Non-mydriatic Camera Research Articles

Screening for diabetic retinopathy with artificial intelligence: a real world evaluation.

Periodic screening for diabetic retinopathy (DR) is effective for preventing blindness. Artificial intelligence (AI) systems could be useful for increasing the screening of DR in diabetic patients. The aim of this study was to compare the performance of the DAIRET system in detecting DR to that of ophthalmologists in a real-world setting. Fundus photography was performed with a nonmydriatic camera in 958 consecutive patients older than 18 years who were affected by diabetes and who were enrolled in the DR screening in the Diabetes and Endocrinology Unit and in the Eye Unit of ULSS8 Berica (Italy) between June 2022 and June 2023. All retinal images were evaluated by DAIRET, which is a machine learning algorithm based on AI. In addition, all the images obtained were analysed by an ophthalmologist who graded the images. The results obtained by DAIRET were compared with those obtained by the ophthalmologist. We included 958 patients, but only 867 (90.5%) patients had retinal images sufficient for evaluation by a human grader. The sensitivity for detecting cases of moderate DR and above was 1 (100%), and the sensitivity for detecting cases of mild DR was 0.84 ± 0.03. The specificity of detecting the absence of DR was lower (0.59 ± 0.04) because of the high number of false-positives. DAIRET showed an optimal sensitivity in detecting all cases of referable DR (moderate DR or above) compared with that of a human grader. On the other hand, the specificity of DAIRET was low because of the high number of false-positives, which limits its cost-effectiveness.

Validation of using smartphone based non-mydriatic camera for retinal photography to diagnose diabetic retinopathy

Purpose: To assess the sensitivity and specificity of retinal imaging captured by portable non-mydriatic ‘fundus on phone’ camera as a screening tool against the conventional seven field digital fundus photography. Design: Prospective comparative study design. Methods: Study was performed over 300 diabetic patients (600 eyes). First fundus pictures were taken with non-mydriatic ‘fundus-on-phone’ camera and then with Zeiss seven field fundus camera after pupillary dilation. Images were analysed and compared by two observers. Results: Out of all the 600 undilated fundus images, 15.5% were ungradable, 76% were graded as poor and average quality by both observers. From the dilated fundus images taken using Zeiss camera, only 0.8% images were found ungradable by both observers. The sensitivity and specificity for detecting any diabetic retinopathy changes and its severity by using ‘fundus-on-phone’ camera against Zeiss fundus camera were found to be 54.92% and 85.5%, respectively, by observer one and 56.48% and 85.5%, respectively, by observer two. Conclusion: Non-mydriatic retinal imaging using fundus-on-phone camera is not a feasible method for screening diabetic retinopathy due to low sensitivity and high number of poor-quality images.

Head to head comparison of diagnostic performance of three non-mydriatic cameras for diabetic retinopathy screening with artificial intelligence

BackgroundDiabetic Retinopathy (DR) is a leading cause of blindness worldwide, affecting people with diabetes. The timely diagnosis and treatment of DR are essential in preventing vision loss. Non-mydriatic fundus cameras and artificial intelligence (AI) software have been shown to improve DR screening efficiency. However, few studies have compared the diagnostic performance of different non-mydriatic cameras and AI software.MethodsThis clinical study was conducted at the endocrinology clinic of Akdeniz University with 900 volunteer patients that were previously diagnosed with diabetes but not with diabetic retinopathy. Fundus images of each patient were taken using three non-mydriatic fundus cameras and EyeCheckup AI software was used to diagnose more than mild diabetic retinopathy, vision-threatening diabetic retinopathy, and clinically significant diabetic macular oedema using images from all three cameras. Then patients underwent dilation and 4 wide-field fundus photography. Three retina specialists graded the 4 wide-field fundus images according to the diabetic retinopathy treatment preferred practice patterns of the American Academy of Ophthalmology. The study was pre-registered on clinicaltrials.gov with the ClinicalTrials.gov Identifier: NCT04805541.ResultsThe Canon CR2 AF AF camera had a sensitivity and specificity of 95.65% / 95.92% for diagnosing more than mild DR, the Topcon TRC-NW400 had 95.19% / 96.46%, and the Optomed Aurora had 90.48% / 97.21%. For vision threatening diabetic retinopathy, the Canon CR2 AF had a sensitivity and specificity of 96.00% / 96.34%, the Topcon TRC-NW400 had 98.52% / 95.93%, and the Optomed Aurora had 95.12% / 98.82%. For clinically significant diabetic macular oedema, the Canon CR2 AF had a sensitivity and specificity of 95.83% / 96.83%, the Topcon TRC-NW400 had 98.50% / 96.52%, and the Optomed Aurora had 94.93% / 98.95%.ConclusionThe study demonstrates the potential of using non-mydriatic fundus cameras combined with artificial intelligence software in detecting diabetic retinopathy. Several cameras were tested and, notably, each camera exhibited varying but adequate levels of sensitivity and specificity. The Canon CR2 AF emerged with the highest accuracy in identifying both more than mild diabetic retinopathy and vision-threatening cases, while the Topcon TRC-NW400 excelled in detecting clinically significant diabetic macular oedema. The findings from this study emphasize the importance of considering a non mydriatic camera and artificial intelligence software for diabetic retinopathy screening. However, further research is imperative to explore additional factors influencing the efficiency of diabetic retinopathy screening using AI and non mydriatic cameras such as costs involved and effects of screening using and on an ethnically diverse population.

