The prevalence of diabetic retinopathy as identified by teleophthalmology in rural Alberta

Integrating AI with tele-ophthalmology in Canada: a review

The field of ophthalmology is rapidly advancing, with technological innovations enhancing the diagnosis and management of eye diseases. Tele-ophthalmology, or the use of telemedicine for ophthalmology, has emerged as a promising solution to improve access to eye care services, particularly for patients in remote or underserved areas. Despite its potential benefits, tele-ophthalmology faces significant challenges, including the need for high volumes of medical images to be analyzed and interpreted by trained clinicians. Artificial intelligence (AI) has emerged as a powerful tool in ophthalmology, capable of assisting clinicians in diagnosing and treating a variety of conditions. Integrating AI models into existing tele-ophthalmology infrastructure has the potential to revolutionize eye care services by reducing costs, improving efficiency, and increasing access to specialized care. By automating the analysis and interpretation of clinical data and medical images, AI models can reduce the burden on human clinicians, allowing them to focus on patient care and disease management. Available literature on the current status of tele-ophthalmology in Canada and successful AI models in ophthalmology was acquired and examined using the Arksey and O'Malley framework. This review covers literature up to 2022 and is split into 3 sections: 1) existing Canadian tele-ophthalmology infrastructure, with its benefits and drawbacks; 2) preeminent AI models in ophthalmology, across a variety of ocular conditions; and 3) bridging the gap between Canadian tele-ophthalmology and AI in a safe and effective manner.

Enhancing diabetic retinopathy screening: Non-mydriatic fundus photography-assisted telemedicine for improved clinical management

The utilization of non-mydriatic fundus photography-assisted telemedicine to screen patients with diabetes mellitus for diabetic retinopathy provides an accurate, efficient, and cost-effective method to improve early detection of disease. It has also been shown to correlate with increased participation of patients in other aspects of diabetes care. In particular, patients who undergo teleretinal imaging are more likely to meet Comprehensive Diabetes Care Healthcare Effectiveness Data and Information Set metrics, which are linked to preservation of quality-adjusted life years and additional downstream healthcare savings.

Cost-effectiveness analysis of artificial intelligence-based diabetic retinopathy screening in rural China based on the Markov model

This study assessed the cost-effectiveness of different diabetic retinopathy (DR) screening strategies in rural regions in China by using a Markov model to make health economic evaluations. In this study, we determined the structure of a Markov model according to the research objectives, which required parameters collected through field investigation and literature retrieval. After perfecting the model with parameters and assumptions, we developed a Markov decision analytic model according to the natural history of DR in TreeAge Pro 2011. For this model, we performed Markov cohort and cost-effectiveness analyses to simulate the probabilistic distributions of different developments in DR and the cumulative cost-effectiveness of artificial intelligence (AI)-based screening and ophthalmologist screening for DR in the rural population with diabetes mellitus (DM) in China. Additionally, a model-based health economic evaluation was performed by using quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios. Last, one-way and probabilistic sensitivity analyses were performed to assess the stability of the results. From the perspective of the health system, compared with no screening, AI-based screening cost more (the incremental cost was 37,257.76 RMB (approximately 5,211.31 US dollars)), but the effect was better (the incremental utility was 0.33). Compared with AI-based screening, the cost of ophthalmologist screening was higher (the incremental cost was 14,886.76 RMB (approximately 2,070.19 US dollars)), and the effect was worse (the incremental utility was -0.31). Compared with no screening, the incremental cost-effectiveness ratio (ICER) of AI-based DR screening was 112,146.99 RMB (15,595.47 US dollars)/QALY, which was less than the threshold for the ICER (< 3 times the per capita gross domestic product (GDP), 217,341.00 RMB (30,224.03 US dollars)). Therefore, AI-based screening was cost-effective, which meant that the increased cost for each additional quality-adjusted life year was merited. Compared with no screening and ophthalmologist screening for DR, AI-based screening was the most cost-effective, which not only saved costs but also improved the quality of life of diabetes patients. Popularizing AI-based DR screening strategies in rural areas would be economically effective and feasible and can provide a scientific basis for the further formulation of early screening programs for diabetic retinopathy.

