Nonmydriatic Fundus Photography Research Articles

Portable widefield fundus camera with high dynamic range imaging capability.

Fundus photography is indispensable for the clinical detection and management of eye diseases. Low image contrast and small field of view (FOV) are common limitations of conventional fundus photography, making it difficult to detect subtle abnormalities at the early stages of eye diseases. Further improvements in image contrast and FOV coverage are important for early disease detection and reliable treatment assessment. We report here a portable, wide FOV fundus camera with high dynamic range (HDR) imaging capability. Miniaturized indirect ophthalmoscopy illumination was employed to achieve the portable design for nonmydriatic, widefield fundus photography. Orthogonal polarization control was used to eliminate illumination reflectance artifacts. With independent power controls, three fundus images were sequentially acquired and fused to achieve HDR function for local image contrast enhancement. A 101° eye-angle (67° visual-angle) snapshot FOV was achieved for nonmydriatic fundus photography. The effective FOV was readily expanded up to 190° eye-angle (134° visual-angle) with the aid of a fixation target without the need for pharmacologic pupillary dilation. The effectiveness of HDR imaging was validated with both normal healthy and pathologic eyes, compared to a conventional fundus camera.

OTRE: Where Optimal Transport Guided Unpaired Image-to-Image Translation Meets Regularization by Enhancing.

Non-mydriatic retinal color fundus photography (CFP) is widely available due to the advantage of not requiring pupillary dilation, however, is prone to poor quality due to operators, systemic imperfections, or patient-related causes. Optimal retinal image quality is mandated for accurate medical diagnoses and automated analyses. Herein, we leveraged the Optimal Transport (OT) theory to propose an unpaired image-to-image translation scheme for mapping low-quality retinal CFPs to high-quality counterparts. Furthermore, to improve the flexibility, robustness, and applicability of our image enhancement pipeline in the clinical practice, we generalized a state-of-the-art model-based image reconstruction method, regularization by denoising, by plugging in priors learned by our OT-guided image-to-image translation network. We named it as regularization by enhancing (RE). We validated the integrated framework, OTRE, on three publicly available retinal image datasets by assessing the quality after enhancement and their performance on various downstream tasks, including diabetic retinopathy grading, vessel segmentation, and diabetic lesion segmentation. The experimental results demonstrated the superiority of our proposed framework over some state-of-the-art unsupervised competitors and a state-of-the-art supervised method.

Detecting eyes with high risk of angle closure among apparently normal eyes by anterior segment OCT: a health examination center-based model

BackgroundThe main barriers keeping individuals with high-risk of angle closure from seeking eye-care service are the absence of both disease awareness and convenient and low-cost access to the ocular health care system. Present study described the efficacy of a health examination center-based screening model designed to detect eyes with high risk of angle closure (HRAC) among healthy individuals using anterior segment optical coherence tomography (AS-OCT).MethodsFrom March 1 to April 30, 2017, consecutive individuals aged ≥ 40 years undergoing routine physical examinations at a health examination center were invited to enroll. Presenting visual acuity (PVA), intraocular pressure (IOP) measurement, non-mydriatic fundus photography and AS-OCT were performed by three trained nurses. Participants with PVA < 6/12 in the better-seeing eye, IOP ≥ 24 mmHg, or abnormal fundus photography in either eye were referred to the outpatient clinic, but not included in the analysis. Eyes with HRAC were defined as having trabecular-iris angle < 12 degrees in ≥ 3 quadrants. Configuration of the iris was classified into flat, bowing, bombe, thick peripheral iris and mixed mechanism.ResultsAltogether, 991 participants (77.3%) with readable OCT images (mean age 55.5 ± 9.0 years; 58.4% men) were included. HRAC was diagnosed in 78 eyes (7.9%, 61.3 ± 8.2 years, 41.0% men). The prevalence of HRAC increased with age (p < 0.001) and was much higher among women (11.2%) than men (5.5%) (p = 0.001). The mixed mechanism iris configuration was most common among eyes with HRAC (37/78, 47.4%).ConclusionHRAC is prevalent among asymptomatic Chinese adults undergoing routine health screening. Health examination center-based eye screening with AS-OCT administered by non-specialists may be a good model to screen narrow angles in the population at large.

