Non-mydriatic Fundus Camera Research Articles

Efficacy of a portable non-mydriatic fundus camera for "rule-out papilledema" consultations: A prospective study.

Ophthalmology is frequently consulted to "rule-out papilledema." We assessed the efficacy of a portable, non-mydriatic fundus camera in detecting optic disc edema in the inpatient and emergency room settings during "rule-out papilledema" consultations, comparing to the gold standard dilated fundus examination (DFE). This prospective, blinded, cohort study included 124 non-mydriatic fundus photographs (62 patients) that were obtained over the 11-month enrollment period. The images, along with a brief clinical history, were evaluated independently by an attending neuro-ophthalmologist (NO), general ophthalmologist (GO), emergency room (ER) physician, and ophthalmology resident (OR), for the presence of disc edema and indication for consultation. Results were compared to DFE. Sensitivity, specificity, and area under receiver operating characteristic (ROC) curves were determined to evaluate the efficacy of the camera. On DFE, disc edema was present in 51 eyes (41.1%). Compared to DFE, NO assessment had the greatest combined sensitivity (84.3%) and specificity (97.3%) for the detection of disc edema, followed by that of GO (sensitivity 77.4%, specificity 100%), OR (sensitivity 96.1%, specificity 80.8%), and ER clinician (sensitivity 68.6%, specificity 89.0%). Areas under ROC curves for NO, GO, OR, and ER physician were all statistically significant for the detection of disc edema (0.908, P < 0.001; 0.892, P < 0.001; 0.885, P < 0.001; 0.788, P < 0.001, respectively). Clinicians were able to correctly identify optic disc edema using non-mydriatic fundus photography. Non-mydriatic fundus photography may be an effective inpatient or telemedicine tool to assess for optic disc edema.

The Assessment of Retinal Image Quality Using a Non-Mydriatic Fundus Camera in a Teleophthalmologic Platform.

This study assesses the quality of retinal images captured using a non-mydriatic fundus camera within a teleophthalmologic platform in Taiwan. The objective was to evaluate the effectiveness of non-mydriatic fundus cameras for remote retinal screening and identify factors impacting image quality. From June 2020 to August 2022, 629 patients from five rural infirmaries underwent ophthalmic examinations, with fundus images captured without pupil dilation. These images were reviewed by senior ophthalmologists and graded based on quality. The results indicated that approximately 70% of images were of satisfactory diagnostic quality. Risk factors for poor image quality included older age, the presence of cataracts, pseudophakia, and diabetes mellitus. This study demonstrates the feasibility of using non-mydriatic fundus cameras for teleophthalmology, highlighting the importance of identifying and addressing factors that affect image quality to enhance diagnostic accuracy in remote settings.

Retinal microvascular remodeling associates with adverse events in continuous-flow left ventricular assist device-supported patients

BackgroundContinuous-flow left ventricular assist device (cfLVAD) use is effective in supporting patients with end-stage heart failure (ESHF). Reduced flow pulsatility within the systemic circulation in cfLVAD-supported patients may lead to alterations within the microcirculation. Temporal changes in microvasculature in relation to adverse events in cfLVAD supported patients has not been studied. We aimed to profile changes within retinal microvasculature and its association with adverse events. MethodsRetinal photography was performed using Topcon TRC-NW8 non-mydriatic fundus camera in cfLVAD supported patients and ESHF control patients. Retinal measurements including arteriolar and venular caliber, fractal dimension, branching angle, and vessel tortuosity were evaluated using a validated semi-automated program. Demographic and adverse event data were documented. Results172 images were recorded from 48 patients (n=29 cfLVAD, n=19 ESHF, mean age 54.2 ± 11.9 years). There were significant trends in retinal arteriolar caliber (B = -0.53 µm, 95% CI: -0.96 – -0.10, p = 0.016) and retinal fractal dimension parameters (B = 0.014, 95% CI: 0.001 – 0.002, p = 0.016) in linear mixed model regressions. Amongst cfLVAD patients, there was a significant association between the incidence of gastrointestinal bleeding and stepwise increases in retinal arteriolar-venular caliber ratio (HR: 3.03, 95% CI: 2.06 – 4.45, p = 0.005), a measure of arteriolar narrowing. ConclusionsWe have observed for the first time that alterations in retinal microvasculature in cfLVAD-supported patients may be associated with gastrointestinal bleeding. While understanding these temporal changes may predict future adverse events in cfLVAD-supported patients, further multi-center studies are required to confirm the associations observed.

