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Thykjaer AS, Andresen J, Andersen N, Bek T, Heegaard S, Hajari J, Schmidt Laugesen C, Möller S, Pedersen FN, Kawasaki R, Højlund K, Rubin KH, Stokholm L, Peto T, Grauslund J. Inter-grader reliability in the Danish screening programme for diabetic retinopathy. Acta Ophthalmol 2023; 101:783-788. [PMID: 37066883 DOI: 10.1111/aos.15667] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/18/2022] [Accepted: 03/27/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE The Danish Registry of Diabetic Retinopathy includes information from >200 000 patients who attends diabetic retinopathy (DR) screening in Denmark. Screening of patients with uncomplicated type 2 diabetes is often performed by practicing ophthalmologists, while patients with type 1 and complicated type 2 diabetes attends screening at hospitals. We performed a clinical reliability study of retinal images from Danish screening facilities to explore the inter-grader agreement between the primary screening ophthalmologist and a blinded, certified grader. METHODS Invitations to participate were sent to screening facilities across Denmark. The primary grader uploaded fundus photographs with information on estimated level of DR (International Clinical Diabetic Retinopathy scale as 0 [no DR], 1-3 [mild, moderate or severe nonproliferative DR {NPDR}], or 4 [proliferative DR {PDR}]), region of screening, image style, and screening facility. Images were then regraded by a blinded, certified, secondary grader. Weighted kappa analysis was performed to evaluate agreement. RESULTS Fundus photographs from 230 patients (458 eyes) were received from practicing ophthalmologists (52.6%) and hospital-based grading centres (47.4%) from all Danish regions. Reported levels of DR by the primary graders were 66.8%, 12.2%, 13.1%, 1.3% and 5.5% for DR levels 0-4. The overall agreement between primary and secondary graders was 93% (κ = 0.83). Based on screening facility agreement was 96% (κ = 0.89) and 90% (κ = 0.76) for practicing ophthalmologists and hospital-based graders. CONCLUSION In this nationwide study, we observed a high overall inter-grader agreement and based on this, it is reasonable to assume that reported DR gradings in the screening programme in Denmark, accurately reflect the truth.
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Affiliation(s)
- Anne Suhr Thykjaer
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Jens Andresen
- Organization of Danish Practicing Ophthalmologists, Copenhagen, Denmark
| | - Nis Andersen
- Organization of Danish Practicing Ophthalmologists, Copenhagen, Denmark
| | - Toke Bek
- Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Heegaard
- Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Javad Hajari
- Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | | | - Sören Möller
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Frederik Nørregaard Pedersen
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ryo Kawasaki
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Vision Informatics, University of Osaka, Osaka, Japan
| | - Kurt Højlund
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Katrine Hass Rubin
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lonny Stokholm
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Jakob Grauslund
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
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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: 1] [Impact Index Per Article: 1.0] [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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Alabdulwahhab KM. Diabetic Retinopathy Screening Using Non-Mydriatic Fundus Camera in Primary Health Care Settings - A Multicenter Study from Saudi Arabia. Int J Gen Med 2023; 16:2255-2262. [PMID: 37304902 PMCID: PMC10255608 DOI: 10.2147/ijgm.s410197] [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: 02/26/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023] Open
Abstract
Background Screening of diabetic retinopathy (DR) using the current digital imaging facilities in a primary health care setting is still in its early stages in Saudi Arabia. This study aims to reduce the risk of vision impairment and blindness among known diabetic people through early identification by general practitioners (GP) in a primary health care setting in Saudi Arabia. The objective of this study was to evaluate the accuracy of diabetic retinopathy (DR) detection by general practitioners (GPs) by comparing the agreement of DR assessment between GPs and ophthalmologists' assessment as a gold standard. Methods A hospital-based, six-month cross-sectional study was conducted, and the participants were type 2 diabetic adults from the diabetic registries of seven rural PHCs, in Saudi Arabia. After medical examination, the participants were then evaluated by fundus photography using a non-mydriatic fundus camera without medication for mydriasis. Presence or absence of DR was graded by the trained GPs in the PHCs and then compared with the grading of an ophthalmologist which was taken as a reference or a gold standard. Results A total of 899 diabetic patients were included, and the mean age of the patients was 64.89 ± 11.01 years. The evaluation by the GPs had a sensitivity of 80.69 [95% CI 74.8-85.4]; specificity of 92.23 [88.7-96.3]; positive predictive value, 74.1 [70.4-77.0]; negative predictive value, 73.34 [70.6-77.9]; and an accuracy of 84.57 [81.8-89.88]. For the consensus of agreement the adjusted kappa coefficient was from 0.74 to 0.92 for the DR. Conclusion This study demonstrates that trained GPs in rural health centers are able to provide reliable detection results of DR from fundus photographs. The study highlights the need for early DR screening programs in the rural areas of Saudi Arabia to facilitate early identification of the condition and to lessen impact of blindness due to diabetes.
