Nonmydriatic Fundus Photography Research Articles

Association between spousal diabetes status and diabetic retinopathy in Chinese patients with type 2 diabetes.

To evaluate the association between spousal diabetes status and the prevalence of diabetic retinopathy in Chinese patients with type 2 diabetes. A cross-sectional community-based study was performed in 1510 patients with type 2 diabetes in Shanghai, China. Non-mydriatic digital fundus photography was used to detect diabetic retinopathy. Spousal diabetes status was assessed using a standardised interview questionnaire. The prevalence of diabetic retinopathy was significantly lower in patients who had diabetic spouses, compared with those who did not (20.2% vs 29.1%, p ⩽ 0.01). The fully adjusted odds ratio for diabetic retinopathy in those had diabetic spouses was decreased by 36% (odds ratio = 0.64, 95% confidence interval = 0.42-1.00, p = 0.048). The negative correlation between spousal diabetes status and diabetic retinopathy was presented in patients with the duration of diabetes ⩾ 10 years, those with HbA1c ⩾ 7% and those not using lipid-lowering drugs (odds ratio = 0.31, 95% confidence interval = 0.13-0.74, p = 0.0082; odds ratio = 0.50, 95% confidence interval = 0.27-0.94, p = 0.031; odds ratio = 0.58, 95% confidence interval = 0.37-0.92, p = 0.021, respectively). We demonstrated that spousal diabetes was associated with a lower diabetic retinopathy prevalence in Chinese patients with type 2 diabetes.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Intraocular Pressure Measurements Found in a Population at High Risk for Glaucoma.

Intraocular pressure (IOP) measurements, when used during telemedicine eye screening alongside nonmydriatic fundus photography, were shown to improve the likelihood of accurate glaucoma and glaucoma-related diagnoses at the follow-up eye examination. To determine if IOP measurements, used as an adjunct to nonmydriatic fundus photography, are useful in glaucoma telemedicine screening. A total of 902 high-risk individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening at visit 1 included fundus photography, assessing family history of glaucoma, and IOP measurements using a hand-held rebound tonometer. Participants with suspicious nerve findings for glaucoma, IOP>21 mm Hg or other ocular pathologies were invited for a follow-up appointment with an ophthalmologist (visit 2). Of the 902 individuals screened at visit 1, 19.6% (n=177/902) had elevated IOP (>21 mm Hg). Fifteen participants were found to have an IOP>30 mm Hg at visit 1, including 2 with an IOP of >40 mm Hg. Among all who attended visit 2 (n=347), 10.9% had glaucoma and 7.2% had ocular hypertension. For participants having both suspicious nerve findings and IOP>21 mm Hg compared with those with neither, the odds ratio (OR) of being diagnosed with glaucoma was 4.48 (95% CI, 1.50-13.93; P=0.007), whereas for participants with suspicious discs and IOP≤21 mm Hg the OR was 2.04 (95% CI, 0.83-5.53; P=0.15). In this telemedicine vision screening setting, having a higher IOP at the screening visit increased the likelihood of receiving a final diagnosis of glaucoma. Therefore, this study supports incorporating IOP measurements, using a portable tonometer, into vision screening programs in high-risk populations.

Awareness of Age-Related Macular Degeneration in Community-Dwelling Elderly Persons in Germany

ABSTRACTBackground: Due to current demographic trends age-related macular degeneration (AMD) is becoming more prevalent. When disease progresses to late-stage neovascular AMD, rapid initiation of treatment is required to achieve optimal outcomes. However, many affected individuals may be unaware of their disease impeding and delaying care seeking. Therefore, in an exploratory study we assessed whether elderly persons living independently in the community were aware of their AMD.Methods: Participants were recruited in eleven seniors’ community centers. Participants underwent a standardized interview followed by non-mydriatic fundus photography of the macula and the optic disc in both eyes (Canon CR-2AF, Canon, New York, USA). The images were graded by an ophthalmologist and the data were analyzed descriptively.Results: A total of 281 participants (73.9 ± 8.1 years; 71.9% women) underwent bilateral fundus photography. The fundus photographs of 208 participants (74%; 73.6 ± 7.0 years; 73.1% women) could be graded. In a third (32.2%, n = 67) no pathological changes were detected. AMD was present in 24.5% of the examined subjects (n = 51). Half of the cases had early (47.1%), followed by intermediate (41.2%) and late (11.7%) AMD. Only one third (n = 16, 31.4%) were aware of their disease.Conclusions: A quarter of community dwelling elderly had AMD but only a third of these were aware of being affected with AMD. This confirms previous studies demonstrating low awareness for age-related eye diseases in the community. Considering the increase in population aging, awareness campaigns for AMD are needed.