Prediction of preeclampsia from retinal fundus images via deep learning in singleton pregnancies: a prospective cohort study.

Early prediction of preeclampsia (PE) is of universal importance in controlling the disease process. Our study aimed to assess the feasibility of using retinal fundus images to predict preeclampsia via deep learning in singleton pregnancies. This prospective cohort study was conducted at Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine. Eligible participants included singleton pregnancies who presented for prenatal visits before 14 weeks of gestation from September 1, 2020, to February 1, 2022. Retinal fundus images were obtained using a nonmydriatic digital retinal camera during their initial prenatal visit upon admission before 20 weeks of gestation. In addition, we generated fundus scores, which indicated the predictive value of hypertension, using a hypertension detection model. To evaluate the predictive value of the retinal fundus image-based deep learning algorithm for preeclampsia, we conducted stratified analyses and measured the area under the curve (AUC), sensitivity, and specificity. We then conducted sensitivity analyses for validation. Our study analyzed a total of 1138 women, 92 pregnancies developed into hypertension disorders of pregnancy (HDP), including 26 cases of gestational hypertension and 66 cases of preeclampsia. The adjusted odds ratio (aOR) of the fundus scores was 2.582 (95% CI, 1.883-3.616; P < 0.001). Otherwise, in the categories of prepregnancy BMI less than 28.0 and at least 28.0, the aORs were 3.073 (95%CI, 2.265-4.244; P < 0.001) and 5.866 (95% CI, 3.292-11.531; P < 0.001). In the categories of maternal age less than 35.0 and at least 35.0, the aORs were 2.845 (95% CI, 1.854-4.463; P < 0.001) and 2.884 (95% CI, 1.794-4.942; P < 0.001). The AUC of the fundus score combined with risk factors was 0.883 (sensitivity, 0.722; specificity, 0.934; 95% CI, 0.834-0.932) for predicting preeclampsia. Our study demonstrates that the use of deep learning algorithm-based retinal fundus images offers promising predictive value for the early detection of preeclampsia.

Risk Factors Associated with Diabetic Retinopathy with and without Macular Edema in Recently Diagnosed Patients with Type 2 Diabetes.

To evaluate the risk factors associated with diabetic macular edema (DME) in patients with a recent type 2 diabetes mellitus (T2DM) diagnosis. We conducted a case-control study at a third-level hospital in Mexico City. We enrolled patients ≥18 years old, with T2DM less than five years of diagnosis, without disabling complications, and non-smokers. The control group was patients with diabetic retinopathy and without macular edema (DR-DME). Cases were patients with DR+DME. We measured fasting glucose, creatinine, lipid profile, urinary albumin/creatinine ratio (ACR), and HbA1c. An ophthalmological examination consisted of visual acuity measurement, digital three-field fundus photography with an automatic non-mydriatic camera, slit lamp, and Optical coherence tomography (OCT) examination. 183 and 61 patients with DR-DME and DR+DME, respectively, were included in the analysis. The prevalence of mild DR was higher in the DR-DME group, but the frequencies of moderate and severe retinopathy were higher in the DR+DME group. Patients in the DR-DME group had better vision than those in the DR+DME group. Logistic regression analysis revealed that age (OR, 1.07), HbA1c (OR, 1.19), and Albumin-to-Creatinine Ratio (ACR) > 30 mg/g (OR, 3.37) were associated with an increased possibility of DME compared to DR-DME. Our study provides insights into the association between risk factors and DME. We found a statistically strong association between HbA1c levels, age, and ACR. Patients with poor metabolic control should undergo an extensive medical examination to screen for DME, which may be related to the chronicity of DM and renal damage.

