Accuracy and Reliability of Telemedicine for Diagnosis of Cytomegalovirus Retinitis

Skalet, Alison H.; Jirawison, Choeng; Ausayakhun, Somsanguan; Keenan, Jeremy D.; Khouri, Claire M.; Nguyen, Khang; Kalyani, P; Heiden, David; Holland, Gary N.; Margolis, Todd P.

doi:10.1016/j.ajo.2011.05.030

Cited by 27 publications

(28 citation statements)

References 21 publications

(22 reference statements)

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“…), as reported previously. 16 In the present study, we performed a training session for 15 nonophthalmologists (including M.Y.) and subsequently asked them to evaluate the same set of fundus photographs reviewed by the CMV retinitis experts.…”

Section: Methodsmentioning

confidence: 99%

“…Similar to the procedures in the prior study, 16 cus that included the entire 85°retinal field, acceptable defined as an image moderately out of focus or not including the entire retinal field but suitable for determination of the presence or absence of CMV retinitis, and poor defined as an image extremely out of focus or including such a small degree of the retinal field that the presence or absence of CMV retinitis could not be determined. Graders identified each image as CMV retinitis present, CMV retinitis absent, or unknown.…”

Section: Image Evaluationmentioning

confidence: 97%

“…We used the same images from a prior study 16 of patients being screened for CMV retinitis at the Ocular Infectious Diseases Clinic at Chiang Mai University. Between August 7, 2008, and April 9, 2009, we enrolled newly referred patients with AIDS who had evidence of CMV retinitis on indirect ophthalmoscopy, as well as patients who had received a CMV retinitis diagnosis in the month before the start of the study.…”

Section: Patient Populationmentioning

confidence: 99%

“…12 Telemedicine, which is used to screen for conditions such as diabetic retinopathy (DR) and retinopathy of prematurity (ROP), [13][14][15] is a promising method for screening at-risk patients with AIDS for CMV retinitis. A prior study 16 showed that telemedicine diagnosis by expert graders has high sensitivity and specificity for CMV retinitis. However, ophthalmologists may have difficulty giving prompt diagnosis because of time demands on their schedules.…”

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confidence: 98%

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Telemedicine Diagnosis of Cytomegalovirus Retinitis by Nonophthalmologists

et al. 2014

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IMPORTANCE Cytomegalovirus (CMV) retinitis continues to be a leading cause of blindness in many developing countries. Telemedicine holds the potential to increase the number of people screened for CMV retinitis, but it is unclear whether nonophthalmologists could be responsible for interpreting fundus photographs captured in a telemedicine program.OBJECTIVE To determine the accuracy of nonophthalmologist photographic graders in diagnosing CMV retinitis from digital fundus photographs. DESIGN, SETTING, AND PARTICIPANTS Fifteen nonexpert graders each evaluated 182 mosaic retinal images taken from the eyes of patients with AIDS who were evaluated at the Ocular Infectious Diseases Clinic at Chiang Mai University in Chiang Mai, Thailand. MAIN OUTCOMES AND MEASURESGraders diagnosed each image as CMV retinitis present, CMV retinitis absent, or unknown. The results from each grader were compared with those of an indirect ophthalmoscopic examination from an experienced on-site ophthalmologist as well as with the consensus grade given by a panel of CMV retinitis experts.RESULTS Relative to the on-site ophthalmologist, the sensitivity of remote CMV retinitis diagnosis by nonexpert graders ranged from 64.0% to 95.5% (mean, 84.1%; 95% CI, 78.6%-89.6%)), and the specificity ranged from 65.6% to 92.5% (mean, 82.3%; 95% CI, 76.6%-88.0%)). Agreement between nonexpert and expert graders was high: the mean sensitivity and specificity values of nonexpert diagnosis using expert consensus as the reference standard were 93.2% (95% CI, 90.6%-95.8%) and 88.4% (95% CI, 85.4%-91.1%), respectively. Mean intrarater reliability also was high (mean Cohen κ, 0.83; 95% CI, 0.78-0.87). CONCLUSIONS AND RELEVANCEThe sensitivity and specificity of remote diagnosis of CMV retinitis by nonexpert graders was variable, although several nonexperts achieved a level of accuracy comparable to that of CMV retinitis experts. More intensive training and periodic evaluations would be required if nonexperts are to be used in clinical practice.

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Section: Methodsmentioning

confidence: 99%

Section: Image Evaluationmentioning

confidence: 97%

Section: Patient Populationmentioning

confidence: 99%

mentioning

confidence: 98%

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Telemedicine Diagnosis of Cytomegalovirus Retinitis by Nonophthalmologists

et al. 2014

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“…The routine use of fundus photography also has advantages related to telemedicine [10][11][12] and record keeping, and it is the method of choice for diabetic eye screening. All too often, referrals from emergency departments to ophthalmology are concluded with a statement such as 'I couldn't see any obvious abnormalities with the ophthalmoscope, but it was difficult…' Digital images can be emailed in a secure fashion between departments, either to support a referral or in order to obtain specialist advice from an ophthalmologist.…”

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confidence: 99%

Direct ophthalmoscopy should be taught to undergraduate medical students—No

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Chong

2015

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Telemedicine Screening for Cytomegalovirus Retinitis at the Point of Care for Human Immunodeficiency Virus Infection

et al. 2015

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IMPORTANCE Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.

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Accuracy and Reliability of Telemedicine for Diagnosis of Cytomegalovirus Retinitis

Abstract: 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.

Cited by 27 publications

References 21 publications

Telemedicine Diagnosis of Cytomegalovirus Retinitis by Nonophthalmologists

Telemedicine Diagnosis of Cytomegalovirus Retinitis by Nonophthalmologists

Direct ophthalmoscopy should be taught to undergraduate medical students—No

Telemedicine Screening for Cytomegalovirus Retinitis at the Point of Care for Human Immunodeficiency Virus Infection

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