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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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Gajiwala UR, Pachchigar S, Patel D, Mistry I, Oza Y, Kundaria D, B R S. Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India. BMJ Open 2022; 12:e058485. [PMID: 35396308 PMCID: PMC8995946 DOI: 10.1136/bmjopen-2021-058485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far to reach indigenous local communities. The present study is a pilot study aimed to compare non-mydriatic fundus photography with indirect ophthalmoscopy for its utilisation as a feasible and logistically convenient screening modality for DR in an older age, rural, tribal population in Western India. DESIGN AND SETTING This community-based, cross-sectional, prospective population study was a part of a module using Rapid Assessment of Avoidable Blindness and DR methodology in 8340 sampled participants with ≥50 years age. In this study, the diabetics identified were screened for DR using two methods: non-mydriatic fundus photography on the field by trained professionals, that were then graded by a retina specialist at the base hospital and indirect ophthalmoscopy by expert ophthalmologists in the field with masking of each other's findings for its utility and comparison. RESULTS The prevalence of DR, sight threatening DR and maculopathy using indirect ophthalmoscopy was found to be 12.1%, 2.1% and 6.6%, respectively. A fair agreement (κ=0.48 for DR and 0.59 for maculopathy) was observed between both the detection methods. The sensitivity and specificity of fundus photographic evaluation compared with indirect ophthalmoscopy were found to be 54.8% and 92.1% (for DR), 60.7% and 90.8% (for any DR) and 84.2% and 94.8% (for only maculopathy), respectively. CONCLUSION Non-mydriatic fundus photography has the potential to identify DR (any retinopathy or maculopathy) in community settings in Indian population. Its utility as an affordable and logistically convenient cum practical modality is demonstrable. The sensitivity of this screening modality can be further increased by investing in better resolution cameras, capturing quality images and training and validation of imagers. TRIAL REGISTRATION NUMBER CTRI/2020/01/023025; Clinical Trial Registry, India (CTRI).
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Affiliation(s)
| | | | - Dhaval Patel
- Retina Department, Divyajyoti Trust, Surat, Gujarat, India
| | - Ishwar Mistry
- General Ophthalmology Department, Divyajyoti Trust, Surat, Gujarat, India
| | - Yash Oza
- General Ophthalmology Department, Divyajyoti Trust, Surat, Gujarat, India
| | - Dhaval Kundaria
- General Ophthalmology Department, Divyajyoti Trust, Surat, Gujarat, India
| | - Shamanna B R
- School of Medical Science, University of Hyderabad, Hyderabad, Telangana, India
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Jimenez-Carmona S, Alemany-Marquez P, Alvarez-Ramos P, Mayoral E, Aguilar-Diosdado M. Validation of an Automated Screening System for Diabetic Retinopathy Operating under Real Clinical Conditions. J Clin Med 2021; 11:jcm11010014. [PMID: 35011754 PMCID: PMC8745311 DOI: 10.3390/jcm11010014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/12/2022] Open
Abstract
Background. Retinopathy is the most common microvascular complication of diabetes mellitus. It is the leading cause of blindness among working-aged people in developed countries. The use of telemedicine in the screening system has enabled the application of large-scale population-based programs for early retinopathy detection in diabetic patients. However, the need to support ophthalmologists with other trained personnel remains a barrier to broadening its implementation. Methods. Automatic diagnosis of diabetic retinopathy was carried out through the analysis of retinal photographs using the 2iRetinex software. We compared the categorical diagnoses of absence/presence of retinopathy issued by family physicians (PCP) with the same categories provided by the algorithm (ALG). The agreed diagnosis of three specialist ophthalmologists is used as the reference standard (OPH). Results. There were 653 of 3520 patients diagnosed with diabetic retinopathy (DR). Diabetic retinopathy threatening to vision (STDR) was found in 82 patients (2.3%). Diagnostic sensitivity for STDR was 94% (ALG) and 95% (PCP). No patient with proliferating or severe DR was misdiagnosed in both strategies. The k-value of the agreement between the ALG and OPH was 0.5462, while between PCP and OPH was 0.5251 (p = 0.4291). Conclusions. The diagnostic capacity of 2iRetinex operating under normal clinical conditions is comparable to screening physicians.
