Screening for diabetic retinopathy: a comparative trial of photography and scanning laser ophthalmoscopy.

AIMS: To evaluate the sensitivity and specificity of wide-field scanning laser ophthalmoscopy (WSLO) in the detection of referable diabetic eye disease, and to compare its performance with digital retinal photography. METHODS: Patients enrolled into the study underwent non-mydriatic WSLO imaging, then single- and dual-field mydriatic digital retinal photography, and examination with slit lamp biomicroscopy, the reference standard. Grading of retinopathy was performed in a masked fashion. RESULTS: A total of 380 patients (759 eyes) were recruited to the study. Technical failure rates for dilated single-field retinal photography, dual-field retinal photography and undilated WSLO were 6.3, 5.8 and 10.8%, respectively (0.005 < p < 0.02 for photography vs. WSLO). The respective indices for screening sensitivity were 82.9, 82.9 and 83.6% (p > 0.2). Specificity was 92.1, 91.1 and 89.5%, respectively (p > 0.2). CONCLUSIONS: Sensitivity and specificity for WSLO were similar to retinal photography. The technical failure rate was greater for the WSLO used in this study.

Macular oedema is not predicted by perifoveal single blot haemorrhages.

AIMS: To ascertain which perifoveal changes on digital retinal screening in diabetes predict the need for subsequent macular grid or focal laser therapy. METHODS: Between 1 January 2004 and 31 December 2005, all consecutive retinal images where any lesion was within one disc diameter of the fovea were reviewed. Patients were categorized by lesion at screening as having microaneurysm, single blot haemorrhage, multiple blot haemorrhages and exudates or circinate exudates within one disc diameter of the fovea. We compared these retinal images with the findings on slit lamp examination and the related decision for laser photocoagulation. RESULTS: Four hundred and twenty-four retinal images were identified. Of these, 52 were excluded, principally because of an interval between photography and clinic attendance of greater than 120 days, leaving 372 retinal images in the study group (313 patients). No patients with a single blot haemorrhage required immediate laser therapy at ophthalmology review compared with 13 (23%) of those with multiple blot haemorrhages and 36 (16%) of those with exudates or circinate lesions (P < 0.001). Thirty-nine patients with a single blot haemorrhage who did not require laser therapy underwent ongoing follow-up. None of these underwent laser therapy for maculopathy within the study time frame (9 months from initial screening event). CONCLUSIONS: In this study, no patients with a single blot haemorrhage within one disc diameter of the fovea on digital retinal screening required laser treatment.

Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease.

AIMS: To assess the effects of (1) mydriasis and (2) single versus three field photography on screening for diabetic eye disease using digital photography METHOD: Slit lamp examination findings were compared to digital fundal photographs for the detection of any retinopathy and for referable retinopathy in 398 patients (794 eyes). A Topcon TRC-NW6S digital non-mydriatic fundus camera was used. Three photographic strategies were used: undilated single field, dilated single field, and dilated multiple fields. The photographs were presented in random order to one of two retinal screeners. For the single field photographs the screeners were masked to the use of mydriatics. In 13% of fundal photographs, grading was performed by both, rather than just one grader. RESULTS: Mydriasis reduced the proportion of ungradable photographs from 26% to 5% (p<0.001). Neither mydriasis nor three field photography improved the sensitivity or specificity for the detection of any retinopathy or of referable retinopathy when compared with undilated single field photography. The sensitivity and specificity for detecting referable retinopathy using undilated single field photography was 77% (95% CI 71 to 84) and 95 % (95% CI 93 to 97) respectively. Using dilated single field photography the figures were 81% (95% CI 76 to 87) and 92% (95% CI 90 to 94) respectively. Using dilated three field photography the figures were 83% (95% CI 78 to 88) and 93% (95% CI 91 to 96) respectively. Intergrader reliability for the detection of referable retinopathy in gradable photographs was excellent (Kappa values 0.86-1.00). CONCLUSIONS: Mydriasis reduces the technical failure rate. Mydriasis and the three field photography as used in this study do not increase the sensitivity or specificity of detecting diabetic retinopathy.

Use of mobile screening unit for diabetic retinopathy in rural and urban areas.