Valérie Biousse: a leader in neuro-ophthalmology

Valérie Biousse: a leader in neuro-ophthalmology

Diabetic Retinopathy Telemedicine Outcomes With Artificial Intelligence-Based Image Analysis, Reflex Dilation, and Image Overread

To examine real-world telemedicine outcomes of diabetic retinopathy (DR) screening with artificial intelligence (AI)-based image analysis, reflex dilation, and secondary image overread in a primary care setting. Validity and reliability analysis. Single institution review of 1052 consecutive adult patients who received diabetic retinopathy photoscreening in the primary care setting over an 18-month period. Nonmydriatic fundus photographs were acquired and analyzed by the IDx-DR AI-based system. When nonmydriatic images were ungradable, reflex dilation (1% tropicamide) and mydriatic photography were performed for repeat AI-based analysis. Manual overread was performed on all images. Patient demographics, clinical characteristics, and screening outcomes were recorded. A total of 965 of 1052 patients (91.7%) had AI-gradable fundus photographs: 580 had gradable nonmydriatic imaging (55.1%) and 440 of 472 patients with ungradable nonmydriatic photographs had reflex dilation (93.2%). One hundred thirty-eight of 965 patients (14.3%) were AI-graded as "positive" (greater than mild NPDR) and 827 of 965 were "negative" (85.7%), with 100% sensitivity (95% CI 90.8-100%), 89.2% specificity (95% CI 87.0-91.1%), 27.5% positive predictive value (95% CI 24.0-31.4%), and 100% negative predictive value (95% CI 99.6-100%) compared with manual overread assessment of greater than mild NPDR requiring further evaluation with a comprehensive dilated examination. Image gradeability was inversely related to patient age: 93.5% gradable (61.9% nonmydriatic) for patients aged <70 years vs 85.3% (31.0% nonmydriatic) for patients aged 70+ years (P < .001). Incorporation of AI-based image analysis into real-world primary care diabetic retinopathy screening yielded no false negative results and offered excellent image gradeability within a protocol combining nonmydriatic fundus photography and pharmacologic dilation, as needed. Image gradeability was lower with increasing patient age.

Comparison of Non-mydriatic Fundus Photography and Optical Coherence Tomography with Dilated Fundus Examination for Detecting Diabetic Retinopathy Including Diabetic Macular Edema

Given increasing diabetes rates worldwide, better screening tools for diabetic retinopathy (DR) and macular edema (DME) are needed. The study aim was to compare reliability and predictive values between non-mydriatic fundus photography (NMFP) and spectral-domain optical coherence tomography (OCT) for detection of DR and DME with dilated fundus examination (DFE). This was a non-interventional, comparative study. Diabetics underwent both NMFP and macula OCT, followed by DFE. Images were interpreted by two masked ophthalmologists. The DFE result was considered gold standard. One hundred and fifty-four eyes of 83 patients were recruited. Sensitivity of NMFP for DR was 77.3% and 80.3% for OCT. Specificity for NMFP was 81.8% and 55.7% for OCT. Area under Receiver Operating Characteristics Curve (AROC) for DR was 0.80 for NMFP and 0.68 for OCT. The sensitivity of NMFP for DME was 63.2% and 82.5% for OCT. Specificity for DME was 90.1% by NMFP and 61.5% for OCT. Positive predictive value (PPV) of NMFP and OCT for DR was 76.1% (95% CI: 63.9-85.3%) and 57.6% (46.8-67.7%), respectively. Negative predictive value (NPV) of NMFP and OCT was 82.7% (95% CI: 72.8-89.7%) and 79.0% (66.4-87.9%) respectively. Positive predictive value of NMFP and OCT for DME was 80.0% (95% CI: 67.6- 88.5%) and 57.3% (45.9-68.0%), respectively. Negative predictive value of NMFP and OCT was 79.6% (95% CI:70.3 - 86.7%) and 84.8% (95% CI:73.4 - 92.1%), respectively. Eyes with normal OCT miss 21% of DR. In conclusion, NMFP is better than OCT for DR screening, while OCT is better than NMFP and DFE for detection of DME. Both modalities should be for better DR screening.

Opportunistic Eye Screening Among First-Degree Relatives of Glaucoma Patients at a Suburban Tertiary Center in Malaysia.