Clinical characteristics and associated factors of diabetic retinopathy in Sudanese patients

Background: Diabetic retinopathy (DR) is a leading cause of vision loss and preventable blindness, particularly in middle- and high-income countries.Aim: This study aimed to assess the characteristics and associated factors of DR in Sudanese patients with type 2 diabetes mellitus (DM).Setting: A cross-sectional hospital-based study included 119 patients with type 2 DM was conducted at EL-Walidain Eye Hospital, Khartoum, Sudan, from February 2021 to May 2021.Methods: A non-mydriatic digital fundus camera was used for fundus photography, and Scottish Diabetic Retinopathy Grading Scheme was used for the final classification of DR.Results: Females comprised 53.8% of patients, mean age of 58.8 ± 8.5 years. Uncontrolled DM was found in 37.8% with a mean duration of 10.5 ± 4.8 years. Myopia was the most common refractive error found in 57.8% of the uncontrolled group, followed by emmetropia (17.8%). Whereas in the controlled group, 47.3% were hyperopic and 39.2% were myopic. Maculopathy grade M1 was found to be 37.8% in the uncontrolled group and 18.9% in the controlled group, with no significant difference (p = 0.361). Conversely, the difference in retinopathy between the two groups was statistically significant (p = 0.043).Conclusion: Decreased vision and increased retinopathy were associated with an increase in patients’ age. More widespread diabetes awareness and screening programmes to improve diabetes management and control in Sudan and other developing countries.Contribution: This study observed maculopathy grade M1 and myopia were more common in uncontrolled DM, and vision function was inversely correlated with age (p 0.05).

Assessment of prevalence and need for screening of diabetic retinopathy using non-mydriatic fundus camera in rural and tribal diabetic populations in Maharashtra.

To assess the prevalence of DR and the need for screening and management of DR with medical management of diabetes in rural and tribal population in Maharashtra. The known diabetics of rural area and tribal area were screened at corresponding primary health centers, subcenters, and village level with the help of local healthcare workers using a portable non-mydriatic fundus camera. The prevalence of blindness among known diabetics in rural area was 1.29%, and 0.84% in tribal area. In the rural area, the prevalence of diabetic retinopathy (DR) was 5.67% ( n = 776), out of those 18.18% had sight threatening diabetic retinopathy (STDR). The prevalence of DR was 7.73% ( n = 711) in tribal areas, out of those, 30.90% had STDR. The significant risk factors were identified to be the duration of diabetes and poor glycemic control. Implementation of targeted interventions for screening and management are required to reduce the risk of blindness among known diabetics in rural and tribal areas.

Impact of a Non-mydriatic Ocular Fundus Camera at a Quaternary Care Emergency Department (P4-15.001)

Impact of a Non-mydriatic Ocular Fundus Camera at a Quaternary Care Emergency Department (P4-15.001)

Accumulation of Microvascular Target Organ Damage in Systemic Lupus Erythematosus Patients Is Associated with Increased Cardiovascular Risk.

