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Huemer J, Wagner SK, Sim DA. The Evolution of Diabetic Retinopathy Screening Programmes: A Chronology of Retinal Photography from 35 mm Slides to Artificial Intelligence. Clin Ophthalmol 2020; 14:2021-2035. [PMID: 32764868 PMCID: PMC7381763 DOI: 10.2147/opth.s261629] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
As a third of people with diabetes mellitus (DM) will suffer the microvascular complications of diabetic retinopathy (DR) and therapeutic options can effectively prevent visual impairment, systematic screening has substantially reduced disease burden in developed countries. In an effort to tackle the rising incidence of DM, screening programmes have modernized in synchrony with technical and infrastructural advancements. Patient evaluation has shifted from face-to-face ophthalmologist-based review delivered through community grassroots to asynchronous store-and-forward modern telemedicine platforms commissioned on a nationwide scale. First pioneered with primitive 35-mm slide film retinal photography, the last decade has seen an emergence of high resolution and widefield imaging devices, which may reveal extents of DR indiscernible to the clinician but with implications of potential earlier identification. Similar progress has been seen in image analysis approaches - automated image analysis of retinal photographs of DR has evolved from qualitative feature detection to rules-based algorithms to autonomous artificial intelligence-powered classification. Such models have, relatively rapidly, been validated and are now receiving approval from health regulation authorities with deployment into the clinical sphere. In this review, we chart the evolution of global DR screening programmes since their inception highlighting major milestones in healthcare infrastructure, telemedicine approaches and imaging devices that have shaped the robust and effective frameworks recognised today. We also provide an outlook for the future of DR screening in the context of recent technological advancements with respect to their limitations in current times.
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Affiliation(s)
- Josef Huemer
- NIHR Biomedical Research Center at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Vienna Institute for Research in Ocular Surgery, A Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
| | - Siegfried K Wagner
- NIHR Biomedical Research Center at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Dawn A Sim
- NIHR Biomedical Research Center at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Glasson NM, Larkins SL, Crossland LJ. What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study. BMC Health Serv Res 2017; 17:158. [PMID: 28222770 PMCID: PMC5320669 DOI: 10.1186/s12913-017-2045-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) is the commonest cause of preventable blindness in working age populations, but up to 98% of visual loss secondary to DR can be prevented with early detection and treatment. In 2012, an innovative outreach DR screening model was implemented in remote communities in a state of Australia. The aim of this study was to explore the acceptability of this unique DR screening model to patients, health professionals and other key stakeholders. METHODS This descriptive qualitative study used semi-structured interviews with patients opportunistically recruited whilst attending DR screening, and purposefully selected health care professionals either working within or impacted by the programme. Interviews were audiotaped, transcribed and analysed using NVIVO. An iterative process of thematic analysis was used following the principles of grounded theory. RESULTS Interviews were conducted with fourteen patients with diabetes living in three remote communities and nine health professionals or key stakeholders. Nine key themes emerged during interviews with health professionals, key stakeholders and patients: i) improved patient access to DR screening; ii) efficiency, financial implications and sustainability; iii) quality and safety; iv) multi-disciplinary diabetes care; v) training and education; vi) operational elements of service delivery; vii) communication, information sharing and linkages; viii) coordination and integration of the service and ix) suggested improvements to service delivery. CONCLUSIONS The Remote Outreach DR Screening Service is highly acceptable to patients and health professionals. Challenges have primarily been encountered in communication and coordination of the service and further development in these areas could improve the programme's impact and sustainability in remote communities. The service is applicable to other remote communities nationally and potentially internationally.
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Affiliation(s)
- Nicola M Glasson
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville City, QLD, 4811, Australia.
| | - Sarah L Larkins
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville City, QLD, 4811, Australia
| | - Lisa J Crossland
- Discipline of General Practice, University of Queensland, Royal Brisbane Hospital, Level 8 Health Sciences Building, Herston, QLD, 4029, Australia
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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 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.
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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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Glasson NM, Crossland LJ, Larkins SL. An Innovative Australian Outreach Model of Diabetic Retinopathy Screening in Remote Communities. J Diabetes Res 2016; 2016:1267215. [PMID: 26798648 PMCID: PMC4698887 DOI: 10.1155/2016/1267215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/21/2015] [Accepted: 09/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Up to 98% of visual loss secondary to diabetic retinopathy (DR) can be prevented with early detection and treatment. Despite this, less than 50% of Australian and American diabetics receive appropriate screening. Diabetic patients living in rural and remote communities are further disadvantaged by limited access to ophthalmology services. Research Design and Methods. DR screening using a nonmydriatic fundal camera was performed as part of a multidisciplinary diabetes service already visiting remote communities. Images were onforwarded to a distant general practitioner who identified and graded retinopathy, with screen-positive patients referred to ophthalmology. This retrospective, descriptive study aims to compare the proportion of remote diabetic patients receiving appropriate DR screening prior to and following implementation of the service. Results. Of the 141 patients in 11 communities who underwent DR screening, 16.3% had received appropriate DR screening prior to the implementation of the service. In addition, 36.2% of patients had never been screened. Following the introduction of the service, 66.3% of patients underwent appropriate DR screening (p = 0.00025). Conclusion. This innovative model has greatly improved accessibility to DR screening in remote communities, thereby reducing preventable blindness. It provides a holistic, locally appropriate diabetes service and utilises existing infrastructure and health workforce more efficiently.