Background and objectiveThe majority of glaucoma patients are asymptomatic and are usually diagnosed at an advanced stage of the disease. This study aimed to assess the outcomes of glaucoma screening among known first-degree relatives of primary glaucoma patients.Materials and methodsThis study involved primary angle-closure glaucoma (PACG), primary open-angle glaucoma (POAG), and juvenile open-angle glaucoma (JOAG) patients who attended the glaucoma clinic at the Hospital Universiti Sains Malaysia between January 2014 and December 2015. First-degree relatives of the patients underwent a preliminary eye-screening evaluation, including visual acuity (Snellen chart), intraocular pressure (IOP) measurement (air-puff tonometry), and non-mydriatic fundus photography. Patients with visual acuity worse than 6/12, IOP measuring more than 21 mmHg or a difference of more than 3 mmHg between the eyes, and a vertical cup-disc ratio (VCDR) of 0.7 or higher were given a comprehensive eye examination.ResultsSeventy indexed glaucoma patients were recognized, and 368 first-degree relatives were identified. Forty-five relatives underwent the preliminary screening. Of these, 29 showed normal findings (62%), one had corneal pathology (2%), and 16 (36%) underwent a complete eye examination after failing the initial screening. Among the indexed JOAG group, five relatives (11%) were diagnosed as having JOAG; two were treated medically, while the remaining three required surgical intervention.ConclusionOpportunistic glaucoma screening of high-risk groups, especially JOAG is a feasible and cost-effective way to detect early glaucoma and prevent irreversible blindness. However, improvement in our healthcare system, including the involvement of multicentre clinics in other states in screening initiatives, is required to promote and facilitate the response to screening opportunities.

Fundoscopy use in neurology departments and the utility of smartphone photography: a prospective prevalence and crossover diagnostic accuracy study amongst neurology inpatients.

Background and purposeAlthough fundoscopy is a crucial part of the neurological examination, it is challenging, under‐utilized and unreliably performed. The aim was to determine the prevalence of fundus pathology amongst neurology inpatients and the diagnostic accuracy of current fundoscopy practice compared with systematic screening with smartphone fundoscopy (SF) and portable non‐mydriatic fundus photography (NMFP).MethodsThis was a prospective cross‐sectional surveillance and diagnostic accuracy study on adult patients admitted under neurology in an Australian hospital. Inpatients were randomized to initial NMFP (RetinaVue 100, Welch Allyn) or SF (D‐EYE) followed by a crossover to the alternative modality. Images were graded by neurology doctors, using telemedicine consensus neuro‐ophthalmology NMFP grading as the reference standard. Feasibility parameters included ease, comfort and speed.ResultsOf 79 enrolled patients, 14.1% had neurologically relevant pathology (seven, disc pallor; one, hypertensive retinopathy; three, disc swelling). The neurology team performed direct ophthalmoscopy in 6.6% of cases and missed all abnormalities. SF had a sensitivity of 30%–40% compared with NMFP (45.5%); however, it had a lower rate of screening failure (1% vs. 13%, p < 0.001), a shorter examination time (1.10 vs. 2.25 min, p < 0.001) and a slightly higher patient comfort rating (9.2 vs. 8/10, p < 0.001).ConclusionOur study demonstrates a clinically significant prevalence of fundus pathology amongst neurology inpatients which was missed by current fundoscopy practices. Portable NMFP screening appears more accurate than SF, whilst both are diagnostically superior to routine fundoscopic practice, feasible and well tolerated by patients.

Association of monocyte-lymphocyte ratio and proliferative diabetic retinopathy in the U.S. population with type 2 diabetes