Background: Systemic lupus erythematosus (SLE) is a prototype autoimmune disease associated with increased cardiovascular (CV) burden. Besides increased arterial stiffness and subclinical atherosclerosis, microvascular dysfunction is considered an important component in the pathophysiology of CV disease. However, there is a lack of data regarding the effect of multiple target organ damage (TOD) on CV health. Objectives: This study aimed to evaluate (i) the presence of microvascular changes in SLE in various vascular beds, (ii) the possible associations between the accumulation of microvascular TOD and CV risk and (iii) whether Galectin-3 represents a predictor of combined microvascular TOD. Methods: Participants underwent (i) evaluation of skin microvascular perfusion (laser speckle contrast analysis), (ii) fundoscopy (non-mydriatic fundus camera), (iii) indirect assessment of myocardial perfusion (subendocardial viability ratio) and (iv) determination of urine albumin-to-creatinine ratio (UACR). CV risk was calculated using the QResearch Risk Estimator version 3 (QRISK3). Serum Galectin-3 levels were determined. Results: Forty-seven SLE patients and fifty controls were studied. SLE patients demonstrated impaired skin microvascular reactivity (160.2 ± 41.0 vs. 203.6 ± 40.1%), retinal arteriolar narrowing (88.1 ± 11.1 vs. 94.6 ± 13.5 μm) and higher UACR levels compared to controls. Furthermore, SLE individuals had significantly higher Galectin-3 levels [21.5(6.1) vs. 6.6(6.6) ng/dL], QRISK3 scores [7.0(8.6) vs. 1.3(3.6)%] and a greater chance for microvascular dysfunction. In the SLE group, patients with multiple TOD exhibited higher QRISK3. In the multivariate analysis, the accumulation of TOD correlated with disease activity and Galectin-3 (p < 0.05). Conclusions: Our study showed for the first time that SLE patients exhibit a greater number of cases of TOD. The accumulation of TOD was associated with increased CV risk. Clinicians dealing with SLE should be aware and seek microvascular alterations.

Prevalence of Diabetic Retinopathy and Associated Risk Factors in Diabetic Type II Patients in Ajdabiya, Libya

Diabetic retinopathy (DR) is One of the most well-known microvascular complications of diabetes mellitus (DM) and is a frequent side effect of untreated diabetes that can lead to blindness and visual impairment. This study was conducted to assess the prevalence of diabetic retinopathy and associated factors among type 2 diabetic patients. A cross sectional study was done at Ajdabiya diabetic center from November 2023 to January 2024. Subjects and Methods: 52 patients (104 eyes) with T2DM were included in this study, their fasting blood sugar and glycosylated hemoglobin level, lipid profile measured.in addition to fundus examination (done by noncontact +90-diopter lens), fundus photographs taken by Non-Mydriatic Fundus Camera TFC-1000. Around 61 eyes (58.7%) had diabetic retinopathy, 27 eyes (26%) had back ground DR, 6 eyes (5.8 %) had pre-proliferative DR, 4 eyes (3.8%) had proliferative DR, 2 eyes (1.9%) had advanced diabetic eye disease, 22 eyes (21.2%) had CSME. Their ages ranges between 36–74 years with mean (58.90) years, (26.9%) were males, (73.1%) were females. There was a significant association between the development of DR and duration of DM (p=0.003), The FBS levels were also determined to be a significant risk factor for DR (p = 0.031), also LDL with (p=0.039). No other factors were found to have a significant association with DR. In this study more than half of diabetic patients had diabetic retinopathy. There was a significant association between the development of DR and duration of DM, FBS, LDL levels, there was no significant relation between diabetic retinopathy and hypertension, HgA1c Serum cholesterol or triglyceride levels or previous cataract surgery.

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.

Improving Access to Eye Care Through Community Health Screenings Using Artificial Intelligence

ABSTRACT Purpose To the best of our knowledge, implementation of artificial intelligence (AI)-based vision screening in community health fair settings has not been previously studied. This prospective cohort study explored the incorporation of AI in a community health fair setting to improve access to eyecare. Methods Vision screening was implemented during a community health fair event using an AI-based non-mydriatic fundus camera. In addition, a questionnaire was provided to survey the various barriers to eyecare and assess eye health literacy. Results A total of 53 individuals were screened at this event. Notably, about 88% of participants had follow-up appointments scheduled accordingly with an approximate 62% attendance rate. The most reported barrier to eyecare was lack of health insurance followed by transportation. Conclusion The addition of AI-based vision screening in community health fairs may ultimately help improve access to eye care.

