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Tomić M, Vrabec R, Hendelja Đ, Kolarić V, Bulum T, Rahelić D. Diagnostic Accuracy of Hand-Held Fundus Camera and Artificial Intelligence in Diabetic Retinopathy Screening. Biomedicines 2023; 12:34. [PMID: 38255141 PMCID: PMC10813433 DOI: 10.3390/biomedicines12010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Our study aimed to assess the role of a hand-held fundus camera and artificial intelligence (AI)-based grading system in diabetic retinopathy (DR) screening and determine its diagnostic accuracy in detecting DR compared with clinical examination and a standard fundus camera. This cross-sectional instrument validation study, as a part of the International Diabetes Federation (IDF) Diabetic Retinopathy Screening Project, included 160 patients (320 eyes) with type 2 diabetes (T2DM). After the standard indirect slit-lamp fundoscopy, each patient first underwent fundus photography with a standard 45° camera VISUCAM Zeiss and then with a hand-held camera TANG (Shanghai Zhi Tang Health Technology Co., Ltd.). Two retina specialists independently graded the images taken with the standard camera, while the images taken with the hand-held camera were graded using the DeepDR system and an independent IDF ophthalmologist. The three screening methods did not differ in detecting moderate/severe nonproliferative and proliferative DR. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, kappa (ĸ) agreement, diagnostic odds ratio, and diagnostic effectiveness for a hand-held camera compared to clinical examination were 0.921, 89.1%, 100%, 100%, 91.4%, infinity, 0.11, 0.86, 936.48, and 94.9%, while compared to the standard fundus camera were 0.883, 83.2%, 100%, 100%, 87.3%, infinity, 0.17, 0.78, 574.6, and 92.2%. The results of our study suggest that fundus photography with a hand-held camera and AI-based grading system is a short, simple, and accurate method for the screening and early detection of DR, comparable to clinical examination and fundus photography with a standard camera.
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Affiliation(s)
- Martina Tomić
- Department of Ophthalmology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Romano Vrabec
- Department of Ophthalmology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Đurđica Hendelja
- Department of Ophthalmology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Vilma Kolarić
- Department of Diabetes and Endocrinology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Tomislav Bulum
- Department of Diabetes and Endocrinology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Dario Rahelić
- Department of Diabetes and Endocrinology, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Ilica 242, 10000 Zagreb, Croatia
- School of Medicine, Josip Juraj Strossmayer University, Josipa Huttlera 4, 31000 Osijek, Croatia
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Caceres J, Zhang Y, Boe L, Zhou Y, Besirli C, Paulus YM, Rosenthal JM. Diabetic Retinopathy Screening Using a Portable Retinal Camera in Vanuatu. Clin Ophthalmol 2023; 17:2919-2927. [PMID: 37814638 PMCID: PMC10560479 DOI: 10.2147/opth.s410425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/30/2023] [Indexed: 10/11/2023] Open
Abstract
Background and Objective Proof-of-concept study to test the feasibility of using an all-in-one portable retinal camera for the screening of diabetic retinopathy in the Pacific Island of Vanuatu, which has a high rate of diabetes and its associated complications and a dearth of ophthalmologists. Study Design/Materials and methods From February 10, 2020, through February 28, 2020, 49 patients with diabetes mellitus from three islands in Vanuatu were recruited to participate in the study. Demographics, basic health data and retinal photography were obtained. A non-mydriatic, handheld camera was used (Volk Pictor Plus). Results Eleven participants (24%) had referral-warranted diabetic retinopathy. There was moderately high inter-rater reliability for our dependent variables: referral status (κ = 0.62, 95% CI 0.42-0.83), retinopathy severity (κ = 0.76, 95% CI 0.55-0.96), and clinically significant macular edema (κ = 0.50, 95% CI 0.25-0.74). Conclusion Our study confirms that portable handheld cameras can be used to obtain retinal images of sufficient quality for diabetic retinopathy screening even in resource limited environments like Vanuatu. Among this cohort, a relatively high (24%) prevalence of referral-warranted diabetic retinopathy was found in Vanuatu.