Dépistage de la rétinopathie diabétique par rétinographie non mydriatique : première campagne nationale au Liban

Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Non-mydriatic fundus photography (NMFP) has been adopted as a screening tool for this disease. We aim to determine the prevalence of DR through this method in Lebanese diabetic patients and to evaluate the impact of such screening in this population. This study explores data from an awareness and screening campaign conducted in Lebanon. Diabetic patients from multiple regions were referred by their endocrinologists to undergo NMFP using the Optomed SmartScope® handheld fundus camera. Photographs were interpreted by a remote observer, and recommendations were given accordingly. The prevalence of DR was calculated, and statistical analyses were performed on the clinical characteristics, fundus findings and number of referrals to ophthalmologists. The campaign lasted 11 months, during which 2205 patients were examined in 37 screening locations. Out of the 97.41% of patients with type 2 diabetes mellitus, 12.56% had signs of DR, with no significant difference between the regions. 6.28% of the photos were uninterpretable. Positive results were associated with a longer duration of diabetes (P<0.01), treatment with insulin (P<0.01), as well as the presence and chronicity of systemic hypertension (P=0.01). 25% of patients with positive testing were retrospectively asked about their follow-up; only one third had an ophthalmologic examination as per the recommendation, among whom 68.18% underwent treatment for proliferative DR and/or diabetic macular edema. Tele-ophthalmology is useful in mass screening for DR. The importance of dilated fundus examinations still needs to be highlighted for diabetic patients, and better collaboration between endocrinologists and ophthalmologists is required to improve screening outcomes.

Dépistage de la rétinopathie diabétique par télétransmission de photographies du fond d’œil : évaluation et aspects épidémiologiques au CHU de Nantes

The goal of our study was to evaluate the results of screening for diabetic retinopathy using the non-mydriatic fundus camera combined with telemedicine in the university hospital of Nantes. This is a retrospective study of all diabetic patients hospitalized in the endocrinology department between June and September 2016 inclusive. The photos were taken by a nurse if the patient had an indication for screening as determined by the attending physician. The ophthalmologist then provided a written interpretation of the photos on a consultant's sheet. Quality control with re-reading of a sample of the photos was performed. A total of 442 patients (48% females, 52% males) were studied. 227 patients (51.3%) had undergone an eye examination within the previous year. 160 patients (36.2%) were screened with fundus photography. Fundus photography of at least one eye could not be graded in 10 patients (6.3%). Diabetic retinopathy was detected in 27 patients (16.9%) and diabetic maculopathy in 5 patients. Longer duration of diabetes and the presence of microalbuminuria were significantly associated with incidence of retinopathy. The double reading of 26% of the photos found a 93% of concordance between the 2 readers. Referral to an ophthalmologist was required in 32 patients (20%), of whom 27 were rescheduled at the university hospital, for unreadable photographs, diabetic retinopathy or concomitant eye disease. 38.5% of rescheduled patients did not come to the appointment. Non-mydriatic fundus photography combined with telemedicine is attractive for diabetic retinopathy screening and identifies patients requiring further eye examination. In our study, it obviated the need for an ophthalmologic examination in 8 out of 10 cases. It is important to continue to educate patients about the necessity of regular eye examinations and post-screening follow-up.

Comparison of glaucoma patients referred by glaucoma screening versus referral from primary eye clinic

