Comparison of Widefield Laser Ophthalmoscopy and ETDRS Retinal Area for Diabetic Retinopathy.

Purpose: To evaluate agreement of nonmydriatic confocal scanning laser ophthalmoscopy (SLO; EIDON [CenterVue]) and the 7-standard field ETDRS area on ultrawide-field (UWF) SLO imaging for identification of diabetic retinopathy (DR) severity. Design: Single-site, prospective, comparative, instrument validation study. Participants: One hundred ten eyes of 55 patients with diabetes mellitus were evaluated. Methods: Each patient underwent nonmydriatic, nonsimultaneous stereoscopic imaging using the EIDON camera and 4 fields of 60° × 55° were acquired (macula centered, disc centered, temporal macula, superotemporal). Mydriatic UWF retinal images were acquired using a nonsimultaneous stereographic protocol with UWF imaging (California; Optos plc). Before grading, a standardized ETDRS 7-field image mask was applied to all UWF retinal images. Images from each device were graded independently by 2 masked graders using the ETDRS clinical DR classification. Any discrepancy in DR grading between the devices was adjudicated by a third grader. Main Outcome Measures: κ Levels of agreement, sensitivity, and specificity for DR thresholds. Results: Severity by ETDRS grading was as follows: no DR, 10.9%; mild nonproliferative DR (NPDR), 45.5%; moderate NPDR, 16.5%; severe NPDR, 11.8%; proliferative DR, 12.7%; high-risk proliferative DR, 2.7%; and ungradable, 0%. After adjudication, the level of DR identified on EIDON images agreed exactly with that of UWF ETDRS imaging in 87% of eyes (n = 96) and was within 1 step in 99.1% of eyes (n = 109) with a simple κ value of 0.8244 ± 0.0439 (95% confidence interval [CI], 0.7385-0.9104) and weighted (linear) κ value of 0.9041 ± 0.0257 (95% CI, 0.8537-0.9545). Sensitivity and specificity compared with ETDRS field grading for any DR were 0.96 and 0.75, for moderate NPDR or worse were 0.96 and 0.97, and for severe NPDR or worse were 0.91 and 1.00, respectively. Conclusions: Nonmydriatic 4-field stereoscopic widefield imaging using the EIDON device was comparable with the DR severity identified within the ETDRS 7-standard field area of UWF images. Future studies will need to evaluate the applicability of this device as a clinical and research tool and the impact of different widefield coverage areas.

The relationship of a diabetes telehealth eye care program to standard eye care and change in diabetes health outcomes.

Several studies suggest that telehealth eye care programs that combine retinal imaging, education, and some care management can improve patient adherence to annual, comprehensive eye examinations and follow-up treatments. Little is known, however, about whether such programs relate to other, more distal outcomes that affect diabetic eye disease, such as blood glucose control. This paper assesses the relationship of participation in a diabetes telehealth eye care program with standard, face-to-face eye care as well as improvements in other diabetes-related health outcomes. We conducted a retrospective study using data from electronic medical records of Joslin Diabetes Center (n=13,752). The data span 2 years: baseline and follow-up. Subjects' eye care groups were no eye care, eye care outside of the clinic, standard eye care at the clinic, or participation in the Joslin Vision Network telehealth eye care program. We analyzed the relationship of participation in the telehealth eye care program at baseline to follow-up eye care groups and changes in hemoglobin A1c, low density lipoprotein levels, and systolic blood pressure. The results show that participation in the telehealth eye care program was significantly correlated with whether subjects later obtained standard eye care, improvement in hemoglobin A1c, and improvement in low density lipoprotein. Thus, telehealth eye care programs that incorporate evaluation, education, and care planning are related to use of recommended eye care and improvements in certain diabetes-related health outcomes. Such programs can address the many aspects of care necessary to reduce risk of vision loss due to diabetic retinopathy and other diabetes-related complications. Future research might test hypotheses suggested by sociological and psychological theories regarding causation between participation in a telehealth eye care program and other diabetes care.

Comparison of nonmydriatic digital retinal imaging versus dilated ophthalmic examination for nondiabetic eye disease in persons with diabetes.