Assessing the feasibility, acceptability, and fidelity of a tele-retinopathy-based intervention to encourage greater attendance to diabetic retinopathy screening in immigrants living with diabetes from China and African-Caribbean countries in Ottawa, Canada: a protocol

BACKGROUND

Diabetic retinopathy is a leading cause of preventable blindness in Canada. Clinical guidelines recommend annual diabetic retinopathy screening for people living with diabetes to reduce the risk and progression of vision loss. However, many Canadians with diabetes do not attend screening. Screening rates are even lower in immigrants to Canada including people from China, Africa, and the Caribbean, and these groups are also at higher risk of developing diabetes complications. We aim to assess the feasibility, acceptability, and fidelity of a co-developed, linguistically and culturally tailored tele-retinopathy screening intervention for Mandarin-speaking immigrants from China and French-speaking immigrants from African-Caribbean countries living with diabetes in Ottawa, Canada, and identify how many from each population group attend screening during the pilot period.

METHODS

We will work with our health system and patient partners to conduct a 6-month feasibility pilot of a tele-retinopathy screening intervention in a Community Health Centre in Ottawa. We anticipate recruiting 50-150 patients and 5-10 health care providers involved in delivering the intervention for the pilot. Acceptability will be assessed via a Theoretical Framework of Acceptability-informed survey with patients and health care providers. To assess feasibility, we will use a Theoretical Domains Framework-informed interview guide and to assess fidelity, and we will use a survey informed by the National Institutes of Health framework from the perspective of health care providers. We will also collect patient demographics (i.e., age, gender, ethnicity, health insurance status, and immigration information), screening outcomes (i.e., patients with retinopathy identified, patients requiring specialist care), patient costs, and other intervention-related variables such as preferred language. Survey data will be descriptively analyzed and qualitative data will undergo content analysis.

DISCUSSION

This feasibility pilot study will capture how many people living with diabetes from each group attend the diabetic retinopathy screening, costs, and implementation processes for the tele-retinopathy screening intervention. The study will indicate the practicability and suitability of the intervention in increasing screening attendance in the target population groups. The study results will inform a patient-randomized trial, provide evidence to conduct an economic evaluation of the intervention, and optimize the community-based intervention.

Cost-effectiveness Analysis of a Personalized, Teleretinal-Inclusive Screening Policy for Diabetic Retinopathy via Markov Modeling

PURPOSE

Although teleretinal imaging has proved effective in increasing population-level screening for diabetic retinopathy (DR), there is a lack of quantitative understanding of how to incorporate teleretinal imaging into existing screening guidelines. We develop a mathematical model to determine personalized DR screening recommendations that utilize teleretinal imaging and evaluate the cost-effectiveness of the personalized screening policy.

DESIGN

A partially observable Markov decision process is employed to determine personalized screening recommendations based on patient compliance, willingness to pay, and A1C level. Deterministic sensitivity analysis was conducted to evaluate the impact of patient-specific factors on personalized screening policy. The cost-effectiveness of identified screening policies was evaluated via hidden-Markov chain Monte Carlo simulation on a data-based hypothetical cohort.

PARTICIPANTS

Screening policies were simulated for a hypothetical cohort of 500 000 patients with parameters based on the literature and electronic medical records of 2457 patients who received teleretinal imaging from 2013 to 2020 from the Harris Health System.

METHODS

Population-based mathematical modeling study. Interventions included dilated fundus examinations referred to as clinical screening, teleretinal imaging, and wait and watch recommendations.

MAIN OUTCOME MEASURES

Personalized screening recommendations based on patient-specific factors. Accumulated quality-adjusted life-years (QALYs) and cost (USD) per patient under different screening policies. Incremental cost-effectiveness ratio to compare different policies.

RESULTS

For the base cohort, on average, teleretinal imaging was recommended 86.7% of the time over each patient's lifetime. The model-based personalized policy dominated other standardized policies, generating more QALY gains and cost savings for at least 57% of the base cohort. Similar outcomes were observed in sensitivity analyses of the base cohort and the Harris Health-specific cohort and rural population scenario analysis.