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Affiliation(s)
- Soledad Jimenez-Carmona
- Ophthalmology Department, Hospital Universitario Puerta del Mar, University of Cadiz, 11009 Cadiz, Spain;
- Correspondence: (S.J.-C.); (P.A.-M.)
| | - Pedro Alemany-Marquez
- Ophthalmology Department, Hospital Universitario Puerta del Mar, University of Cadiz, 11009 Cadiz, Spain;
- Correspondence: (S.J.-C.); (P.A.-M.)
| | - Pablo Alvarez-Ramos
- Ophthalmology Department, Hospital Universitario Puerta del Mar, University of Cadiz, 11009 Cadiz, Spain;
| | - Eduardo Mayoral
- Comprehensive Healthcare Plan for Diabetes, Regional Ministry of Health and Families of Andalusia, Government of Andalusia, 41020 Seville, Spain;
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Martinez-Murcia FJ, Ortiz A, Ramírez J, Górriz JM, Cruz R. Deep residual transfer learning for automatic diagnosis and grading of diabetic retinopathy. Neurocomputing 2021. [DOI: 10.1016/j.neucom.2020.04.148] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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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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Wintergerst MWM, Bejan V, Hartmann V, Schnorrenberg M, Bleckwenn M, Weckbecker K, Finger RP. Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis. Ophthalmic Epidemiol 2021; 29:286-295. [PMID: 34151725 DOI: 10.1080/09286586.2021.1939886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED.Methods: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.).Results: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI.Conclusions: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.
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Affiliation(s)
| | - Veronica Bejan
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Vera Hartmann
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Marina Schnorrenberg
- Institute of General Practice and Interprofessional Care, Faculty of Health/Department of Medicine, University Witten/Herdecke, Witten, Germany
| | - Markus Bleckwenn
- Department of General Practice, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Interprofessional Care, Faculty of Health/Department of Medicine, University Witten/Herdecke, Witten, Germany
| | - Robert P Finger
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
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Li YH, Sheu WHH, Chou CC, Lin CH, Cheng YS, Wang CY, Wu CL, Lee IT. The Clinical Influence after Implementation of Convolutional Neural Network-Based Software for Diabetic Retinopathy Detection in the Primary Care Setting. Life (Basel) 2021; 11:life11030200. [PMID: 33807545 PMCID: PMC8035657 DOI: 10.3390/life11030200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
Deep learning-based software is developed to assist physicians in terms of diagnosis; however, its clinical application is still under investigation. We integrated deep-learning-based software for diabetic retinopathy (DR) grading into the clinical workflow of an endocrinology department where endocrinologists grade for retinal images and evaluated the influence of its implementation. A total of 1432 images from 716 patients and 1400 images from 700 patients were collected before and after implementation, respectively. Using the grading by ophthalmologists as the reference standard, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to detect referable DR (RDR) were 0.91 (0.87-0.96), 0.90 (0.87-0.92), and 0.90 (0.87-0.93) at the image level; and 0.91 (0.81-0.97), 0.84 (0.80-0.87), and 0.87 (0.83-0.91) at the patient level. The monthly RDR rate dropped from 55.1% to 43.0% after implementation. The monthly percentage of finishing grading within the allotted time increased from 66.8% to 77.6%. There was a wide range of agreement values between the software and endocrinologists after implementation (kappa values of 0.17-0.65). In conclusion, we observed the clinical influence of deep-learning-based software on graders without the retinal subspecialty. However, the validation using images from local datasets is recommended before clinical implementation.
