Retinal exams requested at Primary Care Unit: indications, results and alternative strategies of evaluation

Abstract

Objective: To evaluate indications, results and strategy of retinal exams requested at Primary Care Units. Methods: A retrospective study that analyzed the indications and results of retinal exams, in the modalities clinical dilated fundus exams and color fundus photographs. In the following situations, patients were considered eligible for color fundus photographs if visual acuity was normal and ocular symptoms were absent: diabetes mellitus and/or hypertension, in use of drugs with potential retinal toxicity, diagnosis or suspicion of glaucoma, stable and asymptomatic retinopathies, except myopia greater than-3.00 diopters. Results: A total of 1,729 patients were evaluated (66% female, age 63.5±15.5 years), and 1,190 underwent clinical dilated fundus exam and 539 underwent color fundus photographs. Diabetes was present in 32.2%. The main indications were diabetes (23.7%) and glaucoma evaluation (23.5%). In 3.4% of patients there was no apparent indication. The main results were a large cup/disc ratio (30.7%) and diabetic retinopathy (13.2%). Exam was normal in 9.6%, detected peripheral changes in 7% and could not be performed in 1%. Considering patients eligible for fundus photographs (22.4%), more than half underwent clinical dilated fundus exams. Conclusion: Regarding exam modality, there were no important differences in the distribution of indications or diagnosis. Color fundus photograph is compatible with telemedicine and more cost-effective, and could be considered the strategy of choice in some scenarios. Since there are no clear guidelines for retinal exams indications or the modality of choice, this study may contribute to such standardization, in order to optimize public health resources.

The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy

“…This is probably because they are relatively simple to operate, can be maintained by trained technicians, and so can be successfully used in the primary care setting. Non-mydriatic, non-stereo cameras were also among the first to be used in diabetic retinopathy screening, and their use is well established in the field [ 12 – 60 ]. More accurate but at the same time more complicated methods have involved the use of seven-field ETDRS standard stereoscopic photographs of the eye fundus.…”

“…Several DR telescreening models have been implemented. Retinal images are generally acquired by trained primary care physicians, technicians, ophthalmic photographers and nurses [ 7 , 10 , 12 , 13 , 15 , 17 , 18 , 20 , 22 , 23 , 25 – 27 , 27 – 31 , 53 – 60 , 63 – 65 , 68 – 72 , 51 – 53 , 53 , 97 – 101 , 57 , 58 , 58 , 59 , 26 – 30 , 64 , 64 , 65 , 65 , 48 – 55 , 58 – 60 , 63 – 67 , 81 , 82 , 82 , 83 , 79 – 83 ].…”

“…The data collected in medical centers from diabetic patients during camera-based fundus examinations are sent for diabetic retinopathy detection to experts including ophthalmologists or retinal specialists [ 13 , 16 , 18 , 20 , 21 , 23 , 24 , 26 – 29 , 32 , 33 , 35 , 42 – 45 , 47 – 52 , 54 , 56 , 64 , 67 – 75 , 79 , 81 – 83 ], certified technicians and nurses; in more complicated cases, the data are reevaluated by retinal specialists [ 12 , 15 , 20 , 31 , 41 , 44 , 59 , 63 , 66 , 78 , 102 ].…”

“…There were also significant problems regarding telemedicine programs associated with a growing demand for trained/certified eye fundus photographers [ 81 ] and image readers [ 18 , 63 ]. As a solution to that problem, training in picture-taking could be offered to nurses and technicians [ 12 , 15 , 18 , 22 , 23 , 27 , 31 – 34 , 38 , 42 – 45 , 47 , 48 , 50 , 52 – 57 , 60 , 63 , 64 , 68 , 70 – 72 , 74 , 79 – 81 , 98 – 100 ]. One promising solution was in-home testing, where patients themselves took pictures of their retinas [ 97 ].…”

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

“…DR screening is essential in rural community areas to detect cases, which require early referral to expert ophthalmologists for full evaluation 11. A simple non-mydriatic fundus photography is increasingly being used for this purpose owing to its feasibility cum logistical practicality and cost-effectiveness within such population 25–28. The present study compared the sensitivity and specificity of non-mydriatic fundus photography with the indirect ophthalmoscopy to be employed in a rural community for the annual DR screening of patients with diabetes.…”