EyeArt artificial intelligence analysis of diabetic retinopathy in retinal screening events.

Early detection and treatment of diabetic retinopathy (DR) are critical for decreasing the risk of vision loss and preventing blindness. Community vision screenings may play an important role, especially in communities at higher risk for diabetes. To address the need for increased DR detection and referrals, we evaluated the use of artificial intelligence (AI) for screening DR. Patient images of 124 eyes were obtained using a 45° Canon Non-Mydriatic CR-2 Plus AF retinal camera in the Department of Endocrinology Clinic (Newark, NJ) and in a community screening event (Newark, NJ). Images were initially classified by an onsite grader and uploaded for analysis by EyeArt, a cloud-based AI software developed by Eyenuk (California, USA). The images were also graded by an off-site retina specialist. Using Fleiss kappa analysis, a correlation was investigated between the three grading systems, the AI, onsite grader, and a US board-certified retina specialist, for a diagnosis of DR and referral pattern. The EyeArt results, onsite grader, and the retina specialist had a 79% overall agreement on the diagnosis of DR: 86 eyes with full agreement, 37 eyes with agreement between two graders, 1 eye with full disagreement. The kappa value for concordance on a diagnosis was 0.69 (95% CI 0.61-0.77), indicating substantial agreement. Referral patterns by EyeArt, the onsite grader, and the ophthalmologist had an 85% overall agreement: 96 eyes with full agreement, 28 eyes with disagreement. The kappa value for concordance on "whether to refer" was 0.70 (95% CI 0.60-0.80), indicating substantial agreement. Using the board-certified retina specialist as the gold standard, EyeArt had an 81% accuracy (101/124 eyes) for diagnosis and 83% accuracy (103/124 eyes) in referrals. For referrals, the sensitivity of EyeArt was 74%, specificity was 87%, positive predictive value was 72%, and negative predictive value was 88%. This retrospective cross-sectional analysis offers insights into use of AI in diabetic screenings and the significant role it will play in automated detection of DR. The EyeArt readings were beneficial with some limitations in a community screening environment. These limitations included a decreased accuracy in the presence of cataracts and the functional cost of EyeArt uploads in a community setting.

EVALUATION OF THE INCLUSION OF SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY IN A TELEMEDICINE DIABETIC RETINOPATHY SCREENING PROGRAM: A Real Clinical Practice.

To evaluate whether combining spectral domain optical coherence tomography with monoscopic fundus photography using a nonmydriatic camera (MFP-NMC) improves the accuracy of diabetic macular edema (DME) referrals in a teleophthalmology diabetic retinopathy screening program. We conducted a cross-sectional study with all diabetic patients aged 18 years or older who attended screening from September 2016 to December 2017. We assessed DME according to the three MFP-NMC and the four spectral domain optical coherence tomography criteria. The sensitivity and specificity obtained for each criterion were estimated by comparing them with the ground truth of DME. This study included 3,918 eyes (1,925 patients; median age, 66 years; interquartile range, 58-73; females, 40.7%; once-screened, 68.1%). The prevalence of DME ranged from 1.22% to 1.83% and 1.54% to 8.77% on MFP-NMC and spectral domain optical coherence tomography, respectively. Sensitivity barely reached 50% in MFP-NMC and less for the quantitative criteria of spectral domain optical coherence tomography. When macular thickening and anatomical signs of DME were considered, sensitivity increased to 88.3% and the false DMEs and non-gradable images were reduced. Macular thickening and anatomical signs showed the highest suitability for screening, with a sensitivity of 88.3% and a specificity of 99.8%. Notably, MFP-NMC alone missed half of the true DMEs that lacked indirect signs.