CONCLUSIONS

A mathematical model was developed as a decision support tool to identify a personalized screening policy that incorporates both teleretinal imaging and clinical screening and adapts to patient characteristics. Compared with current standardized policies, the model-based policy significantly reduces costs, whereas it is performing comparably, if not better, in terms of QALY gain. A personalized approach to DR screening has significant potential benefits that warrant further exploration.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Role of Telemedicine in Diabetes Management

INTRODUCTION

Telemedicine is a growing arena that may increase access to care for patients with diabetes. It has more relevance for rural populations or those with limited physical access to health care, for improving diabetes care. Telemedicine can also be used to offer diabetes self-education and transportation barriers for patients living in under-resourced areas or with disabilities.

METHOD

"This review explores the landscape of telemedicine approaches and evidence for incorporation into general practice.

RESULTS & DISCUSSION

Telehealth platforms have been shown to be both feasible and effective for health care delivery in diabetes, although there are many caveats that require tailoring to the institution, clinician, and patient population. Research in diabetes telehealth should focus next on how to increase access to patients who are known to be marginalized from traditional models of health care.

A Systematic Review of Current Teleophthalmology Services in New Zealand Compared to the Four Comparable Countries of the United Kingdom, Australia, United States of America (USA) and Canada

Background

Over 700,000 New Zealanders (NZ), particularly elderly and Māori, live without timely access to specialist ophthalmology services. Teleophthalmology is a widely recognised tool that can assist in overcoming resource and distance barriers. Teleophthalmology gained unprecedented traction in NZ during the COVID-19 pandemic and subsequent lockdown. However, its provision is still limited and there are equity issues. The aim of this study was to conduct a systematic review identifying, describing and contrasting teleophthalmology services in NZ with the comparable countries of Australia, USA, Canada and the United Kingdom.

Methods

The electronic databases Embase, PubMed, Web of Science, Google Scholar and Google were systemically searched using the keywords: telemedicine, ophthalmology, tele-ophthalmology/teleophthalmology. The searches were filtered to the countries above, with no time constraints. An integrative approach was used to synthesise findings.

Results

One hundred and thirty-two studies were identified describing 90 discrete teleophthalmology services. Articles spanned from 1997 to 2020. Models were categorised into general eye care (n=21; 16%); emergency/trauma (n=6; 4.5%); school screening (n=25; 19%); artificial intelligence (AI) (n=23; 18%); and disease-specific models of care (MOC) (n=57; 43%). The most common diseases addressed were diabetic retinopathy (n=23; 17%); retinopathy of prematurity (n=9; 7%); and glaucoma (n=8; 6%). Programs were mainly centred in the US (n=72; 54.5%), followed by the UK (n=29; 22%), then Canada (n=16; 12%), Australia (n=13; 10%), with the fewest identified in NZ (n=3; 2%). Models generally involved an ophthalmologist consultative service, remote supervision and triaging. Most models involved local clinicians transmitting fed-forward or live images.

Conclusion

Teleophthalmology will likely play a crucial role in the future of eye care. COVID-19 has offered a unique opportunity to observe the use of teleophthalmology services globally. Feed-forward and, increasingly, live-based teleophthalmology services have demonstrated feasibility and cost-effectiveness in similar countries internationally. New Zealand’s teleophthalmology services, however, are currently limited. Investing in strategic partnerships and technology at a national level can advance health equities in ophthalmic care.

The Future Is Now: Incorporating Telemedicine into Glaucoma Care

Purpose of Review

The field of teleglaucoma has expanded rapidly in recent years with several large-scale teleglaucoma screening programs in existence throughout the world. Additionally, teleglaucoma programs for use in disease management are under study. The limited access to care that resulted from the COVID-19 pandemic highlighted the need for expansion of such programs. This article reviews the literature on teleglaucoma for screening and management of glaucoma, discussing considerations for incorporating teleglaucoma into clinical practice.