PurposeTo investigate whether mass glaucoma screening relative to opportunistic case finding at a primary eye clinic is helpful for early detection of glaucoma.MethodsSubjects referred by glaucoma screening (by non-contact tonometry and non-mydriatic fundus photography; group A, n = 220) and from a primary eye clinic (group B, n = 327) were retrospectively recruited. The positive predictive value (PPV) for glaucoma and the rate of glaucoma awareness were compared. Also, for the newly diagnosed glaucoma (‘definite glaucoma’) patients, the demographics and structural and functional severities of glaucoma were compared.ResultsThe PPV for definite glaucoma was 25.5% for group A and 52.4% for group B. The rate of false-positive for ‘glaucoma referral to tertiary hospital’ was significantly higher for group A than for group B (38.6 vs. 18.3%, P < 0.001). Among the definite-glaucoma patients (group A: n = 56; group B: n = 182), the proportion of glaucoma awareness was significantly higher in group B (69.2%) than in group A (8.9%, P < 0.001). The mean deviation (MD) of visual field (VF) was significantly higher in group A than in group B (–3.08 ± 3.99 vs. –6.70 ± 7.29 dB, Padjusted = 0.040), and the inferior and inferotemporal ganglion cell-inner plexiform layer (GCIPL) thicknesses tended to be greater in group A than in group B, with marginal significance (Padjusted < 0.10).ConclusionsGlaucoma screening can be helpful for early detection of glaucoma. However, improvement of the screening strategy is needed in order to enhance its specificity for glaucoma.

Accuracy of Detection and Grading of Diabetic Retinopathy and Diabetic Macular Edema Using Teleretinal Screening

To determine the accuracy of a county teleretinal screening program of detecting referable diabetic retinopathy (DR) and treatable diabetic macular edema (DME), as well as to evaluate patient compliance with clinic follow-up after referral from teleretinal screening. Retrospective observational study. Patients in the Harris Health System (HHS, Houston, TX) older than 18 years of age who underwent teleretinal screening between July 2014 and July2016. Teleretinal imaging (TRI) consisting of single-field 45-degree nonmydriatic color fundus photography with referral thresholds of severe nonproliferative DR, proliferative DR, and significant DME. Teleretinal imaging results for all referred subjects were obtained and cross-referenced with dilated fundus examination findings with regard to DR severity and the presence of DME. Follow-up status was also noted. Subjects underwent OCT if deemed necessary by the examining specialist. Agreement between TRI and dilated fundus examination (DFE) findings was determined by calculating the Cohen κ coefficient. The primary outcome measure is agreement between TRI results and DFE findings with regard to DR severity and the presence of DME. The secondary outcome measure is compliance with follow-up. Of 1767 patients who were screened and referred for clinical examination, 935 (52.9%) attended their clinic appointment. Overall agreement between DFE and TRI was moderate (weighted κ 0.45) in terms of DR severity. There was agreement within one DR severity level in 86.2% of patients. The positive predictive value for detecting referable disease was 71.3%. Of patients referred for DME, 30.4% were deemed to have treatable DME. The HHS teleretinal screening program demonstrates a high level of accuracy in the detection and classification of referable DR, but a lesser degree of accuracy in the detection of treatable DME. Only slightly more than half of participants were compliant with follow-up after a TRI referral. This large-scale study provides insight into the utility of teleretinal screening in a county health care system.

Nonmydriatic Fundus Photography in Patients with Acute Vision Loss.

Background:Acute visual loss is a common chief complaint in emergency department (ED) patients, but the scarcity of ophthalmologists in most EDs limits its evaluation.Introduction:Our objective was to evaluate whether nonmydriatic fundus photography (NMFP) in the ED helps triage patients with acute visual loss.Materials and Methods:We included 213 patients with acute visual loss evaluated in the ED with NMFP as part of the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED studies. Demographics, referral patterns, results of NMFP, and final diagnoses were recorded.Results:A final ophthalmological diagnosis was made in 109/213 (51%) patients. NMFP allowed a definite diagnosis in 51/109 (47%) patients: 14 nonglaucomatous optic neuropathies, 10 papilledema, 13 acute retinal ischemia, 2 retinal detachments, 2 choroidal metastases, 4 maculopathies, and 6 glaucoma. In 58/109 (53%) patients, NMFP was not diagnostic even when interpreted remotely by ophthalmologists due to disorders undiagnosable with NMFP. Ophthalmology consultation was requested in 109/213 (51%) patients, 41/54 (76%) patients with abnormal NMFP versus 68/159 (43%) patients with normal NMPF (p < 0.001).Discussion:Although NMFP allowed rapid diagnosis in 51/213 (24%) patients presenting to the ED with acute visual loss, NMFP alone was not sufficient to detect all ocular diseases; ophthalmology consultation was more often requested when NMFP was abnormal.Conclusions:Our study emphasizes the limitations of teleophthalmology with NMFP in remotely detecting ocular diseases related to acute visual loss in the ED. NMFP helped triage and referral decisions and can be used to complement ophthalmology consultations in the ED.