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Affiliation(s)
- Yu-Hsuan Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-H.L.); (W.H.-H.S.)
- Department of Computer Science & Information Engineering, National Taiwan University, Taipei 10617, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-H.L.); (W.H.-H.S.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Chien-Chih Chou
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-C.C.); (C.-H.L.); (Y.-S.C.); (C.-Y.W.)
| | - Chun-Hsien Lin
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-C.C.); (C.-H.L.); (Y.-S.C.); (C.-Y.W.)
| | - Yuan-Shao Cheng
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-C.C.); (C.-H.L.); (Y.-S.C.); (C.-Y.W.)
| | - Chun-Yuan Wang
- Department of Ophthalmology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-C.C.); (C.-H.L.); (Y.-S.C.); (C.-Y.W.)
| | - Chieh Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Department of Automatic Control Engineering, Feng Chia University, Taichung 40703, Taiwan
| | - I.-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-H.L.); (W.H.-H.S.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- College of Science, Tunghai University, Taichung 40704, Taiwan
- Correspondence:
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Chariwala RA, Shukla R, Gajiwala UR, Gilbert C, Pant H, Lewis MG, Murthy GVS. Effectiveness of health education and monetary incentive on uptake of diabetic retinopathy screening at a community health center in South Gujarat, India. Indian J Ophthalmol 2020; 68:S52-S55. [PMID: 31937730 PMCID: PMC7001183 DOI: 10.4103/ijo.ijo_2118_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose: The effectiveness of Accredited Social Health Activists (ASHAs) with and without monetary incentive in uptake of diabetic retinopathy (DR) screening at community health center (CHC) was compared in South Gujarat, India. Methods: In this non-randomized controlled trial, ASHAs were incentivized to refer people with diabetes mellitus (PwDM) from their respective villages for DR screening after people were sensitized to DM and DR. The minimum sample size was 63 people in each arm. Results: Of 162, 50.6% were females, 80.2% were literate, 56.2% were >50 years, 54.3% had increased random blood sugar (RBS), and 59.9% had diabetes for 5 years. The percentage of screening was significantly higher [relative risk (RR) = 4.37, 95% confidence interval (CI) 2.79, 6.84] in ASHA incentive group and health education (HE) group (RR = 3.67, 95% CI 2.35, 5.75) compared with baseline. Providing incentive to ASHAs was not found to be of extra advantage (RR = 1.19, 95% CI 0.89, 1.57). The likelihood of uptake of screening was higher among uncontrolled PwDM, poor literacy, and higher duration of diabetes in incentive phase (P < 0.001) compared with HE. The results show that age (P = 0.017), education (P = 0.015) and level of RBS (P = 0.001) of those referred were significantly associated with incentives to ASHAs. Conclusion: ASHAs can be used effectively to refer known PwDM for DR screening especially when DR screening program is introduced in population with low awareness and poor accessibility. When incentives are planned, additional burden on resources should be kept in mind before adapting this model of care.