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Affiliation(s)
- Nicola M. Glasson
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville City, QLD 4811, Australia
- *Nicola M. Glasson:
| | - Lisa J. Crossland
- Discipline of General Practice, University of Queensland, Level 8 Health Sciences Building, Royal Brisbane Hospital, Herston, QLD 4029, Australia
| | - Sarah L. Larkins
- College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville City, QLD 4811, Australia
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Cichosz SL, Johansen MD, Knudsen ST, Hansen TK, Hejlesen O. A classification model for predicting eye disease in newly diagnosed people with type 2 diabetes. Diabetes Res Clin Pract 2015; 108:210-5. [PMID: 25765665 DOI: 10.1016/j.diabres.2015.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/19/2015] [Accepted: 02/19/2015] [Indexed: 01/19/2023]
Abstract
Diabetic retinopathy may be present at the time type 2 diabetes is diagnosed, and initial screening encompassing an eye examination performed by an ophthalmologist or optometrist is therefore recommended. However, proper screening for retinopathy may be challenging in many parts of the world. We hypothesized that simple, commonly available patient characteristics can be used to identify patients at high risk for having retinopathy. We investigated data from multiple years extracted from the National Health and Nutrition Examination Survey which holds information about blood glucose and eye examinations. Individuals with hitherto undiagnosed diabetes were classified according to the presence or absence of retinopathy. Linear classification was used to predict which patients had retinopathy at the time of diagnosis. A total of 266 individuals with undiagnosed diabetes were identified from the cohorts. Of these, 222 individuals had no sign of retinopathy, whereas 44 had mild or moderate non-proliferative retinopathy. Using information regarding HbA1c, BMI, waist circumference, age, systolic blood pressure, urinary albumin, and urinary creatinine, we were able to construct a model that predicts the presence of retinopathy with a positive predictive value of 22% and a negative predictive value of 99%. Only one true positive (1/44) with mild non-proliferative retinopathy was falsely classified. A classification model using readily available patient information and routine biochemical measures can be used to identify patients at high risk of having retinopathy at the time their diabetes is diagnosed. The model may be used to identify high-risk patients for retinopathy screening.
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Affiliation(s)
- Simon Lebech Cichosz
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Endocrinology, Aarhus University Hospital, Denmark.
| | | | | | | | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Denmark
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Bashshur RL, Shannon GW, Smith BR, Woodward MA. The empirical evidence for the telemedicine intervention in diabetes management. Telemed J E Health 2015; 21:321-54. [PMID: 25806910 PMCID: PMC4432488 DOI: 10.1089/tmj.2015.0029] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/17/2015] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic retinopathy. The impetus derives from the confluence of high prevalence of these diseases, increasing incidence, and rising costs, while telemedicine promises to ameliorate, if not prevent, type 2 diabetes and its complications. MATERIALS AND METHODS A purposeful review of the literature identified relevant publications from January 2005 to December 2013. These were culled to retain only credible research articles for detailed review and analysis. The search yielded approximately 17,000 articles with no date constraints. Of these, 770 appeared to be research articles within our time frame. A review of the abstracts yielded 73 articles that met the criteria for inclusion in the final analysis. Evidence is organized by research findings regarding feasibility/acceptance, intermediate outcomes (e.g., use of service, and screening compliance), and health outcomes (control of glycemic level, lipids, body weight, and physical activity.) RESULTS Definitions of telediabetes varied from study to study vis-à-vis diabetes subtype, setting, technology, staffing, duration, frequency, and target population. Outcome measures also varied. Despite these vagaries, sufficient evidence was obtained from a wide variety of research studies, consistently pointing to positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise. The major contributions point to telemedicine's potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated. CONCLUSIONS Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.