Prevalence and risk factors of diabetic retinopathy in Basrah, Iraq

This study aimed to measure the prevalence and risk factors of diabetic retinopathy (DR) among patients with diabetes mellitus aged 20 to 82 years attending the Faiha Diabetes, Endocrine, and Metabolism Center (FDEMC) in Basrah. A cross-sectional study was conducted at FDEMC, including 1542 participants aged 20 to 82 from January 2019 to December 2019. Both eyes were examined for evidence of DR by a mobile nonmydriatic camera, and statistical analysis was performed to measure the prevalence rates (95% CI) for patients with different characteristics. The mean age of participants was 35.9, with 689 males (44.7%; 95% CI: 42.2-47.2%) and 853 females (55.3%; 95% CI: 52.8-57.8%). The prevalence rate of DR was 30.5% (95% CI: 28.1-32.8%), and 11.27% of cases were proliferative retinopathy. DR significantly increased with age (p-value=0.000), it was higher in females (p-value=0.005), and significantly increased with a longer duration of diabetes (p-value<0.001), hyperglycemia (p-value<0.001), hypertension (p-value=0.004), dyslipidemia (p-value<0.001), nephropathy (p-value<0.001) and smoking (p-value<0.001). There was no statistical association between DR and the type of diabetes or obesity. One-third of the participants in this study had DR. Screening and early detection of DR using a simple tool such as a digital camera should be a priority to improve a person's health status.

Alteraciones retinianas detectadas por screening con cámara retinal no midriática y derivación a oftalmología en una población de alto riesgo cardiovascular

ObjectiveTo describe the main retinal alterations detected by non-mydriatic retinal camera screening and to evaluate factors related to referral to ophthalmology in a population at high cardiovascular risk in Palmira, Colombia. Materials and methodsCross-sectional observational study, which included 11,983 photographic imaging records of patients with hypertension and diabetes mellitus from Gesencro's S.A.S. comprehensive chronic disease care program between 2018 and 2020. Risk factors associated to referral to ophthalmology were evaluated with logistic regression, and crude and adjusted ORs (odds ratios) were obtained. ResultsA total of 11,880 records were analyzed; 67.7±12years old, and 69.5% were women. Among the retinal alterations were patients with diabetic retinopathy classified as more than mild in 10% and gradeI hypertensive retinopathy in 54.9% right eye, 51.9% left eye. Macular edema was also identified. Only 2069 patients (17.4%) required referral to ophthalmology, and for imaging control 82.6%. In the multivariate analysis, the risk factors associated with the probability of being referred were male gender, age 60years and older, glycosylated hemoglobin out-of-target, advanced chronic kidney disease and the microalbumin-to-creatinine ratio moderate to severely elevated. ConclusionThis study makes it possible to determine the importance of screening with a non-mydriatic retinal camera in patients at high cardiovascular risk to detect retinal abnormalities and assess risk factors associated with referral to ophthalmology. Early documentation of ocular compromise in these patients could prevent and avoid visual impairment and blindness.

Prevalence of hypertensive retinopathy among the known diabetics in a community-based setting using a non-mydriatic fundus camera

Hypertension is a leading cause of morbidity and mortality and is associated with the risk of cardiovascular, cerebrovascular disease, and target organ damage. The risk increases exponentially in individuals with diabetes. Hypertensive retinopathy is a marker for target organ damage, so screening for hypertensive retinopathy helps in cardiovascular risk stratification. This study was conducted with an objective to screen for hypertensive retinopathy among known diabetics using a portable non-mydriatic fundus camera to ascertain its prevalence. The study was conducted in three selected field practice areas of the Department of Community Medicine. A house-to-house survey was performed using a predesigned, pretested questionnaire among 302 known diabetics. The study participants were subjected to visual acuity examination using Snellen's chart and retinal fundus examination using a portable non-mydriatic Bosch Mobile Eye Care Solutions fundus camera. The fundus images were transferred to a laptop and were reviewed and graded by an experienced Ophthalmologist. Among the 302 participants studied, 60 were diagnosed with hypertensive retinopathy. The prevalence of hypertensive retinopathy among diabetic patients was 19.9 % (95% CI: 15.7% - 24.6%). The prevalence was found to be higher in ** (21.8%; 95% CI: 16% - 28.6%) as compared to ** (17.5%; 95% CI: 11.8% - 24.6%). Early detection of hypertensive retinopathy with cardiovascular risk stratification and initiation of prompt treatment among the high-risk individuals will help reduce the morbidity caused due to end-organ damage and premature mortality to a greater extent and will pave the way forward to achieving sustainable developmental goals.