Use of Telehealth Screening to Detect Diabetic Retinopathy and Other Ocular Findings in Primary Care Settings.

Purpose: To determine the incidence of diabetic retinopathy (DR) and other ocular findings in previously diagnosed diabetes using telehealth retinal screening with nonmydriatic fundus photography (nFP) in primary care physicians' offices.Methods: A retrospective study based on electronic chart review was performed. All diabetic patients who participated in the Wills Eye Hospital (WEH) telehealth retinal screening program from July 1, 2012 to February 20, 2017 were included. In addition to evaluation of DR, other eye pathologies of the retina were detected using nFP.Results: Overall, 9,946 diabetics participated in the WEH telehealth screening system. After exclusion of missing or unreadable images, 15,180 eyes of 7,624 (76.7%) patients were eligible for final analysis. A total of 1,269 (16.6%) patients were noted to have DR changes in at least one eye. Of those, 475 (37.4%) had mild nonproliferative DR (NPDR) in the more severely affected eye, 712 (56.1%) had moderate NPDR, 33 (2.6%) had severe NPDR, 19 (1.5%) had proliferative DR, and 30 (2.4%) have received pan-retinal photocoagulation previously. In addition, there was evidence of diabetic macular edema detectable on nFP in 34 eyes of 29 patients. Other ocular findings included hypertensive retinopathy (709, 9.3%), increased or asymmetric cup-to-disc ratio (562, 7.4%), age-related cataract (379, 5.0%), cotton-wool spots (221, 2.9%), choroidal nevus (74, 1.0%), age-related macular degeneration (AMD) (66, 0.9%), and epiretinal membrane (48, 0.6%). Patients with hypertensive retinopathy, glaucomatous findings, cataract, or AMD were significantly older (p < 0.001) than those without these ocular pathologies.Conclusion: The WEH Telehealth Screening Program identified DR in approximately one out of six patients and other ocular pathologies in over 25% of the diabetic population that received screenings in Philadelphia area primary care offices. Given the importance of early detection and routine eye care to prevent vision loss for DR patients, these findings have a significant impact.

Advances in Retinal Imaging and Applications in Diabetic Retinopathy Screening: A Review.

Rising prevalence of diabetes worldwide has necessitated the implementation of population-based diabetic retinopathy (DR) screening programs that can perform retinal imaging and interpretation for extremely large patient cohorts in a rapid and sensitive manner while minimizing inappropriate referrals to retina specialists. While most current screening programs employ mydriatic or nonmydriatic color fundus photography and trained image graders to identify referable DR, new imaging modalities offer significant improvements in diagnostic accuracy, throughput, and affordability. Smartphone-based fundus photography, macular optical coherence tomography, ultrawide-field imaging, and artificial intelligence-based image reading address limitations of current approaches and will likely become necessary as DR becomes more prevalent. Here we review current trends in imaging for DR screening and emerging technologies that show potential for improving upon current screening approaches.

Association Between Folic Acid Supplementation and Retinal Atherosclerosis in Chinese Adults With Hypertension Complicated by Diabetes Mellitus.

Background: This cross-section investigation included 2,199 participants with hypertension complicated by diabetes mellitus, a cohort of the China Stroke Primary Prevention Trial in which 20,702 patients with essential hypertension were given enalapril with folic acid or enalapril-only double-blind treatment for 5 years. This study aimed to explore the correlation between folic acid supplementation and retinal atherosclerosis (RA) in adults with hypertension complicated by diabetes mellitus.Methods: The diagnosis of RA was determined by non-mydriatic fundus photography and classified by the Keith-Wagener-Barker system. The statistical correlation of folic acid supplementation with RA prevalence and severity was assessed.Results: Of our cohort, 1,698 (77.6%) participants were diagnosed with RA, and the prevalence in males and females was 78.0 and 75.6%, respectively. Participants in the enalapril group had higher total homocysteine (tHcy) levels than those in enalapril–folic acid group. Compared with the enalapril group in the tHcy > 15 μmol/L group of females, the odds ratio for the enalapril–folic acid group was 0.28 (95% confidence interval, 0.11–0.67, P = 0.0061).Conclusions: The prevalence of RA was high (77.6%) in our cohort of adults with hypertension complicated by diabetes mellitus. Folic acid supplementation was significantly associated with reduced risk of RA in females with hyperhomocysteinemia. No significant association were seen in males.