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Affiliation(s)
| | - Rajan Shukla
- South Asia Centre for Disability Inclusive Development Research, Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
| | - Uday R Gajiwala
- Divyajyoti Trust, Tejas Eye Hospital, Mandvi, District-Surat, Gujarat, India
| | - Clare Gilbert
- Department of Clinical Research, International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Hira Pant
- South Asia Centre for Disability Inclusive Development Research, Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
| | - Melissa Glenda Lewis
- South Asia Centre for Disability Inclusive Development Research, Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India
| | - G V S Murthy
- South Asia Centre for Disability Inclusive Development Research, Indian Institute of Public Health, Public Health Foundation of India, Hyderabad, Telangana, India; Department of Clinical Research, International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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12
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Review of retinal cameras for global coverage of diabetic retinopathy screening. Eye (Lond) 2020; 35:162-172. [PMID: 33168977 DOI: 10.1038/s41433-020-01262-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/10/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022] Open
Abstract
The global burden of diabetes has resulted in an increase in the prevalence of diabetic retinopathy (DR), a microvascular complication of diabetes. Lifelong repetitive screening for DR is essential for early detection and timely management to prevent visual impairment due to the silent sight-threatening disorder. Colour fundus photography (CFP) is helpful for documentation of the retinopathy as well as for counselling the patient. CFP has established roles in DR screening, detection, progression and monitoring of treatment response. DR screening programmes use validated mydriatic or non-mydriatic fundus cameras for retinal imaging and trained image graders identify referable DR. Smartphone-based fundus cameras and handheld fundus cameras that are cost-effective, portable and easy to handle in remote places are gaining popularity in recent years. The images captured with these low-cost devices can be immediately sent to trained ophthalmologists for grading of DR. Recent increase in numbers of telemedicine programmes based on imaging with digital fundus cameras and remote interpretation has facilitated larger population coverage of DR screening and timely referral of those with sight-threatening DR to ophthalmologists. Good-quality retinal imaging and accurate diagnosis are essential to reduce inappropriate referrals. Advances in digital imaging such as ultra-wide field imaging and multi-modal imaging have opened new avenues for assessing DR. Fundus cameras with integrated artificial intelligence (AI)-based automated algorithms can also provide instant DR diagnosis and reduce the burden of healthcare systems. We review the different types of fundus cameras currently used in DR screening and management around the world.
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Boucher MC, Nguyen MTD, Qian J. Assessment of Training Outcomes of Nurse Readers for Diabetic Retinopathy Telescreening: Validation Study. JMIR Diabetes 2020; 5:e17309. [PMID: 32255431 PMCID: PMC7175194 DOI: 10.2196/17309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND With the high prevalence of diabetic retinopathy and its significant visual consequences if untreated, timely identification and management of diabetic retinopathy is essential. Teleophthalmology programs have assisted in screening a large number of individuals at risk for vision loss from diabetic retinopathy. Training nonophthalmological readers to assess remote fundus images for diabetic retinopathy may further improve the efficiency of such programs. OBJECTIVE This study aimed to evaluate the performance, safety implications, and progress of 2 ophthalmology nurses trained to read and assess diabetic retinopathy fundus images within a hospital diabetic retinopathy telescreening program. METHODS In this retrospective interobserver study, 2 ophthalmology nurses followed a specific training program within a hospital diabetic retinopathy telescreening program and were trained to assess diabetic retinopathy images at 2 levels of intervention: detection of diabetic retinopathy (level 1) and identification of referable disease (level 2). The reliability of the assessment by level 1-trained readers in 266 patients and of the identification of patients at risk of vision loss from diabetic retinopathy by level 2-trained readers in 559 more patients were measured. The learning curve, sensitivity, and specificity of the readings were evaluated using a group consensus gold standard. RESULTS An almost perfect agreement was measured in identifying the presence of diabetic retinopathy in both level 1 readers (κ=0.86 and 0.80) and in identifying referable diabetic retinopathy by level 2 readers (κ=0.80 and 0.83). At least substantial agreement was measured in the level 2 readers for macular edema (κ=0.79 and 0.88) for all eyes. Good screening threshold sensitivities and specificities were obtained for all level readers, with sensitivities of 90.6% and 96.9% and specificities of 95.1% and 85.1% for level 1 readers (readers A and B) and with sensitivities of 86.8% and 91.2% and specificities of 91.7% and 97.0% for level 2 readers (readers A and B). This performance was achieved immediately after training and remained stable throughout the study. CONCLUSIONS Notwithstanding the small number of trained readers, this study validates the screening performance of level 1 and level 2 diabetic retinopathy readers within this training program, emphasizing practical experience, and allows the establishment of an ongoing assessment clinic. This highlights the importance of supervised, hands-on experience and may help set parameters to further calibrate the training of diabetic retinopathy readers for safe screening programs.