Recent Findings

Teleglaucoma screening reduces the rate of false-positive referrals and can accurately screen at-risk populations with accuracy similar to in-person screening. The use of teleglaucoma for the management of glaucoma shows promise for low-risk patients with early disease. Furthermore, teleglaucoma is cost-effective and reduces travel burden for patients resulting in high patient satisfaction.

Summary

Teleglaucoma offers potential for improving access to glaucoma care, reducing the burden on patients and health care systems.

Sociodemographics Associated With Risk of Diabetic Retinopathy Detected by Tele-Ophthalmology: 5-Year Results of the Toronto Tele-Retinal Screening Program

OBJECTIVES

Our aim in this study was to describe screening outcomes and sociodemographic characteristics of patients in an urban tele-ophthalmology screening program for diabetic retinopathy (DR).

METHODS

A prospective cohort study was conducted on adults with diabetes type 1 or type 2 enrolled in the Toronto Tele-Retinal Screening Program between September 2013 and March 2019.

RESULTS

A total of 1,374 screenings were completed, of which 344 (25%) detected DR. Of all participants, 17% did not have provincial health coverage and 21% never had an eye exam. Of the 587 patients who completed sociodemographic questionnaires, the majority (84%) were born outside of Canada, and only 62% preferred English as their spoken language. Forty percent reported a household income of <$25,000, with these participants having an increased likelihood of detectable DR (odds ratio [OR], 1.83; p<0.01).

CONCLUSIONS

Participants with low income are more likely to screen positive for DR. Tele-ophthalmologic screening can be effective in an urban, culturally diverse and socioeconomically disadvantaged population.

The role of tele-ophthalmology in diabetic retinopathy screening

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States. Considering the increasing incidence of DR, it is extremely important to detect the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system. Despite the advances in retinal imaging, analysis techniques are still superseded by expert ophthalmologist interpretation. Teleophthalmology presents an immense opportunity, with high rates of sensitivity and specificity, to manage the steadily increasing demand for eye care of patients with diabetes, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

Burden of disease and costs associated with type 2 diabetes in emerging and established markets: systematic review analyses

Objectives: To estimate the clinical and economic burden of type 2 diabetes (T2D) in established (EST) and emerging markets (EMG).Methods: Three systematic literature reviews were conducted in MEDLINE and Embase to capture all relevant publications reporting 1) the epidemiology of T2D and complications in T2D and 2) the economic burden of T2D and associated complications.Results: In total, 294 studies were included in this analysis. Evidence indicates a high and increasing overall prevalence of T2D globally, ranging up to 23% in EMG markets and 14% in EST markets. Undiagnosed cases were higher in EMG versus EST markets (up to 67% vs 38%), potentially due to a lack of education and disease awareness in certain regions, that could lead to important clinical and economic consequences. Poor glycemic control was associated with the development of several complications (e.g. retinopathy, cardiovascular diseases and nephropathy) that increase the risk of morbidity and mortality. Direct costs were up to 9-fold higher in patients with vs without T2D-related complications.Conclusions: The burden of T2D, related complications and inherent costs are higher in emerging versus established market countries. This review explores potential strategies to reduce costs and enhance outcomes of T2D treatment in developing countries.

Diabetic retinopathy among Omanis: Prevalence and clinical profile

PURPOSE

The aim of this study is to describe the prevalence, severity and clinical profile of diabetic retinopathy (DR) among Omani diabetic patients attending a tertiary care hospital.

MATERIALS AND METHODS

This is a retrospective study involving the record review of diabetic patients attending the diabetes retina clinic of the National Diabetes and Endocrine Centre in the period between June 2015 and May 2016. Retinal evaluation of 442 native patients was conducted using direct ophthalmological examination and digital photography. DR was graded using the Early Treatment DR Study criteria. The statistical analysis was conducted using SPSS, version 20.

