine eye examination to identify and treat these patients on a regular basis. Telemedicine is a possible answer in these situations where patients could be remotely screened and appropriately advised. With the advent of several technological advances such as low cost hand-held nonmydriatic camera, increased capabilities of the smartphones to take external eye and retinal photographs coupled with improving broadband connectivity; teleophthalmology in the management of DR could be a reality in the not too distant future.

Telemedicine in diabetic retinopathy: current status and future directions

Telemedicine is exchange of medical data by electronic telecommunications technology that allows a patient's medical problems evaluated and monitored by a remotely located physician. Over the years, telemedicine and telescreening have become important components in health care, in both disease detection and treatment. Highly visual and image intensive ophthalmology is uniquely suited for telemedicine. Because of rising disease burden coupled with high opportunity cost in detection, diabetic retinopathy is an ideal ophthalmic disease for telescreening and decision-making. It fits to Wilson and Jungner's all 10 criteria of screening for chronic diseases and the American Telehealth Association's 4 screening categories.

Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine

IMPORTANCE

The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care.

OBJECTIVE

To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings.

MAIN OUTCOMES AND MEASURES

The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings.

RESULTS

A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7% having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1% of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7% of the other ocular findings were cataract.

CONCLUSIONS AND RELEVANCE

In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated.

Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis

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.

Feasibility of retinal screening in a pediatric population with type 1 diabetes mellitus

PURPOSE

To study the feasibility of using a nonmydriatic camera to screen children with type 1 diabetes mellitus (DM1) as young as 2 years for diabetic retinopathy.

METHODS

Prospective pilot imaging study involving children with DM1 aged 2 to 17 years. The screening consisted of: (1) intake form; (2) measurement of blood pressure, pulse, and oximetry; (3) assessment of visual acuity (SIMAV, Padova, Italy); and (4) nonmydriatic color imaging (Canon CX-1 45° 15.1 megapixel camera; Canon Corp., Tokyo, Japan). Images were assessed for signs of diabetic retinopathy and graded for quality on a scale of 1 to 5 by two clinicians. Kappa coefficient was calculated to determine inter-observer agreement.

RESULTS

One hundred four of 106 (98%) children underwent imaging (mean age: 11.1 years, 51% male, 88% white). One (1%) child had nonproliferative diabetic retinopathy and 2 (1.9%) had incidental findings. Only 62% of children had an eye examination within the past year, with children with DM1 for more than 5 years significantly more likely to have done so (P = .03). Children who had an eye examination within the past year were significantly older than their counterparts (P = .01). Images of high quality (grades 4 and 5) were acquired in 178 (86%) eyes, and images of some clinical value (grades ≥ 2) were obtained in 207 (99.5%) eyes. Inter-observer agreement for image quality was 0.896.

CONCLUSIONS

The feasibility of using a nonmydriatic camera to screen children as young as 2 years for changes related to diabetic eye disease was demonstrated. Nonmydriatic imaging may supplement standard dilated clinical ophthalmology examinations for select patient populations.

The use of mobile robotic telemedicine technology in the neonatal intensive care unit

OBJECTIVE

To describe the use of a wireless, mobile, robotic telecommunications system in the Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

In this prospective study utilizing 304 patient encounters on 46 preterm and term neonates in a level IIIa NICU, a bedside neonatologist ('on-site neonatologist'; ONSN) and a neonatologist at a distant location ('off-site neonatologist'; OFFSN) evaluated selected demographic information, laboratory data and clinical and radiological findings of the subjects. The OFFSN used a commercial wireless, mobile, robotic telecommunications system controlled from a remote site. The two physicians were blinded to each other's findings and agreement rates of the evaluations between the ONSN and the OFFSN were compared using kappa statistics. Agreement rates between two ONSNs using the same protocol with 39 patient encounters served as the reference standard. The dependability and timeliness of data transmission were also assessed.

RESULT

Excellent or intermediate-to-good agreements were noted for all but a few physical examination assessments between both the ONSN and OFFSN and the two ONSNs. Poor agreements were found for certain physical examination parameters (breath-, heart- and bowel-sounds and capillary refill time) with or without the use of telemedicine. The median duration of the encounters by the ONSN and OFFSN and the two ONSNs was similar. Five encounters were excluded from the analysis because of technical difficulties. No complications associated with the use of the mobile robot were noted.

CONCLUSION

Our findings indicate that the use of mobile robotic telemedicine technology is feasible for neonates in the NICU.

Prevalence and determinants of diabetic retinopathy among persons ≥ 40 years of age with diabetes in Qatar: a community-based survey

PURPOSE

We present the prevalence and determinants of diabetic retinopathy (DR) in persons 40 years and older with diabetes in Qatar.

METHODS

This community-based survey was held in 2009 at 49 randomly selected clusters. Demographic details and history of diabetes mellitus (DM) and its management were collected by nurses. Ophthalmologists examined the retina by slit-lamp biomicroscopy using +90 D lens and/or indirect ophthalmoscopy. Digital photographs of retina were obtained. The best-corrected visual acuity of each eye was noted. Diabetic retinopathy was graded as mild, moderate, or severe nonproliferative DR, proliferative DR, or diabetic macular edema.

RESULTS

We examined 540 (97.3%) participants with DM. Diabetes mellitus status of 487 persons could be confirmed from medical records. The age- and sex-adjusted prevalence of DR among the diabetic population 40 years and older was 23.5% (95% confidence interval [CI] 19.7-27.3), with 8192 cases of DR among patients with DM. Longer duration of diabetes (odds ratio 1.14 [95% CI 1.10-1.19]) and poor glycemic control (odds ratio 1.12 [95% CI 1.02-1.23]) were risk factors for DR. Awareness of regular eye checkup was found in 62% of participants. Only 20% of persons with sight-threatening DR had undergone laser treatment in at least 1 eye. Visual acuity in the better eye was 6/6 to 6/18 in 90% of persons with DR.

CONCLUSIONS

Universal and periodic eye screening of patients with diabetes is recommended in Qatar. Health promotion for primary prevention and resource review are needed for early detection and management of sight-threatening DR.