Non-Mydriatic Fundus Retinography in Screening for Diabetic Retinopathy: Agreement Between Family Physicians, General Ophthalmologists, and a Retinal Specialist.

Leonardo Provetti Cunha,Marcus Gomes Bastos,Carolina Ferreira Costa,Marise Machado De Oliveira,Henrique Pereira Araújo,Evelyn Alvernaz Figueiredo,Aline Mota Freitas Matos,José De Melo Costa Neto,Mário Luiz Ribeiro Monteiro,Luciana Virgínia Ferreira Costa-Cunha

doi:10.3389/fendo.2018.00251

Abstract

To determine the level of agreement between trained family physicians (FPs), general ophthalmologists (GOs), and a retinal specialist (RS) in the assessment of non-mydriatic fundus retinography in screening for diabetic retinopathy (DR) in the primary health-care setting. 200 Diabetic patients were submitted to two-field non-mydriatic digital fundus camera. The images were examined by four trained FPs, two GOs, and one RS with regard to the diagnosis and severity of DR and the diagnosis of macular edema. The RS served as gold standard. Reliability and accuracy were determined with the kappa test and diagnostic measures. A total of 397 eyes of 200 patients were included. The mean age was 55.1 (±11.7) years, and 182 (91%) had type 2 diabetes. The mean levels of serum glucose and glycosylated hemoglobin A1c were 195.6 (±87.3) mg/dL and 8.9% (±2.1), respectively. DR was diagnosed in 166 eyes by the RS and in 114 and 182 eyes by GO1 and GO2, respectively. For severity, DR was graded as proliferative in 8 eyes by the RS vs. 15 and 9 eyes by GO1 and GO2, respectively. The agreement between the RS and the GOs was substantial for both DR diagnosis (GO1k = 0.65; GO2k = 0.74) and severity (GO1k = 0.60; GO2k = 0.71), and fair or moderate for macular edema (GO1k = 0.27; GO2k = 0.43). FP1, FP2, FP3, and FP4 diagnosed DR in 108, 119, 163, and 117 eyes, respectively. The agreement between the RS and the FPs with regard to DR diagnosis was substantial (FP2k = 0.69; FP3k = 0.73; FP4k = 0.71) or moderate (FP1k = 0.56). As for DR severity, the agreement between the FPs and the RS was substantial (FP2k = 0.66; FP3k = 069; FP4k = 0.64) or moderate (FP1k = 0.51). Agreement between the FPs and the RS with regard to macular edema was fair (FP1k = 0.33; FP2k = 0.39; FP3k = 0.37) or moderate (FP4k = 0.51). Non-mydriatic fundus retinography was shown to be useful in DR screening in the primary health-care setting. FPs made assessments with good levels of agreement with an RS. Non-mydriatic fundus retinography associated with appropriate general physicians training is essential for the DR screening.

Highlights

Diabetic retinopathy (DR) is one of the main complications of diabetes mellitus (DM) and the main cause of preventable blindness in the world, especially in economically active populations in developed countries, affecting and threatening the vision of over 12.6 million and 37.3 million people, respectively [1, 2]
The purpose of this study was to determine the level of agreement between trained family physicians (FPs), general ophthalmologists (GOs), and a retinal specialist (RS) in the assessment of non-mydriatic fundus retinography in DR screening in the primary health-care setting
Using a non-mydriatic fundus camera, Bhargava et al found a prevalence of 17.8% in a sample of 367 diabetic patients from two primary health-care clinics in Singapore [19]

Summary

Introduction

Diabetic retinopathy (DR) is one of the main complications of diabetes mellitus (DM) and the main cause of preventable blindness in the world, especially in economically active populations in developed countries, affecting and threatening the vision of over 12.6 million and 37.3 million people, respectively [1, 2]. Screening for diseases such as DR should be performed at primary healthcare facilities. This can be done by direct ophthalmoscopy, a relatively inexpensive and accessible method. As shown by ample evidence, this important tool is underused in Brazilian primary health care [7]. Another attractive option for DR screening is non-mydriatic fundus retinography, a diagnostic device that provides detailed images of the eye fundus and obtain high-quality images of the retina and optic nerve head, covering a total area of 45°. Despite the somewhat high initial cost of the equipment, obtaining retinal images with the device is simple, fast, inexpensive, and requires no pupil dilation. The fundus images can be acquired by trained non-physicians and storaged for evaluation by an ophthalmologist, if necessary [8,9,10,11,12,13]

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Conclusion