RESULTS

The estimated total prevalence of DR was 31% (95% confidence interval: 26.6-35.3). Mild nonproliferative diabetic retinopathy (NPDR) constitutes 21.3%, while moderate-to-severe NPDR and proliferative diabetic retinopathy constitute 4.5% and 5.2%, respectively. The prevalence of vision-threatening diabetic retinopathy (VTDR) and diabetic maculopathy was 15.4% and 13.3%, respectively. Retinopathy was significantly associated with age, diabetes duration, Type 2 diabetes mellitus, coexisting comorbidities or complications, systolic blood pressure, glycated hemoglobin (HbA1c), fasting blood sugar, triglycerides, and albumin/creatinine ratio. In the regression analysis, age (P = 0.02), duration (P < 0.001), and HbA1c (P < 0.001) were independently associated with DR.

CONCLUSIONS

The prevalence of DR and VTDR among Omani diabetics is high. Age, duration of diabetes, and HbA1c are the risk factors for the development of DR among Omanis. This emphasizes the importance of planning resources for different modalities of treatment of DR to face the future challenge.

Prevalence of Diabetic Retinopathy in Type 1 and Type 2 Diabetes Mellitus Patients in North-East Poland

Background and Objectives: The global epidemic of diabetes, especially type 2 (DM2), is related to lifestyle changes, obesity, and the process of population aging. Diabetic retinopathy (DR) is the most serious complication of the eye caused by diabetes. The aim of this research was to assess the prevalence of diabetic retinopathy in type 1 and type 2 diabetes mellitus patients in north-east Poland. Materials and Methods: The eye fundus was assessed on the basis of two-field 50 degrees color fundus photographs that showed the optic nerve and macula in the center after the pupil was dilated with 1% tropicamide. Results: The experimental group included 315 (26%) patients with type 1 diabetes mellitus (DM1) and 894 (74%) patients with DM2. DM1 patients were diagnosed with DR in 32.58% of cases, with non-proliferative diabetic retinopathy (NPDR) in 24.44% of cases, proliferative diabetic retinopathy (PDR) in 1.59% of cases, diabetic macular edema (DME) in 5.40% of cases, and PDR with DME in 0.95% of cases. DR was found in DM2 patients in 23.04% of cases, NPDR in 17.11% of cases, PDR in 1.01% of cases, DME in 4.81% of cases, and PDR with DME in 0.11% of cases. Conclusions: The presented study is the first Polish study on the prevalence of diabetic retinopathy presenting a large group of patients, and its results could be extrapolated to the whole country. Diabetic retinopathy was found in 25.48% of patients in the whole experimental group. The above results place Poland within the European average, indicating the quality of diabetic care offered in Poland, based on the number of observed complications.

Epidemiology of Diabetic Retinopathy at Eye Clinic Svjetlost Sarajevo: Two Years Retrospective Single Center Study

Introduction:

Diabetic retinopathy (DR) is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. 2.6% of global blindness can be attributed to diabetes. Disease severity was most often classified by the Early Treatment Diabetic Retinopathy Study (ETDRS) classification for DR severity. Patients are usually categorized based on the severity of DR as having mild nonproliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, or proliferative diabetic retinopathy (PDR).

Aim:

To evaluate DR status among patients at Eye Clinic Svjetlost Sarajevo , both, type 1 and type 2 DM patients who presented in our clinic at 2 years period – from June 2016 to June 2018. This is single center study.

Methods:

Retrospective analysis of 753 diabetic patients that came for the first check up in our institution during those two years, 363 patients were male and 390 were female. Patients were divided in 3 groups (based on DR changes): a) No changes, b) Nonproliferative DR (with and without Diabetic macular edema–DME), c) Prolipherative DR (with and without DME + Advanced PDR).

Results:

There were 35% of patients with no ocular changes, 41.2% had NPDR and 24% had PDR. Prevalence of DR in our study was 65.32%. Distribution of NPDR was 66.27%, and PDR was 33.73%. DME was present in 33.70% cases. In NPDR, DME was presented in 51% of the cases, while in PDR was presented in 49% of the cases. In state of advanced PDR, PDR was presented in 30.52% cases, tractional detachment and haemophtalmus in 50.20% of cases and neovascular glaucoma in 19.28%. Sixty-three patients ended up with vitroretinal surgery (8.4%) while in other studies that number is up to 3%. Out of that number 9 patients were patient with virgin eyes (14.28%). Neovascular glaucoma occurred in 19.28% of diabetics with proliferative retinopathy and 4.60% in all of diabetics.