Retinal microvasculature and risk of spontaneous abortion in multiethnic Southeast Asian women

To better understand the underlying pathogenesis of spontaneous abortion that affects 10%-20% of recognized pregnancies. We used retinal imaging to study the role of systemic microvasculature and the risk of spontaneous abortion. A prospective multiethnic preconception cohort study conducted in Singapore. Hospital-based. A total of 1,032 Southeast Asian women who intended to conceive naturally were screened at study entry, among which 480 women spontaneously conceived within the 12-month observation period. After excluding 24 women who were lost to follow-up, we calculated the spontaneous abortion rate among 456 women. Further, we included 379 women for the final association analysis because 63 women did not undergo preconception retinal imaging examination and 14 had other types of pregnancy loss instead of spontaneous abortion. Trained photographers performed retinal examination using a 45-degree nonmydriatic retinal camera at study entry during the preconception screening. Using a semiautomated, computer-based program, we assessed quantitative retinal microvascular measurements, including caliber, fractal dimension, curvature tortuosity, and branching angle. Clinical research coordinators collected information on sociodemographic status, menstrual characteristics, and lifestyle, and assessed blood pressure and anthropometry at study entry. We performed a modified Poisson regression model to estimate the relative risk (RR) and 95% confidence interval (CI) for each retinal microvascular feature and its association with spontaneous abortion after adjusting for major confounders such as maternal prepregnancy, body mass index, and previous pregnancy loss history. We reported a spontaneous abortion rate of 13.4% (61 out of 456). Among all retinal microvascular features, retinal arteriolar caliber, retinal arteriolar, and venular curvature tortuosity were associated with a high risk of incident spontaneous abortion. In the regression model, per SD increase in retinal curvature tortuosity was associated with a 25%-34% increased risk of incident spontaneous abortion (arteriolar: unadjusted RR, 1.29 [95% CI, 1.06-1.56] and adjusted RR, 1.26 [1.04-1.53]; venule: unadjusted RR, 1.30 [1.08-1.55] and adjusted RR, 1.34 [1.09-1.64]). Our prospective cohort observed an increased risk of spontaneous abortion among Asian women with more tortuous retinal vessels assessed during the preconception phase. Our results indicate a role of vascular inflammatory and oxidative stress in the pathogenesis of spontaneous abortion. ClinicalTrials.gov, NCT03531658.

Obstructive sleep apnea, chronic obstructive pulmonary disease and hypertensive microvascular disease: a cross-sectional observational cohort study

Hypertensive microvascular disease is associated with an increased risk of diastolic heart failure, vascular dementia and progressive renal impairment. This study examined whether individuals with obstructive sleep apnoea (OSA) had more retinal hypertensive microvascular disease than those with chronic obstructive pulmonary disease (COPD) and hospital controls. This was a single-centre, cross-sectional, observational study of participants recruited consecutively from a general respiratory clinic and a general medical clinic. OSA was diagnosed on overnight polysomnography study (apnoea:hypopnoea index ≥ 5), and controls with COPD had a forced expiratory volume/forced vital capacity (forced expiratory ratio) < 70%. Individuals with both OSA and COPD were excluded. Hospital controls had no COPD on respiratory function testing and no OSA on specialist physician questioning. Study participants completed a medical questionnaire, and underwent resting BP measurement, and retinal photography with a non-mydriatic camera. Images were deidentified and graded for microvascular retinopathy (Wong and Mitchell classification), and arteriole and venular calibre using a semiautomated method at a grading centre. Individuals with OSA (n = 79) demonstrated a trend to a higher mean arterial pressure than other hospital patients (n = 143) (89.2 ± 8.9 mmHg, p = 0.02), and more microvascular retinopathy (p < 0.001), and narrower retinal arterioles (134.2 ± 15.9 μm and 148.0 ± 16.2 μm respectively, p < 0.01). Microvascular retinopathy and arteriolar narrowing were still more common in OSA than hospital controls, after adjusting for age, BMI, mean arterial pressure, smoking history and dyslipidaemia (p < 0.01, p < 0.01, respectively). Individuals with OSA demonstrated a trend to a higher mean arterial pressure than those with COPD (n = 132, 93.2 ± 12.2 mmHg and 89.7 ± 12.8 mmHg respectively, p = 0.07), and more microvascular retinopathy (p = 0.0001) and narrower arterioles (134.2 ± 15.9 and 152.3 ± 16.8, p < 0.01). Individuals with OSA alone had more systemic microvascular disease than those with COPD alone or other hospital patients without OSA and COPD, despite being younger in age.