ObjectiveDiabetic retinopathy (DR), especially proliferative diabetic retinopathy (PDR) is a common cause of blindness and visual impairment. Early prediction of its occurrence and progression is important to improved patient outcomes. Inflammation-related markers may play important roles, and the monocyte-lymphocyte ratio (MLR) can act as a novel inflammatory marker. However, the association between MLR and PDR remains unclear. The aim of the present study was to investigate the association between MLR and PDR in the U.S. population with type 2 diabetes (T2D) based on DR data from NHANES in 2005–2008.MethodsThis cross-sectional study was conducted in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008. DR was defined by the criteria of the Early Treatment for Diabetic Retinopathy Study based on nonmydriatic fundus photography. The MLR is the monocyte count/lymphocyte count. The lymphocyte count and monocyte count can be obtained directly from laboratory data files. Logistic regression was used to explore the association between MLR and PDR. Stratified analyses were also conducted according to age, sex, hemoglobin, and glycated hemoglobin categories. We applied the duration of diabetes with multiple imputations of missing data.ResultsA total of 367 participants were included, among whom the PDR prevalence was 7% (27/367). Multivariate regression models revealed that PDR was significantly associated with 0.1 unit increase in MLR (adjusted OR = 1.46, 95% CI: 1.08−1.96) after all covariates were adjusted. In the subgroup analysis, effect size of MLR on the presence of PDR in subgroups were stable (all P values > 0.05).ConclusionsMLR was significantly associated with PDR in participants with T2D. Assessing the MLR might be a valuable part of follow-up visits for patients with T2D.Graphical

Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India

ObjectivesThe impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far...

Association between Dietary Calcium and Potassium and Diabetic Retinopathy: A Cross-Sectional Retrospective Study.

Background: Micronutrients are considered to have an important role in metabolic process. The relationships between micronutrients and diabetic complication, such as retinopathy, are rarely discussed. The main purpose of the current study was to investigate the relationship between dietary micronutrients and diabetic retinopathy in an adult population. Methods: 5321 participants from National Health and Nutritional Examination Survey (NHANES) 2005–2008 were included in this cross-sectional study. Diabetic retinopathy was diagnosed by the severity scale of the Early Treatment Diabetic Retinopathy Study (ETDRS) using nonmydriatic fundus photography. Micronutrients were assessed by 24-h dietary recall. The relationship between dietary micronutrients and the occurrence of diabetic retinopathy was analyzed by a logistic regression model. Results: Dietary calcium and potassium were inversely associated with diabetic retinopathy (OR: 0.729, 95%CI: 0.562–0.945; OR: 0.875, 95%CI: 0.787–0.973). Higher quartile of dietary calcium and potassium was associated with lower occurrence of diabetic retinopathy (OR: 0.664, 95%CI: 0.472–0.933; OR: 0.700, 95%CI: 0.495–0.989). Furthermore, increased amounts of dietary calcium and potassium were significantly associated with reduced occurrence of diabetic retinopathy (OR: 0.701, 95%CI: 0.546–0.900; OR: 0.761, 95%CI: 0.596–0.972). Conclusions: Higher levels of dietary calcium and potassium are suggested to reduce the risk of diabetic retinopathy with dose–response effect. The evaluation of dietary micronutrients might be a part of treatment for patients with diabetic complications.

Mobile Telemedicine Screening for Diabetic Retinopathy Using Nonmydriatic Fundus Photographs in Burgundy: 11 Years of Results.

We analyzed the results of mobile screening for diabetic retinopathy (DR) using retinal photographs, comparing these results between rural and periurban areas, and before and after the first national COVID-19 pandemic lockdown. The Burgundy Union Régionale des Professionnels de Santé (URPS) has organized an annual DR screening since 2004. The examination, performed by an orthoptist, consisted of taking the patient′s history, intraocular pressure measurement, and taking retinal photographs. After remote transmission, the examinations were interpreted by participating ophthalmologists at the Dijon University Hospital. In September 2016, the screening was open to periurban townships. In 11 years, 10,220 patients were screened: 1420 patients (13.9%) had DR of any type, with an average age of 68.5 (±11.3) years, and 59.2% were men. These patients had a statistically significantly higher glycated hemoglobin level (7.4% vs. 7.0%) and a longer duration of diabetes (13.8 vs. 9.3 years) than patients without DR. When comparing rural and periurban areas and periods before and after the beginning of the COVID-19 pandemic, we did not find any significant difference in the screening results. The results of this study are in line with the average findings of similar studies comparing screening strategies for DR. The early detection of DR can benefit from mobile telemedicine screening, identifying a considerable number of patients at an elevated risk, especially in rural areas where access to ophthalmological care is limited.

