Real-Time Ultrawide Field Image Evaluation of Retinopathy in a Diabetes Telemedicine Program

Abstract

OBJECTIVETo evaluate the ability of trained nonphysician retinal imagers to perform diabetic retinopathy (DR) evaluation at the time of ultrawide field retinal (UWF) imaging in a teleophthalmology program. RESEARCH DESIGN AND METHODSClinic patients with diabetes received Joslin Vision Network protocol retinal imaging as part of their standard medical care. Retinal imagers evaluated UWF images for referable DR at the time of image capture. Training of the imagers included 4 h of standardized didactic lectures and 12 h of guided image review. Real-time evaluations were compared with standard masked gradings performed at a centralized reading center. RESULTSA total of 3,978 eyes of 1,989 consecutive patients were imaged and evaluated. By reading center evaluation, 3,769 eyes (94.7%) were gradable for DR, 1,376 (36.5%) had DR, and 580 (15.3%) had referable DR. Compared with the reading center, real-time image evaluation had a sensitivity and specificity for identifying more than minimal DR of 0.95 (95% CI 0.94-0.97) and 0.84 (0.82-0.85), respectively, and 0.99 (0.97-1.00) and 0.76 (0.75-0.78), respectively, for detecting referable DR. Only three patients with referable DR were not identified by imager evaluation. CONCLUSIONSPoint-of-care evaluation of UWF images by nonphysician imagers following standardized acquisition and evaluation protocols within an established teleophthalmology program had good sensitivity and specificity for detection of DR and for identification of referable retinal disease. With immediate image evaluation, <0.1% of patients with referable DR would be missed, reading center image grading burden would be reduced by 60%, and patient feedback would be expedited.Patients with diabetes require lifelong ophthalmic care that generally includes an annual retinal evaluation (1). Given the rapidly growing population affected by diabetes, a 20-year estimate of .2.7 million eyes worldwide will need to be evaluated each day just to fulfill these needs (2). This enormous task is unlikely to be accomplished by the current approaches of diabetes eye care programs. Despite more than one decade of research, no real-time, fully automated retinal image analysis system is currently in active clinical use (2). Until such capability exists, other approaches to speed efficiency of current programs without sacrificing accuracy are urgently needed.

Fundamental principles of an effective diabetic retinopathy screening program

“…Non-mydriatic ultra-wide-field (UWF) imaging and optical coherence tomography (OCT) may be applicable in future DR screening efforts; work is ongoing to establish the validity and cost-effectiveness of these tools at the point of care and in a telemedicine setting [15][16][17][18][19].…”

Retinopathy

“…This has been greatly facilitated by the advent of high-resolution ultra-wide field imaging (UWFI). The Joslin Vision Network, an ocular telehealth program at the Joslin Diabetes Center, demonstrated that UWFI employed by trained certified imagers adhering to defined imaging and grading protocols, accurately evaluated images for the presence of diabetic retinopathy or diabetic retinopathy that required referral for prompt ophthalmic care, with a sensitivity and negative predictive value approaching 1.0 (27). Furthermore, UWFI technology has permitted the identification of peripheral diabetic retinal lesions, missed by standard 7-field fundus photography, that more accurately identifies the severity level of diabetic retinopathy and the risk of retinopathy progression over 4 years (28).…”

Effectiveness of multimodal imaging for the evaluation of retinal odema and new vessels in diabetic retinopathy

“…In such a scenario this calculation may be conservative. To be able to detect if the sensitivity of the new pathway (photographer/imaging technician pathway) with 80% and 90% power (10% and 12% higher than the 80% minimal target set) would require 89 participants with each DMO/ PDR who have reactivated (active DMO/PDR), with 2-sided 5% significance level (23). 93 participants who have not reactivated (inactive DMO/PDR) would enable a specificity 15% (10%) higher than the 65% target to be detected with 90% power.…”