Retinal small vessel dilatation in the systemic inflammatory response to surgery

Retinal microvascular calibre has been proposed as a predictor of cardiac events. Surgery is a major stimulus for inflammation which potentially affects small vessel calibre. This study examined the effects of surgery on retinal, and thus systemic, small vessel size, and the potentially confounding effect of surgery when retinal vessel calibre is used to predict cardiac risk in hospital patients. Consecutive participants were recruited from a preoperative assessment clinic at a teaching hospital. They provided demographic and clinical details, and underwent retinal imaging before and again, within 3 days after surgery, with a non-mydriatic retinal camera. Images were graded for vessel calibre using semi-automated software based on the Parr-Hubbard formula with Knudtson’s modification (IVAN, U Wisconsin). Differences were examined using Fisher’s exact test or a paired t-test, and calibre determinants identified from univariate and multiple linear regression analysis (STATA version 11.2). Sixty-eight participants (23 men, 34%) with a mean age of 55 ± 14.5 years, were recruited. Fourteen (21%) underwent a laparotomy which was considered major surgery and 54 (79%) had Other surgery. Mean C-reactive protein (CRP) levels increased post-operatively from 7.8 ± 20.2 mg/L to 43.9 ± 55.1 mg/L (p < 0.01), and mean serum albumin decreased from 38.9 ± 4.4 g/L to 33.9 ± 5.5 g/L (p < 0.01). Mean central retinal arteriole and venular equivalent calibre (CRAE, CRVE) increased post-operatively (142.4 ± 13.3 µm to 146.4 ± 13.0 µm, p < 0.01 and 213.1 ± 16.8 µm to 217.9 ± 18.3 µm, p < 0.01, respectively). The systemic microvasculature dilates post-operatively possibly secondary to inflammation and endothelial dysfunction. These changes were present within 3 days of surgery and may confound the use of small vessel calibre to predict cardiac risk in surgical inpatients. Microvascular dilatation in response to other inflammatory stimuli such as pneumonia is a known potential confounder in hospital patients.

Feasibility of telemedicine program using a hand-held nonmydriatic retinal camera in Panama.

To evaluate the image quality of a telemedicine screening program for retinal disease using a nonmydriatic camera among rural island communities in Bocas del Toro, Panama. In June 2018, a group of three medical students volunteered at clinics operated by the Floating Doctors in the province of Bocas del Toro, Panama. Non-mydriatic images of the retina were obtained using the Pictor Plus (Volk Optical, Mentor OH), randomized, and sent to two board-certified ophthalmologists at the University of California, Irvine for analysis using a modified version of the FOTO-ED scale. Inter-rater reliability was calculated using the kappa statistic. Seventy patients provided a total of 127 images. Average image quality was 3.31, and most frequent image quality was 4/5 on the FOTO-ED scale. Thirty patients had at least one eye image with ideal quality (42.86%), while only one patient had no adequate photos taken (1.43%). However, high quality images were obtained in both eyes in only 12 patients (17.14%). The inter-rater reliability between the two ophthalmologists was 0.614. Further improvements are necessary to acquire higher quality images more reliably. This may include further training and experience or mydriasis.

Efficacy of smartphone-based retinal photography by undergraduate students in screening and early diagnosing diabetic retinopathy

BackgroundTo evaluate the efficacy of retinal photography obtained by undergraduate students using a smartphone-based device in screening and early diagnosing diabetic retinopathy (DR).MethodsWe carried out an open prospective study with ninety-nine diabetic patients (194 eyes), who were submitted to an ophthalmological examination in which undergraduate students registered images of the fundus using a smartphone-based device. At the same occasion, an experienced nurse captured fundus photographs from the same patients using a gold standard tabletop camera system (Canon CR-2 Digital Non-Mydriatic Retinal Camera), with a 45º field of view. Two distinct masked specialists evaluated both forms of imaging according to the presence or absence of sings of DR and its markers of severity. We later compared those reports to assess agreement between the two technologies.ResultsConcerning the presence or absence of DR, we found an agreement rate of 84.07% between reports obtained from images of the smartphone-based device and from the regular (tabletop) fundus camera; Kappa: 0.67; Sensitivity: 71.0% (Confidence Interval [CI]: 65.05–78.16%); Specificity: 94.06% (CI: 90.63–97.49%); Accuracy: 84.07%; Positive Predictive Value (PPV): 90.62%; Negative Predictive Value (NPV): 80.51%. As for the classification between proliferative diabetic retinopathy and non-proliferative diabetic retinopathy, we found an agreement of 90.00% between the reports; Kappa: 0.78; Sensitivity: 86.96%; (CI: 79.07–94.85%); Specificity: 91.49% (CI: 84.95–98.03%); Accuracy: 90.00%; PPV: 83.33%; NPV: 93.48%. Regarding the degree of classification of DR, we found an agreement rate of 69.23% between the reports; Kappa: 0.52. As relating to the presence or absence of hard macular exudates, we found an agreement of 84.07% between the reports; Kappa: 0.67; Sensitivity: 71.60% (CI: 65.05–78.16%); Specificity: 94.06% (CI: 90.63–97.49%); Accuracy: 84.07%; PPV: 90.62%; NPV: 80.51%.ConclusionThe smartphone-based device showed promising accuracy in the detection of DR (84.07%), making it a potential tool in the screening and early diagnosis of DR.