Prevalence and risk factors for diabetic retinopathy in prediabetes in Asian Indians

AimTo assess the prevalence of diabetic retinopathy (DR) and associated risk factors in Asian Indians with prediabetes. MethodsIn a cross-sectional study conducted at two tertiary care diabetes centres in Chennai, India, clinical and biochemical assessment and nonmydriatic ultra-wide field fundus photography was performed in individuals with prediabetes (impaired fasting glucose [IFG] and/or impaired glucose tolerance [IGT]) based on oral glucose tolerance test (OGTT) and/or glycated hemoglobin (HbA1c) between 5.7% and 6.4% in 2019. The retinal photographs were graded by certified ophthalmologists. Systemic risk factors associated with DR in prediabetes were assessed. ResultsThe mean age of the 192 individuals with prediabetes was 48 ± 13 years (55.2% were males). DR was present in 12 (6.3%) individuals of which nine (4.7%) had mild non-proliferative DR (NPDR) and three (1.6%) had moderate NPDR. None had severe sight-threatening DR. The Poisson multiple regression analysis showed that after adjusting for other systemic covariates, HbA1c values ≥ 6% (6–6.4%) was associated with 2 times higher relative risk of DR (Risk ratio 1.95 (95% CI 1.07–3.545, p = 0.028) in comparison to HbA1c < 6%). ConclusionDR was present in about 6% of the Asian Indians with prediabetes. Higher HbA1c values among individuals with prediabetes was associated with twice the relative risk for DR. Robust control of HbA1c should be encouraged even before the diagnosis of diabetes is established.

Micronutrients and Diabetic Retinopathy: Evidence From The National Health and Nutrition Examination Survey and a Meta-analysis

To investigate the associations between circulating micronutrients (vitamins A, C, D, E, and carotenoids) and risk of diabetic retinopathy (DR). Cross-sectional study and meta-analysis. The cross-sectional study included 517 diabetic participants aged ≥40 years in the 2005-2006 National Health and Nutrition Examination Survey. Serum vitamin D was converted to liquid chromatography-tandem mass spectrometry-equivalent results, while other micronutrients were measured using high-performance liquid chromatography. Presence of DR was determined based on non-mydriatic fundus photographs. A meta-analysis was subsequently performed, which included relevant studies published from January 01, 1990 to December 31, 2020. Of the 517 included participants, DR was identified in 159 participants (25.17%). After adjusting for multiple confounders, only serum vitamin C was associated with a lower risk of DR (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.38-0.95). A total of 35 studies were included in the subsequent meta-analysis. Comparing 1056 participants with DR to 920 controls, the pooled weighted mean difference (WMD) of vitamin C was -11.01 (95% CI: -19.35 to -2.67). Regarding vitamins D and E, the pooled WMD was -3.06 (95% CI: -5.15 to -0.96) and -3.03 (95% CI: -4.24 to -1.82), respectively. No associations were identified between DR and circulating vitamin A or carotenoids. Lower levels of circulating vitamins C, D, and E were found in DR patients than those without. More high-quality studies are required to assess the real effects of micronutrients on DR.

Nonmydriatic Retinal Photography in the Outpatient Neurology Resident Clinic.

The funduscopic examination is an essential component of the neurologic examination. However, examination of the ocular fundus with a direct ophthalmoscope is often difficult. Nonmydriatic ocular fundus photography allows direct visualization of the ocular fundus with high-quality photographs. We used nonmydriatic ocular fundus photography to improve patient care and funduscopy skills of residents in the Neurology Resident Clinic. At the time of triage, funduscopic photographs of all new neurology resident clinic patients were taken. The images were imported into the hospital's imaging software. The residents completed a full neurologic examination, including a funduscopic examination with a handheld ophthalmoscope. At the time of staffing the patients with the attendings, the residents received immediate feedback and teaching on retina photograph evaluation. A total of 255 patients were enrolled. Of those, 230 (90%) had at least one high-quality funduscopic photograph. Retinal photographs were normal in 161 (70%). Out of the 69 abnormal photographs, only 7% of abnormalities were detected by the residents. Ninety-three percent of residents found the retinal photographs useful. Nonmydriatic ocular fundus photography improved the care in patients presenting to a Neurology resident clinic and facilitated residents in recognizing funduscopic findings. Its benefits are clear when one considers (1) the high risk of negative patient outcomes and possible medicolegal consequences due to missed findings, (2) the ease of incorporating retinal photographs into the patients' medical records, and (3) the benefit of improving resident education in regard to the ophthalmologic examination.