OBJECTIVES: To compare the effectiveness of a mobile screening unit with a non-mydriatic polaroid camera in detecting diabetic retinopathy in rural and urban areas. To estimate the cost of the service. DESIGN: Prospective data collection over two years of screening for diabetic retinopathy throughout Tayside. SETTING: Tayside region, population 390,000, area 7770 km2. SUBJECTS: 961 patients in rural areas and 1225 in urban areas who presented for screening. MAIN OUTCOME MEASURES: Presence of diabetic retinopathy, need for laser photocoagulation, age, duration of diabetes, and diabetic treatment. RESULTS: Compared with diabetic patients in urban areas, those in rural areas were less likely to attend a hospital based diabetic clinic (46% (442) v 86% (1054), p < 0.001); less likely to be receiving insulin (260 (27%) v 416 (34%), p < 0.001 and also after correction for differences in age distribution); more likely to have advanced (maculopathy or proliferative retinopathy) diabetic retinopathy (13% (122) v 7% (89), p < 0.001); and more likely to require urgent laser photocoagulation for previously unrecognised retinopathy (1.4% (13) v 0.5% (6), p < 0.02). The screening programme cost 10 pounds per patient screened and 1000 pounds per patient requiring laser treatment. CONCLUSION: The mobile diabetic eye screening programme detected a greater prevalence of advanced retinopathy in diabetic patients living in rural areas. Patients in rural areas were also more likely to need urgent laser photocoagulation. Present screening procedures seem to be less effective in rural areas and rural patients may benefit more from mobile screening units than urban patients.

Can we predict which patients are at risk of having an ungradeable digital image for screening for diabetic retinopathy?

PURPOSE: We aimed to determine the reasons for, and variables which predicted, ungradeable retinal photographs during screening patients for diabetic retinopathy. MATERIALS AND METHODS: Age, duration of diabetes, visual acuity, and HbA1c were recorded. Following dark adaptation, a single 45 degrees nonmydriatic photograph was taken of each fundus. The pupils were then dilated and the photograph repeated. Using slit lamp biomicroscopy, lenticular changes (LOCS III), and fundus appearance were recorded. RESULTS: In ungradeable photographs the fovea could not be visualised in 98% of cases of images from nonmydriatic photography, and in 88% if mydriasis was used. Poor definition in the nonmydriatic image was associated with a subsequent ungradeable mydriatic photograph (P=0.001), however, the positive predictive value was poor (34%). Age, posterior subcapsular cataract, and near vision predicted ungradeable status of nonmydriatic photographs (P<0.001, P=0.004, P=0.006, respectively; regression analysis). Nuclear colour and poor definition of the nonmydriatic photograph predicted ungradeable status of mydriatic photographs (P=0.006 & P=0.001, respectively). CONCLUSION: Inability to visualise the fovea is the commonest cause of an ungradeable image from digital retinal photography. Age and posterior subcapsular cataract were best predictors of ungradeable status of nonmydriatic fundus photographs. Nuclear colour was the strongest predictor for ungradeable mydriatic photography.

Implementation of national diabetes retinal screening programme is associated with a lower proportion of patients referred to ophthalmology.

AIMS: To examine the impact of a new national retinal screening programme on screening attendance, technical quality of images, and referrals to the ophthalmology clinic. METHODS: Results from the previous ad hoc retinal screening service were compared with data from the first year of the new Scottish Diabetes Retinal Screening Programme in Dundee, which was administered according to criteria recommended by the Health Technology Board Scotland. RESULTS: Of 5150 patients invited for screening, 10.3% of patients did not attend. Overall, 4574 patients underwent single-field digital retinal photography and 25.4% required mydriasis for an adequate image. After screening, 1.9 and 90.5% were recalled for repeat photography at 6 months and 1 year, respectively, whilst 4.6% were ungradable and 3.0% were referred to the ophthalmology clinic. Compared with the last 18 months of the previous scheme, with the new programme a smaller proportion of patients were referred to ophthalmology (3.0 vs. 5.9%; P < 0.001, difference 2.9%: 95% confidence interval 2.1-3.7%). Moreover, the attendance was higher (89 vs. 82%; P < 0.01) and there were fewer ungradable images (4.6 vs. 7.1%; P < 0.001). CONCLUSIONS: Introduction of a systematic retinal screening programme can reduce the proportion of patients referred to the ophthalmology clinic, and use ophthalmology services more efficiently.

The Rodenstock scanning laser ophthalmoscope in clinical practice.

Scanning laser ophthalmoscopy is a revolutionary method of imaging the fundus oculi. The system uses monochromatic lasers to image the retina which can ultimately be recorded on videotape. Computer image digitization allows quantitative assessment which is significant in ophthalmic research. Future developments include the use of the instrument as a multi-functional ophthalmic examining tool. The capital cost of the system is expensive. However, operational costs are 20% that of a conventional film system which results in a cost-effective method in the long term. Finally, there are many benefits to the patient which include the convenience and tolerance to the low light levels required for scanning.

Diabetic photographic eye screening using a mobile unit in Tayside, Scotland.

Early detection and hospital referral of patients with diabetic changes (retinopathy) is essential if laser photocoagulation is to be effective. The British Diabetic Association (BDA) have therefore funded several diabetic mobile eye screening units and donated them to areas throughout the country, the aim being to screen patients for diabetic retinopathy in those areas. This article describes the use and findings of such a unit in the Tayside area.

A new method of image analysis of fluorescein angiography applied to age-related macular degeneration.