Criteria-Based Assessment of a Teleophthalmology Diabetic Retinopathy Evaluation Program in a Primary Care Setting.

Background:Studies have shown that teleophthalmology programs using a nonmydriatic camera in primary care settings can improve rates of diabetic retinopathy (DR) screening. However, such programs are not yet widespread due to common challenges in sustainability.Purpose:To comprehensively evaluate clinical and operational measures of an urban primary care clinic's 1-year pilot teleophthalmology DR evaluation program.Materials and Methods:This retrospective analysis used five metrics to evaluate the program: clinical diabetic retinal exam (DRE) rate, visual acuity and pathology, camera utilization, billing and insurance reimbursements, and outcomes of follow-up referrals.Results:Two hundred eleven patients were screened over 14 months. The DRE rate had more than doubled (34-75%). Of the patients, 55.9% had vision better than 20/50 in each eye and 21% with at least 1 eye worse than or equal to 20/70. DR was noted in 11% of patients. The program's first few months saw greatest camera use. Government and Medicare Advantage insurers were significantly (p < 0.001) less likely to reimburse than commercial insurers. Twenty-seven percent of patients screened had documented follow-up with an eye care provider within 16 months of their screening. Patients diagnosed with DR or recommended follow-up within 1 month were significantly (p < 0.001) more likely to schedule an appointment.Discussion:Challenges to program sustainability include efficient utilization, reimbursement from governmental insurers, and adherence to follow-up recommendations.Conclusions:Assessing teleophthalmology programs with the aforementioned five metrics allows for a comprehensive evaluation of impact and sustainability. This may be utilized to standardize the implementation and evaluation of such programs across diverse settings.

Retinal drusen in glomerulonephritis with or without immune deposits suggest systemic complement activation in disease pathogenesis

Retinal drusen are characteristic of macular degeneration and complement activation, but also occur in C3, lupus and IgA nephropathy. This cross-sectional observational study compared drusen counts in different forms of glomerulonephritis. Consecutive individuals with glomerulonephritis attending a general renal or transplant clinic underwent retinal imaging with a non-mydriatic camera. Drusen were counted in deidentified images by trained graders, compared with matched hospital patients, and correlated with clinical features. Eighty-four individuals with glomerulonephritis had a mean drusen count of 10 ± 27 compared with 3 ± 8 in hospital controls (p = 0.007). Fourteen individuals with glomerulonephritis (17%) and 4 hospital controls (4/49, 8%) had increased drusen counts (≥ 10) (p = 0.20). Increased drusen counts ≥ 10 were present in 13 (13/63, 21%) of those with glomerulonephritis and immune deposits [membranous (n = 8), antiglomerular basement membrane nephritis (n = 6), FSGS (n = 49)], and one of the 21 (5%) with glomerulonephritis without immune deposits [ANCA-associated (n = 15), minimal change disease (n = 6)]. In antibody-mediated glomerulonephritis (n = 14), mean drusen counts were 2 ± 3 in individuals with normal kidney function, 16 ± 41 with impaired function and 5 ± 7 with kidney failure . Mean counts were 24 ± 56 in individuals with glomerular IgG deposits and 1 ± 1 in those without (p = 0.76), and 23 ± 60 with complement deposits and 4 ± 8 in those without. Drusen counts were also less in immunosuppressed individuals (p = 0.049). The demonstration of retinal drusen in some forms of glomerulonephritis is consistent with systemic complement activation, and suggests that treatment targeting the complement pathways is worthwhile.