Conclusion:

Diabetic retinopathy status of patients presenting at Eye clinic Svjetlost Sarajevo, Bosnia and Herzegovina is quite poor. There is a big need for early DR screening measures, good prevention and management of DR risk factors. Adequate and ON TIME management of DM and its vision threatening complications is of major importance.

New imaging systems in diabetic retinopathy

Various imaging modalities are of significant utility in the screening, grading, treatment, and follow-up of the different stages of diabetic retinopathy (DR) and diabetic macular edema. Color stereographic photography, fluorescein angiography, and optical coherence tomography (OCT) have been the gold standard for DR imaging for years. Besides these tools, newer technologies are gaining validation and popularity, such as fundus autofluorescence and OCT angiography. Furthermore, widefield retinography and ultra-widefield retinography have been introduced for a more comprehensive evaluation of the medium-far and very-far retinal peripheries, which is crucial for the assessment of the diverse manifestations of the disease. The aim of this review is to illustrate the recent advancements of the imaging systems for diagnosing DR, with a focus on the newest and noninvasive diagnostic tools.

Scaling Up Teleophthalmology for Diabetic Eye Screening: Opportunities for Widespread Implementation in the USA

PURPOSE OF REVIEW

We discuss opportunities to address key barriers to widespread implementation of teleophthalmology programs for diabetic eye screening in the United States (U.S.).

RECENT FINDINGS

Teleophthalmology is an evidence-based form of diabetic eye screening. This technology has been proven to substantially increase diabetic eye screening rates and decrease blindness. However, teleophthalmology implementation remains limited among U.S. health systems. Major barriers include financial concerns as well as limited utilization by providers, clinical staff, and patients. Possible interventions include increasingly affordable camera technology, demonstration of financially sustainable billing models, and engaging key stakeholders. Significant opportunities exist to overcome barriers to scale up and promote widespread implementation of teleophthalmology in the USA. Further development of methods to sustain effective increases in diabetic eye screening rates using this technology is needed. In addition, the demonstration of cost-effectiveness in a variety of billing models should be investigated to facilitate widespread implementation of teleophthalmology in U.S. health systems.

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.

The prevalence and systemic risk factors of diabetic macular edema: a cross-sectional study from Turkey

Background

The aim of this study was to evaluate the prevalence of diabetic macular edema (DME) utilizing optical coherence tomography (OCT), and to clarify the effects of the systemic findings and risk factors on the development of DME.

Methods

This cross-sectional study was conducted in the departments of ophthalmology and endocrinology at the Dokuz Eylul University School of Medicine in Izmir, Turkey. The demographics, type and duration of diabetes mellitus, treatment modality, smoking and alcohol consumption habits, as well as the systemic blood pressure, renal functional tests, hemoglobulin A1c level, serum lipid profile, and 24-h urine albumin level were noted and statistically analyzed. The relationships between the systemic findings and DME were studied.

Results

Four-hundred and thirteen eyes of 413 diabetic patients who were examined between January 2011 and July 2012 were enrolled in this study. The prevalence of DME was 15.3% among the patients. The males exhibited DME significantly more frequently than the females (p = 0.031), and the duration of diabetes was significantly longer in those patients with DME (p < 0.001). Those patients without DME frequently used antihyperlipidemic drugs and had a higher level of high density lipoprotein cholesterol (p = 0.040 and p = 0.046, respectively). The patient’s alcohol consumption, nephropathy, neuropathy, previous cataract surgery, severity of diabetic retinopathy, and insulin usage were statistically significant factors with regard to the DME prevalence.

Conclusions

This study demonstrated the prevalence of DME in Turkey by utilizing OCT. The development of DME can be avoided or limited and the response to treatment may be improved by the regulation of the DME risk factors.

