Long-term Comparative Effectiveness of Telemedicine in Providing Diabetic Retinopathy Screening Examinations

Mansberger, Steven L.; Sheppler, Christina; Barker, Gordon T.; Gardiner, Stuart K.; Demirel, Shaban; Wooten, Kathleen; Becker, Thomas M.

doi:10.1001/jamaophthalmol.2015.1

Cited by 155 publications

(131 citation statements)

References 23 publications

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“…However, objective fundus photography is widely considered to be the standard-of-care method. 27 Moreover, we speculate that increased use of photography and telemedicine may actually improve adherence to screening 28 and lower the cost, even though the cost of photography is currently higher than that of ophthalmoscopy.…”

Section: Discussionmentioning

confidence: 97%

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes

Dcct¹,

et al. 2017

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BACKGROUND In patients who have had type 1 diabetes for 5 years, current recommendations regarding screening for diabetic retinopathy include annual dilated retinal examinations to detect proliferative retinopathy or clinically significant macular edema, both of which require timely intervention to preserve vision. During 30 years of the Diabetes Control and Complications Trial (DCCT) and its longitudinal follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study, retinal photography was performed at intervals of 6 months to 4 years. METHODS We used retinal photographs from the DCCT/EDIC study to develop a rational screening frequency for retinopathy. Markov modeling was used to determine the likelihood of progression to proliferative diabetic retinopathy or clinically significant macular edema in patients with various initial retinopathy levels (no retinopathy or mild, moderate, or severe nonproliferative diabetic retinopathy). The models included recognized risk factors for progression of retinopathy. RESULTS Overall, the probability of progression to proliferative diabetic retinopathy or clinically significant macular edema was limited to approximately 5% between retinal screening examinations at 4 years among patients who had no retinopathy, 3 years among those with mild retinopathy, 6 months among those with moderate retinopathy, and 3 months among those with severe nonproliferative diabetic retinopathy. The risk of progression was also closely related to mean glycated hemoglobin levels. The risk of progression from no retinopathy to proliferative diabetic retinopathy or clinically significant macular edema was 1.0% over 5 years among patients with a glycated hemoglobin level of 6%, as compared with 4.3% over 3 years among patients with a glycated hemoglobin level of 10%. Over a 20-year period, the frequency of eye examinations was 58% lower with our practical, evidence-based schedule than with routine annual examinations, which resulted in substantial cost savings. CONCLUSIONS Our model for establishing an individualized schedule for retinopathy screening on the basis of the patient’s current state of retinopathy and glycated hemoglobin level reduced the frequency of eye examinations without delaying the diagnosis of clinically significant disease.

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Section: Discussionmentioning

confidence: 97%

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes

Dcct¹,

et al. 2017

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“…Using portable non-mydriatic fundus imaging in high volume eye camps or primary care offices globally may improve access to recommended diabetic eye care and decrease DR related blindness as the robust telemedicine DR screening program has done in the United Kingdom. [8,26,27] Furthermore, the knowledge from our study of the patient characteristics that are associated with poor image quality would allow screening services to target highly “imageable” patients, while opting to directly refer all other patients to the ophthalmologist, as patients who are difficult to image often have other referral-warranted pathology present such as cataract or vitreous hemorrhage.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy

et al. 2017

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Purpose: To analyze predictors of image quality for a handheld nonmydriatic fundus camera used for screening of vision-threatening diabetic retinopathy. Methods: An ophthalmic photographer at an Aravind Eye Hospital obtained nonmydriatic and mydriatic fundus images from 3 fields in 275 eyes of 155 participants over 13 months using a Smartscope camera (Optomed, Oulu, Finland) and a Topcon tabletop fundus camera (Topcon, Tokyo, Japan). Two fellowship-trained retina specialists graded the images. Repeated-measures logistic regression assessed predictors of the main outcome measure: gradability of the fundus images. Results: Of 2,475 images, 76.2% of the Smartscope nonmydriatic images, 90.1% of the Smartscope mydriatic images, and 92.0% of the Topcon mydriatic images were gradable. Eyes with vitreous hemorrhage (OR = 0.24, p < 0.0001) or advanced cataract (OR = 0.08, p < 0.0001) had decreased odds of image gradability. Excluding eyes with cataract or vitreous hemorrhage, nonmydriatic macular image gradability improved from 68.4% in the first set of 55 eyes to 94.6% in the final set of 55 eyes. Conclusion: With sufficient training, paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera, particularly in patients with clear lenses and clear ocular media.

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“…17–21 In digital imaging for both diabetic retinopathy and age-related macular degeneration, imaging protocols, grading algorithms, disease morphologies, and classification and staging of disease have been extensively examined and rigorously evaluated. The current reference standard for detecting, staging, and monitoring the progression of diabetic retinopathy is a protocol determined by the Early Treatment Diabetic Retinopathy Study that requires the use of a set of 7 different 30° retinal fields taken in stereo.…”

Section: Discussionmentioning

confidence: 99%

Analysis of Discrepancy Between Diagnostic Clinical Examination Findings and Corresponding Evaluation of Digital Images in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity Study

et al. 2016

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IMPORTANCEAs effective treatments for potentially blinding retinopathy of prematurity (ROP) have been introduced, the importance of consistency in findings has increased, especially with the shift toward retinal imaging in infants at risk of ROP.OBJECTIVE To characterize discrepancies in findings of ROP between digital retinal image grading and examination results from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity study, conducted from May 2011 to October 2013. DESIGN, SETTING, AND PARTICIPANTSA poststudy consensus review of images was conducted by 4 experts, who examined discrepancies in findings between image grades by trained nonphysician readers and physician examination results in infants with referral-warranted ROP (RW-ROP). Images were obtained from 13 North American neonatal intensive care units from eyes of infants with birth weights less than 1251 g. For discrepancy categories with more than 100 cases, 40 were randomly selected; in total, 188 image sets were reviewed. MAIN OUTCOMES AND MEASURESConsensus evaluation of discrepant image and examination findings for RW-ROP components. RESULTS Among 5350 image set pairs, there were 161 instances in which image grading did not detect RW-ROP noted on clinical examination (G−/E+) and 854 instances in which grading noted RW-ROP when the examination did not (G+/E−). Among the sample of G−/E+ cases, 18 of 32 reviews (56.3%) agreed with clinical examination findings that ROP was present in zone I and 18 of 40 (45.0%) agreed stage 3 ROP was present, but only 1 of 20 (5.0%) agreed plus disease was present. Among the sample of G+/E− cases, 36 of 40 reviews (90.0%) agreed with readers that zone I ROP was present, 23 of 40 (57.5%) agreed with readers that stage 3 ROP was present, and 4 of 16 (25.0%) agreed that plus disease was present. Based on the consensus review results of the sampled cases, we estimated that review would agree with clinical examination findings in 46.5% of the 161 G−/E+ cases (95% CI, 41.6-51.6) and agree with trained reader grading in 70.0% of the 854 G+/E− cases (95% CI, 67.3-72.8) for the presence of RW-ROP.CONCLUSIONS AND RELEVANCE This report highlights limitations and strengths of both the remote evaluation of fundus images and bedside clinical examination of infants at risk for ROP. These findings highlight the need for standardized approaches as ROP telemedicine becomes more widespread.

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Long-term Comparative Effectiveness of Telemedicine in Providing Diabetic Retinopathy Screening Examinations

Cited by 155 publications

References 23 publications

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes

Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy

Analysis of Discrepancy Between Diagnostic Clinical Examination Findings and Corresponding Evaluation of Digital Images in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity Study

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