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Affiliation(s)
- Marie Carole Boucher
- Maisonneuve-Rosemont Ophthalmology University Center, Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada
| | | | - Jenny Qian
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, ON, Canada
- Hamilton Regional Eye Institute, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Mastropasqua L, Perilli R, D'Aloisio R, Toto L, Mastropasqua A, Donato S, Taraborrelli M, Ginestra F, Porta M, Consoli A. Why Miss the Chance? Incidental Findings while Telescreening for Diabetic Retinopathy. Ophthalmic Epidemiol 2020; 27:237-245. [PMID: 31958252 DOI: 10.1080/09286586.2020.1715450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To report on incidental pathological findings met while screening for Diabetic Retinopathy (DR) in Diabetes Clinics (DC) by ophthalmologist-graded digital fundus imaging. METHODS At the DC of Pescara (central Italy), for 3,859 eyes of 1,930 consecutive patients having not undergone fundus examination in the last year, two mydriatic fundus digital images, taken with a CenterVue DRS Digital Retinal Camera, were sent along with Best Corrected Visual Acuity, on a "store-and-forward" basis, to an ophthalmologist trained in DR screening, and graded according to the UK Diabetic Eye Screening Programme. Incidental fundus abnormalities other than DR were reported. RESULTS No adverse event to mydriasis was reported. One hundred and eighty eyes (4.66%) were ungradable. Among the 3,679 gradable ones, 1,105 (30.04%) showed different degrees of DR (R1 to R3), and 126 (3.42%) maculopathy (M1). Any Age-Related Macular Degeneration was present in 387 eyes (10.52%), any optic disc and parapapillary area features suspect for glaucoma in 562 eyes (15.27%), any hypertensive retinopathy in 1,263 eyes (34.33%), vitreoretinal interface disease in 252 eyes (6.84%), myopic choroidopathy in 92 eyes (2.50%), disc pallor in 31 eyes (0.84%). Mean time was 5 min for screening, 2 min for grading. CONCLUSION Teleretinography is a well-established, cost-effective procedure in DR screening. Along with increased attendance, locating a digital camera in a DC with a retina-specialist grader results in finding fundus pathologies also beyond DR, very similarly to fundus examination in an outpatient ophthalmic setting.
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Affiliation(s)
- Leonardo Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Roberto Perilli
- Territorial Ophthalmology Unit, Local Health Authority , Pescara, Italy
| | - Rossella D'Aloisio
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Lisa Toto
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Alessandra Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Simone Donato
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Merilda Taraborrelli
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Federica Ginestra
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Massimo Porta
- Chair of Internal Medicine, Department Of Medical Sciences, University of Turin , Turin, Italy
| | - Agostino Consoli
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
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15
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Manresa JM, Forés R, Vázquez X, Alzamora MT, Heras A, Delgado P, Torán P. [Reliability of retinography for the detection of hypertensive retinopathy in Primary Care]. Aten Primaria 2019; 52:410-417. [PMID: 31694763 PMCID: PMC7256805 DOI: 10.1016/j.aprim.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/08/2019] [Accepted: 06/13/2019] [Indexed: 01/21/2023] Open
Abstract
Objetivo La hipertensión arterial es una de las enfermedades más prevalentes en la población general adulta. Su importancia reside en las complicaciones que ocasiona en el lecho vascular de órganos diana como riñón, corazón, cerebro y ojo. El objetivo de este trabajo es evaluar la concordancia en la lectura e interpretación de retinografías de pacientes hipertensos realizads por médicos de familia y por oftalmólogos. Material y métodos Es un estudio transversal multicéntrico que contó con 976 pacientes hipertensos de 50 a 70 años, participantes del proyecto «Investigating Silent Strokes in HYpertensives: a Magnetic Resonance Imaging Study» (ISSYS) realizado en centros de Atención Primaria de Barcelona y que accedieron a realizarse una retinografía. Seis médicos de familia y 2 oftalmólogos valoraron la presencia de lesiones en la retina mediante los criterios de Keith-Wagener-Barker. Resultados Se analizó la concordancia Kappa inter- e intraobservador de las lecturas. La valoración de las retinografías en condiciones habituales de práctica clínica obtuvo un alto componente subjetivo, con valores de concordancia inter- e intraobservador pobres-bajos en los criterios de Keith-Wagener-Barker. Solo la valoración de los microaneurismas presentó una concordancia moderada; la ratio arteria/vena fue la menos concordante. Se recomienda la utilización de sistemas de lectura objetivos en la valoración de retinografías en pacientes hipertensos. Conclusiones La valoración de las retinografías en condiciones habituales de práctica clínica tiene un alto componente subjetivo que se refleja en unos valores de concordancia inter- e intraobservador pobres o bajos. Se recomienda la utilización de sistemas de lectura objetivos en la valoración de retinografías en pacientes hipertensos.