Fetal Growth Restriction Leads to an Enlarged Cup-to-Disc Ratio in Adults Born at Full Term

PurposeThis study explores associations between fetal growth restriction or excessive fetal growth, along with perinatal factors on the optic nerve head morphology in adulthood. DesignRetrospective cohort study. MethodsThis retrospective cohort study involved a prospective ophthalmological examination of individuals born at full term (with a gestational age of ≥37 weeks) from 1969 to 2002. Each participant underwent non-mydriatic fundus camera photography to capture images of the optic discs, followed by manual measurements. The vertical cup-to-disc ratio (VCDR) and optic disc area were examined and analyzed in relation to the baby's birth weight relative to the gestational age. These categories included those with former moderate (birth weight percentile between the 3rd and <10th), severe SGA (below the 3rd percentile), normal (AGA, 10th-90th percentile), and moderately (birth weight >90th to 97th percentile) and severely (birth weight >97th percentile) large for gestational age (LGA) adults within the age range of 18 to 52 years. ResultsOverall, 535 eyes of 280 individuals (age 29.74±9.23 years, 144 females) born at full term were included. Multivariable analysis showed a significant association between a larger VCDR and the severe SGA group (B = 0.05, 95% CI 0.01-0.10; p = 0.02). In the univariable model, placental insufficiency was associated with VCDR (B=0.10, 95% CI 0.01-0.19; p=0.03). Other perinatal factors did not demonstrate an association with VCDR. Furthermore, there was an indication of an association suggesting a smaller optic disc area in individuals born moderately SGA at full term (B = -0.17, 95% CI -0.33- -0.001; p = 0.05). ConclusionThis study provides evidence that individuals born at-term with severe SGA have an increased VCDR, suggesting that fetal growth restriction has a lasting impact on optic disc morphology independent of prematurity throughout adulthood.

Artificial Intelligence-based quantitative evaluation of retinal vascular parameters in thyroid-associated ophthalmopathy.

Thyroid-associated ophthalmopathy (TAO) may result in increased metabolism and abnormalities in microcirculation. The fractal dimension (Df) of retinal vessels has been shown to be related to the pathology of a number of ophthalmic disorders, but it hasn't been investigated in TAO. We analyzed 1078 participants aged 18 to 72 (548 healthy volunteers and 530 TAO). Images were captured using a non-mydriatic 45-degree fundus camera. Baseline retinal characteristics, such as vessel width, tortuosity, and Df were measured using semiautomated software from fundus images. The average retinal parameters were compared between the two groups. The receiver operation curve (ROC) was used to assess the diagnostic efficacy of various retinal vascular parameters for TAO. Despite controlling for potential confounding variables, Df, vessel width, and tortuosity significantly increased in TAO compared to healthy volunteers. Compared to active TAO, patients in the inactive phase had a larger retinal venous caliber (p < 0.05), but there was no difference in Df or arterial caliber. Moderate and severe cases had a higher Df compared with mild cases (EUGOGO guidelines). The area under the ROC for Df, tortuosity, and vascular caliber in the diagnosis of TAO was 0.904 (95% CI: 0.884-0.924), 0.638 (95% CI: 0.598-0.679), and 0.617 (95% CI: 0.576-0.658), respectively. Due to its accessibility, affordability, and non-invasive nature, retinal vascular Df may serve as a surrogate marker for TAO and might be used to identify severe cases. With relatively high diagnostic performance, the Df is of some utility for the detection of TAO.