Application and observation of artificial intelligence in clinical practice of fundus screening for diabetic retinopathy with non-mydriatic fundus photography: a retrospective observational study of T2DM patients in Tianjin, China.

Objective:To observe the consistency of a preliminary report of artificial intelligence (AI) in the clinical practice of fundus screening for diabetic retinopathy (DR) using non-mydriatic fundus photography.Methods:Patients who underwent DR screening in the Metabolic Disease Management Center (MMC) of our hospital were selected as research participants. The degree of coincidence of the AI preliminary report and the ophthalmic diagnosis was compared and analyzed, and the kappa value was calculated. Fundus fluorescein angiography (FFA) was performed in patients referred to the out-of-hospital ophthalmology department, and the consistency between fluorescein angiography and AI diagnosis was evaluated.Results:In total, 6146 patients (12,263 eyes) completed the non-mydriasis fundus examination. The positive DR screening rate was 24.3%. When considering moderate nonproliferative retinopathy as the cut-off point, the kappa coefficient was 0.75 (p < 0.001), the sensitivity was 0.973, and the precision was 0.642, which was shown in the precision–recall curve. Fifty-nine patients referred to receive FFA were compared with non-mydriatic AI diagnoses. The kappa coefficient was 0.53, and the coincidence rate was 66.9%.Conclusion:Non-mydriasis fundus examination combined with AI has a medium-high consistency with ophthalmologists in DR diagnosis, conducive to early DR screening. Combining diagnosis and treatment modes with the Internet can promote the development of telemedicine, alleviate the shortage of ophthalmology resources, and promote the process of blindness prevention and treatment projects.

Nonmydriatic Ultra-Widefield Fundus Photography in a Hematology Clinic Shows Utility for Screening of Sickle Cell Retinopathy

To determine the feasibility and accuracy of nonmydriatic ultra-widefield (UWF) fundus photographs taken in a hematology clinic setting for screening of sickle cell retinopathy (SCR) DESIGN: Prospective cohort study. This single-site study took place at the Johns Hopkins Sickle Cell Center for Adults and the Wilmer Eye Institute. The study population was 90 eyes of 46 consecutive adults with sickle cell disease (SCD). Bilateral nonmydriatic fundus photos taken by clinic personnel during the participants' routine hematology appointment were graded by 2 masked retina specialists at the Wilmer Eye Institute for the presence of nonproliferative SCR (NPSR) and proliferative sickle retinopathy (PSR). A third retina specialist adjudicated in cases of grader disagreement. All participants underwent the standard dilated fundus examination (DFE) within 2 years of acquisition of UWF photographs. The main outcome measure was the sensitivity and specificity of nonmydriatic UWF images for the detection of NPSR and PSR RESULTS: PSR was noted in 19 of 90 eyes that underwent DFE and in 9 of 67 gradable UWF images. Interrater agreement between the 2 graders was moderate, with κ=0.65 (range 0.43-0.87) for PSR. For gradable UWF photos, the sensitivity and specificity of detecting SCR using the nonmydriatic photos compared with the DFE were 85.2% and 62.5% for NPSR, respectively, and 69.2% and 100% for detection of PSR, respectively. One participant required ophthalmic therapy in both eyes for active sea-fan neovascularization. UWF imaging shows utility in screening for SCR and may help identify patients with PSR who require a DFE and who may benefit from treatment.

Imaging Modalities Employed in Diabetic Retinopathy Screening: A Review and Meta-Analysis.