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Affiliation(s)
- Josep M Manresa
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, España; Departament d'Infermeria, Universitat Autònoma de Barcelona, Cerdanyola del Vallès (Barcelona), España; Centre d'Atenció Primària Riu Nord-Riu Sud, Santa Coloma de Gramenet, Direcció d'Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, España
| | - Rosa Forés
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, España; Centre d'Atenció Primària Riu Nord-Riu Sud, Santa Coloma de Gramenet, Direcció d'Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, España.
| | - Xosé Vázquez
- Secció d'Oftalmologia, Hospital Municipal de Badalona, Badalona Serveis Assistencials, Badalona (Barcelona), España
| | - M Teresa Alzamora
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, España; Centre d'Atenció Primària Riu Nord-Riu Sud, Santa Coloma de Gramenet, Direcció d'Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, España
| | - Antonio Heras
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, España; Centre d'Atenció Primària Riu Nord-Riu Sud, Santa Coloma de Gramenet, Direcció d'Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, España
| | - Pilar Delgado
- Laboratori de Malalties Neurovasculars, Institut de Recerca Vall d'Hebron, Institut Català de la Salut, Barcelona, España; Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Pere Torán
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, España; Facultat de Medicina, Universitat de Girona, Gerona, España
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16
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Yaslam M, Al Adel F, Al-Rubeaan K, AlSalem RK, Alageel MA, Alsalhi A, AlNageeb D, Youssef AM. Non-mydriatic fundus camera screening with diagnosis by telemedicine for diabetic retinopathy patients with type 1 and type 2 diabetes: a hospital-based cross-sectional study. Ann Saudi Med 2019; 39:328-336. [PMID: 31580703 PMCID: PMC6832323 DOI: 10.5144/0256-4947.2019.328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Diabetic retinopathy (DR) is considered the fifth leading cause of visual impairment worldwide and is associated with a huge social and economic burden. OBJECTIVE Describe the practicality of non-mydriatic funduscopic screening photography for the detection of DR among patients with type 1 and type 2 diabetes. DESIGN Cross-sectional hospital-based study. SETTING Diabetes center, Riyadh. PATIENTS AND METHODS Between July and December 2017, patients with diabetes and aged ≥18 years were selected by systematic random sampling from the University Diabetes Center. Fundoscopic eye examination was performed using the TRC-NW8 non-mydriatic camera, which performs ocular coherence tomography (OCT) to detect macular edema. Using telemedicine, pictures were graded by a retinal-specialized ophthalmologist using the international clinical DR disease severity scale. Patients were classified according to the type and severity of DR. MAIN OUTCOME MEASURES Detection and classification of DR. SAMPLE SIZE 978 Saudi patients with diabetes. RESULTS Of 426 (43.5%) patients with DR, 370 had nonproliferative DR and 55 had proliferative DR. Nineteen (1.9%) had macular edema. The most important risk factors for DR were longer diabetes duration and poor glycemic control. Both older age and insulin use contributed to the higher prevalence of DR and macular edema. DR was more common among type 1 patients at 55.4% compared with 49% among type 2 patients. In addition, more females had macular edema (57.1% versus 42.9% among males). Nine patients with macular edema (47.3%) had hypertension while 154 of 426 patients with DR (36.2%) had hypertension. CONCLUSION Non-mydriatic funduscopic screening photography was practical and useful for the detection of DR in patients with type 1 and type 2 diabetes. LIMITATIONS Conducted in a single center. CONFLICT OF INTEREST None.
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Affiliation(s)
- Maram Yaslam
- From the College of Medicine, University Diabetes Center, King Saud University
| | - Fadwa Al Adel
- From the Department of Ophthalmology, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Khalid Al-Rubeaan
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rakan K AlSalem
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Musab A Alageel
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdaulaziz Alsalhi
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Dehkra AlNageeb
- From the Research Department, King Saud University, Riyadh, Saudi Arabia
| | - Amira M Youssef
- From the Registry Department, King Saud University, Riyadh, Saudi Arabia
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