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Affiliation(s)
- Rashid L. Bashshur
- E-Health Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Gary W. Shannon
- Department of Geography, University of Kentucky, Lexington, Kentucky
| | - Brian R. Smith
- E-Health Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Maria A. Woodward
- Departments of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
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Schulze-Döbold C, Erginay A, Robert N, Chabouis A, Massin P. Ophdiat(®): five-year experience of a telemedical screening programme for diabetic retinopathy in Paris and the surrounding area. DIABETES & METABOLISM 2012; 38:450-7. [PMID: 22765981 DOI: 10.1016/j.diabet.2012.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 05/22/2012] [Accepted: 05/22/2012] [Indexed: 10/28/2022]
Abstract
AIM This report describes our 5 years of experience with the ophthalmological diabetes telemedical network Ophdiat(®), designed to screen for diabetic retinopathy. METHODS Seventeen hospitals, 11 primary healthcare centres and two prisons in the Paris area were gradually equipped with a non-mydriatic funduscopic camera between June 2004 and December 2009. Photos were taken by trained orthoptists and nurses, and interpreted by an average of seven certified ophthalmologists. The software was updated twice in 2008. RESULTS In all, 38,596 patients were screened during 51,741 examinations between June 2004 and December 2009. Of these patients, 13,726 (26.55%) were referred to an ophthalmologist because of unreadable photographs (9.94%), advanced stages of retinopathy (14.71%) or concomitant eye diseases (1.90%). Patients screened in hospitals and prisons exhibited a greater prevalence of retinopathy and at more advanced stages. CONCLUSION Telemedicine is a screening method that is well adapted for diabetic patients. In view of the increasing number of such patients and the decreasing number of ophthalmologists, expansion of the Ophdiat(®) screening network is desirable.
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Affiliation(s)
- C Schulze-Döbold
- Assistance publique-Hôpitaux de Paris, Paris-Diderot University, Ophthalmology Department, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris cedex 10, France
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Pirie CG, Pizzirani S. Reflex-free digital fundus photography using a simple and portable camera adaptor system. A viable alternative. J Vis Commun Med 2012; 34:146-55. [PMID: 22229473 DOI: 10.3109/17453054.2011.635293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To describe a digital single lens reflex (dSLR) camera adaptor for posterior segment photography. METHOD A total of 30 normal canine and feline animals were imaged using a dSLR adaptor which mounts between a dSLR camera body and lens. Posterior segment viewing and imaging was performed with the aid of an indirect lens ranging from 28-90D. Coaxial illumination for viewing was provided by a single white light emitting diode (LED) within the adaptor, while illumination during exposure was provided by the pop-up flash or an accessory flash. Corneal and/or lens reflections were reduced using a pair of linear polarizers, having their azimuths perpendicular to one another. RESULTS Quality high-resolution, reflection-free, digital images of the retina were obtained. Subjective image evaluation demonstrated the same amount of detail, as compared to a conventional fundus camera. A wide range of magnification(s) [1.2-4X] and/or field(s) of view [31-95 degrees, horizontal] were obtained by altering the indirect lens utilized. CONCLUSION The described adaptor may provide an alternative to existing fundus camera systems. Quality images were obtained and the adapter proved to be versatile, portable and of low cost.
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Affiliation(s)
- Chris G Pirie
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA 01536, USA.
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Abstract
Diabetes has emerged as a major public health concern in developing nations. Health systems in most developing countries are yet to integrate effective prevention and control programs for diabetes into routine health care services. Given the inadequate human resources and underfunctioning health systems, we need novel and innovative approaches to combat diabetes in developing-country settings. In this regard, the tremendous advances in telecommunication technology, particularly cell phones, can be harnessed to improve diabetes care. Cell phones could serve as a tool for collecting information on surveillance, service delivery, evidence-based care, management, and supply systems pertaining to diabetes from primary care settings in addition to providing health messages as part of diabetes education. As a screening/diagnostic tool for diabetes, cell phones can aid the health workers in undertaking screening and diagnostic and follow-up care for diabetes in the community. Cell phones are also capable of acting as a vehicle for continuing medical education; a decision support system for evidence-based management; and a tool for patient education, self-management, and compliance. However, for widespread use, we need robust evaluations of cell phone applications in existing practices and appropriate interventions in diabetes.
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Affiliation(s)
- Vamadevan S Ajay
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical MedicineLondon, United Kingdom
- Centre for Chronic Disease Control, Public Health Foundation of India, Safdarjung Development AreaNew Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Public Health Foundation of India, Safdarjung Development AreaNew Delhi, India
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Whitten P, Holtz B, Laplante C. Telemedicine: What have we learned? Appl Clin Inform 2010; 1:132-41. [PMID: 23616832 DOI: 10.4338/aci-2009-12-r-0020] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 04/15/2010] [Indexed: 12/12/2022] Open
Abstract
As the health care industry is facing many challenges and is undergoing extensive change, telemedicine is in the position to address these challenges and be an important part of health care's development. Telemedicine has been used for approximately a half century, in which researchers have explored the different technologies utilized, clinical outcomes, cost benefits, perceptions, and adoption challenges of its use. This paper reviews and summarizes these findings and presents possible future research endeavors. Examining what is known about telemedicine can aid in the development of innovative, sustainable and beneficial health technologies that could positively impact health care delivery and outcomes.
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