Abstract WMP56: Diagnosis of Acute Central Retinal Artery Occlusion With a Nonmydriatic Ocular Fundus Camera Combined With Optical Coherence Tomography in the Emergency Department: A New Paradigm

Background: Central retinal artery occlusion (CRAO) is a retinal infarction with causes/management similar to cerebral infarction. However, CRAO diagnosis is often delayed, resulting in missed opportunities for rapid treatment. Diagnosis by ophthalmologists is essential prior to management by stroke neurologists and may be challenging within a few hours of vision loss. Our goal is to provide a new paradigm in the emergency department (ED) with the implementation of a nonmydriatic ocular fundus camera (NMFP) combined with optical coherence tomography (OCT) to allow for ultrarapid remote diagnosis and stroke alert as soon as patients present to the ED. Methods: Prospective collection of data from consecutive patients who had NMFP-OCT for acute monocular vision loss in our general ED affiliated with a comprehensive stroke center. We collected timing of photographs; final diagnosis (CRAO/other causes of vision loss); time between vision loss onset and CRAO diagnosis; NMFP-OCT findings. Results: Over 9 weeks, 27 patients had NMFP-OCT obtained for acute monocular visual loss, including 9 CRAO [others included 7 retinal detachments; 8 vitreous hemorrhages; 3 temporal arteritis]. Diagnosis of acute CRAO was made remotely on NMFP-OCT obtained 30, 33, 36 min after arriving in ED in 3 patients presenting to ED within 3.5 hrs of vision loss. In all 3 patients, the ocular color photographs were almost normal and acute CRAO diagnosis was made primarily from the OCT showing inner retinal edema/hyperreflectivity. Conclusion: Incorporating NMFP-OCT into the ED workflow can be used as a substitute for funduscopic examination/pupillary dilation, allowing for remote diagnosis of CRAO by ophthalmologists who can provide real time recommendations before in person visit. These positive preliminary results suggest that this strategy accelerates the diagnosis of urgent vision loss, resulting in improved patient outcomes. Results of the first 6 months will be presented at the conference.

Diabetic retinopathy screening guidelines for Physicians in India: position statement by the Research Society for the Study of Diabetes in India (RSSDI) and the Vitreoretinal Society of India (VRSI)-2023

Diabetic retinopathy (DR) is a leading cause of blindness among working-age adults worldwide. India is the diabetes capital of the world and one in five adults is said to have diabetes in India. With the increase in diabetes, there is an increasing burden of diabetic retinopathy (DR). All patients with diabetes have a risk of losing vision due to DR. The prevalence of diabetic retinopathy is 12.5%; out of which, 4% are said to have vision-threatening diabetic retinopathy (VTDR) The early stages of DR are symptomless, necessitating a proactive screening for an early detection of DR in all people with diabetes before they develop VTDR. This is a position statement jointly developed by RSSDI (Research Society for the Study of Diabetes in India) and VRSI (Vitreo Retinal Society of India) to provide guidelines for Physicians on DR screening in India. These guidelines emphasize the need for regular DR screening of all people with diabetes. It is recommended that the Physicians establish an effective DR screening model in their clinics, eg., a non-mydriatic fundus camera utilizing artificial intelligence (AI) algorithms for fundus photography to identify referral or non-referral DR. This will facilitate early detection and timely referral to an ophthalmologist thereby preventing VTDR. The need to create public awareness regarding blindness due to DR and a collaboration between Physicians and ophthalmologists for the management of diabetes, opportunistic screening of DR, and timely management of DR may play a crucial role in decreasing the burden of blindness secondary to diabetes.

Prevalence and Predictors of Diabetic Retinopathy, Its Progression and Regression in Indian Children and Youth With Type-1 Diabetes