Feasibility of the Digital Retinography System Camera in the Pediatric Emergency Department.

Direct ophthalmoscopy may be difficult without pupillary dilation and patient cooperation. Nonmydriatic ocular fundus photography (NMOFP) has been shown to be easily and efficiently accomplished by medical providers and improve the detection of abnormalities in adult emergency department (ED) patients. Nonmydriatic ocular fundus photography for pediatric ED patients has not been studied. The purpose of this study was to assess the ease of use of the Digital Retinography System (DRS) camera for NMOFP in ED patients aged 5 to 12 years and the quality of retinal images obtained with the DRS. Retinal images were obtained with the DRS by a pediatric emergency medicine physician using a convenience sample of ED patients aged 5 to 12 years. Time to procedure completion, patient cooperation (Likert scale 1-5, with 5 being most cooperative), and satisfaction with the images (Likert scale 1-5, with 5 being completely satisfied) were recorded. Any satisfaction score less than 5 required the physician to describe a reason for dissatisfaction (brightness, field of view, focus). An ophthalmologist was consulted regarding any abnormal image. The accompanying parent completed a survey following the procedure. Estimated time to completion of the procedure and a rating of the overall comfort and cooperation of the child during the procedure (Likert scale 1-5) were recorded. A second pediatric emergency medicine physician reviewed all images and rated the level of satisfaction, reasons for dissatisfaction, and whether the images were normal. Descriptive statistics were used to analyze survey responses. A Mann-Whitney U test was used to compare continuous data for age groups 5 to 8 and 9 to 12 years. A Krippendorff α or κ coefficient was used to measure agreement between the physician obtaining the images and the secondary reviewer for image satisfaction and image abnormalities. One hundred three patients were enrolled: 50 aged 5 to 8 years and 53 aged 9-12 years (mean, 9.1 [SD, 2.1] years). Five patients failed to cooperate, and no images were obtained. The mean length of time (LOT) to procedure completion was 1.8 (SD, 0.86) minutes. Overall, mean cooperation score was 4.4, and mean image satisfaction score was 4.6. One or more reasons for image dissatisfaction were given in 27 patients (imperfect focus most commonly). There was moderate agreement between the 2 physicians for image satisfaction (Krippendorff α coefficient = 0.48) and image abnormalities (κ coefficient = 0.38). Mean LOT did not differ between 5- to 8-year-olds and 9- to 12-year-olds (P = 0.23). Older patients had higher mean cooperation scores and image satisfaction scores (P < 0.001 and P = 0.04 respectively). Parental mean score for perceived LOT was 4.6 (5 = very short), 4.8 for patient comfort (5 = very comfortable), and 4.8 for patient cooperation (5 = very cooperative). Our data suggest that NMOFP using the DRS camera is a rapid and easy method of obtaining high-quality images of the retina in pediatric ED patients.

Near-infrared light-guided miniaturized indirect ophthalmoscopy for nonmydriatic wide-field fundus photography.

A portable fundus imager is essential for emerging telemedicine screening and point-of-care examination of eye diseases. However, existing portable fundus cameras have limited field of view (FOV) and frequently require pupillary dilation. We report here a miniaturized indirect ophthalmoscopy-based nonmydriatic fundus camera with a snapshot FOV up to 67° external angle, which corresponds to a 101° eye angle. The wide-field fundus camera consists of a near-infrared light source (LS) for retinal guidance and a white LS for color retinal imaging. By incorporating digital image registration and glare elimination methods, a dual-image acquisition approach was used to achieve reflection artifact-free fundus photography.

Prevalence of glaucoma in the Australian National Eye Health Survey

AimTo estimate the prevalence of glaucoma in Australia.MethodsThis was a population-based study of 3098 non-Indigenous Australians (50–98 years) and 1738 Indigenous Australians (40–92 years) stratified by remoteness. Each participant underwent...