OBJECTIVE: To evaluate the ability of stereoscopic nonmydriatic digital retinal imaging to detect ocular pathologic features other than diabetic retinopathy (DR) in patients with diabetes mellitus (DM) compared with dilated retinal examination by retinal specialist ophthalmologists. DESIGN: Clinic-based comparative instrument study and retrospective chart review. PARTICIPANTS: Two hundred eighty Joslin Diabetes Center outpatients (560 eyes) with type 1 or type 2 DM. METHODS: Nonsimultaneous stereoscopic nonmydriatic digital retinal images (640 x 480 pixels) of three 45 degrees retinal fields were acquired and graded for clinical level of DR and other ocular pathologic features by certified readers according to Joslin Vision Network (JVN) protocol. Retrospective chart review compared findings from JVN digital images with findings from dilated retinal examination by retinal specialists performed within an average of 39.6 days of digital imaging. An independent senior retinal specialist adjudicated disagreements by review of 7 standard field 35-mm Early Treatment Diabetic Retinopathy Study protocol fundus photographs and JVN images. MAIN OUTCOME MEASURES: Detection of non-DR ocular pathologic features by digital imaging as compared with clinical examination. RESULTS: Nonmydriatic digital evaluation identified at least 1 non-DR ocular finding in 40.7% of patients (114/280). Non-diabetes mellitus ocular pathologic features identified by digital images, clinical examination, or both included cataract (n = 100); age-related maculopathy (n = 52); suspicion of glaucoma (n = 18); choroidal lesions (n = 18); evidence of systemic disorder (e.g., hypertension or renal disease; n = 15); epiretinal membrane (n = 11); chorioretinal atrophy, scar, or both (n = 6); retinal emboli (n = 3); retinitis pigmentosa (n = 1); and asteroid hyalosis (n = 1). Agreement of nonmydriatic imaging with clinical examination for presence and absence of these findings was 95.4%, 91.3%, 98.2%, 98.6%, 98.2%, 99.6%, 100%, 100%, 100%, and 100%, respectively. Kappa values for all non-DR lesions demonstrated near perfect agreement (kappa> or =0.80) except for age-related maculopathy (kappa = 0.71) and choroidal lesions (kappa = 0.73), where agreement was substantial. Overall, only 55 eyes (9.8%) were ungradable for level of DR and 85 eyes (15.2%) were ungradable for macular edema. CONCLUSIONS: Joslin Vision Network nonmydriatic digital imaging demonstrated excellent agreement with dilated ophthalmic examination by retinal specialists in the detection of ocular disease other than DR, suggesting a potential role for this technology in evaluating non-DR disorders and highlighting the extent of findings other than retinopathy in patients with diabetes.

Nonmydriatic digital imaging alternative for annual retinal examination in persons with previously documented no or mild diabetic retinopathy.

PURPOSE: To prospectively evaluate the Joslin Vision Network (JVN) for follow-up annual retinal examination for level of diabetic retinopathy (DR). DESIGN: Prospective cohort study. METHODS: Fifty-two patients with no or mild nonproliferative DR (Early Treatment Diabetic Retinopathy Study [ETDRS] level < or = 35) and no diabetic macular edema (DME) at dilated retinal examination 11 or more months earlier were imaged. Patients then had dilated retinal examination and color 35-mm seven standard field stereoscopic photography (ETDRS photographs) and completed a satisfaction survey. Level of DR determined from JVN images, clinical examination, and ETDRS photographs was compared. RESULTS: Two (1.9%) eyes had JVN images ungradable for level of DR. In the 102 gradable eyes (98.1%), JVN diagnosis exactly matched clinical examination for level of DR in 82 eyes (77.9%) and was within one level of DR in all eyes (100%). Three eyes (2.9%) had JVN images ungradable for DME; one of these eyes had DME by clinical examination. JVN diagnosis matched clinical examination for DME in all eyes (101) gradable by JVN. Fifty patients (96.1%) reported JVN imaging improved their understanding of eye disease, 100% were satisfied with JVN, and forty-eight (92.3%) would consider replacing dilated examination by their eye doctor with JVN imaging. CONCLUSIONS: JVN digital imaging closely matched clinical examination for level of DR and DME, would have resulted in no patients receiving less stringent follow-up, and was well accepted by patients. JVN digital imaging may be a suitable alternative for annual dilated retinal examination for determining level of DR or DME and appropriate follow-up comprehensive ophthalmic examination.

A telemedicine program for diabetic retinopathy in a Veterans Affairs Medical Center--the Joslin Vision Network Eye Health Care Model.

PURPOSE: To extend access to diabetic eye care and characterize the extent of diabetic retinopathy {DR) and other ocular findings using the Joslin Vision Network (JVN). DESIGN: Retrospective observational cohort study. METHODS: Outpatients at the Togus VA Medical Center with diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance underwent JVN protocol imaging. Images were transmitted to the Joslin Diabetes Center for grading and recommended treatment plan. RESULTS: The study included 1,219 patients (2,437 eyes); 1,536 eyes (63.0%) had no (DR), 389 (16.0%) had mild nonproliferative DR (NPDR), 105 (4.3%) moderate NPDR, 35 (1.4%) severe NPDR, 20 (0.8%) very severe NPDR, and 21 (0.9%) had proliferative DR (PDR). Regarding diabetic macular edema (DME), 1,907 eyes (78.3%) had no DME, 34 (1.4%) had early DME, and 16 (0.7%) had clinically significant macular edema (CSME). Of all patients, 354 (29.0%) had either no DR or mild NPDR in both eyes, no evidence of DME, and no significant nondiabetic findings; 679 (55.7%) had no DR in either eye, and 229 (18.8%) had mild NPDR in the more severe eye. Of the 908 patients (74.5%) with either no DR or mild NPDR in the more severe eye, 533 (58.7%) had at least one nondiabetic ocular finding necessitating referral. Finally, 320 eyes (13.1%) were ungradable for both DR and DME and 160 (6.6%) were ungradable for DME alone. CONCLUSION: In a non-ophthalmic setting, JVN identifies the severity of DR and nondiabetic ocular conditions, permitting appropriate triage for eye care.