Quantitative analysis of retinal and choroidal abnormalities using current photographic techniques is complex and laborious. Digital image analysis techniques using the scanning laser ophthalmoscope overcome many of the problems with present techniques and allow reliable quantitation. A prerequisite of quantitation is accurate image acquisition and registration. The authors describe a reliable method of image analysis and apply it to the quantitation of hyperfluorescence in scanning laser fluorescein angiograms of different forms of age-related macular degeneration. Retrospective analysis of scanning laser fluorescein angiograms obtained using a standardised technique was undertaken. Eighty-six angiograms from patients with age-related macular degeneration were analysed and categorised as dry maculopathy, geographic atrophy of the retinal pigment epithelium, retinal pigment epithelial detachment (PED) or subretinal neovascularisation (SRNV). Fluorescein characteristics of both SRNV and PED showed a characteristic pattern of fluorescence. The advantages and disadvantages of the technique are discussed.

Screening for diabetic retinopathy in a widely spaced population using non-mydriatic fundus photography in a mobile unit. Tayside Mobile Eye Screening Unit.

A screening project was established to assess the prevalence and severity of retinopathy in diabetic patients in Tayside (area: 3000 square miles, population: 390,000). A questionnaire was used to examine patient acceptability. Of 2112 patients photographed during the first year, 32% had abnormal photographs; 20.2% had diabetic retinopathy; 7.4% cataracts; 4.6% non-diabetic eye disease. Among this patient population, 73% were registered at a hospital diabetic clinic. The overall prevalence of diabetic retinopathy was similar between the two groups (hospital 23% vs non-hospital 20%). The prevalence of severe diabetic retinopathy was also similar (hospital 8.5% vs non-hospital 10%). This had been previously unrecognized or incorrectly defined in 6.5% of those not attending a hospital diabetic clinic, compared to 3.7% attending the hospital clinic (p less than 0.01). A favourable response to the service was indicated by 40% of patients with 7% unfavourable and 41% uncommitted. Non-mydriatic fundal photography housed in a mobile unit is a practical and effective method of assessing diabetic retinopathy. It is particularly suitable for screening in a widely spread population.

Does direct ophthalmoscopy improve retinal screening for diabetic eye disease by retinal photography?

AIMS: To identify whether after performing retinal photography, direct ophthalmoscopy can improve the yield of screening for the detection of sight-threatening diabetic eye disease (STDED). METHODS: Patients (n = 408) who had previously received both dilated direct ophthalmoscopy by a diabetologist and retinal photography graded by a diabetologist within 3 months of each other were included. The results of the other screening modality were not available to the grader/screener. The first 308 patients were consecutive attendees at the clinic who fulfilled the study criteria and 100 were selected because they were identified as having potential STDED by either one of these modalities. An ophthalmologist using slit lamp biomicroscopy then examined patients identified with potential STDED. RESULTS: In 357 (88%) patients there was agreement between the two modalities about whether referral to an ophthalmologist was required (kappa 0.62). Retinal photography identified 38 patients for referral to ophthalmology which ophthalmoscopy missed. Of these, the ophthalmologist agreed that STDED was present in 32 (84%) and four patients required early laser. Ophthalmoscopy identified 13 patients for referral who were not identified by photography. Of these, the ophthalmologist agreed with the diabetologist that STDED was present in seven (54%) and one patient required early laser. CONCLUSION: Ophthalmoscopy may identify the occasional patient with diabetes who has STDED which is missed by retinal photography. For a systematic retinal screening programme, adding ophthalmoscopy to retinal photography will increase false-positive referrals and is likely to detect only a few extra patients requiring laser.

Blindness in patients with diabetes who have been screened for eye disease.

PURPOSE: Detection of diabetic retinopathy by screening is a major public health concern. Fundus photography has been shown to be a useful screening tool for the detection of diabetic retinopathy. In this paper the authors assess the incidence of blind and partially sighted registration due to diabetic eye disease in patients screened by a mobile fundus photography unit and identify the factors that contributed to loss of vision in the registered group. METHODS: A retrospective review of blind and partially sighted registrations between 1990 and 1995 was performed in a diabetic population screened by a mobile fundus photography unit in a region with a population of 390,000. The incidence of blind and partially sighted registration in the screened diabetic population was calculated. In the registered group, cause of visual loss, accuracy of photograph reporting, delay in laser treatment, adequacy of laser treatment and non-attendance rates at ophthalmic clinics were assessed. RESULTS: Of the 5390 patients screened by the mobile unit over 6 years, 68 (210 per 10(5) patient-years) were registered blind or partially sighted, but in only 17 patients (53 per 10(5) patient-years) was this as a result of diabetes. The factors contributing to loss of vision were found to be failure of laser treatment, rapidly progressive disease and poor patient attendance. CONCLUSIONS: As the majority of visual impairment in patients with diabetes is not due to diabetic retinopathy, this has important implications for screening programmes and may make the St Vincent Declaration targets difficult to achieve. The rate of new blind and partially sighted registration due to diabetes in the screened population was low at 53 per 10(5) patient-years (95% confidence interval, 29-76).