Feasibility and patient acceptability of a novel artificial intelligence-based screening model for diabetic retinopathy at endocrinology outpatient services: a pilot study

The purpose of this study is to evaluate the feasibility and patient acceptability of a novel artificial intelligence (AI)-based diabetic retinopathy (DR) screening model within endocrinology outpatient settings. Adults with diabetes were recruited from two urban endocrinology outpatient clinics and single-field, non-mydriatic fundus photographs were taken and graded for referable DR ( ≥ pre-proliferative DR). Each participant underwent; (1) automated screening model; where a deep learning algorithm (DLA) provided real-time reporting of results; and (2) manual model where retinal images were transferred to a retinal grading centre and manual grading outcomes were distributed to the patient within 2 weeks of assessment. Participants completed a questionnaire on the day of examination and 1-month following assessment to determine overall satisfaction and the preferred model of care. In total, 96 participants were screened for DR and the mean assessment time for automated screening was 6.9 minutes. Ninety-six percent of participants reported that they were either satisfied or very satisfied with the automated screening model and 78% reported that they preferred the automated model over manual. The sensitivity and specificity of the DLA for correct referral was 92.3% and 93.7%, respectively. AI-based DR screening in endocrinology outpatient settings appears to be feasible and well accepted by patients.

Diabetic retinopathy screening programme utilising non-mydriatic fundus imaging in slum populations of New Delhi, India.

To develop and implement a community-based programme for screening of diabetic retinopathy (DR) in urban populations of Delhi. Known diabetics (KDs) aged 40 years and older were identified through house-to-house surveys, volunteers and publicity. All KDs were referred to DR screening camps organised locally where procedures included brief medical history, ocular examination and non-mydriatic fundus photography using portable handheld camera. Fundal images were graded on the spot by trained optometrists for DR. Patients with DR were referred to tertiary centre for management. A total of 11 566 KDs were identified, of whom 9435 (81.6%) visited DR screening camps and 8432 (89.4%) had DR gradable images. DR was identified in 13.5% of subjects; 351 cases were mild NPDR, 567 moderate, 92 severe. Seventy-seven had PDR, and 49 had DME, and 2.7% of participants were blind (presenting visual acuity <3/60 in better eye). Non-use of lifestyle management, presence of systemic complications, BMI <18.5 kg/m2 , disease duration of >5 years and uncontrolled diabetes were associated with increased odds of DR. All cases with DR were referred, and 420 (37%) successful referrals to base hospital were observed. The programme of creating awareness about DR, identifying KDs and optometrist-led DR screening using non-mydriatic fundus camera based in slums was successful.

Reliability and reproducibility of disc-foveal angle measurements by non-mydriatic fundus photography.

PurposeAbnormal torsion could be associated with cyclovertical strabismus, but torsion measurements are not reliable in children. To assess an objective fundus torsion evaluation in a paediatric population, we used Non-Mydriatic Fundus photography (NMFP) in healthy and cyclovertical strabismus patients to evaluate the disc-foveal angle over time and observers.MethodsWe used a retrospective set of NMFP including 24 A or V-pattern strabismus and 27 age-matched normal children (mean age 6.4 and 6.7 years respectively), taken during 2 distinct follow-up consultations (separated by 251 and 479 days respectively). Each disc-foveal angle measurement (from which the ocular torsion can be assessed) was performed by 5 different observers, using graphical software and based on reproducible fundus anatomical marks. Statistical analysis was performed with a multivariate ANOVA using group, time and observers as factors, in addition to intraclass coefficient correlation (ICC) to assess measurement reproducibility.ResultsA significant difference of disc-foveal angle measures was observed between groups (p<0,001): 18.73° (SD = 6.42), -3,25° (SD = 5.51) and 6,89° (SD = 4,41) respectively for V-pattern, A- pattern and normal subjects. Neither observers (F = 0,2028 p = 0,9369) nor time between 1st and 2nd NMFP (F = 0,6312 p = 0,4271) seem to influence the measure of disc-foveal angle. The evaluation of disc-foveal angle was very reproducible between observers (ICC>0,97).ConclusionAbnormal amount of objective torsion could be associated with alphabet-pattern strabismus. Disc-foveal angle evaluation by NMFP in a children population appears as a non-invasive, reliable and reproducible method.

Analysis of yield of retinal imaging in a rural diabetes eye care model.