The Role of Teleophthalmology in the Management of Diabetic Retinopathy

The emergence of diabetes as a global epidemic is accompanied by the rise in diabetes‑related retinal complications. Diabetic retinopathy, if left undetected and untreated, can lead to severe visual impairment and affect an individual's productivity and quality of life. Globally, diabetic retinopathy remains one of the leading causes of visual loss in the working‑age population. Teleophthalmology for diabetic retinopathy is an innovative means of retinal evaluation that allows identification of eyes at risk for visual loss, thereby preserving vision and decreasing the overall burden to the health care system. Numerous studies worldwide have found teleophthalmology to be a reliable and cost‑efficient alternative to traditional clinical examinations. It has reduced barriers to access to specialized eye care in both rural and urban communities. In teleophthalmology applications for diabetic retinopathy, it is critical that standardized protocols in image acquisition and evaluation are used to ensure low image ungradable rates and maintain the quality of images taken. Innovative imaging technology such as ultrawide field imaging has the potential to provide significant benefit with integration into teleophthalmology programs. Teleophthalmology programs for diabetic retinopathy rely on a comprehensive and multidisciplinary approach with partnerships across specialties and health care professionals to attain wider acceptability and allow evidence‑based eye care to reach a much broader population.

Models of care in tele-ophthalmology: A scoping review

The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.

Prognostic value of high-resolution magnetic resonance imaging in evaluating carotid atherosclerotic plaque in patients with ischemic stroke

BACKGROUND

Ischemic stroke (IS) is a devastating occurrence affecting millions worldwide. This study aimed to evaluate the prognostic value of high-resolution magnetic resonance imaging (HRMRI) in assessing carotid atherosclerotic plaque in IS patients.

METHODS

Between January 2013 and March 2015, 338 IS patients were recruited for the investigative purposes of the study. All participants of the study underwent an HRMRI inspection procedure after being admitted into the hospital. During this study, we systematically analyzed and measured various types of fibrous caps, lipid compositions, and plaque lipid ratios. Univariate and multivariate logistic regression analyses were performed for predicting prognosis of IS patients. A receiver-operating characteristic (ROC) curve was employed to determine the accuracy of the IS prognosis.

RESULTS

The percentage of type I fibrous caps exhibited significant decrease, while the percentage of type III fibrous caps, lipid compositions, and lipid ratios all displayed increase. The results of the univariate analysis indicated that age, hypertension, hyperlipidemia, treatment regimens, fibrous cap type, plaque type, lipid composition, and lipid ratio shared a correlation in regards to the poor prognosis of IS patients. Multivariate logistic regression analysis demonstrated that the prognosis of IS patients was not necessarily dependent on fibrous cap type, plaque type, or age. ROC curves revealed that the HRMRI possessed a strong predicative ability in relation to the identification of the prognosis of IS patients through factors such as type of plaque and fibrous caps determination.

CONCLUSION

Our study conclusively intimated the promise of HRMRI as an evaluative tool for the determination of carotid atherosclerotic plaques in patients with IS.

Cost-effectiveness of a National Telemedicine Diabetic Retinopathy Screening Program in Singapore

PURPOSE

To determine the incremental cost-effectiveness of a new telemedicine technician-based assessment relative to an existing model of family physician (FP)-based assessment of diabetic retinopathy (DR) in Singapore from the health system and societal perspectives.

DESIGN

Model-based, cost-effectiveness analysis of the Singapore Integrated Diabetic Retinopathy Program (SiDRP).

PARTICIPANTS

A hypothetical cohort of patients aged 55 years with type 2 diabetes previously not screened for DR.

METHODS

The SiDRP is a new telemedicine-based DR screening program using trained technicians to assess retinal photographs. We compared the cost-effectiveness of SiDRP with the existing model in which FPs assess photographs. We developed a hybrid decision tree/Markov model to simulate the costs, effectiveness, and incremental cost-effectiveness ratio (ICER) of SiDRP relative to FP-based DR screening over a lifetime horizon. We estimated the costs from the health system and societal perspectives. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). Result robustness was calculated using deterministic and probabilistic sensitivity analyses.

MAIN OUTCOME MEASURES

The ICER.