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Affiliation(s)
- Juan Caceres
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Yibing Zhang
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Lawrence Boe
- Penama Provincial Health, Godden Memorial Hospital, Ambae, Vanuatu
| | - Yunshu Zhou
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Cagri Besirli
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Yannis M Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Julie M Rosenthal
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
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Fernández-Gutiérrez DÁ, Núñez-Marrero J, Martínez-Alberto CE, Rodríguez-Álvaro M, García-Hernández AM, Brito-Brito PR. Knowledge of Diabetic Retinopathy among Primary Care Nurses Performing Fundus Photography and Agreement with Ophthalmologists on Screening. NURSING REPORTS 2023; 13:1064-1076. [PMID: 37606461 PMCID: PMC10443370 DOI: 10.3390/nursrep13030093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023] Open
Abstract
Diabetic retinopathy (DR) is one of the complications of diabetes mellitus (DM), with macular oedema being one of the leading causes of avoidable blindness among individuals with DM worldwide. Fundus screening is the only method for early detection and treatment. High-quality training programmes for professionals performing primary care screening are essential to produce high-quality images that facilitate accurate lesion identification. This is a two-phase observational, descriptive, and cross-sectional study. The first phase analysed DR knowledge in a sample of nurses. The second phase explored agreement on DR screening between referral ophthalmologists in image assessment (gold standard) and a small group of nurses involved in the previous phase. In phase 1, the agreement rate for screening results was 90%. In phase 2, the overall raw agreement on the screening of fundus photography results between nurses and ophthalmologists was 75% (Cohen's kappa = 0.477; p < 0.001). Agreement on screening with ophthalmologists was moderate, suggesting that implementing a specific training programme for nurse-led imaging screening would help develop this competence among nurses, ensuring a good level of agreement and patient safety and adding value for users, and also for the sustainability of the healthcare system. This study was not registered.
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Affiliation(s)
- Domingo Ángel Fernández-Gutiérrez
- Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain; (D.Á.F.-G.); (P.R.B.-B.)
- Primary Care Management Board of Tenerife, The Canary Islands Health Service, 38003 Santa Cruz de Tenerife, Spain;
| | - Janet Núñez-Marrero
- Primary Care Management Board of Tenerife, The Canary Islands Health Service, 38003 Santa Cruz de Tenerife, Spain;
| | | | - Martín Rodríguez-Álvaro
- Health Services Management Board of La Palma, The Canary Islands Health Service, 38713 Breña Alta, Spain
| | | | - Alfonso Miguel García-Hernández
- Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain; (D.Á.F.-G.); (P.R.B.-B.)
| | - Pedro Ruymán Brito-Brito
- Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain; (D.Á.F.-G.); (P.R.B.-B.)
- Primary Care Management Board of Tenerife, The Canary Islands Health Service, 38003 Santa Cruz de Tenerife, Spain;
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Land MR, Patel PA, Bui T, Jiao C, Ali A, Ibnamasud S, Patel PN, Sheth V. Examining the Role of Telemedicine in Diabetic Retinopathy. J Clin Med 2023; 12:jcm12103537. [PMID: 37240642 DOI: 10.3390/jcm12103537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
With the increasing prevalence of diabetic retinopathy (DR), screening is of the utmost importance to prevent vision loss for patients and reduce financial costs for the healthcare system. Unfortunately, it appears that the capacity of optometrists and ophthalmologists to adequately perform in-person screenings of DR will be insufficient within the coming years. Telemedicine offers the opportunity to expand access to screening while reducing the economic and temporal burden associated with current in-person protocols. The present literature review summarizes the latest developments in telemedicine for DR screening, considerations for stakeholders, barriers to implementation, and future directions in this area. As the role of telemedicine in DR screening continues to expand, further work will be necessary to continually optimize practices and improve long-term patient outcomes.
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Affiliation(s)
- Matthew R Land
- Department of Ophthalmology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Parth A Patel
- Department of Ophthalmology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Tommy Bui
- Department of Ophthalmology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Cheng Jiao
- Department of Ophthalmology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Arsalan Ali
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76129, USA
| | - Shadman Ibnamasud
- Department of Ophthalmology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Prem N Patel
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Veeral Sheth
- Department of Ophthalmology, University Retina and Macula Associates, Oak Forest, IL 60452, USA
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Chawla S, Chawla A, Chawla R, Jaggi S, Singh D, Trehan S. Trained nurse–operated teleophthalmology screening approach as a cost-effective tool for diabetic retinopathy. Int J Diabetes Dev Ctries 2022. [DOI: 10.1007/s13410-021-01037-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Sivaprasad S, Netuveli G, Wittenberg R, Khobragade R, Sadanandan R, Gopal B, Premnazir L, Conroy D, Srinath J, Ramakrishnan R, George S, Sahasranamam VI. Complex interventions to implement a diabetic retinopathy care pathway in the public health system in Kerala: the Nayanamritham study protocol. BMJ Open 2021; 11:e040577. [PMID: 34183333 PMCID: PMC8240569 DOI: 10.1136/bmjopen-2020-040577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Using a type 2 hybrid effectiveness-implementation design, we aim to pilot a diabetic retinopathy (DR) care pathway in the public health system in Kerala to understand how it can be scaled up to and sustained in the whole state. METHODS AND ANALYSIS Currently, there is no systematic DR screening programme in Kerala. Our intervention is a teleophthalmology pathway for people with diabetes in the non-communicable disease registers in 16 family health centres. The planned implementation strategy of the pathway will be developed based on the discrete Expert Recommendations for Implementing Change taxonomy. We will use both quantitative data from a cross-sectional study and qualitative data obtained from structured interviews, surveys and group discussions with stakeholders to report the effectiveness of the DR care pathway and evaluation of the implementation strategy.We will use logistic regression models to assess crude associations DR and sight-threatening diabetic retinopathy and fractional polynomials to account for the form of continuous covariates to predict uptake of DR screening. The primary effectiveness outcome is the proportion of patients in the non-communicable disease register with diabetes screened for DR over 12 months. Other outcomes include cost-effectiveness, safety, efficiency, patient satisfaction, timeliness and equity. The outcomes of evaluation of the implementation strategies include acceptability, feasibility, adoption, appropriateness, fidelity, penetration, costs and sustainability. Addition of more family health centres during the staggered initial phase of the programme will be considered as a sign of acceptability and feasibility. In the long term, the state-wide adoption of the DR care pathway will be considered as a successful outcome of the Nayanamritham study. ETHICS AND DISSEMINATION The study was approved by Indian Medical Research Council (2018-0551) dated 13 March 2019. Study findings will be disseminated through scientific publications and the report will inform adoption of the DR care pathway by Kerala state in future. TRIAL REGISTRATION NUMBER ISRCTN28942696.