Purpose:The aim of this study is to analyze the yield of retinal images obtained in a rural diabetes eye care model.Methods:An analysis of a sample of nonmydriatic fundus photography (NMFP) of posterior segment ophthalmic images, obtained by an indigenous equipment (3 nethra-Forus Royal), was done in a district-wide rural diabetic retinopathy (DR) screening program; a trained optometrist did the initial image grading. DR and diabetic macular edema (DME) were classified based on international DR and DME severity scale. The agreement between the optometrist and retina specialist was very good (κ = 0.932; standard error = 0.030; 95% confidence interval = 0.874–0.991).Results:Posterior segment images of 2000 eyes of 1000 people with diabetes mellitus (DM) were graded. The mean age of the participants was 55.7 ± 11.5 standard deviation years. Nearly 42% of the screened participants (n = 420/1000) needed referral. The most common referable posterior segment abnormality was DR (8.2%). The proportion of people with any form of DR was seen in 110/1225 eyes, and sight-threatening DR was seen in 35/1225 eyes. About 62% of posterior segment images were gradable. The reasons for ungradable posterior segment images (34%) were small pupil, unfocused/partially available field of images, and cataract.Conclusion:A NMFP model was able to detect referable posterior segment abnormalities in a rural diabetes eye care program. Reasons found for ungradability of images in the present study can be addressed while designing future DR screening programs in the rural areas.

Sensitivity and specificity of automated analysis of single-field non-mydriatic fundus photographs by Bosch DR Algorithm-Comparison with mydriatic fundus photography (ETDRS) for screening in undiagnosed diabetic retinopathy.

Diabetic retinopathy (DR) is a leading cause of blindness among working-age adults. Early diagnosis through effective screening programs is likely to improve vision outcomes. The ETDRS seven-standard-field 35-mm stereoscopic color retinal imaging (ETDRS) of the dilated eye is elaborate and requires mydriasis, and is unsuitable for screening. We evaluated an image analysis application for the automated diagnosis of DR from non-mydriatic single-field images. Patients suffering from diabetes for at least 5 years were included if they were 18 years or older. Patients already diagnosed with DR were excluded. Physiologic mydriasis was achieved by placing the subjects in a dark room. Images were captured using a Bosch Mobile Eye Care fundus camera. The images were analyzed by the Retinal Imaging Bosch DR Algorithm for the diagnosis of DR. All subjects also subsequently underwent pharmacological mydriasis and ETDRS imaging. Non-mydriatic and mydriatic images were read by ophthalmologists. The ETDRS readings were used as the gold standard for calculating the sensitivity and specificity for the software. 564 consecutive subjects (1128 eyes) were recruited from six centers in India. Each subject was evaluated at a single outpatient visit. Forty-four of 1128 images (3.9%) could not be read by the algorithm, and were categorized as inconclusive. In four subjects, neither eye provided an acceptable image: these four subjects were excluded from the analysis. This left 560 subjects for analysis (1084 eyes). The algorithm correctly diagnosed 531 of 560 cases. The sensitivity, specificity, and positive and negative predictive values were 91%, 97%, 94%, and 95% respectively. The Bosch DR Algorithm shows favorable sensitivity and specificity in diagnosing DR from non-mydriatic images, and can greatly simplify screening for DR. This also has major implications for telemedicine in the use of screening for retinopathy in patients with diabetes mellitus.

Ophthalmoscopy in the 21st century

Although the usefulness of viewing the ocular fundus is well-recognized, ophthalmoscopy is infrequently and poorly performed by most nonophthalmologist physicians, including neurologists. Barriers to the practice of ophthalmoscopy by nonophthalmologists include not only the technical difficulty related to direct ophthalmoscopy, but also lack of adequate training and discouragement by preceptors. Recent studies have shown that digital retinal fundus photographs with electronic transmission and remote interpretation of images by an ophthalmologist are an efficient and reliable way to allow examination of the ocular fundus in patients with systemic disorders such as diabetes mellitus. Ocular fundus photographs obtained without pharmacologic dilation of the pupil using nonmydriatic fundus cameras could be of great value in emergency departments (EDs) and neurologic settings. The Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study showed that ED providers consistently failed to correctly identify relevant ocular funduscopic findings using the direct ophthalmoscope, and that nonmydriatic fundus photography was an effective alternate way of providing access to the ocular fundus in the ED. Extrapolating these results to headache clinics, outpatient neurology clinics, and adult and pediatric primary care settings seems self-evident. As technology advances, nonmydriatic ocular fundus imaging systems will be of higher quality and more portable and affordable, thereby circumventing the need to master the use of the ophthalmoscope. Visualizing the ocular fundus is more important than the method used. Ocular fundus photography facilitates nonophthalmologists' performance of this essential part of the physical examination, thus helping to reestablish the value of doing so.