Objective: There are very few reports on the prevalence of diabetic retinopathy (DR) in children and youth with type-1 diabetes (T1D). Studies have also found very low rates of referral for DR screening in children and youth with T1D. We conducted this study to determine the prevalence of DR, to study the reliability of ISPAD screening recommendations and to identify predictors of DR, its progression and regression in Indian children and youth with T1D. Methods: This study included 882 children and youth with T1D. Demographic data, anthropometry, blood pressure, sexual maturity rating, ophthalmological examination (slit lamp for cataract) and biochemical measurements were performed using standard protocols. Fundus images were captured using the Forus Health 3netra classic digital non-mydriatic fundus camera by the same experienced operator. De-identified images were assessed by a senior grader and ophthalmologist (Belfast Ophthalmic Reading Center). Severity of DR was graded as per the UK National Health Service (NHS) DR classification scale. Result: We report 6.4% and 0.2% prevalence of DR and cataract in Indian children and youth with T1D, respectively. All the subjects with DR had early non-proliferative DR. We report that amongst subjects with DR, only 2 subjects were aged less than 11 years and had duration of illness less than 2 years. Presence of hypertension and older age were significant predictors of DR ( P &lt; .05). Subjects with DR had significantly higher triglyceride concentrations ( P &lt; .05), of these, 6.9% had progression and 2.9% had regression at 1 year follow up; the change in glycaemic control was a significant positive predictor of progression of DR ( P &lt; .05). None of the participants included in the study progressed to develop sight-threatening DR. Conclusion: DR is not uncommon in Indian children and youth with T1D, thus screening for DR needs to be initiated early, particularly in older individuals with higher disease duration. Controlling blood pressure and triglyceride concentrations may prevent occurrence of DR. Improving glycaemic control may prevent progression of DR in Indian children and youth with T1D.

Use of a smartphone-based, non-mydriatic fundus camera for patients with red flag ophthalmic presentations in a rural general practice

Use of a smartphone-based, non-mydriatic fundus camera for patients with red flag ophthalmic presentations in a rural general practice

Health economic evaluation of telemedicine diabetic retinopathy examination using a non-mydriatic fundus camera in China

Objective: To perform a health economic evaluation of telemedicine diabetic retinopathy (DR) examination with a non-mydriatic fundus camera in China and to investigate the optimal examination interval. Methods: Based on 18 peer-reviewed articles related to epidemiology, clinical trial, and health economic evaluation of DR, surveys from 9 ophthalmologists in 3 tertiary hospitals in China, price lists for medical services in each province, and the negotiated price in 2021, a Markov model was conducted to evaluate the cost utility of telemedicine eye examination for diabetes mellitus patients aged 45 and older from the health system perspective. Separate analyses were performed for no examination and for examination intervals of every 1 to 5 years to predict the lifetime health gain, including cumulative days of blindness, cumulative life years, and quality-adjusted life years (QALYs), and costs for unilateral and bilateral direct medication with a 3.5% discount rate. Results: The cumulative days of blindness in the absence of a DR screening were 2 375.00 days, and ranged from 701.00 to 738.00 days for five different DR screening interval programs. The cumulative life years for no screening and five DR screening programs ranged from 27.120 34 to 28.005 00 years, with QALYs ranging from 9.502 96 to 9.875 02. The direct medication costs in the absence of a DR screening program were 72 785.00 yuan for both unilateral and bilateral scenarios. For the five DR screening intervals, the direct medication costs ranged from 52 065.00 to 52 408.00 yuan for unilateral and 79 100.00 to 79 603.00 yuan for bilateral. Comparing the incremental cost-effectiveness ratios between the DR screening intervals and no screening, the 1-to 5-year intervals were dominant in the unilateral scenario (between -56 368.54 and -55 523.75 yuan/QALY). In the bilateral scenario, the ratios ranged from 17 469.07 to 18 325.15 yuan/QALY. Using a willingness-to-pay threshold equal to the per capita GDP (80 976 yuan/QALY), the 1-year DR screening interval had an 85.9% probability of being cost-effective and a 55.2% probability of being dominant in the unilateral scenario. In the bilateral scenario, the 2-year interval held a 61.4% probability of being cost-effective. Conclusions: Analyses on the remote fundus consultation in diabetic patients and health economics based on the Markov model indicate that telemedicine DR examination through a non-mydriatic fundus camera can be effectively employed for diabetes mellitus patients in China. DR examination every two years is recommended for general diabetic patients, and DR examination every year may be chosen in developed areas.

