[Agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients]

Development and Validation of a Diabetic Retinopathy Referral Algorithm Based on Single-Field Fundus Photography

Purpose

To develop a simplified algorithm to identify and refer diabetic retinopathy (DR) from single-field retinal images specifically for sight-threatening diabetic retinopathy for appropriate care (ii) to determine the agreement and diagnostic accuracy of the algorithm as a pilot study among optometrists versus “gold standard” (retinal specialist grading).

Methods

The severity of DR was scored based on colour photo using a colour coded algorithm, which included the lesions of DR and number of quadrants involved. A total of 99 participants underwent training followed by evaluation. Data of the 99 participants were analyzed. Fifty posterior pole 45 degree retinal images with all stages of DR were presented. Kappa scores (κ), areas under the receiver operating characteristic curves (AUCs), sensitivity and specificity were determined, with further comparison between working optometrists and optometry students.

Results

Mean age of the participants was 22 years (range: 19–43 years), 87% being women. Participants correctly identified 91.5% images that required immediate referral (κ) = 0.696), 62.5% of images as requiring review after 6 months (κ = 0.462), and 51.2% of those requiring review after 1 year (κ = 0.532). The sensitivity and specificity of the optometrists were 91% and 78% for immediate referral, 62% and 84% for review after 6 months, and 51% and 95% for review after 1 year, respectively. The AUC was the highest (0.855) for immediate referral, second highest (0.824) for review after 1 year, and 0.727 for review after 6 months criteria. Optometry students performed better than the working optometrists for all grades of referral.

Conclusions

The diabetic retinopathy algorithm assessed in this work is a simple and a fairly accurate method for appropriate referral based on single-field 45 degree posterior pole retinal images.

[Ophthalmic disease in diabetes mellitus: management from primary health care]

OBJECTIVE

To study the feasibility of a basic ophthalmological examination for the eye disease in diabetic patients by Primary Health Care (PHC).

PATIENTS AND METHODS

A multi-centre prospective study. A sample of 712 type 2 diabetics.

INTERVENTIONS

Visual acuity examination, intraocular pressure measurement and the eye fundus photograph with a non-mydriatic camera taken by an optometrist. The interpretation and subsequent referral to an ophthalmology department by ophthalmologists and general practitioners (GP).

RESULTS

Visual acuity deficiency: GP, 43.7%; ophthalmologist, 36.1%; concordance, 70%; glaucoma suspicion: GP, 8.8%; ophthalmologist, 7.6%; concordance, 94%; diabetic retinopathy: GP, 28.2%; ophthalmologist, 13.4%; concordance, 78%. Ophthalmology Department referral: GP, 56.8%; ophthalmologist, 41.3% (P=0.001).

CONCLUSIONS

Agreement between GP and ophthalmologist leads to a reliable ophthalmological examination of the diabetic patient in PHC. Despite an over-diagnosis and 16% of non-justified referrals by the GP, Ophthalmology Department referral is avoided in almost half of the diabetic patients.