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Affiliation(s)
- Sobha Sivaprasad
- Medical Retina Department, NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
- Vision Sciences, UCL, London, UK
| | - Gopalakrishnan Netuveli
- Institute of Connected Communities, University of East London-Duncan House Campus, London, UK
| | - Raphael Wittenberg
- Nuffield Department of Primary Health Care Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Rajan Khobragade
- Directorate of Health, Government of Kerala, Thiruvananthapuram, India
| | - Rajeev Sadanandan
- Directorate of Health, Government of Kerala, Thiruvananthapuram, India
| | - Bipin Gopal
- Non-Communicable Diseases Department, Directorate of Health Services, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Lakshmi Premnazir
- Directorate of Health Services, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | | | - Jyotsna Srinath
- Institute of Connected Communities, University of East London-Duncan House Campus, London, UK
| | | | - Simon George
- Ophthalmology Department, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, India
| | - Vasudeva Iyer Sahasranamam
- Ophthalmology Department, Regional Institute of Ophthalmology, Government Medical College, Thiruvananthapuram, India
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Pieczynski J, Kuklo P, Grzybowski A. The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy. Ophthalmol Ther 2021; 10:445-464. [PMID: 34156632 PMCID: PMC8217784 DOI: 10.1007/s40123-021-00353-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/15/2021] [Indexed: 01/30/2023] Open
Abstract
In the presence of the ever-increasing incidence of diabetes mellitus (DM), the prevalence of diabetic eye disease (DED) is also growing. Despite many improvements in diabetic care, DM remains a leading cause of visual impairment in working-age patients. So far, prevention has been the best way to protect vision. The sooner we diagnose DED, the more effective the treatment is. Thus, diabetic retinopathy (DR) screening, especially with imaging techniques, is a method of choice for vision protection. To alleviate the burden of diabetic patients who need ophthalmic care, telemedicine and in-home testing are used, supported by artificial intelligence (AI) algorithms. This is why we decided to evaluate current image teleophthalmology methods used for DR screening. We searched the PubMed platform for papers published over the last 5 years (2015–2020) using the following key words: telemedicine in diabetic retinopathy screening, diabetic retinopathy screening, automated diabetic retinopathy screening, artificial intelligence in diabetic retinopathy screening, smartphone diabetic retinopathy testing. We have included 118 original articles meeting the above criteria, discussing imaging diabetic retinopathy screening methods. We have found that fundus cameras, stable or mobile, are most commonly used for retinal photography, with portable fundus cameras also relatively common. Other possibilities involve the use of ultra-wide-field (UWF) imaging and even optical coherence tomography (OCT) devices for DR screening. Also, the role of smartphones is increasingly recognized in the field. Retinal fundus images are assessed by humans instantly or remotely, while AI algorithms seem to be useful tools facilitating retinal image assessment. The common use of smartphones and availability of relatively cheap, easy-to-use adapters for retinal photographs augmented by AI algorithms make it possible for eye fundus photographs to be taken by non-specialists and in non-medical setting. This opens the way for in-home testing conducted on a much larger scale in the future. In conclusion, based on current DR screening techniques, we can suggest that the future practice of eye care specialists will be widely supported by AI algorithms, and this way will be more effective.
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Affiliation(s)
- Janusz Pieczynski
- Chair of Ophthalmology, University of Warmia and Mazury, Zolnierska 18, 10-561, Olsztyn, Poland. .,The Voivodal Specialistic Hospital in Olsztyn, Olsztyn, Poland.
| | - Patrycja Kuklo
- Chair of Ophthalmology, University of Warmia and Mazury, Zolnierska 18, 10-561, Olsztyn, Poland.,The Voivodal Specialistic Hospital in Olsztyn, Olsztyn, Poland
| | - Andrzej Grzybowski
- Chair of Ophthalmology, University of Warmia and Mazury, Zolnierska 18, 10-561, Olsztyn, Poland.,Institute for Research in Ophthalmology, Poznan, Poland, Gorczyczewskiego 2/3, 61-553, Poznan, Poland
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