Validation of an autonomous artificial intelligence–based diagnostic system for holistic maculopathy screening in a routine occupational health checkup context

PurposeThis study aims to evaluate the ability of an autonomous artificial intelligence (AI) system for detection of the most common central retinal pathologies in fundus photography.MethodsRetrospective diagnostic test evaluation on a raw dataset of 5918 images (2839 individuals) evaluated with non-mydriatic cameras during routine occupational health checkups. Three camera models were employed: Optomed Aurora (field of view — FOV 50º, 88% of the dataset), ZEISS VISUSCOUT 100 (FOV 40º, 9%), and Optomed SmartScope M5 (FOV 40º, 3%). Image acquisition took 2 min per patient. Ground truth for each image of the dataset was determined by 2 masked retina specialists, and disagreements were resolved by a 3rd retina specialist. The specific pathologies considered for evaluation were “diabetic retinopathy” (DR), “Age-related macular degeneration” (AMD), “glaucomatous optic neuropathy” (GON), and “Nevus.” Images with maculopathy signs that did not match the described taxonomy were classified as “Other.”ResultsThe combination of algorithms to detect any abnormalities had an area under the curve (AUC) of 0.963 with a sensitivity of 92.9% and a specificity of 86.8%. The algorithms individually obtained are as follows: AMD AUC 0.980 (sensitivity 93.8%; specificity 95.7%), DR AUC 0.950 (sensitivity 81.1%; specificity 94.8%), GON AUC 0.889 (sensitivity 53.6% specificity 95.7%), Nevus AUC 0.931 (sensitivity 86.7%; specificity 90.7%).ConclusionOur holistic AI approach reaches high diagnostic accuracy at simultaneous detection of DR, AMD, and Nevus. The integration of pathology-specific algorithms permits higher sensitivities with minimal impact on its specificity. It also reduces the risk of missing incidental findings. Deep learning may facilitate wider screenings of eye diseases.

Direct Observation of Retinal Microvessels in Cancer Patients After Systemic Administration of Bevacizumab and Oxaliplatin.

Antiangiogenic chemotherapy is the backbone of the various anticancer therapies. To date no practical biomarker predicting their antitumor effects and toxicity has been reported. We aimed to determine the feasibility of direct retinal observation as a practical biomarker in antiangiogenic chemotherapy. By direct retinal observation using a nonmydriatic retinal camera, we measured retinal microvessel diameters in 10 patients with colorectal cancer before and after intravenous infusion of bevacizumab and oxaliplatin. All patients also received oral capecitabine during their therapy. Retinal microvessel diameters were decreased from baseline temporarily by 14.5±6.5% after infusion of bevacizumab and oxaliplatin in five patients who responded to treatment and 8.8±6.2% in the other five patients (p=0.008). Measurement of retinal microvessel diameters by direct observation appears to be feasible in patients receiving systemic chemotherapy. The decrease of retinal microvessel diameters might indicate improved tumor response to treatment with bevacizumab-containing systemic chemotherapy.

Association between retinal vascular measures and brain white matter lesions in schizophrenia.

Recent studies have examined retinal vascular abnormalities in schizophrenia as retinal vascular imaging is a non-invasive proxy to cerebral microvasculature. However, relation between retinal vascular abnormalities and brain structure is not well examined in schizophrenia. Hence in this study, for the first time, we examined the relationship between retinal vascular measures and brain white matter lesions in schizophrenia. We examined brain white matter lesions as they are considered a predictive marker for future adverse cerebrovascular event. We acquired retinal vascular images of both eyes using a non-mydriatic camera and calculated retinal vascular diameter, tortuosity, trajectory and fractal dimension using validated methods. All patients underwent Magnetic Resonance Imaging of bran and we computed white matter hypo-intensities using Freesurfer software. We performed a linear regression analysis to examine the relationship between white matter hypo-intensities and retinal vascular measures controlling for age, sex, fasting blood sugar, creatinine, whole-brain volume, and antipsychotic dose. The regression model was significant in Schizophrenia patients (R=0.983;R2=0.966;-F=10.849;p=0.008) but not in healthy volunteers (R=0.828;R2=0.686;F=0.182; p=0.963). Among the retinal vascular measures, arterial tortuosity (β=0.963;p-0.002), tortuosity (β=-1.002;p=0.001) and fractal dimension (β=-0.688;p=0.014) were significant predictors of white matter lesions. The current study's findings support the conclusion that retinal vascular fractal dimension and tortuosity are associated with changes in cerebral white matter and may be considered proxy markers for cerebral microvasculature in schizophrenia. Considering the relationship between white matter lesions and stroke, these observations could have important clinical implications to screen schizophrenia patients for risk of adverse cerebrovascular event.