Application of a Deep Learning System to Detect Papilledema on Nonmydriatic Ocular Fundus Photographs in an Emergency Department

The Fundus photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) studies showed that ED providers poorly recognized funduscopic findings in patients in the ED. We tested a modified version of the Brain and Optic Nerve Study Artificial Intelligence (BONSAI) deep learning system on nonmydriatic fundus photographs from the FOTO-ED studies to determine if the deep learning system could have improved the detection of papilledema had it been available to ED providers as a real-time diagnostic aid. Retrospective secondary analysis of a cohort of patients included in the FOTO-ED studies. The testing data set included 1608 photographs obtained from 828 patients in the FOTO-ED studies. Photographs were reclassified according to the optic disc classification system used by the deep learning system ("normal optic discs," "papilledema," and "other optic disc abnormalities"). The system's performance was evaluated by calculating the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity using a 1-vs-rest strategy, with reference to expert neuro-ophthalmologists. The BONSAI deep learning system successfully distinguished normal from abnormal optic discs (AUC 0.92 [95% confidence interval {CI} 0.90-0.93]; sensitivity 75.6% [73.7%-77.5%] and specificity 89.6% [86.3%-92.8%]), and papilledema from normal and others (AUC 0.97 [0.95-0.99]; sensitivity 84.0% [75.0%-92.6%] and specificity 98.9% [98.5%-99.4%]). Six patients with missed papilledema in 1 eye were correctly identified by the deep learning system as having papilledema in the other eye. The BONSAI deep learning system was able to reliably identify papilledema and normal optic discs on nonmydriatic photographs obtained in the FOTO-ED studies. Our deep learning system has excellent potential as a diagnostic aid in EDs and non-ophthalmology clinics equipped with nonmydriatic fundus cameras. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Retinal microvascular complexity as a putative biomarker of biological age: a pilot study.

Physiological changes associated with aging increase the risk for the development of age-related diseases. This increase is non-specific to the type of age-related disease, although each disease develops through a unique pathophysiologic mechanism. People who age at a faster rate develop age-related diseases earlier in their life. They have an older "biological age" compared to their "chronological age". Early detection of individuals with accelerated aging would allow timely intervention to postpone the onset of age-related diseases. This would increase their life expectancy and their length of good quality life. The goal of this study was to investigate whether retinal microvascular complexity could be used as a biomarker of biological age. Retinal images of 68 participants ages ranging from 19 to 82years were collected in an observational cross-sectional study. Twenty of the old participants had age-related diseases such as hypertension, type 2 diabetes, and/or Alzheimer's dementia. The rest of the participants were healthy. Retinal images were captured by a hand-held, non-mydriatic fundus camera and quantification of the microvascular complexity was performed by using Sholl's, box-counting fractal, and lacunarity analysis. In the healthy subjects, increasing chronological age was associated with lower retinal microvascular complexity measured by Sholl's analysis. Decreased box-counting fractal dimension was present in old patients, and this decrease was 2.1 times faster in participants who had age-related diseases (p = 0.047). Retinal microvascular complexity could be a promising new biomarker of biological age. The data from this study is the first of this kind collected in Montenegro. It is freely available for use.

Imaging and qualitative depth analysis with a portable nonmydriatic fundus camera using oblique illumination

The photographic assessment of the optic nerve has been one of the original and most extensively used methods to evaluate patients for glaucoma. The depth evaluation of the optic disc in the retinal fundus is important for the early detection of glaucoma. Conventional fundus cameras have a limited field-of-view for imaging of the retina and its peripheral areas. In this article, we report the design and fabrication of a non-mydriatic wide-field fundus camera using a contact-free trans-scleral illumination that is capable of taking 3D images of the optic disc using oblique illumination. We demonstrate that, using oblique illumination through sclera, a quasi 3D image of the optic disc along with its shadow can be obtained. The shadow provides important information on the shape and depth of the optic disc. The depth values of the optic disc obtained by our proposed method using shadow length measurements are in good agreement with the values obtained using an optical coherence tomography device. The results indicate that our fabricated fundus camera could be an easy-to-handle and low-cost tool for remote detection and diagnosis of ocular diseases without the need of an ophthalmologist.