Introduction: Urbanization has caused dramatic changes in lifestyle, and these rapid transitions have led to an increased risk of noncommunicable diseases, such as type 2 diabetes. In terms of cost-effectiveness, screening for diabetic retinopathy is a critical aspect in diabetes management. The aim of this study was to review the imaging modalities employed for retinal examination in diabetic retinopathy screening. Methods: The PubMed and Web of Science databases were the main sources used to investigate the medical literature. An extensive search was performed to identify relevant articles concerning “imaging”, “diabetic retinopathy” and “screening” up to 1 June 2021. Imaging techniques were divided into the following: (i) mydriatic fundus photography, (ii) non-mydriatic fundus photography, (iii) smartphone-based imaging, and (iv) ultrawide-field imaging. A meta-analysis was performed to analyze the performance and technical failure rate of each method. Results: The technical failure rates for mydriatic and non-mydriatic digital fundus photography, smartphone-based and ultrawide-field imaging were 3.4% (95% CI: 2.3–4.6%), 12.1% (95% CI: 5.4–18.7%), 5.3% (95% CI: 1.5–9.0%) and 2.2% (95% CI: 0.3–4.0%), respectively. The rate was significantly different between all analyzed techniques (p < 0.001), and the overall failure rate was 6.6% (4.9–8.3%; I2 = 97.2%). The publication bias factor for smartphone-based imaging was significantly higher than for mydriatic digital fundus photography and non-mydriatic digital fundus photography (b = −8.61, b = −2.59 and b = −7.03, respectively; p < 0.001). Ultrawide-field imaging studies were excluded from the final sensitivity/specificity analysis, as the total number of patients included was too small. Conclusions: Regardless of the type of the device used, retinal photographs should be taken on eyes with dilated pupils, unless contraindicated, as this setting decreases the rate of ungradable images. Smartphone-based and ultrawide-field imaging may become potential alternative methods for optimized DR screening; however, there is not yet enough evidence for these techniques to displace mydriatic fundus photography.

Utilization of Remote Diabetic Retinal Screening in a Suburban Healthcare System.

PurposeWe conducted a cross-sectional study to assess the utilization of a tele-ophthalmology screening program in a low-risk, suburban population of patients with diabetes.MethodsA total of 214 diabetic patients without previously documented diabetic retinopathy (DR) underwent point-of-care non-mydriatic fundus photography through their primary care providers at five Beth Israel Lahey Health locations. The characteristics of the patients who received remote screening were compared with those patients who were eligible for screening but did not take part in the program. Time-driven activity-based costing (TDABC) was implemented to examine the cost of screening by tele-ophthalmology compared with in-person examinations.ResultsTele-ophthalmology screening was more likely to be provided for patients who were younger (OR 0.985; 95% CI 0.973–0.997, p=0.016), who were obese (OR 2.04; 95% CI: 1.47–2.84, p=0.008), who had an HbA1c above 8.0% (OR 1.60; 95% CI: 1.13–2.26, p=0.031), or who had an eye examination in the past year (OR 5.55; 95% CI: 3.89–7.92, p<0.001). Those patients newly diagnosed with DR because of the program were more likely to have diabetic nephropathy (OR 7.79; 95% CI: 1.73–35.05, p=0.007). TDABC identified a health system cost-savings of between $8 and $29 per patient screened by tele-ophthalmology compared with the cost of in-person eye examinations.ConclusionTele-ophthalmology presents an opportunity to reduce the costs of screening patients without prior evidence of DR, especially those who have completed a comprehensive eye examination within the prior year.

Impact on patient management of non-mydriatic fundus photography compared to direct ophthalmoscopy in a regional Australian emergency department.

To investigate the management impact of non-mydriatic fundus photography (NMFP) implementation for appropriate ED patients; compare the diagnostic accuracy of direct ophthalmoscopy (DO) and NMFP, and determine the prevalence of fundus pathology in a regional Australian ED. This before/after crossover study prospectively enrolled patients presenting with headache, neurological deficit, visual disturbance and/or hypertensive urgency. Patients received DO examination, then separate NMFP examination. Emergency clinicians (ECs) were surveyed on their patient management plans following both DO examination and NMFP imaging. Telemedicine review of NMFP images was performed by an ophthalmologist within 48 h, and any additional management changes were documented. The use of NMFP influenced changes in management in 52 (39%) of 133 enrolled patients (95% confidence interval 31-48%). Of these, 65% were escalations of management due to acute fundus pathology, while 35% were de-escalating changes following normal fundus findings. ECs diagnostic accuracy for acute fundus pathology improved from 0% to 29% sensitivity, and 59% to 84% specificity using DO and NMFP respectively, and telemedicine registrar review increased this to 50% sensitivity and 86% specificity. The period prevalence of acute fundus pathology was 10.5% (95% confidence interval 6-17%). The addition of NMFP images can significantly impact the management of ED patients requiring fundus examination, facilitating expedited and optimised patient care. NMFP improves ECs diagnostic acumen for fundus pathology over DO examination and telehealth specialist review is important for diagnostic accuracy. There is a clinically important prevalence of fundus pathology in this regional ED setting.