RESULTS

From the societal perspective that takes into account all costs and effects, the telemedicine-based DR screening model had significantly lower costs (total cost savings of S$173 per person) while generating similar QALYs compared with the physician-based model (i.e., 13.1 QALYs). From the health system perspective that includes only direct medical costs, the cost savings are S$144 per person. By extrapolating these data to approximately 170 000 patients with diabetes currently being screened yearly for DR in Singapore's primary care polyclinics, the present value of future cost savings associated with the telemedicine-based model is estimated to be S$29.4 million over a lifetime horizon.

CONCLUSIONS

While generating similar health outcomes, the telemedicine-based DR screening using technicians in the primary care setting saves costs for Singapore compared with the FP model. Our data provide a strong economic rationale to expand the telemedicine-based DR screening program in Singapore and elsewhere.

Six-year prevalence and incidence of diabetic retinopathy and cost-effectiveness of tele-ophthalmology in Manitoba

OBJECTIVE

The purpose of this study was to evaluate the diabetic retinopathy (DR) tele-ophthalmology screening program in Manitoba to determine prevalence and incidence of DR, as well as to estimate the program's cost-effectiveness.

DESIGN

Retrospective chart review.

PARTICIPANTS

A total of 4676 patients with type 2 diabetes examined 9334 times from 2007 to 2013.

METHODS

Focused ophthalmic histories were recorded and examinations were performed by trained nurses, including visual acuities, intraocular pressure, and mydriatic 7 standard field stereoscopic fundus photography. Images were evaluated by retinal specialists according to the Early Treatment of Diabetic Retinopathy Study criteria. DR prevalence and incidence were then calculated during the study period. Cost-effectiveness was estimated by comparing the cost of running the tele-ophthalmology program compared with the cost of screening the same volume of patients in-office.

RESULTS

The average prevalence of any DR in each year was 25.1%. The cumulative incidence of DR across 6 years was 17.1% (95% CI, 15.4%-18.7%). The average savings per tele-ophthalmology examination was $1007.

CONCLUSIONS

DR is highly prevalent among the studied population. Tele-ophthalmology provides a cost-effective means of monitoring patients as well as identifying new or treatable disease.

Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss

Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.

Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss

Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.

Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss

Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.

The empirical evidence for the telemedicine intervention in diabetes management

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.

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.

A novel tele-eye protocol for ocular disease detection and access to eye care services

BACKGROUND

Telemedicine can improve access to care, especially for rural patients, and ophthalmology is a field that lends itself readily to telemedicine because interpretation of photographs is a routine part of diagnosing eye disease and patient care. We developed a novel tele-eye protocol based on diabetic teleretinal screening. We performed a feasibility study to see if our tele-eye program was comparable to the gold standard face-to-face eye exam.

MATERIALS AND METHODS

Fifty-two subjects underwent the tele-eye protocol and then received a face-to-face exam. A masked reader reviewed the tele-eye data remotely and developed an impression and plan for the patient. The provider assessments from the face-to-face exams and the tele-eye exams were compared. Sensitivity, specificity, and percentage agreement were calculated for the tele-eye protocol, focusing on the most common age-related eye diseases: cataract, macular degeneration, and glaucoma. The difference between the autorefraction and manifest eyeglass prescription was calculated.

RESULTS

The pilot study showed excellent percentage agreement between the screening protocol and the face-to-face exam. The percentage agreement for cataract was 100%, that for macular degeneration was 96%, and that for glaucoma suspect was 87%. The difference between the autorefraction's eyeglass prescription and the final manifest refraction was within American National Standards Institute for lens manufacturing guidelines.

CONCLUSIONS

The initial data suggest that the tele-eye program is feasible to execute and appears fairly accurate when compared with the gold standard face-to-face eye exam. However, the study is significantly limited by the small sample size. This pilot provides justification of a much larger study of a similar design.

Ophdiat(®): five-year experience of a telemedical screening programme for diabetic retinopathy in Paris and the surrounding area

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.

Risk factors for progression of diabetic retinopathy in Alberta First Nations communities

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.

Accuracy and reliability of telemedicine for diagnosis of cytomegalovirus retinitis

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.